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 THE LIBRARY 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES
 
 MicU LoutfalU 
 
 APR 3o 1943 
 
 ^B.
 
 Loutfatlak
 
 OPHTHALMIC SURGERY 
 BEARD 
 
 MicU LouifalU
 
 OPHTHALMIC SURGERY 
 
 A TREATISE ON SURGICAL OPERATIONS PERTAINING TO 
 
 THE EYE AND ITS APPENDAGES, WITH CHAPTERS 
 
 ON PARA-OPERATIVE TECHNIC AND 
 
 MANAGEMENT OF INSTRUMENTS 
 
 BY 
 
 CHARLES H. BEARD, M. D. 
 
 SURGEON TO THE ILLINOIS CHARITABLE EYE AND EAR INFIRMARY; OCULIST TO THE PASSAVANT 
 
 MEMORIAL HOSPITAL, CHICAGO; EX-PRESIDENT OF THE CHICAGO OPHTHALMOLOGICAL 
 
 SOCIETY; MEMBER OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY, ETC. 
 
 WITH 9 PLATES, SHOWING 100 INSTRUMENTS 
 AND 300 OTHER ILLUSTRATIONS 
 
 PHILADELPHIA 
 P. BLAKISTON'S SON & CO. 
 
 1012 WALNUT STREET 
 1910
 
 COPYRIGHT, 1910, BY P. BLAKISTON'S SON & Co 
 
 i 
 
 fainted by 
 
 The Maple Press 
 
 York. Pa.
 
 lef 
 
 PREFACE. 
 
 THE selection of the matters discussed in the following pages 
 and the manner of treating them are the results of the careful 
 study and practical application of the involved principles made in 
 hospitals, dispensaries, and in private practice, extending over a 
 period of twenty-six years. They began while the author was a 
 student under Agnew and Knapp, in 1883, were later continued 
 in England and on the Continent of Europe, and have ever since 
 been diligently prosecuted. 
 
 There has been no separate work on the surgery of the eye 
 published in the United States for nearly half a century, and but 
 little written upon the subject in connection with the more general 
 treatises on ophthalmology, if we except the admirable contribu- 
 tion of Knapp to the System of Norris and Oliver some twelve 
 years ago. The object here has been to supply a work that would 
 embody not only what ^experience has taught and judgment 
 prompted as being the more valued measures of all countries, but, 
 in particular, those of our own country. 
 
 The presentation of portions devoted to the history of the dif- 
 ferent procedures is deemed of great importance, but to keep 
 them from appearing obtrusive they have been made as concise 
 as practicable. 
 
 The classification followed has seemed the logical one to adopt. 
 The chapter on the extraction of foreign bodies from the interior 
 of the eye has been placed in a class of its own instead of with 
 the operations upon the globe. In the author's opinion, the
 
 VI PREFACE. 
 
 handling of foreign bodies in the eye is a subject apart, the 
 methods employed in their diagnosis, localization, and extraction 
 involving so much that is not in line with other branches of 
 ophthalmic surgery. 
 
 In view of the fact that the illustrations have been chiefly the 
 fruits of his individual labor, the writer begs his confreres not to 
 consider them in the light of mere pictures or from the stand- 
 point of artists, but as conceptions of how these things should 
 appear by one with considerable experience in the matters de- 
 picted and with a little facility in the power of delineation. 
 
 In closing, the author offers his sincere thanks to all others who 
 have been instrumental in supplying whatever of merit this volume 
 contains. 
 
 CHARLES H. BEARD. 
 
 Chicago, 1910.
 
 LIST OF CONTENTS. 
 
 CHAPTER I. 
 
 PAGE 
 
 PARA-OPERATIVE TECHNIC i 
 
 The preparation of surgeons, assistants, patient, instruments, 
 and dressings. Sterilization, anesthesia, blood-letting; in 
 short, all appliances, applications, and methods employed 
 in connection with ophthalmic operations and with their 
 after-treatment. 
 
 CHAPTER II. 
 
 INSTRUMENTS AND THEIR MANAGEMENT 55 
 
 The approved qualities and forms of the instruments used 
 in ophthalmic surgery, and what features are commendable 
 and what objectionable in them, with reasons and explana- 
 tions. Minute descriptions of models, and, in conclusion, 
 the manipulation or handling, and the care or maintenance 
 of eye instruments. 
 
 CHAPTER III. 
 
 OPERATIONS UPON THE APPENDAGES OF THE EYE. THE LACRIMAL 
 
 APPARATUS 123 
 
 The surgical treatment of affections of the lacrimal canal, 
 together with detailed descriptions of the principal oper- 
 ations performed upon the entire lacrimal apparatus, both 
 secretory and drainage. 
 
 CHAPTER IV. 
 
 THE APPENDAGES CONTINUED. OPERATIONS UPON THE EXTRINSIC 
 
 MUSCLES OF THE EYE 158 
 
 The different kinds of squint and a history of the surgery of 
 the defect. The technic of the leading measures for its 
 correction, including tenotomy, advancement, shortening and 
 lengthening of tendons and check ligaments, and the acci- 
 dents and complications that may occur. Critical consider- 
 ations of methods of advancement. 
 
 CHAPTER V. 
 
 THE APPENDAGES CONTINUED. OPERATIONS UPON THE LIDS . . . 206 
 Eversion, epilation, and electrolysis of cilia, methods for 
 chalazion, canthoplasty, tarsorrhaphy, and epicanthus. 
 
 vii
 
 yiii LIST OF CONTENTS. 
 
 CHAPTER VI. 
 
 PAGE 
 
 THE APPENDAGES CONTINUED. OPERATIONS FOR PTOSIS . - 228 
 Kinds of ptosis, history of the surgical measures devised for 
 it, with the principles underlying them. Descriptions of the 
 technic evolved in the leading methods for righting the fallen 
 lid, and an extended summary dealing with the different 
 procedures and their relative values. 
 
 CHAPTER VII. 
 
 THE APPENDAGES CONTINUED. OPERATIONS FOR ENTROPION, 
 
 ECTROPION AND BLEPHAROPLASTY ............. 250 
 
 Operations for spastic entropion, cicatricial entropion and 
 trichiasis, with the history and evolution of such surgery. 
 'Ectropion, its varieties, such as spastic, mechanical, mucous, 
 atonic, and cicatricial. Blepharoplasty in all its phases, as by 
 sliding and pedunculated flaps, by dermic and epidermic 
 grafts, etc., with exhaustive detail of technic under each of 
 the several headings. 
 
 CHAPTER VIII. 
 
 THE APPENDAGES CONTINUED. OPERATIONS UPON THE CONJUNCTIVA. 321 
 The surgery of partial and total symblepharon, and the 
 restoration of the conjunctival cul-de-sacs. Pterygium, 
 true, false, and recurrent, and appropriate surgical measures 
 for the different kinds, including excision, transplantation, 
 ligation, cauterization, and skin grafting. Peritomy and 
 peridectomy. 
 
 CHAPTER IX. 
 
 THE APPENDAGES CONTINUED. THE SURGICAL TREATMENT OF 
 
 TRACHOMA ...................... . 356 
 
 Historical. The classification of methods into mechanical, 
 chemical, and operative. Details of technic relative to each 
 class, as scraping, massage, expression, cauterization, 
 radiation, and excision. The last comprises all forms of 
 excision, whether of conjunctiva alone or of that membrane 
 combined with excision of the tarsus. 
 
 CHAPTER X. 
 
 OPERATIONS UPON THE GLOBE 371 
 
 These relate first to the outer walls of the globe comprised 
 by cornea and sclera. Measures for foreign bodies in the 
 cornea, corneal cautery, paracentesis, massage, keratoplasty, 
 anterior staphyloma, conical cornea and tattooage. The 
 scleral surgery includes sclerotomy, anterior and posterior, 
 cyclodialysis, trephining, amputations, exenteration, enuclea- 
 tion, and the substitution of a prothesis in the globe or in 
 Tenon's capsule. Operations upon the iris. Iridotomy, 
 irito-dialysis, irito-ectomy, synechiotomy, and iridectomy in 
 all its forms and phases.
 
 LIST OF CONTENTS. IX 
 
 CHAPTER XI. 
 
 PAGE 
 
 OPERATIONS UPON THEGLOBE CONTINUED. EXTRACTION OF CATARACT. 478 
 Preparation of the patient and of the eye. Description of 
 approved technic for the various forms of extraction. Ex- 
 tended commentary on the accidents and complications 
 incident to extraction, their causes and their remedies. 
 Discission of primary and secondary cataract, couching or 
 depression, and suction. Extraction of the lens in its 
 capsule. The history of extraction and its instrumentation, 
 with concluding dissertation on the modern corneal section. 
 
 CHAPTER XII. 
 
 OPERATIONS UPON THE ORBIT 598 
 
 The surgery of foreign bodies in the orbit. Kronlein's 
 operation and its modifications. The removal of tumors. 
 Incisions of the orbit evacuant and diagnostic. Exenter- 
 ation, partial and total. 
 
 CHAPTER XIII. 
 
 THE REMOVAL OF FOREIGN BODIES FROM THE INTERIOR OF THE EYE . 610 
 Their abstraction from the anterior chamber; from the iris; 
 from the posterior chamber; from the vitreous chamber. 
 Their localization in the eye and in the orbit. Magnet 
 operations and their technic. 
 
 CHAPTER XIV. 
 
 ALPHABETICAL INDEX 659
 
 OPHTHALMIC SURGERY. 
 
 CHAPTER I. 
 PARA-OPERATIVE TECHNIC. 
 
 Asepsis. According to Snellen, all wounds, especially those of 
 the eye, tend to heal per primam intentionem, and it is gratifying 
 to know that the work of the ophthalmic surgeon has made good 
 this assertion. While it is true that this branch of surgery has 
 seemed to profit more than the others by antiseptic measures, yet, 
 when we consider the status of our knowledge of the value and of 
 the means of asepsis, our operative results are a reproach. The 
 fact remains that the vast majority of untoward consequences are 
 due to some form of infection. Thus the advantage is still on the 
 side of the operator who is most thorough and consistent in carrying 
 out antiseptic precautions, rather than on the side of mere skill. 
 Lack of these precautions oft turns into abject failure the most 
 brilliantly executed surgical measure, while attention to them can 
 make a perfect triumph of a wretched bungle. We are in constant 
 need not only of an "antiseptic conscience," but of an aseptic 
 subconsciousness as well. We should acquire a habit of surgical 
 cleanliness and try to impart it to everybody about us. Unless 
 one is broadly grounded in this training, he is being forever the 
 victim of his own anti-climaxes, as, for example, picking his teeth 
 with his finger-nail, scratching his head, or taking an instrument 
 between his lips just after having made the most elaborate and up- 
 to-date preparation for an operation. With some of the older 
 ones the genuine habit is difficult at times impossible to attain. 
 With the younger ones it should be easy. 
 
 The key-note to asepsis is sterilization. This is of two kinds, 
 relative and absolute. The first refers to the preparation of the 
 hands and persons of surgeons, attendants, patients, and of the 
 
 i
 
 2 PARA-OPERATIVE TECHNIC. 
 
 parts concerned in the proposed surgical measure. The second 
 is applicable only to inanimate objects, such as instruments, articles 
 used in making applications, the materials for dressings, etc. 
 Obviously vital animal tissue cannot be subjected to this form of 
 sterilization Therefore, in the use of purifying solutions upon it, 
 one is inclined to make up in abundance what is lacking in strength. 
 
 Preparation of the Hands and Forearms. It is well to include 
 the hands and arms of the patient as well as those of the operator 
 and all of his aids in this process. They are first scrubbed with 
 good soap, liquid or solid, and tepid water, by means of a brush 
 that is not too stiff. The nails are trimmed, cleaned and scrubbed 
 with the brush. The hands are then rinsed with pure warm water, 
 using the brush. After drying on a sterile towel, they may now be 
 anointed with a mixture of alcohol, glycerin, and one of the highly 
 antiseptic essential oils, as that of cloves or of cinnamon, to be 
 immediately followed by a good rubbing. This has the property 
 of great penetration, entering into the ducts of the sweat and 
 sebaceous glands, and permeating the deeper layers of epithelial 
 masses. Lastly, they are washed lightly in sterile water and wiped 
 perfectly dry on a sterile towel. Allowing the hands to dry spon- 
 taneously is not so cleanly, as the moisture catches dust. The oft- 
 repeated washing of the hands with solutions of irritating antisep- 
 tics like sublimate, formalin, and carbolic acid has the effect of 
 making them sore, and rough with dead epidermis, without in the 
 least rendering them less infectious. A soap impregnated with a 
 grinding material is excellent for hands that are inclined to be rough. 
 
 Gloves. The more important and exacting operations upon 
 the eye are performed without the surgeon's fingers ever coming in 
 contact with the field of operation. Hence, the wearing of rubber 
 gloves on his part would be not only uncalled for, but when the 
 extreme exactness of most opthalmic surgery as considered, positively 
 unadvised. For all of his assistants, however, to wear them, were 
 both prudent and desirable. Especially is this true as regards those 
 who make and handle the cotton sponges, or thread, or any object 
 that actually touches the site of operation. 
 
 Sterilization of Instruments. There are three methods more 
 or less in use for this purpose, that by dry heat, that by moist heat, 
 and that by strong antiseptics. It need hardly be said that this
 
 STERLIZATION OF INSTRUMENTS. 3 
 
 proceeding takes place immediately before the operation. When 
 prepared by dry heat the instruments are put into some form of 
 stove or oven, of which there are many efficient kinds on the market. 
 Here they are exposed for twenty minutes, or longer, to a temperature 
 of 300 F. This is applicable to all kinds of instruments, even to 
 those with ivory handles. In winter, or in very moist weather, 
 the door of the oven is left open for a few moments after the heat 
 is started, in order to prevent the quick corrosion of fine edges and 
 points that comes from condensation. Sterilizing in a flame is 
 fatal to any instrument. 
 
 By Moist Heat. It is customary to put in this class sterilization 
 by means of live steam, in an autoclave, under pressure. In reality, 
 if carried out to the letter, this is a form of dry sterilization. In this 
 country eye instruments are rarely subjected to this process. The 
 method most in vogue, and most to be recommended is by boiling. 
 Contrary to many adverse statements and comments, I believe 
 this method the best for all kinds of eye instruments. That is, 
 just as appropriate as any for the finer cutting implements. True 
 the instruments must be manufactured with a view to being so 
 treated. They must have metal handles be all of metal, in fact, 
 and the procedure must be conducted by one who knows and 
 does full duty in the matter. I cannot do better than give a descrip- 
 tion of it as practised in the Illinois Eye and Ear Infirmary. All 
 the more delicate instruments are placed in a metal rack, provided 
 with a handle and with a clamp which holds them securely, the 
 points and edges of the sharp ones having been previously tested 
 on the trial-kid. The rack projects beyond the extremities of the 
 instruments so that they cannot be jammed against the boiler. 
 There is a separate compartment in the boiler for this rack. The 
 coarser and non-cutting articles are dropped carefully into another 
 compartment. The boiler contains a solution of soda or borax, 
 one to two parts per thousand. The presence of the salt serves 
 to elevate the degree of ebullition and to restrain oxidation. The 
 solution is perfect i.e., there must be none of the salt undissolved. 
 The instruments are not put in until the water reaches the boiling- 
 point. Of course the boiling ceases the moment they are immersed. 
 One waits, then, until it begins again before starting to time the 
 sterilization. The time should not be less than ten minutes.
 
 4 PARA-OPERATIVE TECHNIC. 
 
 Fifteen would not be too long. The instruments are then lifted out 
 drained, and laid on sterile towels on the trays of the serving tables. 
 It would be well to have a small oven in which to dry them quickly 
 just before using. The plan, so generally followed, of putting them 
 fresh from the boiler into some liquid, there to remain till used, is 
 not cons'stent with good surgery. It is not pleasant to either operator 
 or operated to have water dropping into the eye from the instru- 
 ments; besides, since the sterilization of the hands is only relative, 
 infection could in this way, be carried from the ringers into the 
 wounds. If promptly dried the moment they are removed from 
 the sterilizer one need have no apprehension as to the points and 
 edges of the finest knives. If left in the air, covered w r ith moisture, 
 oxidation becomes at once very active, and it is precisely the thin 
 edges and sharp points that will suffer most. All sutures are boiled 
 ready threaded in their needles. If to be treated with paraffin, 
 or other waxy material, this is best put on afterward, as the consider- 
 able handling necessitated by the threading is apt to contaminate 
 the suture. 
 
 By Strong Antiseptics. This is the least satisfactory method, 
 and must ever be one of expedition, not of choice. It consists in 
 letting the instruments lie for 15 minutes or longer in a bath of one of 
 several liquids. The commoner are 40% formalin, 95% phenol, 
 95% alcohol, and pure chloroform. They are then taken out and 
 washed in sterile water. This is an uncertain process, for if there 
 be the thinnest possible film of any fatty or albuminous substance 
 on the instrument it acts as a barrier to disinfection. Moreover, 
 all these fluids attack the steel with some degree of activity. This 
 form of sterilization is made much surer by wiping the instruments 
 repeatedly, and hard, with sterile, soft linen just before putting 
 them into the bath. If done intelligently, this also enhances the 
 polish and the keenness of the trenchant articles wiped. It is not 
 a bad idea to have the cloth wet with the antiseptic. It was the 
 practice of Agnew, of New York, to wipe his Graefe knife long and 
 hard with soft linen, before the days of antisepsis, to render it 
 cleaner, brighter and sharper. 
 
 Preparation of the Patient. This is divided into general and 
 local. General preparation is of two kinds, physical and mental. 
 General preparation may be begun at an indefinite time previous
 
 PREPARATION OF THE PATIENT. 5 
 
 to the operation, and should never, in case of major operations, be 
 started less than 24 hours previously. First, on entering the hospi- 
 tal come the taking of the histories, family, personal, and clinical, 
 then the physical examinations, general and local. These include 
 urinalysis, inquiry into the state of circulatory and vascular systems 
 (if subject is not young), nose, throat, lungs, heart, digestion, etc. 
 The bowels are emptied by broken doses of calomel followed by 
 citrate of magnesia or salts, or by castor oil. The diet is liquid 
 or very light. If the operation is to be under narcosis, or if the 
 subject is nervous or apprehensive, it is well to give a small dose 
 of morphin, or chloretone, or bromid of sodium, thirty to forty 
 minutes before the start for the surgical room. The patient is 
 questioned as to cough, and, if general anesthesia is contemplated, 
 as to behavior in any former narcosis. Both eyes and their ap- 
 pendages are thoroughly examined and the results recorded. Partic- 
 ular care is directed to the condition of the pupils, the fundi, the 
 cornea, the conjunctiva and the lacrimal canals. Bacteriologic 
 investigation of even the healthy appearing conjunctiva is of positive 
 advantage in that an incipient pathogenic or pyogenic infection 
 may be discovered and disaster averted by a postponement of the 
 proposed operation. The vision, the refraction, fields, etc., are 
 noted. The subject must be made as clean as possible, but it is 
 best to leave it to the discretion of a trained attendant whether 
 or not regular tub bathing and shampooing be resorted to. Along 
 with all this goes the mental or psychologic preparation. The 
 beauties and advantages of hospital life and treatment are extolled 
 and instructions given as to how best to profit by them, how friendly 
 everyone is to everyone else, etc. Incidentally the patient is put 
 through a system of training in the matter of turning the eyes in 
 various directions, opening and closing them without undue effort, 
 and of having them touched and handled. Unless there is some 
 positive indication, no local preparation is inaugurated prior to 
 one hour, or even 30 minutes, before the operation. The use of 
 antiseptics in the conjunctival sac and of bandages for a day or 
 two before hand is omitted as worse than useless. Much of this 
 subject is given in the Chapter on Extraction. Suffice it to state 
 here that, by way of local preparation the eyelids and surrounding 
 areas are scrubbed with sterile soap and warm water, followed by
 
 6 PARA-OPERATIVE TECHNIC. 
 
 rinsing with warm sublimate solution 1-2,000, the subject mean- 
 while keeping the eyes tightly shut. The supercilia are not shaved 
 unless extra heavy. The cilia are washed, and the lids manipulated 
 to empty the Meibomian and other ducts along the free borders. 
 The cilia before extractions and iridectomies are coated by wiping 
 them with cotton wet with benzin, and, lastly, the conjunctival 
 sac is copiously douched with w^arm boric acid solution. A light 
 boric acid dressing is then put on the eye and fixed by a simple 
 muslin strip tied on diagonally, to be left till the time for the opera- 
 tion arrives. The hair of women is neatly combed back and 
 braided. The nails are manicured and the hands are scrubbed. 
 The patient is taken to the operating room in night clothing, i.e., 
 all ready for bed. The eye is copiously flooded with warm boric 
 or salt solution before, during, and after the operation. One at- 
 tempts by this liberal use of a mild antiseptic to make up, as it were, 
 for one's inability to employ a strong one. 
 
 Sterilization of all dressings, such as bandages, cotton, gauze, 
 and of gowns, caps, masks, inhalers, etc., is done by means of the 
 large steam autoclaves. Usually the various articles are done up 
 in stout cotton bags, which are securely tied. They are not removed 
 either from the sterilizer or from the bags until needed. All ap- 
 pliances, applications, implements, and drugs, of whatever descrip- 
 tion, used before, during, or after the operation, are sterilized by 
 either dry or moist heat. 
 
 Everyone who has a duty to perform in connection \vith an opera- 
 tion is clad in a sterile gown and in a cap to cover the hair. Nurses 
 and aids wear gloves, while the surgeon and his immediate assistant 
 have mouths and beards covered by masks. 
 
 Surgeon's Operating Masks. "The principal object of these 
 convenient appliances is to protect the operative field against in- 
 fection from the expiratory efforts of the operator and assistants 
 in talking, coughing, sneezing, etc. They supersede the use, for 
 the same purpose, of plain pieces of gauze tied over the lower part 
 of the face around to the back of the head. By the latter method, 
 however, aside from its being a far less convenient one than the 
 other, to say nothing of the discomfort to the wearer, there was 
 always more or less danger of having the operator's hands con- 
 taminated by coming in contact with the hair while in the act of
 
 OPERATING MASKS. 7 
 
 tying the gauze at the back of the head. This and other objections 
 to wearing some sort of shield have been done away with by such 
 wire masks as we illustrate; these may be easily attached to the head 
 in a manner similar to spectacles, requiring only the handling of 
 the mask itself, which should be previously sterilized. Wilson, 
 of Bridgeport, has attachments on the mounting of his operating 
 spectacles for holding the gauze mask. 
 
 "One of the two best-known patterns of these wire masks is that 
 of Mikulicz, which consists of a wire framework so made that 
 
 FIG. i. Mikulicz mask. 
 
 FIG. 2. Mikulicz mask. 
 
 when covered with two thicknesses of gauze stitched to all sides, 
 it effectually covers the nose and mouth of the wearer when it is 
 placed in position. It is instantly adjusted to the head, and when 
 not in use a number of them may be nested and temple bars folded 
 over, so as to take up a minimum amount of room. 
 
 "The other pattern now being rapidly adopted by many leading 
 surgeons and hospitals, as fulfilling the purpose admirably, is known 
 as Tuttle's mask. This is a modification, by Dr. Edward C. 
 Tuttle, of a somewhat similar contrivance used in some European 
 hospitals; and while they are also made of wire, they are different 
 in construction to those first described, as will be seen by comparing 
 the illustrations shown herewith. On these frames the gauze is 
 to be attached only to the upper part, but for the entire length of 
 same, back to the very ends of the temple bars, so as to allow the 
 gauze, after the mask has been put on, to hang down 16 to 18 inches
 
 8 
 
 PARA-OPERATIVE TECHNIC. 
 
 over the front and sides of the head, covering also the ears; the 
 lower part of the gauze is then placed underneath the operating 
 gown before the latter is buttoned up, afford 'ng protection in every 
 needed way. It will be seen that the bottom part of the frame 
 stands out from the lower part of the wearer's face in such a position 
 as to hold the gauze away from it, thereby insuring comfort. 
 
 "Of the two kinds of masks herein described, the first mentioned 
 has the advantage of being instantly adjusted to the head, whereas 
 the other, even though it may take a trifle longer to put on, is pre- 
 
 FIG. 3. Tuttle's mask. 
 
 FIG. 4. Tuttle's mask. 
 
 ferred by many on account of its giving the desired protection in a 
 more complete way. It is well to note that where an operating 
 cap is worn with a Tuttle's Mask, only the eyes and their immediate 
 vicinity are left exposed, while the remaining portions of more than 
 the entire front half of head and neck are completely covered. 
 Furthermore, it should be remembered that both types mentioned 
 are so constructed as not to allow the gauze to rest against the 
 face of wearer, thereby enabling him to feel at perfect ease, which 
 is not the case where gauze alone is worn; also that the wire temple 
 bars may be easily bent, so that the masks can be readily adjusted 
 to fit almost anyone." 
 
 The Operating Room. The best sort of operating room, de- 
 scribed in a general way, is one that is dry, commodious, that is well 
 ventilated without opening windows or doors, easily heated in
 
 THE OPERATING ROOM. 9 
 
 winter, and that has an abundance of light. Particularly desirable 
 is a broad north window. This insures a uniform light without 
 interference by direct sunlight. If this window be set at an angle 
 of 30 to 45, inclining inward, it is preferable to a perpendicular 
 window. Operations wherein corneal reflections can be a disturb- 
 ing factor are made easier by a window thus inclined. With the 
 patient lying on the table, feet toward the vertical window, as is the 
 favorite position, unless the table be so far removed from the window 
 as to greatly reduce the illumination, the image of the window lies 
 inconveniently high up on the cornea. Now, if the window were 
 tilted toward the table, just in proportion as the slant of the window 
 would increase up to 45, just in the same degree would the reflex be 
 lowered. This is illustrated by the accompanying drawings. 
 
 A B 
 
 FIG. 5. A, Reflex near vertical window. B, Reflex near inclined window. 
 
 A and B represent the left eye of a subject lying on a table with 
 feet toward the window. A shows the image of a vertical window 
 and B that of one inclined inward about 40, the distance of the 
 table from the window being the same in both instances. Next 
 in choice to the inclined window as a source of light is the vertical, 
 though to get the best illumination the table would be placed 
 diagonally, with the foot near the window. A sky-light is not 
 satisfactory. Perhaps the best all-around light is the artificial, 
 for by the use of portable electric phosphores, or other electric 
 hand-lamps, and large biconvex lenses, one can get whatever 
 intensity is desirable, and can cause the reflexes to fall wherever 
 they are least in the way. Walls, ceiling, floor, woodwork and 
 furniture of the room are all white and of materials, or covered 
 with materials, that most readily admit of washing, fumigating,
 
 10 PARA-OPERATIVE TECHNIC. 
 
 or vigorous disinfection generally. Window shades are of a material 
 easily cleaned, and work from below by heavy gilt (metallic) picture 
 cord, so as to raise the least amount of dust in being put up or down. 
 No pus cases and no re-dressings are allowed in the clean operating 
 room. 
 
 Anesthesia. Instead of the classification "local" and "general," 
 it would be simpler and better English to distinguish these two con- 
 ditions by the terms anesthesia, meaning the loss of sensation in any 
 particular part of the body due to the contact of the sensory nerves 
 supplying that part with a drug that causes temporary paralysis, 
 and narcosis, meaning that condition of general stupor and uncon- 
 sciousness, resembling sleep, caused by the wide diffusion of the 
 poisonous drug in the circulation. Thanks to local anesthetics the 
 eye-surgeon is now enabled to dispense with narcosis for the vast 
 majority of operations. Indeed, there is no surgical measure 
 resorted to by the oculist for which narcosis is not, now and then, 
 omitted. 
 
 Local. Local anesthesia is produced, in eye surgery, in several 
 ways; as by the instillation of solutions of anesthetics into the con- 
 junctival sac applicable to operations upon the mucous membrane 
 or upon the globe. Instillation of the same solutions into open 
 surgical wounds applicable to operations upon the globe or its 
 appendages, and by the infiltration method of Oberst, or the com- 
 bined infiltration and cocain method of Schleich; the last two being 
 applicable only to operations upon the appendages. Another form 
 of local anesthesia proper to mention is that by freezing with the 
 spray of anesthyl or plain chlorid of ethyl or other highly volatile 
 substance. This serves well for the incision of abscesses of the lids 
 or orbit, especially in children or excessively sensitive adults. Of 
 course, the eyeball must be protected from the cold. So far 
 ophthalmic surgeons have had little or nothing to do with the 
 intraneural method of Gushing, and nothing with the spinal 
 anesthesia of Corning and Bier. 
 
 Of all the local anesthetics cocain, after twenty-five years of 
 trial, still retains its supremacy. Its maximum of efficiency can 
 be obtained with solutions varying in strength from 2 to 4%. 
 Stronger solutions only serve to increase the objectionable qualities 
 of the drug. Holocain stands next in popularity. It is effective
 
 ANESTHESIA. II 
 
 in solution of only i%, and has the advantage of retaining its proper- 
 ties longer than cocain. The chief objections to cocain arise from 
 overdosage or prolonged application. This leads to dryness and 
 desquamation of the corneal epithelium, to dilation or relaxation 
 of the blood-vessels, and to hypotonicity of the globe. The first 
 favors infection, and the last two cause hemorrhage. The third 
 objection is turned to a virtue, however, in glaucoma, where cocain, 
 notwithstanding its mydriatic effect, may be used with impunity 
 not only as an anesthetic, but also as a remedy. The first effects 
 of cocain on the normal eye are contraction of the blood-vessels 
 and perfect anesthesia. Hence, it is most expedient to operate 
 during the primary stage in so far as it is possible. To this end the 
 instillations should not be begun longer than ten minutes before the 
 operation. A good rule is to start the boiling of the instruments 
 and the application of the cocain simultaneously. Four drops with 
 two-minute intervals is sufficient. If the eye be hyperemic it is less 
 susceptible to the drug, but it can be blanched by adrenalin, and 
 then anesthetized. A convenient and highly efficacious form of 
 cocain application is the fresh sterile cocain ointment. This has 
 such staying qualities that a single laying-on is enough. More- 
 over, it is said not to disturb the corneal epithelium when fat instead 
 of water is the vehicle. Ramsay recommends a few drops of 5% 
 chloretone solution, along with the cocain, to offset the harmful 
 results to the epithelium. It has been often denied that there is 
 aught accomplished by dropping cocain into the open wound in 
 operations upon the appendages, but the facts do not seem to up- 
 hold the denial. 
 
 Infiltration Anesthesia. It had long been known that a dense 
 infiltration, of the skin, for instance, caused anesthesia of the part. 
 Oberst, in 1889, turned this to account by producing artificial 
 infiltration, by means of a hypodermic syringe and distilled or 
 salt water preparatory to the making of incisions. Schleich, in 
 1889, went further, and added a modicum of cocain (1/8 to 1/4%) 
 to the fluid for the syringe. Both these methods are rather exten- 
 sively employed in the surgery of the lids. A wheal, or a series of 
 wheals, of edema is raised at the site of the proposed operation by 
 introducing a fine hypodermic needle nearly its whole length 
 into the skin, and gradually withdrawing it as the liquid is injected.
 
 12 PARA- OPERATIVE TECHNIC. 
 
 To be free from danger, if the Schleich method is used, either the 
 cocain should be in very minute quantity or else the ring of a 
 clamp should be thrown around the wheal to prevent the solution 
 from entering the general circulation. The anesthesia is absolute, 
 but the changed aspect of the tissues, and the swelling, are against 
 the procedure, as is also the greater post-operative reaction which 
 ensues. A good formula for the solution is that of Guttman, 
 of New York, to wit: Natr. chlorid 0.2, cocain hydrobrom. 0.05, 
 aqua destill., 100. 
 
 Narcosis. It would seem that there are always to be a certain 
 number of operations, such as iridectomies for acute glaucoma, 
 enucleations, extensive plastic measures, not to speak of those upon 
 the timid and the very young, etc., that must be done under narcosis. 
 How choose a narcotic ? This is a matter that is largely a question 
 of natural selection. That is to say, it is decided mainly by the 
 conditions the age and physical state of the patient, the character 
 of the operation, etc. My preference would be for ether, preceded 
 by nitrous oxid, all things being equal, but I would not give ether 
 to persons of advanced age with diseased lungs or kidneys or to 
 those with bronchitis. For these, provided the operation were of 
 short duration, I would choose nitrous oxid followed by ethyl 
 chlorid or even the latter alone or either alone. Chloroform 
 is the nicest of all narcotics, but the dangers one death in a little 
 over three thousand to my mind, more than counterbalance its 
 advantages. Nitrous oxid is the safest, but it is impracticable 
 for any but the briefest operations. Ether is practically as safe 
 one death in 15,000. The risks with ether are almost nil and those 
 of chloroform are greatly lessened if they are given properly warmed, 
 and after the most approved methods. A tyro ought never to be 
 entrusted with the narcosis, and constant watchfulness is necessary 
 on the part of the most skilled anesthetist. It is important that the 
 psychic state of the subjects be favorable. To this end they are 
 encouraged and cheered in every possible way. In addition to 
 these suggestive measures those who seem to be filled with dread or 
 fright are given a dose of some calming drug 1/6 to 1/4 gr. of 
 morphin, 5 to 10 grains of chloretone, or 30 gr. of bromid of soda, 
 45 minutes to one hour before taking the anesthetic. The more 
 composed the patient the more quiet the first stages of the narcosis,
 
 INHALER. 13 
 
 and the freer the post-narcotic period from nausea. The practice 
 of bringing the patient into the operating room in a perfectly 
 conscious state, there to be confronted by surgeons and attendants, 
 all gowned, and by a great array of paraphernalia suggestive of 
 blood, completely demoralizes certain timid subjects and is much to 
 be deprecated. The narcosis should be produced either in the 
 private room or in a special anesthesia chamber. Above all, 
 perhaps, is the importance of making the period of narcosis as brief 
 as possible. In general surgery it is not so much the operation that 
 counts for fatal results at it is deep and prolonged narcosis. 
 
 During any operation on the eye, the mucus which so frequently 
 accumulates in the mouth and throat during the administration of 
 ether, is most objectionable, as it necessitates stopping the opera- 
 tion for its removal and endangers the field. This excessive secre- 
 tion may be most effectually prevented by the hypodermic exhibi- 
 tion of atropin sulphate gr. 1/200 to 1/150, combined with morphin 
 sulphate gr. 1/16 to 1/8, about one hour before the operation. 
 
 Inhalers. As to inhalers the simplest apparatus is usually 
 the best. The drop method on a simple, gauze covered wire 
 inhaler for ether and chloroform is about as good as any. I prefer 
 Jordan's inhaler for eye operations as there is a notch for the 
 nose at the top, and the handle projects over the chin, thus putting 
 the hand that holds it out of the way. Where this is not at hand, 
 the cone of towel and paper with absorbent cotton to hold the liquid, 
 for ether, or a simple towel or napkin for chloroform, will answer 
 the purpose. The subject is first made to breathe with the inhaler 
 in place, but uncharged with the anesthetic. The latter is then 
 gradually added. Screaming children may have a deep cone, i.e., 
 with plenty of air space, saturated with ether clapped on at once, 
 trusting partly to asphyxia to produce sleep. Along with the 
 tanks of nitrous oxid there is always one of oxygen, and hypodermic 
 syringes are provided, ready loaded with strychnia, brandy, or other 
 stimulants, nor is there wanting the means for making infusion of 
 salt solution. All these things to be used in an emergency must 
 be prepared and on the spot. The patient is carefully watched for an 
 hour or two immediately after the narcosis for the double purpose 
 of noting his physical condition and of preventing injury to the eye 
 or derangement of the dressing by some unconscious act.
 
 14 PARA-OPERATIVE TECHNIC. 
 
 Dressings. The materials that compose modern eye-dressings 
 are not of great variety or overnumerous, but their forms and 
 modes of application, at the hands of the different individuals, are 
 diverse as well as interesting. Relatively few seem to be so precise 
 and exacting as a matter of such prime importance demands. If 
 the surgeon himself is negligent and slovenly in this respect what 
 can be expected of other attendants like internes and nurses ? 
 
 Gauze. This fabric does not enter so largely into the needs of 
 the opthalmic surgeons as into the requirements of those who practise 
 other branches of the art. It comes in sealed packages, supposedly 
 ready for use, but it is well to sterilize it again if means are at hand 
 for doing so. For the most part plain gauze not impregnated 
 with any drug is employed. This should be of soft texture and 
 highly absorbent. Borated gauze is interchangeable with the plain 
 and stands sterilization perfectly. Certain of the impregnated 
 gauzes, however, as the moist ones, lose their properties by the 
 process and must be used directly from the can. lodoform gauze is 
 useful chiefly as a packing, e.g., in the form of tents for abscess 
 cavities. Bichlorid gauze is apt to be irritating, especially to the 
 skin of many patients. 
 
 Cotton. The quality of absorbent cotton as found on sale is 
 an uncertain thing unless one knows and can obtain particular 
 brands. The best cotton is white, clean, of long fibre, and is 
 instantly absorbent. It comes neatly laminated, and with the 
 great bulk of the fibres running lengthwise of the bolt or roll. A 
 distinctive feature is its feel. It is clingy to the touch, and when 
 rubbed between the fingers show great friction. Poor cotton is not 
 white, not clean, is shoddy, or of short fibre, is irregularly laminated, 
 and, because of the oil remaining in it, does not readily absorb 
 liquids. To the touch it has a silky feel, and when rubbed between 
 the fingers is slippery. Absorbent cotton is used either plain or 
 borated. It cannot be trusted without being freshly sterilized. 
 The roll of cotton is not made into pieces of appropriate size by 
 cutting, but by pulling. When cut, the edges are too thick and 
 abrupt. 
 
 Bandages. These are made of white flannel, gauze, muslin, 
 or netting, cut into strips of suitable width and length. For a 
 pressure bandage flannel is probably the most fitting fabric, because
 
 BANDAGING. 15 
 
 of its elasticity This same quality makes it objectionable for 
 general use; besides, it is rather warm for summer. Muslin, ex- 
 cept it be of the sleaziest, is too stiff and unyielding. Gauze makes 
 a fine bandage, but to be good it is expensive. The material that 
 seems most nearly to fulfill all requirements is a good quality of 
 white mosquito netting. This was first employed for eye bandages 
 at the Illinois Eye and Ear Infirmary 22 years ago. Its use has 
 now become almost universal in this country. The choicest kind 
 is quite white, is well covered with sizing, has a moderately small 
 mesh, is free from bars of heavier weaving, and costs, now, about 
 70 cents per bolt. The bolts each contain a single piece eight 
 yards long and two yards wide. The length is just right for one 
 double or for two single bandages. It is so folded that by opening 
 the bolt very slightly one has a strip 1/2 yard by 2 yards, containing 
 sixteen thicknesses. By pinning this to a cloth on a table, it can 
 be cut with heavy shears or pinned to a regular cutting table, 
 can be more accurately divided with a strong, sharp knife. Thus, 
 a cut of 1 8 inches will make a strip 8 yards long. The strips are 
 exactly three and one-half inches wide They are nicely rolled, 
 and the end fastened \vith a pin. The goods must be folded 
 straight, and the cutting done with exactness, else the bandage will 
 be on the bias and ravel badly. This bandage is applied wet- 
 soaking w r et. With a little practice it can be put on quite smoothly. 
 It conforms to the head and, when dry, has staying qualities that 
 are truly remarkable. The netting bandage is never used a second 
 time. In order to remove it from the head it is cut with strong, 
 blunt-pointed scissors just above the unoperated eye, or at the 
 temple. Starch bandages are rarely used in eye practice. There 
 are two forms of bandage, the simple strip, or tie (Fig. 6), and 
 the roller, or full length. The last may be either double or single. 
 For the adult bandage the width is three inches strip or roller; 
 for children, somewhat narrower. The netting bandage is made 
 wider because, being applied wet, it stretches and grows narrower. 
 The length of the simple tie is about one yard, or meter; that of 
 the roller, four yards. The double eye bandage is, of course, 8 
 yards long. 
 
 Bandaging. This is an art that few acquire to a high degree. 
 Before applying the bandage a proper pad of cotton must be built
 
 i6 
 
 PARA-OPERATIVE TECHNIC. 
 
 up over the closed lids. Dry cotton must never come in contact with 
 the bare lids, either in bandaging or wiping an eye, as the loose fibres 
 get into the palpebral fissure and irritate. This does not happen 
 with wet cotton. A thin, gauze-like layer of cotton is lifted from a 
 piece, it is fashioned into a rough square, measuring about two 
 inches each way, dropped into a pan of boric acid solution, taken 
 
 FIG. 6. Netting strip. Also first step in application of collodion bandage. 
 
 up dripping wet and applied to the gently closed lids, with the 
 fibres running vertically i.e., athwart the palpebral fissure. Thus, 
 each fibre helps to hold the lids together. This veil-like piece of 
 cotton is smoothed down squeegeed, as it were on the skin, by 
 gentle touches with the bulbs of the finger. On this is built, in a 
 number of successive layers, a generous pad of dry cotton, being 
 careful to fill in, first, the deeper depression around the globe. The
 
 BANDAGING. 17 
 
 pad is not built straight out, i.e. perpendicular to the plane of 
 the front face but inclined toward the temple, for the reason that 
 the first turn of the bandage, coming as it does, from beneath the 
 ear on that side, would, in the first instance, pull the pile of cotto 
 over onto nose and forehead. It is highly imprudent and bungling 
 to dab the whole quantity of dry cotton on in one big wad. The 
 
 FIG. 7. Collodionized netting bandage. 
 
 greatest pressure is thus brought to bear upon the cornea alone, 
 instead of being evenly distributed over the lids and globe as when 
 the pad is properly built on. If it is to be a tie bandage, the strip is 
 laid, near its middle, onto the pad of cotton, and diagonally, one 
 end passing beneath the ear on the same side, and the other up-over 
 the forehead on the opposite side, then the ends are brought to- 
 gether and snugly tied a little to one side of the top of the head.
 
 l8 PARA-OPERATIVE TECHNIC. 
 
 If netting is used it is put on dry (see Fig. 6). If both eyes 
 are to be bandaged, another strip is put on in the same way, or a 
 single strip may be put straight around the head, and tying at the 
 side not over the occiput. Needless to state, tie bandages are 
 not expected to remain on for long intervals. 
 
 Another of the Infirmary specialties in dressings is that shown in 
 Fig. -7. It is, to begin with, the netting strip tied on as in 
 Fig. 6, though extra smooth and tight. Now, it is painted 
 over on forehead and cheek with a thick coating of flexible collodion.
 
 BANDAGING. 19 
 
 As soon as the collodion dries, the bandage is untied and the ends 
 cut off as shown in F'g. 7. This makes an excellent dressing, 
 particularly for hot weather, or for children at any season, and for 
 all ambulant cases. It serves well for women, also, who then have 
 an opportunity of arranging their hair, which is always a source 
 of worry to them when the entire head is swathed. 
 
 The Single or Monocular Roller. (Fig. 8.) The cotton 
 pad is put on precisely as for the tie bandage described. The 
 
 FIG. 9. Profile view of monocular bandage to show manner 
 of engaging occipital prominence. 
 
 four-yard netting bandage, well soaked in boric acid solution, is 
 lightly squeezed to prevent dripping. The end is started on the 
 forehead just above the eye to be bandaged and passing thence 
 over the other eye. In the figure it is the right eye. ' The bandage 
 is given one snug turn straight around the head and in such a way 
 that the highest point of the occipital prominence is in the center 
 of the strip. This prevents slipping either up or down (see
 
 20 PARA-OPERATIVE TECHNIC. 
 
 Fig. 9). The strip is carried on around, inclining downward at 
 the left side of the head, but always keeping well above the left 
 eye. It passes just above the left ear, then across the base of the 
 occiput, then close up beneath the right ear, thence diagonally 
 upward over the center of the pad of cotton, thence almost vertically 
 across the forehead, as if it were going over the top of the head. 
 Now it is reversed, carried downward and backward around again, 
 passed again over the pad of cotton, this time with its edge against 
 the nose up and reversed as before, carried a third time around 
 and up. This, the last turn that lies on the cotton pad, is carried 
 more toward the right temple, so that now the entire pad is covered. 
 It is again taken upward and reversed, but, instead of passing 
 downward at the back, what remains of the bandage is passed 
 straight around the head, as was the first turn. The end is fixed 
 with two ordinary pins not with safety pins. The edge of bandage, 
 and frazzles of cotton at the side of the nose are tucked under with 
 closed scissors blades. The bandage is not carried low enough 
 at the back to rest upon the neck, for the movements of the head 
 would stretch and loosen it. If, after the bandage dries, the patient 
 complains of its cutting h!s ear, a drop of vaselin just at the spot 
 will soften the netting there and give relief. It should not be 
 nicked with knife or scissors. 
 
 The Double or Binocular Roller. (Fig. 10.) The pad is 
 put on each eye and a wad of cotton laid between them at the base 
 of the nose. The bandage is started in the same manner as the 
 single, but after the first turn around the head the strip is carried 
 downward over the center of the pad covering the left eye (the right 
 being the operated eye). It passes thence round the base of the 
 occiput under the right ear, upward over the right pad again 
 round the occipital prominence, again downward over the left pad, 
 and so on. It will be seen that this is a regular figure-of-8 bandage. 
 After three turns over each pad the remainder is carried straight 
 around the head, to fix the whole, and pinned. Now, if a dab of 
 flexible collodion be put on the thin places in the bandage here and 
 there about the forehead and cheek the most restless patient cannot 
 disturb it under 48 hours. This applies to the single or the double 
 bandage or the tie. For extractions, and other particular cases, 
 in addition to the dabs of collodion, it is my custom to paste on a
 
 BANDAGING. 
 
 21 
 
 strip of gauze, half over the nose and half over the bandage, as in 
 Fig. ii. This not only helps to secure the dressing, but, better 
 still, prevents the patient from fingering the eye and from lifting 
 the bandage. It must be borne in mind that the netting bandage 
 loosens up a trifle upon drying, hence it must be a little tight when 
 freshly applied. When the patient is lying on the table the head 
 
 FIG. 10. Binocular bandage. 
 
 is held up free for the bandaging not by any effort of his own 
 but by the hands of an aid. One hand is placed on the top of the 
 head, fingers pointing backward, and the other beneath the chin. 
 In this way the hands are not in the way of the bandaging. 
 
 Adhesive plaster as a means of holding eye-dressings in place 
 has been considerably used. In connection with gauze it does 
 very well, but with cotton it makes a nasty mess.
 
 22 
 
 PARA-OPERATIVE TECHNIC. 
 
 Non-sticking Films. Cotton and gauze have the unfortunate 
 property of becoming firmly adherent to a bleeding wound, or a 
 raw surface, when kept in contact for a few hours. This constitutes 
 a decided objection, especially in dressings applied after plastic 
 operations wherein mucous or cutaneous grafts are employed. 
 
 FIG. ii. 
 
 Despite the utmost pains in removing the dressing long soaking, 
 etc. the graft may be loosened by traction of the adherent fibres, 
 and perish in consequence. To prevent this, various substances 
 have been placed next to .the wound. Vaselin, for example, or 
 a mixture of one part paraffin to 4 parts of vaselin may be smeared
 
 PATCHES. 
 
 2 3 
 
 onto the already moistened film of cotton. Better still is a layer 
 of fine gutta percha tissue or the thinnest of gold-beater's skin, 
 but the tissue or the skin must contain a series of small slits to 
 
 FIG. 12. Monocular patch. 
 
 FIG. 13. Binocular patch. 
 
 insure proper drainage. Pieces of these are kept ready in a jar of 
 some appropriate antiseptic solution. If the solution is of a kind 
 that is irritating to skin or flesh the film is washed with warm 
 boric or salt solution just before 
 applying. 
 
 Patches. These are among the 
 various devices for taking the place 
 of the bandages. Like the bandages, 
 they are made monocular or binocular, 
 and of white or black cotfon or silk. 
 Figs. 12 and 13 show forms of single 
 and double patch devised by Dr. 
 Agnew, of New York, and first used 
 at the Manhattan Eye and Ear Hos- 
 pital. The single patch is of black 
 sateen, two thicknesses, with stiffen- 
 ing between. It is oval in shape, the 
 tape being attached in the long axis of the oval. The double one 
 is black sateen outside, with white lining. Unlike the oval patch, 
 it contains no stiffening. Both are furnished with black tape for 
 
 FIG. 14. Monocular patch.
 
 24 PARA-OPERATIVE TECHNIC. 
 
 tying on, the last-described having a piece fast to each of the four 
 corners. It has a notch for the nose. The tape for all patches, 
 shades, and shields should be left long on one side and short on the 
 other, so that the knot will be at the side of the head rather than at 
 the back. Fig. 14 represents a patch much employed at the Illinois 
 Eye Infirmary. Beneath each is worn the regulation dressing, as 
 
 FIG. 15. Ring's mask over binocular bandage. 
 
 described further back. Indeed, the object of all bandages and 
 their substitutes is merely the holding of the dressing in place. 
 
 Protective Masks and Shields. Many an operated eye, 
 particularly after extraction, has been injured by a knock or a 
 blow received on top of both bandage and dressing. It was to 
 prevent such accidents that these were devised. One of the best 
 is the mask given by the late Frank Ring, of New York, and shown
 
 PROTECTIVE MASKS AND SHIELDS. 25 
 
 in Fig. 15. It is of sateen black without and white within. 
 It is treated with a heavy size in the making, then moulded into 
 form, and can withstand considerable pressure without indenting. 
 There are large concavities to receive the dressings, it fits nicely 
 over the nose and is held on by four strings of black tape. Although 
 it is made double, or binocular, it can easily be adapted to a single 
 eye-dressing by merely cutting a good-sized hole on the side of the 
 eye left open. Unfortunately, one will serve for a single case only, 
 which is a slight drawback in a large charitable hospital, though 
 not in private practice, as the mask is not expensive. I have long 
 had in mind the idea of having made, after the Ring model, an 
 aluminum mask, but with a circular opening ready-made at the cen- 
 
 FIG. 16. 
 
 ter of each of the dressing concavities. Say these openings were 
 one inch or an inch and a quarter in diameter, the mask would 
 still afford ample protection from the usual sources of injury, and 
 would be adapted to either monocular or binocular dressings. 
 They could be manufactured economically by the stamping process, 
 would be light, and could be cleansed and used over and over, 
 indefinitely. Emerson, of New York, has also devised a practical 
 protective mask. It is of wire, and in form is almost a counter- 
 part of that of Ring. Fig. 16 shows the monocular wire mask of 
 Fuchs. This is also made in binocular form. The last admit of 
 vision in the unoperated eye if the dressing is left off. Figs. 17 
 and 1 8 represent rather cumbersome modifications of the Fuchs 
 masks. Fig. 19 gives an idea of the metallic shield of Snellen. 
 It is a shell-shaped contrivance with openings through which run 
 the white tape by which it is kept in position.
 
 26 PARA-OPERATIVE TECHNIC. 
 
 Shades. After the eye has sufficiently recovered to leave off the 
 dressing it is usually not in condition to be exposed at once to the 
 full glare of light, to the air, and to the dust. Then it is that shades, 
 goggles, and coquilles are put on. Shades also are monocular 
 or binocular. Single shades are made of celluloid, flesh tinted, or, 
 like the patch, of black silk, double, and with cardboard between 
 
 FIG. 17. Wire shield, or mask, for one eye. Over monocular bandage. 
 
 the two layers. Double shades are most often made like the visor 
 of a cap, and are of celluloid or papier mache. They are not worn 
 to hold dressings in place and none should ever be placed beneath 
 them. Any handy seamstress can make the single shades, the 
 necessary materials being tough card-board for stiffening, black 
 silk or satin for covering, and black tape for tying on. They are 
 usually made, a number at a time, by the nurses or other attendants
 
 PROTECTIVE GLASSES. 
 
 2 7 
 
 about hospitals, are sterilized, used for a single patient, for a few 
 days, then destroyed. The tape is tied straight around the head, 
 just above the eyebrows, and the shade hangs in front of the eye 
 without touching even the lashes. Fig. 20. 
 
 Protective Glasses. These are mounted either as spectacles 
 or nose-glasses pince nez. They are either plain glass or lenses 
 
 FIG. 18. Double wire mask. 
 
 to suit the peculiar refraction of the wearer. In many instances 
 the glasses are flat and of ordinary size, but they fulfill their office 
 better if they are decidedly concavo-convex and of extra large lateral 
 dimensions. These are called coquilles. They should never be 
 of pressed or moulded glass, as they are then irregular concave 
 lenses, which are very trying to the eyes, but should be ground 
 into the proper form. Their protective qualities are due to their
 
 28 
 
 PARA-OPERATIVE TECHNIC. 
 
 color. Formerly, they were shades of green, then of blue, then of 
 violet; later they were graded "smoke " or gray; and now orange 
 or amber is de regie. Theoretically, they should be either deep 
 amber or orange-scarlet or gray. In the first two instances they 
 would act as ray-filters to eliminate the actinic and irritating portion 
 of the light, viz., the violet and ultra-violet. In the second, they 
 
 FIG. 19 Metal shield over monocular bandage. 
 
 would merely serve, according to the density of the gray, to reduce 
 the intensity of the light. It is desirable in fitting coquilles to have 
 them sit as close as possible to the eyes not to touch the lashes. 
 
 Goggles. The original of these were of plain glass green or 
 blue surrounded by wire screens that rested snug against the lids, 
 the whole being held in place by a rubber band around the head. 
 Villainous things they were, too. Of recent years, especially since
 
 CLEANSING AND REDRESSING. 
 
 2 9 
 
 the advent and rise of the automobile, there has been a veritable 
 deluge of different improved styles, so that one were hard to please 
 if he cannot be suited with a pair. Their glasses may be had in any 
 tint, and some of them are about all that could be desired in the 
 way of protective glasses. 
 
 Cleansing and Redressing. All the beneficient results hoped 
 for from a given surgical operation have often either not been 
 realized or have been turned to actual disaster by inattention to 
 some essential detail in the more im- 
 mediate after-treatment. Many a 
 prolapse of the iris after extraction, 
 for example, has occurred through 
 carelessness on the part of the one 
 who removes the first dressing and 
 applies the second. It is also safe to 
 assert that similarly many an eye has 
 been infected. The inconsistence of 
 a large proportion of surgeons as re- 
 gards their attitude toward the patient 
 at the time of the operation and after 
 the same is curious to behold. Dur- 
 ing the first few days not only is 
 skill and care in handling needed, 
 
 but trained supervision as well, to the end that the first signs of 
 threatened complications may be detected in good season. When 
 practicable, the patient is taken to a room especially prepared for 
 the dressing that is, favorably prepared for a room used only 
 for such purposes might be the least favorable. The air of the 
 apartment must be as free as possible from dust. Great tact is 
 resorted to in properly adjusting the patient's mental state to the 
 occasion, for there is often more apprehension relative to "the 
 first dressing" than to the operation itself. Persons of considerable 
 intelligence are apt to have very vague notions as to what it means 
 to have the eye "dressed," and a few words in explanation serve 
 to relieve the situation as regards all concerned. Everything needed 
 must be thought of and at hand. Towels are put around the patient's 
 neck and around the head to cover the hair, and a catch-basin is 
 placed beneath the chin. In most instances it pleases the patient 
 
 FIG. 20. Monocular shade.
 
 30 PARA-OPERATIVE TECHNIC. 
 
 to be allowed to hold the basin, as he feels that he is helping the 
 cause. He is cautioned to keep both eyes gently closed, and not 
 make any effort to open them until told to do so, and that he must 
 never squeeze them. The bandage is cut, and is so stripped off 
 as to leave the pad of cotton covering the eye. This is usually 
 stuck more or less tightly to the lids, so as to require soaking slightly 
 by dropping warm boric acid solution behind it with a dropper 
 to make it let go. After cutting and removing the bandage, and 
 placing the towel over the hair, it were best that the dresser put 
 on a pair of sterilized rubber gloves. I know this is seldom done, 
 but it is the proper thing. The warm solution for use with the 
 cotton sponges is in a glass flask or in an ordinary eight-ounce 
 bottle. From this it is poured upon the sponges, over the catch- 
 basin. It does not comport with true cleanliness to dip the sponges 
 into a vessel of liquid with the fingers, especially if they be not 
 gloved. Always warn the dresses as to what is about to be done. 
 The mere touching of a finger to the forehead or of a sponge to the 
 lids might otherwise cause a tremendous start and a squeeze. He 
 is also told not to put up the hands. What follows here refers 
 mainly to cases where the operation has been upon the globe. The 
 first sponge is made dripping wet. It is oblong, and one end is 
 allowed to project well beyond the tips of the fingers to avoid giving 
 the eye an unguarded poke or thump. This loose end is raked 
 gently back and forth over the eyelashes to soften the dried dis- 
 charges from the eye accumulated along the palpebral fissure. 
 Following this, another sponge, but wrung dry this time, is lightly 
 drawn along to drink up the moisture clinging to the lashes. After 
 the first sponge, all of them, while wet, must yet be in a more or 
 less absorbent condition that is, they should take from the parts 
 they touch rather than give. Observance of this point prevents 
 driving polluted solution from without into the eye. Several wet 
 sponges are used about the lids, brow, nose, cheek, and temple, 
 always beginning at the center of the area to be washed and ending 
 at the periphery, i.e., never going back to the lids or to the cilia 
 with a bit of cotton that has touched the adjacent surfaces. A 
 sponge is never re-wetted and again applied. By way of a finish, a 
 pledget is squeezed hard, and with it the parts are sponged to free 
 from drops. The lids of the unbandaged eye are also often glued
 
 THE REMOVAL OF SUTURES. 3! 
 
 together, so that it, too, should be bathed, then opened, by the 
 dresser not by the dressee. With oblong sponge in the fingers 
 of one hand one proceeds, with the thumb of the other placed over 
 the upper rim of the orbit, gingerly to lift the lid of the operated 
 eye. If it is still stuck the wet sponge is again brought into requisi- 
 tion; meantime repeating the command that the patient make no 
 attempt to move the lids himself. When it is seen that both eyes 
 are free to open he may be asked in a quiet manner to open the eyes 
 and to look in any desired direction, and to avoid snapping and 
 nipping of the lids. Having been assured that the patient has proper 
 control of the lids, one may proceed more thoroughly to cleanse 
 lashes, free borders and canthi; using the long end of sponge. 
 Cleansing and inspection are made to consume the shortest time 
 consistent with prudence, not to expose the eye unnecessarily to 
 harmful agents. Whatever is indicated in the way of medication 
 or other attention is now disposed of and the eye re-dressed as per 
 instructions given under "Bandaging." Each time, as one is 
 about to make the application, irrigation, instillation, or the like, 
 it is made known to the patient what to expect. It is neither safe 
 nor pleasant, as regards the party most directly interested, to have 
 things put into and upon the eyes without any sort of warning, 
 even when deftly and gently done. How much worse, then, to 
 have them dropped from heights, squirted forcibly, and shot in, 
 or dabbed on with a splash! 
 
 The Removal of Sutures. It is a curious fact that there is al- 
 most as much dread of this performance on the part of our patients 
 as of the operation that makes it necessary. Sometimes there is 
 even more. This is something they have not counted upon and 
 nerved up for, and it is faced with a poorer grace in consequence. 
 Hence, great adroitness is often required to bring them to the point 
 of calm submission. They must be disabused of the idea that the 
 thread is tightly adherent to the flesh and that the instruments are 
 put in actual contact with the parts involved. On the other hand, 
 it is well to have impressed upon them the dangers of leaving the 
 sutures /// situ after the lapse of a certain period. Indeed, this is 
 not a sophism got up merely to influence the mind. Sutures should 
 be got rid of just as soon as they have served their purpose, and 
 this is much earlier than many seem to suppose. After that they
 
 32 PARA-OPERATIVE TECHNIC. 
 
 not only continue to act as foreign bodies but, worse yet, they' 
 together with their canals, form most alluring open roads for the 
 entrance and growth of bacteria. Ordinary cutaneous and con- 
 junctival sutures ought not to remain longer than 48 hours. A 
 few special ones, such as advancement and ptosis sutures, would 
 better be left longer from 4 to 8 days. If the sutures are outside 
 of the conjunctival sac they are first softened and cleansed with a 
 moderately strong, warm, antiseptic solution, and wiped fairly dry. 
 The most suitable instruments for the purpose, to my mind, are a 
 pair of small, but stiff, dressing-forceps and a pair of small, blunt- 
 pointed scissors, curved on the flat Stevens' strabismus scissors, 
 for example. Toothed forceps do not seize the thread readily. 
 It is indispensable that the scissors cut well at the very extremity 
 of the blades. It is best to have the patient prone upon the table, 
 though he may sit upright. In either case the head would better 
 be steadied by an assistant. The same helper may also hold the 
 lids apart when the sutures are inside the palpebral fissure. But, 
 in the latter case, unless one is pretty sure of his patient, and his 
 assistant, it were better to use a blepharostat at once, the eye having, 
 of course, been cocainized. The operator steadies the hands on 
 some contiguous part, and watches closely the tendency of the 
 operated, so as to be in the closest touch in order to anticipate 
 moves or to move with him, thus avoiding sudden yanks upon the 
 thread. In taking out cutaneous sutures an end of thread is 
 grasped with the forceps and so pulled upon as to draw the suture 
 well out of its canal on that side; it is then cut close up, the scissors 
 being held with the convexity of the blades upward. In this 
 manner one obviates pulling a soiled portion of thread a part that 
 has lain on the outside of the skin through the entire stitch canal, 
 to possibly infect it. A wet cotton sponge is held, or laid, con- 
 veniently near, on which to wipe forceps or scissors. There is 
 usually slight bleeding which may require sponging. The stitches 
 all removed, the parts are again bathed with the antiseptic and 
 sponged. 
 
 Sponges. The natural sponge, as a part of the surgeon's 
 armentarium, is a thing of the past, having been, quite properly, 
 superseded by the artificial kinds. They are made chiefly of cotton 
 or gauze preferably the former. Indeed, gauze sponges are
 
 SPONGES. 33 
 
 seldom used in eye surgery. The regulation shape is fusiform, and 
 the sponges vary in size according to the nature of the operation 
 with which they are to be used. Those destined for the surgery 
 of the conjunctiva and the globe are the smallest, measuring, 
 when freshly wrung, about two inches from tip to tip, and one- 
 half inch across at the middle. For operations upon the lacrimal 
 apparatus, for enucleations and the grosser plastic operations they 
 are larger, and less fusiform. The property most essential in a 
 sponge is great absorptivity. It is not alone sufficient that the 
 cotton from which it is made is highly absorbent, the sponge must 
 be compressed and damp. Dry cotton, no matter how fitting the 
 quality, lacks this property; and so does damp cotton if in a loose 
 wad. Besides, dry cotton is most objectionable in surgery because 
 of the detached fibres getting into the wound and clinging to the 
 instruments. To the most effective the sponge must be newly and 
 tightly wrung out of the solution with which it is impregnated. It 
 is a mistake, therefore, to make and wring, then sterilize them in the 
 autoclave, and consider them ready for use. They are made too 
 dry and too loose in this way. They should be freshly prepared 
 from sterilized cotton. The hands of the one who makes them 
 are clad in aseptic rubber gloves. Pieces of suitable size are pulled 
 from the roll of cotton and fashioned into shape by the fingers 
 and by rolling with the palms. They are then dropped into the 
 antiseptic solution, covered securely, and left there till needed, 
 when they are wrung again with the gloved hands, a few at a time 
 and put on or in some sort of server. It should be remembered 
 that the tips are the working parts, hence, they should be handled 
 at their middles by both the surgeon and the aid who passes or 
 uses them. By the operating table is an enameled jar with in- 
 verted cone for cover, and truncated by an opening. Into this 
 the discarded sponges are dropped, and not scattered promiscuously 
 all around. Nurses and assistants need considerable training in 
 the matter of sponging before venturing to help in this capacity 
 at an operation. It is no mean art. They must know when to 
 take the initiative, and when to wait for an order to apply; when 
 to hold out the sponge for the operator to wipe an instrument upon, 
 etc. The corneal epithelium is to be spared contact with the sponge 
 whenever practicable. 
 3
 
 34 PARA-OPERATIVE TECHNIC. 
 
 Applicators, Brushes and Swabs. An applicator may be of 
 metal or wood. It serves merely at the handle for a brush or a 
 swab. Of the metals silver is probably the best adapted to the 
 purpose. Excellent wood applicators are found ready made in 
 tooth-picks, especially those made of bamboo, called Japanese. 
 The great advantage of these is their extreme cheapness, admitting 
 of throwing away after once using. Whatever the material, the 
 eye applicator must be delicate and light. One and one-half to 
 two mm. thick at the large end', thence gradually tapering to a point, 
 or nearly, and ten to twelve centimeters in length. Not infre- 
 quently metal applicators are seen that are roughened, or nicked, 
 for a short distance from their working ends. This will do in a 
 
 FIG. 21. a, To make a brush, b, To make a swab. 
 
 wooden one, that is not used a second time, but is a serious draw- 
 back in a metal one, for reasons given further along. The same 
 objections may be urged to the probe, or bulbous pointed applicator. 
 Formerly, camels' hair brushes were used in the treatment of eyes. 
 In the light of modern medical science they would be deemed abomi- 
 nations, and justly so. The ideal brush, or swab, is now made of 
 absorbent cotton wound onto an applicator. It all lies in the manner 
 of the winding whether the brush or a swab is the result. The 
 difference between the two is just what the names imply the 
 brush having a pliant free end and the swab being a compact bunch. 
 To make a brush a small quantity of cotton is taken from the rool 
 and its irregularities of outline are pulled off till it assumes the 
 square shape shown in Fig. 21. It is so held between the left 
 thumb and index that the fibres composing it run horizontally. 
 The small end of the applicator is laid diagonally across the upper right
 
 DROPPERS. 35 
 
 hand corner (Fig. 21 a), and the shaft of the applicator is revolved 
 with the other thumb and index away from the maker, at the same 
 time the right thumb and finger help the instrument to get hold of 
 the extreme corner fibres of the cotton. As soon as these begin 
 to wind on, the left thumb and index take a firmer hold on the cotton, 
 to make the winding tight. All that remains is to continue turning 
 the applicator till all the cotton is wound on, and the brush is made. 
 If it seems too long or uneven, the fibres are pulled out till it assumes 
 the proper dimensions. To make a swab or firm mop, one takes 
 the same thin, square bit of cotton, but before starting to turn the 
 applicator, which is laid on just as for the brush, the fibres are made 
 to run in the vertical sense (Fig. 21 b). The winding is begun as 
 before, but when it has got well under way, the fibres that would 
 otherwise project beyond the end of the shaft, are turned back- 
 ward by the left index, and the turning kept up until all the cotton 
 is on and smoothed down into a good, firm, rounded mass. In 
 both instances the cotton is wound on very tightly. In this way the 
 implement will bear sterilization. No roughening is needed to 
 keep the cotton from slipping off. If made properly, the cotton 
 will only come off by unscrewing it, as it were, i.e., turning the 
 shaft in the opposite sense, or toward one. In this way it may be 
 stripped off at once, whereas if the shaft is roughened the cotton 
 id 1 1 not strip. The brush is employed when the remedy is to be 
 painted or penciled on, the swab when it is to be rubbed on. The 
 swab is also useful in putting ointment into the eye, as well as for 
 rubbing it on. 
 
 Droppers. By the term eye-dropper is commonly understood 
 the combination of small rubber bulb and glass tube with narrowed 
 extremity. The word pipette is sometimes used as interchangeable. 
 The last is literally "little pipe," and refers to the old medicine 
 dropper, or drop-counter, which consists of a glass tube without 
 the rubber bulb. The small end of the tube is immersed in the 
 liquid and when enough has flowed in, the finger is clapped onto 
 the larger end. The tube may then be lifted out and no liquid 
 will escape till the finger is raised. Both appliances are useful in 
 ophthalmic practice. The pipette is only adapted to the gentle 
 instillation of one or several drops, while the eye-dropper may, in 
 addition, be used for a forceful and copious flushing. This is true,
 
 36 PARA-OPERATIVE TECHNIC. 
 
 at least, of those with the larger bulbs, for glass and rubber can 
 both be filled. Those with tiny bulbs are specially designed to 
 make it impossible to fill them full an admirable thing in an 
 unsterilized dropper, as the rubber cavity contains a powder that 
 contaminates. Whether the narrowed extremity is curved or straight 
 makes little difference, though the straight one is more easily cleaned, 
 and will enter more readily into the mouths of vials. The smaller 
 the opening in the end and the sharper the end itself, the smaller 
 the drop that is formed, and small drops are sometimes preferable 
 to large ones. The pipette is free from some of the annoyances 
 caused by the rubber, is easily sterilized, and is sure to work and not 
 to leak. Who has not seen the dropper, in careless hands, made 
 to suck back, by relaxing the hold on the rubber bulb while the 
 tip is in fluid, like blood, or pus? In truth, allowing the tip of 
 either dropper or pipette to actually touch the parts is inexcusable. 
 Much vexation even calamity has been caused by getting 
 droppers mixed, putting borric acid solution, for example, into 
 a glaucomatous eye with a dropper that has been used for atropin 
 solution. To obviate this, the bulbs may have marked on them, 
 with indelible ink, the name of its particular drug; or the rubber 
 may be of different color for each of the more mischief-making 
 solutions. 
 
 The method of instilling drops with either the eye-dropper 
 or the pipette deserves a word. A few drops are drawn into the 
 glass tube, the forefinger of the free hand is placed just beneath 
 the lower lid, which is lightly depressed, to open the lower cul-de-sac, 
 the patient is told to look upward, the dropper is approached till 
 its tip is about one-eighth of an inch above the center of the free 
 border, when a drop is squeezed out and allowed to touch at that 
 point. It immediately enters the conjunctival sac attracted by 
 the moisture on the inner side of the lid (Fig. 22). If the patient 
 cannot control the lids, the middle finger Holds up the upper lid 
 while the index depresses the lower. In cases of children and 
 excessively touchy persons, it is made easier by putting them 
 flat on their backs. The drops should never fall from a height, 
 but should either be made to touch the free border, or be let fall a 
 few millimeters only into the inner canthus. If the cul-de-sac is 
 full of tears, the drop will simply cause an overflow and be wasted.
 
 METHOD OF INSTILLING DROPS. 
 
 37 
 
 A sponge is first used to exhaust the tears. The systematic effects 
 of poisonous instillations can be, in great measure, prevented by 
 having the patient compress the canaliculi with the forefinger. 
 
 FIG. 22. 
 
 It need hardly be urged that the finger must be there before the 
 drop is put in, else the first winking of the lids will draw the solution 
 into the lacrimal sac. This precaution is especially advisable when 
 the instillations are repeated in quick succession.
 
 38 PARA-OPERATIVE TECHNIC. 
 
 Irrigators or Douches. These refer to various appliances by 
 which quantities of liquid are brought into contact with the eye for 
 therapeutic purposes. They work by (i) pouring, as from special 
 vessels, the stream being directed by a spout and controlled by placing 
 the finger as a valve over a separate opening; or by (2) gravity, 
 as from elevated reservoirs, w r hen the stream is directed by a rubber 
 tube and controlled by compressing the tube; or by (3) ejection, as 
 from some form of syringe, in which the stream is directed as in 
 either of the foregoing, but is controlled by pressure upon a rubber 
 bulb. To the first belong the divers glass and enameled flasks 
 known as undines, compte-gouttes, etc. (Fig. 23); to the second, the 
 
 FIG. 23. a, Undine, b, Morax compte-gouttes. c, Wickerkiwicz eye 
 douche, d, Tumbler to show relative size. 
 
 fountain syringes, the percolators, and the tube syphons; to the third, 
 the bulb syringes, bulb-syphons, and hand-sprays. The eye-dropper 
 is but a form of bulb-syringe. The glass flasks are most appropriate 
 for gentle washing of the eye. They are neat and cleanly, and the 
 stream is gentle except they be held too high. They are necessarily 
 of limited capacity in order to be convenient to hold with one hand, 
 therefore adapted to the less copious and prolonged irrigations. 
 Those in the second category are just the ones designed for irriga- 
 tion on the larger scale. The reservoir is of soft rubber, enameled 
 metal, or glass, and may be of any desired size. Some of them are 
 quite elaborate, having means for heating, thermometer attach- 
 ment, etc. Reservoirs of glass, however, will always appeal more
 
 IRRIGATION OR DOUCHING. 
 
 39 
 
 strongly to the aseptic instinct, because of their transparency, 
 and their resistance to all modes of sterilization. The force of the 
 stream is governed by the height to which the source is elevated, 
 and, to a limited degree, by compressing the tube with the fingers. 
 There are different devices by which the liquid is delivered to the 
 eye after passing through the rubber pipe. The simplest is a 
 nozzle composed of the glass tube of an eye-dropper. Then there 
 are the multiple vent-nozzles, some form of which is very desirable 
 in irrigation of the upper cul-de-sac, particularly in purulent 
 conjunctivitis. Among the simplest is one of 
 glass, celluloid or hard rubber, of flattened, 
 rounded shape, after the manner of Jaeger's lid 
 spatula, with several openings in the free, or 
 specialized, end. An effective, though rather 
 complex attachment is the irrigating retractor of 
 Lagrange (Plate VIII, No. 93). As to the 
 ejectors, their name is legion, and they are, on 
 the whole, least to be recommended, as they are, 
 for the most part, complex, unreliable, and 
 bunglesome. The one uncompounded style of 
 this class is the rubber bulb alone, or the bulb with glass spout, 
 as represented by the common eye-dropper. Their streams are 
 steady, intermittent, or broken into spray. Among the last, one of 
 the least objectionable as well as of the earliest, was suggested by 
 Agnew, of New York, and is known as the Manhattan Eye-douche 
 (Fig. 24). Its extreme compactness enables one to manage it easily 
 with one hand. 
 
 Eye Cup or Bath. This is the primitive douche. It is a small 
 cup whose lip is designed to fit snugly just within the bony rim of 
 the orbit. It is filled and put into position with the head thrown 
 far forward- prone. The head is then inclined in the opposite 
 direction, or supine, and while the cup is held close, the eye is al- 
 ternately opened and shut. This serves to bathe the cornea and 
 part of the ocular conjunctiva, but, as the lids fit almost water-tight 
 to the globe, the liquid does not reach the fornices to any great 
 extent. 
 
 Irrigation or Douching. All solutions must be freshly made 
 and of the purest ingredients it is possible to obtain. As a rule, the 
 
 FIG. 24
 
 4O PARA-OPERATIVE TECHNIC. 
 
 liquid for the procedure is warm, 100 or more. It is thus more 
 agreeable and more efficacious. The patient may sit or lie. Towels 
 are placed round neck and over hair. A catch-basin is held 
 usually by the patient to catch the overflow. If the posture is 
 sitting, the basin is held as in Fig. 25, except that it is put more 
 toward the side upon which is the eye that is being treated. The 
 concavity of the basin is held tight to the neck, and it must be seen 
 to that no part of the towel gets in between neck and basin, so as 
 
 FIG. 25. Manner of holding catch-basin. Sitting. 
 
 to overhang, or project above the rim, for this would form a drain 
 that would lead the liquid down the neck. If the posture is lying, 
 the basin is held close beneath the ear and angle of the jaw, as in 
 Fig. 26. Same precautions. The lids are washed and sponged 
 with absorbent cotton. The lids are everted, one at a time or both 
 at once, and the warm solution poured gently on them. The lids 
 are replaced, the upper one is raised by placing the thumb over 
 the upper rim of the orbit, the patient is made to look down, and 
 the stream is played over the cornea and conjunctiva. The gaze 
 is then ordered upward, the lower lid is depressed by the index,
 
 OINTMENTS. 41 
 
 and the lower fornix is irrigated. All the while, the vent of the 
 irrigator, whatever the kind, is held close up, so as not to shock 
 the eye. The cornea, in particular, soon becomes intolerant of 
 the douching unless the force and the temperature of the stream 
 are just right. A very strong jet is justifiable only for the dislodg- 
 ment of a sticky discharge. Under proper conditions, no un- 
 favorable reaction follows prolonged and copious irrigation. 
 
 FIG. 26. Manner of holding pus-basin. Recumbent. 
 
 Ointments. The fatty media of ointments suitable for use in 
 the eye are chiefly vaselin, lard, castor and olive oil, and lanolin, 
 or a m'xture of these substances with varying proportions of bees- 
 wax or paraffin, to give greater firmness. As this is not a chapter 
 on ocular therapeutics, but one on the technic of applications, 
 the aim here is to indicate the manner of handling and putting the 
 ointment into the eye. The most convenient, preservative, and 
 sanitary receptacle for the ointment is the collapsible tube of block 
 tin. A very few have ingredients that are not compatible with
 
 42 PARA-OPERATIVE TECHNIC. 
 
 the tin. Next to this is the light-proof glass, or porcelain box, 
 with screw-cap and paraffined washer. The tube, or box, should 
 be small holding two dr. to 1/2 oz. Large quantities are not 
 admissible, as the ointment should be quickly renewed. The 
 ointment is applied by means of the cotton swab wound on an ap- 
 plicator, as described a little further back, or of a naked, smoothly 
 rounded silver probe. If the swab is used, it is first moistened 
 with boric acid solution. This keeps the cotton from taking up 
 too much of the ointment and also causes it to let go easier. The 
 
 Fir,. 27. Method of applying ointment. 
 
 requisite quantity say, a mass the size of a split pea is lifted from 
 the box, or squeezed from the tube, as nearly as possible on the 
 very extremity of the instrument. The lower lid of the patient is 
 depressed with the left index, while, with the middle finger, the 
 upper lid is supported. The patient is told to look upward, the 
 ointment is approached to the eye with the probe held in a horizontal 
 position, and parallel with the palpebral fissure, the handle pointing 
 outward; the end holding the ointment is laid gently in the lower 
 cul-de-sac, the patient's lids are then closed, and the probe with- 
 drawn toward the temple, leaving the ointment behind (see 
 Fig. 27).
 
 CAUSTICS. 43 
 
 Caustics. The peculiar chemical energy of these substances, 
 when brought in contact with living tissues, makes them at once 
 either most serviceable or most pernicious all depends upon the 
 conditions and manner of contact. Among the more common 
 caustics used in ophthalmic practice are alum, sulphate of copper, 
 nitrate of silver and carbolic and chromic acids. They are em- 
 ployed pure or in mitigated substance, or in aqueous solution 
 Mitigation and solution both mean simply dilution to lessen the 
 severity of the agent. The first is accomplished by mixing with 
 the caustic an inert powder, usually nitrate of potash or borate 
 of soda; the second by the strength or percentage of the solution. 
 The pure, the mixed, and the mitigated substances are all to be 
 had at the pharmacists in sticks, or crayons, ready pointed, fast in 
 holders and with cap to cover. If the crayon needs sharpening 
 this is best done by rubbing it on fine sand-paper, care being taken 
 to keep down the dust; that is, the rubbing should not be done in 
 a draught, and the sand-paper should not be flirted about. Whether 
 applied pure, mitigated or dissolved, the touch to any part of the 
 eye, particularly of the more active caustics, should be by a fine 
 point. For the solutions, the cotton brush on the applicator is 
 used. The eye is bathed and sponged, the part to be touched is 
 wiped dry w r ith a bit of gauze, then the caustic is applied. As 
 the object is to affect only the diseased area the caustic must be 
 scrupulously kept from spreading to the healthy tissues. If done 
 with the crayon, there will be little tendency to spread so long as no 
 moisture comes in contact with the spot treated. Hence, in touch- 
 ing any part within the palpebral fissure, it is necessary to keep 
 the tears all away by means of the little, spindle-shaped cotton 
 sponge. In order to strictly localize the application when in 
 solution and with the brush, it is essential that there be no super- 
 fluous fluid in the brush. That is, there should not be so much 
 that when the contact is made a drop will be given off, to run down 
 over the healthy surfaces and injure them. The tip of the brush is 
 first touched to a sponge. Here, too, the tears must be kept away, 
 just as in using the crayon. The application having been deemed 
 sufficient, if within the conjunctival sac, the action of the caustic 
 is always nullified at once by plentiful douching either with warm 
 solution of boric acid or of something that will neutralize chemically,
 
 44 
 
 PARA-OPERATIVE TECHNIC. 
 
 as, of common salt, for example, when the caustic is nitrate of 
 silver. It contributes much to the comfort of the patient if a 
 drop of cocain solution is put in just before the application, and 
 another just after the douching. 
 
 FIG. 28. Thermaphore. 
 
 Heat is most grateful and beneficial to the eye in most all of its 
 inflammations and painful affections. It may be applied either 
 dry or moist. A primitive mode of using dry heat is to heat some 
 salt in a skillet, tie it up in a woolen stocking and lay on the eye. 
 A more up-to-date method is by means of hot water in a rubber
 
 APPLICATION OF HEAT. 45 
 
 bag, but the first will still answer in a pinch. Yet other simple 
 modes are to heat small pads of cotton or wool in an oven or Japanese 
 muff-warmer or, best of all, beneath a hot flat-iron. Among the 
 more scientific methods is that by the thermaphore, illustrated in 
 Fig. 28, and that by the electric pad. The thermophore con- 
 sists of a double tank for the water. The hot water flows outward 
 from one tank through a rubber pipe, passes through a rubber coil 
 (A), thence returns through another tube to the other tank. The 
 heat is supplied by a gas-burner or a spirit lamp. The one shown 
 in the illustration has four sets of pipes and four coils, suitable 
 for both eyes of two persons, or one eye each of four. The coil is 
 wrapped in a small towel before applying. In lieu of the elaborate 
 heating apparatus one may use a jug of hot water, placed some- 
 what higher than the patient's head. From this the water is 
 syphoned through tube and coil, and thence to another jug on the 
 floor. The supply jug is wrapped in woolen cloth to retain the 
 heat. The electric pad consists of a resistance coil contained in an 
 asbestos envelope, and connected by insulated conducting wires 
 with the socket of an ordinary incandescent lamp. The heater is 
 wrapped in dry flannel before using. The temperature of either 
 pad or coil must be carefully watched to avoid burning the skin. 
 If the source of heat is not continuous the application is renewed 
 every few minutes. The duration of either procedure is from 5 to 
 30 minutes. The temperature is usually as high as can be endured 
 or just short of doing harm. Moist heat may be either plain or 
 antiseptic. The simplest form of either is that of bathing or 
 douching. To bathe the eye with a hot liquid the patient would 
 better sit erect, so that there is a minimum of blood in the head. 
 Stooping over would cause congestion. The water or solution 
 is conta'ned in a bowl or basin, held close up beneath the chin, 
 and is dabbed on, over the closed lids, by cotton, gauze, or a piece 
 of clean soft 1'nen. The conjunctival douche is applied as already 
 directed. Or the applications may be in the form of fomentations- 
 plain or antiseptic, such as small pads of cotton or wool, wrung 
 out of the very hot liquid, or out of moderately hot, and further 
 heated under a flat-iron. This obviates burning the hands of the 
 attendant. As soon as the pad is in place it is covered with a dry 
 flannel cloth or other non-conducting material. Of course, the
 
 46 PARA-OPERATIVE TECHNIC. 
 
 heat from the rubber or the electric coil may be made moist, plain 
 or antiseptic, by keeping the wrapping of the coil wet with the ap- 
 propriate liquid. 
 
 Cold finds its chief indication in severe, acute inflammations 
 of the conjunctiva, and immediately following injuries of the eye 
 or its appendages. Like heat, it is applied dry or moist. Dry 
 cold is most often from cracked ice, in a rubber bag, laid on the 
 closed lids. A good plan is to syphon ice-water through a very 
 small rubber tube from a large vessel, placed just a little higher 
 
 / 
 
 FIG. 29. FIG. 30. 
 
 Leiter's coils of soft rubber tubing for dry or moist heat or cold. 
 
 than the patient's head through a coil laid on the eye, thence, 
 through a still smaller tube to another vessel (Figs. 29 and 30). 
 This has been called mediate irrigation, and may be either dry or 
 moist. Leiter's lead coils are too heavy for use upon the eye. Moist 
 cold is best transferred to the eye by bits of old, heavy table-linen. 
 This is more absorbent than new linen. One need hardly say the 
 linen must be aseptic. Pads two to two and one-half inches square, 
 and composed of several thicknesses, are wrung out of ice-water 
 and laid on the lids. A more conven'ent way is to put a large 
 block of ice into a pan or basin and lay six or eight of the linen
 
 HOT AND COLD APPLICATIONS. 47 
 
 pads onto the block. They are patted down into good contact, 
 and, when one is wet through, it is placed smoothly over the eye. 
 Every minute thereafter the used pad is put back on the ice and 
 a fresh one put on the eye. The patient is apt to take a sort of 
 grim pleasure in making the applications himself and can be, with 
 impunity, intrusted with the task. Indeed, this is true of most of 
 the applications of heat and cold. 
 
 The author has found the following a most convenient and highly 
 effective manner of applying moist heat or cold: The patient may 
 be either seated or recumbent. A catch-basin is so held as to fit 
 snugly to the neck on the side of the affected eye. A moderately 
 large pad of absorbent cotton is dipped into the liquid hot or cold 
 that is to be applied, then laid, without squeezing, on the closed 
 lids. The attendant then drops the liquid from an ordinary eye- 
 dropper continuously over the pad of cotton. The cotton remains 
 soft and in perfect contact with the skin, the temperature is evenly 
 maintained, the eye is not shocked by too sudden sense of heat or 
 cold,, the patient is not disturbed by any changing of the applica- 
 tion, nor of having the eye hurt by an unguarded finger-bump, and 
 the attendant is spared the discomfort of putting the hands into 
 the liquid. 
 
 Madame Bonsignorio, p. 200, in giving the indications for heat 
 and cold in ocular therapeutics, says that, generally speaking, heat 
 is sedative and calming, but should never be applied when there is 
 much secretion present nor when there is edema of the conjunctiva. 
 She classes in six categories the eye affections to which heat and 
 cold are appropriate: 
 
 1. In the diseases a f rigor b; iritis, vernal catarrh, heat. 
 
 2. In other forms of conjunctivitis, cold. 
 
 3. In corneal infections with edema, especially in serpent ulcer, 
 cold. 
 
 4. In inflammations of the appendages of the globe, such as 
 phlegmon of the orbit, abscess of the lids, and acute dacryocystitis, 
 cold. 
 
 5. In glaucoma and retinal hemorrhages, heat, moderate and 
 prolonged. 
 
 6. In the deeper inflammations, where there is no tendency to 
 suppuration, like papillitis, chorio-retinitis, cyclitis, and iritis, heat.
 
 48 PARA-OPERATIVE TECHNIC. 
 
 Most authorities have written that heat is better applied for a 
 longer time than is cold. With this I do not agree, but rather believe 
 with the minority that short sittings of intensely hot applications 
 have much the same effect as prolonged ones of cold. Three to 
 five minutes of the first will accomplish more good, however, than 
 one hour of the second, or than one-half hour of the first. Certain 
 it is that fomentations should not be kept on for twenty and thirty 
 minutes each, and thus kept up for hours. The effect is then much 
 like that of a poultice, and this we all know to be bad. In general, 
 I prefer short sittings for the hot applications three to ten minutes, 
 as hot as can be borne 115 to 125 F. for the moist, somewhat 
 higher for the dry, and with intervals not too short not over four 
 to six in twenty-four hours, unless there is severe pain which is 
 relieved by the heat. The intervals may then, in a measure, be 
 regulated by the paroxysms of pain. 
 
 Massage. As it relates to the surgery of the eye, this mode of 
 treatment is useful mainly in connection with paracentesis or 
 iridectomy for glaucoma. It is, however, a most valuable, and 
 important accession to ocular therapeutics in general. Its principal 
 virtue seems to lie in the clearing and quickening effect it has upon 
 the local lymphatic and venous channels. Massage is plain, or 
 medicamentous ', manual (digital, rather, as concerns the eye) ; 
 instrumental, that is, when an implement of some sort, as a glass 
 rod or a swab, intervenes between the hand and eye; mechanical, 
 as when made by a vibratory machine; and electric, as when per- 
 formed with the electrode of a galvanic or other current. The 
 technic of digital massage is given in the chapter on paracentesis 
 of the cornea, and that of instrumental in that on the surgical treat- 
 ment of trachoma. 
 
 Tissue Injections. Among the varying therapeutic tissue 
 injections practised in ophthalmology are the hypodermic, or 
 subcutaneous, the intramuscular, the sub-con junctival, the sub-tenonian, 
 and the intraocular. They are all made by means of the ordinary 
 hypodermic syringe. The simplest and best form of this instrument 
 is that in which all is of glass save the needle. The barrel has a 
 scale of minims marked on its exterior. The inner surface of the 
 barrel and the outer surface of the piston are ground so that they 
 fit exactly one upon the other. The nub at the extremity of the
 
 TISSUE INJECTIONS. 49 
 
 barrel is threaded to screw into the needle. Such a syringe will 
 stand all standard means of sterilization, and may be kept ready 
 in a strong antiseptic solution. The needle is of platinum, is kept 
 scrupulously sharp, and is sterilized by boiling. The socket contains 
 a soft-rubber washer to prevent leakage. To use, the barrel is 
 filled before the needle is screwed on, then, having put the needle on, 
 the latter is pointed straight upward to expel the air. Enough of 
 the liquid is then shot back into the receptacle to bring the piston 
 to the proper mark on the graduated scale. The hypodermic 
 injection is administered by picking up a fold of skin and plunging 
 the needle into the fold coincident with its long axis, and so as to 
 just miss the tips of the thumb and finger holding the fold, and the 
 fluid is forced slowly in. The plunge of the needle is positive 
 and quick not hesitating and slow. In this way one gives strychnia 
 and other stimulants to overcome the evil effects of narcotics and 
 shock in the operating-room, and morphin for its quieting influence 
 and for the pain after the operation. It matters little upon what 
 part of the body the fold of the skin is chosen. Having withdrawn 
 the needle, the part is gently massaged to favor quick absorption. 
 It goes without saying that for any form of tissue injection the parts 
 involved are aseptically prepared. In the intramuscular injection 
 the chosen muscle is suddenly and deeply stabbed with the needle, 
 avoiding the larger blood-vessels and the underlying bone. This is 
 the kind usually employed for the administration of solutions of the 
 mercuric salts for their constitutional effects. For the subcon- 
 junctival injection the eye is washed, douched, and cocainized. 
 The lids are held apart by an assistant with fingers or retractors 
 or by the blepharostat. The patient is directed to look up, a 
 vertical fold of conjunctiva is picked up with broad-jawed fixation 
 forceps, just below the cornea. The needle is passed into the lower 
 half of the fold, tangential to, but not hugging, the globe, and pointing 
 somewhat downward. The contents of the syringe, usually some 
 10 or 12 minims of solution, are then exhausted, causing a large 
 bleb of conjunctiva to rise. The syringe is withdrawn, the lids 
 carefully closed over the bleb, and the eye bandaged. This is the 
 form employed in the less virulent infections of the globe after opera- 
 tions, for the local effects of mild antiseptics, like weak salt solutions 
 and mercuric solutions. The most all-round satisfactory solution
 
 50 PARA-OPERATIVE TECHNIC. 
 
 in mild cases is the physiologic salt. It is followed by little distur- 
 bance when used alone, and is not so painful nor so apt to result in 
 small round-cell infiltration of the conjunctiva as are the stronger 
 salt solutions. None but chemically pure salt is admissible. They 
 are specially useful in the treatment of the lingering forms of 
 uveitis following certain extractions, and certain iridectomies for 
 chronic irritative glaucoma, particularly those characterized by 
 recrudescences. The subtenonian injection is, as its name implies, 
 into Tenon's capsule. Another name is intracapsular injection. 
 It is one of the sheet anchors in the treatment of severe septic infection 
 threatening panophthalmitis. The eye is prepared and the lids 
 held apart as for the subconjunctival injection. Cocain, however, 
 often has little effect, owing to the hyperemia and inflammation 
 that are apt to be present, so that it is advisable in cases of very 
 sore eyes and demoralized patients to narcotize with nitrous oxid. 
 The bottom of the external conjunctival cul-de-sac is seized with 
 strong fixation forceps in such a way as to include a fold of the 
 outer check 1 gament, the eye being meanwhile in adduction. 
 This is drawn forward (upward, one might better say) and the 
 needle passed backward, deep into Tenon's capsule, following the 
 sheath of the external rectus. The regulation dose with us consists 
 of 12 minims of i% salt solution in \vhich are dissolved i/ioo gr. 
 of mercuric cyanid and 1/25 gr. of dionin. A small dose of acoin 
 or morphin is sometimes added to alleviate the suffering that is 
 almost inevitable afterward. Dionin has come to be regarded as 
 an almost necessary ingredient of the last two forms of tissue injec- 
 tions. It adds greatly to the local disturbance which ensues. In 
 fact, the reaction is often so great, and of such a character, as to 
 be positively scarey, especially to . a novice. Fortunately, the 
 benefit is, as a rule, commensurate with the reaction, and the latter 
 is, therefore, welcomed. A subsequent injection is not given until 
 the visible results of the previous one have passed away, except in 
 desperate cases. Between mildly reacting injections 2 days, and 
 between the severer ones four to six days, is about the average 
 time but if speedy loss of the eye is threatened, they may be given 
 daily. If the pain during the reactive stage be great, fomentations 
 as hot as can be borne, are applied to the closed lid, and hot douches 
 to the conjunctival sac. The therapeutic value of these subcon-
 
 OPERATION OF VENESECTION OR PHLEBOTOMY. 51 
 
 junctival and intracapsular injections is due, in all probability, 
 to several causes partly to osmosis, partly to local antisepsis, 
 and largely to local counter-irritation, and, when dionin is present, 
 also largely to their lymphagogue properties. Intraocular injections 
 are such as are employed in artificial ripening of cataract into 
 the lens substance and, in detachment of the retina into the 
 vitreous or beneath the retina. They cannot be called true and 
 tried measures and have no real place here. 
 
 Blood-letting. This venerable therapeutic measure seems 
 now to hold a higher place in ophthalmology than in any other 
 department of medicine. This is true, at least, of local or topic 
 blood-letting. General blood-letting, or venesection, is now often 
 resorted to in the treatment of the eye, and it is regaining some of 
 its ancient prestige at the hands of the internists. It is especially 
 valuable for lowering high blood-pressure before operations for 
 cataract and glaucoma. Other names for the last mentioned are 
 phlebotomy and arteriotomy, as indicating whether a vein or an 
 artery is opened. 
 
 The Operation of Venesection or Phlebotomy. The patient 
 should be seated in a chair or in bed, rather than recumbent, es- 
 pecially where marked effects are desired, as the more rapidly 
 the blood is abstracted the less will be required to lower the force 
 of the circulation. Standing might induce syncope prematurely, 
 while the prone position might allow too great an abstraction of 
 blood before syncope which is Nature's danger signal, had been 
 produced. 
 
 Septic phlebitis is the most serious complication to be feared 
 after phlebotomy, and should be guarded against by rigid asepsis. 
 The hands of the operator, the instruments, and the field of opera- 
 tion having been rendered thoroughly aseptic, a bandage or cord 
 is tied about the middle of the upper arm, with moderate firmness, 
 so as to arrest the venous flow without interfering with the arterial. 
 Grasping a stick, or roll of bandage, or merely closing the hand 
 tightly will then cause the veins to become prominent (Fig. 31). 
 The median basilic is now fixed by pressure of the left thumb, and, 
 with a sharp cataract knife or bistoury the vein is opened (not 
 divided) obliquely to its long axis at about its middle point. The 
 middle portion of the vein is chosen as being farthest removed from
 
 PARA-OPERATIVE TECHNIC. 
 
 the brachial artery on the outer side and also from the internal 
 cutaneous nerve on the inner side. The first is separated from 
 the basilic vein only by the semilunar fascia of the biceps tendon, 
 and may be located by its pulsation, and the second lies on top of 
 the vein, just where it joins the common ulnar vein. Blood will 
 probably flow from the wound in a full 
 stream; but if it does not, bleeding may 
 be promoted by alternately opening and 
 closing the hand. The blood should be 
 collected in a graduated bowl, so as to 
 estimate the amount withdrawn. Ten to 
 twenty ounces will be necessary. It is best 
 to have a sphygmomanometer attached 
 to the opposite arm so as to measure the 
 blood-pressure from minute to minute. 
 The pulse will also indicate when the req- 
 uisite effect has been produced. When 
 this is accomplished apply a dry aseptic 
 compress, and secure this by a figure-of-8 
 bandage around the elbow, and place the 
 arm at rest until the wound is healed. 
 Occasionally neuralgic pain is caused by 
 the implication of some of the fibres of the 
 internal cutaneous nerve in the cicatrix. 
 
 Local blood-letting, as practised by the 
 eye specialist, consists in extracting quanti- 
 ties of blood, varying in amount from 1/2 
 oz. to 2 oz., from a limited area external to 
 the outer canthus by means of leeching. 
 The leech may be natural or artificial. The 
 best natural leech is the Scandinavian variety, which is to be had in 
 most of the larger pharmacies. Each one is capable of drawing 
 nearly 1/2 ounce of blood before becoming gorged and letting go. 
 Two of them are sufficient, for if it is desirable to abstract more 
 than i oz. one may increase the quantity to the proper measure 
 by encouraging the after-bleeding. This will, in many instances, 
 continue till made to stop, which is easily accomplished by holding 
 a tiny bit of absorbent cotton tightly on the bite with the finger. 
 
 FIG. 31. 
 
 i. Opening in median 
 basilic vein. 2, Median 
 cephalic vein. 3, Median 
 vein. 4, Basilic vein. 5, 
 Internal cutaneous nerve. 
 6, Brachial artery. Only 
 the semilunar fascia of the 
 biceps separates median 
 basilic vein from brachial 
 artery.
 
 LEECHING. 53 
 
 The bleeding having ceased, the cotton is left sticking to the spot. 
 Preparatory to either mode of leeching, the temple is rendered 
 aseptic. Unfortunately, the natural leech cannot be sterilized, 
 but, fortunately, it is naturally a cleanly thing, even if it does live 
 in mud. The most suitable place to apply the leech, either living 
 or artificial, is that which is on a level with the outer canthus, 
 and just external to the outer rim of the orbit. When two or 
 more leeches are applied their heads are placed close together 
 and in a horizontal line. One who is experienced in applying the 
 leech can guide the animal's head accurately to the point selected for 
 the bite by holding its body in the folds of a napkin. The tyro 
 would better use a leech-tube. Into this the leech is dropped, 
 
 FIG. 32. 
 
 big end first. The mouth is in the small end that is forever reach- 
 ing out. If the leech does not take hold readily, lightly scraping 
 off the epidermis with a scalpel or putting a drop of milk on at 
 the spot will induce it to do so. Having once begun to draw 
 blood, it is allowed to remain attached till it falls off. The used, 
 or "stripped" leech is never so good as a fresh one. There are 
 several kinds of artificial leeches. The one bearing the name of 
 Baron Heurteloup is still the favorite. Recently the elaborate scari- 
 fier that formerly went with it has been omitted. The leech is 
 shown in Fig. 32. It consists of a metallic piston with asbestos 
 packed head fitting very tightly in a glass cylinder and worked by 
 a thumb-screw. The skin is scarrified at the point indicated for 
 the leech-bite, the free end of the cylinder is moistened, applied to 
 the part, and the air gradually exhausted by turning the screw. The 
 relief and the improvement that result from leeching are often re- 
 markable, though not usually immediate; from 6 to 24 hours may 
 elapse before the benefits are apparent. It is difficult, therefore, to 
 conceive of the modus operandi. Can it be the mere topic depletion
 
 54 PARA-OPERATIVE TECHNIC. 
 
 whereby the pain is relieved by freeing the sensory end-bodies from 
 pressure, and the inflammation reduced through quickening the 
 circulation in the blood and lymph channels by the ensuing relax- 
 ation? Hardly. The natural leech seems to be more effective 
 than the artificial, and for this reason I have sometimes wondered 
 if it were not because of its more potent psychic effect.
 
 CHAPTER II. 
 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 "Us doivent etre, pour le praticien, des objets sacro-caints; des objets 
 auxquels il ne laisse toucher personne de profane, qu'il considere lui-meme 
 avec amour a cause de leur perfection, avec respect a cause de leur desti- 
 nation. II apportera le plus grand soin, non seulement a leur choix, 
 mais aussi a leur entretien " Landolt. 
 
 "They should be for the practitioner, objects almost sacred; 
 objects not to be profaned by vulgar hands that he regards with 
 fondness because of their perfection, and with respect because of 
 their destination. He will exercise the utmost care not only in 
 their selection, but also in their maintenance." 
 
 Thus wrote my friend and teacher, over twenty years ago, in a 
 little work called "A Box of Instruments." While with him, he 
 commissioned me to translate it for publication in this country. 
 I sent the English version to a friend in New York who consigned 
 it to oblivion as concerned the ophthalmic world, by turning it 
 over to a journal for general medicine. It was deserving of a better 
 fate by reason of its subject matter. This, then, would seem 
 a fitting time and place to revive some of the excellent precepts 
 and principles embodied in that book, and to add thereto whatever 
 seems appropriate, in order to bring the subject abreast of the time. 
 
 The word management in the above caption refers to both the 
 manipulation and the care of instruments. 
 
 First, as to the instruments themselves: What are the qualities 
 requisite and desirable in them ? This is a broad question and one 
 of many sides. I shall attempt to answer it, not assuming the role 
 of an oracle, but as one who has taken an active interest in the mat- 
 ter, both practical and theoretical, for the past two and one-half 
 decades. Much has been written concerning the instruments of the 
 "Vienna School," of the "Parisian School," of the "Berlin School," 
 and of the 'London School," but little concerning the " American 
 School"; therefore, an effort will be made to show also something of 
 
 55
 
 56 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 what our countrymen have done in the line of surgical instruments 
 for the eye specialist. Of the myriad instruments that have been 
 conceived as applicable to ocular surgery, the vast majority have 
 not stood the test of time; and it is, after all, remarkable how few 
 really are necessary or desirable. Every surgeon and every maker 
 of surgical instruments, even down to every salesman, has his 
 own ideas on that point. The writer has great respect for the pecu- 
 liar notions of others, especially, in this instance, if they be those 
 of a confrere. So long as his work comes up to the standard, no 
 matter how peculiar his notions, all honor to him. But his imple- 
 ments may not be above criticism. As to the maker, he is prone to 
 regard the matter solely from a mechanical standpoint, without 
 taking into consideration the human element that figures so largely 
 in the material upon which the instruments in question are employed. 
 With regard to the salesman well, his business is to sell; and as 
 a proof that he fully understands his business, witness the manner 
 in which he beguiles the artless and aspiring tyro into stocking 
 himself up with a lot of junk. 
 
 The first great requisite in any mechanical contrivance is efficiency, 
 but the maximum of efficiency should be attained along with the 
 maximum of simplicity. And surgical instruments are, perhaps, 
 peculiar in demanding the most rigid enforcement of this law. 
 These are the key-notes Close after them come such other at- 
 tributes as grace of outline, delicacy of parts, and elegance of finish. 
 They should be simple in the sense of being uncomplicated, as also 
 in that of being plain. These properties are conducive to both 
 cleanliness and dexterity hence, to safety and success. They 
 should be as light as is consistent with adequate strength, which is 
 also an advantage in their use; hence, the need of delicacy of parts. 
 And they should be pleasing to the eye of their possessor, at least. 
 This were argument enough for the grace of outline and the elegance 
 of finish; but there are decidedly practical reasons also. One is 
 actually capable of better effort when there is present a conscious 
 pride in his means; again, the smoother and truer and brighter 
 the surface, the easier to maintain, therefore, the demand for 
 attractiveness. 
 
 Another most excellent thing in connection with the operative 
 equipment especially of the oculist is a certain uniformity, or
 
 INSTRUMENTS AND THEIR MANAGEMENT. 57 
 
 harmony, of the corresponding parts of the different articles. In 
 the form and size of the handles, for example, as also in the size 
 of scissors rings, the length of scissors branches, and in the angle 
 at which the blades of keratomes are set. To be sure, this cannot 
 be carried out to the letter, on account of the inevitably great dif- 
 ference in bulk. But most of the smaller instruments in daily use 
 can be made to conform to this principle. There are undeniable 
 advantages in the habitual feel of the instrument imparted to the 
 fingers in this way, not to speak of those as to appearances, that 
 such a collection would enjoy over a heterogeneous assortment. 
 Among the most obvious essentials in all instruments is superiority 
 of material. This is especially true of the cutting instruments. 
 Unfortunately, this is a quality of which it is difficult to judge 
 beforehand. A few years ago all of our finer steel instruments were 
 made in Europe, and the names of Collin, Liier, Richter, Windier, 
 Weiss, and a few others were not merely guarantees of high quality, 
 as they are still, but they were the and the only ones. Now good 
 and bad instruments are made "all over," and one may take his 
 chances. Certainly the best of those turned out in the United States 
 are second to none. 
 
 Thus, in a general way, is answered the question as to what are 
 the qualities requisite and desirable in a surgical instrument. And 
 what is true of these as a whole is true of those pertaining to any 
 branch. Now, to particularize. 
 
 Following Landolt's classification we shall begin with the instru- 
 ments with handles. "And :'n passing, let us bestow a word upon 
 this feature of the instrument a feature of greater importance 
 than many seem to think. Is it not the intermediary between the 
 hand that guides and the part that engages? Is it not through 
 it that the sensitive fingers of the operator are made aware of the 
 resistance their movements encounter; these fingers which put in 
 touch with the work the reason that contrives, the intellect that 
 seeks, and the power that executes?" 1 The handle was formerly 
 made of ivory or bone, but these materials have now, quite properly, 
 yet reluctantly, been discarded for metal, such as aluminum, to 
 admit of boiling. Yet ivory is an ideal material. Its weight is 
 just right. It is a poor conductor of heat and cold, and its best 
 
 1 Passages in quotation marks are Landolt's.
 
 DESCRIPTION OF PLATE I. 
 
 1. Arlt scalpel, medium. 
 
 2. Arlt scalpel, large. 
 
 3. Beard scalpel, extra convex. 
 
 4. Beard scalpel. 
 
 5. Sharp straight bistoury. 
 
 6. Blunt curved bistoury. 
 
 7. Beer (or Earth) knife. 
 
 8. Weber lacrimal knife, straight. 
 
 9. Weber lacrimal knife, curved. 
 10. Agnew lacrimal knife. 
 
 u. Graefe knife. 
 
 12. Bent lance keratome, small. 
 
 13. Bent lance keratome, large. 
 
 14. Bent lance keratome, medium. 
 
 15. Neuter cystotome. 
 
 1 6. Graefe cystotome. 
 
 17. Knapp cystotome. 
 
 18. Beard cystotome. 
 
 19. Pagenstecher knife needle. 
 
 20. Knapp knife needle. 
 
 21. Beard blunt dissector.
 
 PLATE I.
 
 INSTRUMENTS AND THEIR MANAGEMENT. 6l 
 
 quality is a peculiar adhesiveness. "Clings to the fingers," as 
 Landolt says. Their rectangular, or rather, octagonal form has, 
 with equal propriety, been retained. The classic form is that of a 
 slightly fusiform, quadrilateral beam with chamfered edges. The 
 heaviest part of the beam is at the junction of the first and middle 
 thirds, where, in cross section, it measures 4.5x6 mm. From here 
 it gradually tapers to either extremity, where the cross sections each 
 represent a rectangle whose sides are 3x4 mm. for the free end and 
 3.5x4.5 mm. for the other not allowing, of course, for the chamfer. 
 The regulation length is about 10.5 centimeters. This size and shape 
 are common, or should be so, to knives, including lances, to needles, 
 knife-needles, cystotomes, hooks, curets, wire-loops, spatulas, 
 spoons, spuds, and retractors. There are several reasons for its 
 existence: First, it is handy to hold and to manipulate, adapting 
 itself nicely to the pulps of the fingers. Second as alHhe working 
 parts are attached with their flats in the same plane as the greater 
 transverse diameter of the handle, one feels, in turning the handle 
 on its long axis, just how much rotation he has imparted to the 
 instrument. This is of the greatest value in such acts as the making 
 of the corneal section, and in the cystotomy of a cataract operation. 
 One can always know the position of the blade or other implement 
 by noting that of the greater width of the handle. The edge of 
 the blade or the point of a hook moves in the sense of the greater 
 width. Moreover, the name of the maker is supposed to be stamped 
 on the side o" the handle that corresponds to the back of the instru- 
 ment, so that, unless it be a blade with double edge, an additional, 
 and often serviceable, sign is given. Landolt suggested that, while 
 none of these instruments Should have round handles, the sides should 
 be equal (square in cross section) on instruments one of whose 
 offices is to rotate in working, such as cystotomes and needles. 
 It is just as essential to know the position and direction of the blade 
 of a cystotome as that of a knife. It often disappears behind the 
 iris, but one can be absolutely guided by the two lateral dimensions 
 of the handle, in applying the point to the capsule, and in giving 
 those two quarter turns that are such an important part of the cap- 
 sulotomy. The little difference in the two opposite sides does not 
 interfere with rotation. Then, as to the needle, it, too, has its 
 blade a double-edged one. It is the proper thing to withdraw
 
 62 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 it from the anterior chamber, for instance, in the same sense that 
 it entered; but, with the blade hidden in an opaque lens, as is often 
 the case, and the aqueous most likely evacuated, this would not be 
 so easy if there were not the handle to point the way. 
 
 So much for the handles. Next, for the instruments which they 
 carry, together with a few notes as to their manipulation. Let us 
 begin with the 
 
 Scalpels. Of these there should be at least two one after Von 
 Arlt's model and another with a blade of great convexity. Arlt's 
 is excellent for use in many ways, yet the other, while just as good 
 for all around work, is superior under certain special conditions. 
 The knife in question is one devised by the writer about twelve 
 years ago, though the latest modification of it has even greater con- 
 vexity of edge. Originally intended mainly for use in blepharo- 
 plasty, it has become my chosen knife in most instances where a 
 scalpel is needed. It owes its individuality and its value to the 
 extraordinary convexity of that part of the edge which is situated 
 near the extremity of the blade. The length of the latter is about 
 2.5 centimeters, and its width, at the broadest part, 7 to 8 mm., 
 while Arlt's is 3 to 3.5 centimeters long, and its greatest width is 
 5 to 6 mm. With the ordinary scalpel, held pen-holder fashion, 
 according to rule, and with incisions of average penetration, the 
 extent to which the edge engages the tissues- is very slight, being 
 limited to the point and several contiguous millimeters. Even 
 with the handle as near as possible to the horizontal as is consistent 
 with this manner of holding the handle, the length of available 
 edge is less than one-fourth of the whole. Therefore, as regards 
 the cutting qualities of any but the terminal third of the blade, it 
 were as well that they did not exist. It is desirable, then, that the 
 trenchancy of the part concerned be heightened in the utmost. 
 This is precisely what is aimed at in this scalpel. A single point, 
 like that of the bistoury or the Beer's knife, is insufficient, for the 
 reason that it soon loses its keenness; whereas, the extended con- 
 tact unavoidable with an edge of low convexity, is yet more unfitting, 
 because it is less guidable and requires more force on account 
 of the friction. The special configuration of the blade under 
 consideration offers an efficient mean between the two extremes. 
 If held fiddle-bow fashion, as would seem to be the preferable
 
 BEER'S KNIFE. 63 
 
 for its use in general, its incisive qualities are truly remarkable. 
 It has the added property of being able to cut nearly as well in 
 pushing as in pulling a veritable fiddle-bow action. With it such 
 measures as the Streatfield counter-grooving of the tarsus, the 
 intermarginal incision to receive the graft in restoration of the free 
 border of the lid, etc., are particularly facilitated. The custom 
 of making the free extremity of the handle into a blunt dissector 
 or of making "double-header" instruments of any description is 
 to be decried as not in keeping with advanced ideas. Besides, 
 there is little to be gained in time or convenience by their use. 
 Who has not seen in the well-known Daviel's spoon combination 
 the persistence with which the cystotome member tried to get 
 caught into things while the spoon member was occupied? The 
 very diminutive scalpels often seen may have a place in ophthalmic 
 surgery; if so, the writer has never found it. 
 
 Bistouries. Two of these also. One having a long, straight- 
 edged blade, with good, stiff back, joined to the handle by a strong 
 shank, for work such as deeply thrust incisions for orbital cellulitis. 
 The blade should be at least 4 centimeters in length, and 1/2 
 centimeter wide at the hilt, gradually tapering, by the back, in a 
 slight curve to the point. The other smaller, with blade curved, 
 concave on the edge, and extremity neatly blunted. Its length 
 should not exceed 3 centimeters, and its greatest breadth, which 
 is also at the base, scant 3 mm. This has been called a probe- 
 pointed bistoury, and is most useful in enlarging openings, or 
 fistulous tracks, into suppurating cavities, or leading to foreign 
 bodies in the orbit, etc. It would also answer, in a pinch, for 
 extending an inadequate corneal section in extraction. 
 
 Beer's Knife. One of these is sufficient, and it should be of the 
 true Beer, or, rather, Earth, pattern, i.e., not of convex edge, like 
 the old Beranger cataract knife, but straight both edge and back, 
 and somewhat smaller in all dimensions than that of Beer. Three 
 centimeters long and 8 mm. at the widest point is ample, whereas 
 the original was 4 centimeters long by i centimeter for the rise of 
 the hypotenuse. Although no longer employed in the capacity 
 for which it was intended, yet for the incision of hordeola, and of 
 chalazions by the Agnew method, through the border of the lid, 
 there is no knife its equal.
 
 64 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 Lacrimal Knife. Owing to the few occasions, these latter days, 
 for Bowman's operation, a single representative of this class is 
 enough; and my choice would be for that of Agnew. The blade, 
 including the probe, is i 1/2 centimeters, of \vhich the probe and its 
 neck comprise a trifle more than one mm. The back has a slight 
 convexity, and the edge a more decided one. The greatest width 
 is at the middle, where it measures 2 mm., and it is connected w y ith 
 the handle by a round, malleable iron shank, about 3 1/2 centi- 
 meters long. The object and advantages of this last feature, in 
 adapting the knife to the overhanging brow and permitting of its 
 entrance into the nasal duct, are too well known to dwell upon. 
 The Weber knife is lacking here, and the neck of its probe, being 
 too long and curved, renders it liable to snap off in the tissues. 
 
 Graefe Knives. One could manage to get on with three cataract 
 knives, provided he were within convenient distance of a reputable 
 instrument maker or repair shop, but from four to six would not be 
 considered an excessive number. Graefe knives, in common with 
 all keratomes, are the most exacting of all the ocular instruments 
 as to their keeping. This is especially true of the point. No 
 matter how faultless the edge, if the point is not perfect the instru- 
 ment, for the moment, is worthless. So exceedingly delicate is it 
 that the merest touch against the box in which it is kept, or against 
 the tray or dish in which it is cleansed, or against the towel in 
 wiping it, and it is out of service. For these reasons it is advisable 
 to have a reserve supply, and, in preparing for an extraction or 
 iridectomy, to make ready two such knives lest one should come 
 to grief. The blade of the most approved model is 30 to 32 mm. 
 long, full, strong, 2 mm. wide at its base, where it joins the shank; 
 at this point also it is full 1/2 mm. thick, and from here both width 
 and thickness decrease by insensible degrees toward the extremity, 
 till, within 4 or 5 mm. of it the w r idth is reduced to less than i i / 2 mm. 
 From here the lines converge, in a slight curve, to form the point. 
 An error, often found in connection with the Graefe knife, is that 
 the more pronounced narrowing of the blade begins too far back, 
 and that, instead of the opposite sides approaching in the correct 
 outward sweep, they do so in straight lines. This makes a long, 
 needle-like point, that is extremely frail and difficult to keep in 
 order. On the other hand, too abrupt a termination, while not so
 
 LANCE KERATOMES. 65 
 
 objectionable as the kind just described, is also objectionable in 
 that it lacks penetrating qualities. These defects are more apt to 
 be acquired at the hands of unskilled repairers than to be present 
 in the new instrument. The back is scrupulously rounded. Blade 
 and handle are connected by a pedestal-shaped shank fully 1/2 
 centimeter long, which must be strong and firm. 
 
 Lance Keratomes. It would be well to have not less than four, 
 say two with blades of average dimensions, the third of somewhat 
 larger, and the fourth of smaller measurement. This knife is 
 usually referred to as the keratome, and, although strictly speaking, 
 it is not any more of a keratome than any other knife that is used 
 to incise the cornea, usage has made it more entitled to the name 
 than the others. Its origin was, in England, as "the bent lance," 
 and it came to be known in Europe as the "English lance-knife." 
 It has undergone many modifications and been put to many uses. 
 The present model is essentially that given by Friederich Jager, and 
 its employment is almost exclusively confined to corneal incisions 
 for iridectomy and, in short, all operations requiring a linear, 
 corneal opening, of relatively limited extent. C/ermak recommends 
 it for making the intermarginal incision in restoration of the border 
 of the lid in trichiasis. The blade is almost an equilateral triangle, 
 the measurement from heal to point in the median line, consti- 
 tuting the altitude, being greater by one mm. than that across the base. 
 The dimensions of the average size, of which it is well to possess 
 two, would be <) mm. for the base and 10 mm. for the altitude. 
 Those of the other two 7x8, and lox i i mm., respectively. Jager's 
 blade was set at an angle of about 45 to that of the handle. This 
 has been found too great a bend for any but the most deeply sunken 
 eyes. The most convenient angle for all around utility is about 
 35. And I quite agree with Knapp in recommending, as has been 
 stated, that all the keraiomes be set at the same angle. These four, 
 at any rale. ( )n rare occasions a narrower and comparatively 
 long blade, and an ordinary one. of good si/.e, mounted on a bayonet 
 shank iBadcr'si would come handy the first, for instance, in 
 certain optic iridectomies. and the second for extraperipheral 
 iridectomy in a subject with great overhang of brow. Landolt's 
 well-known keratome with the broad curved shank, and the blade 
 with rounded corners, is a practical instrument, but as it requires
 
 66 
 
 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 special manipulation because of the peculiar construction of the 
 shank, one should have either all or none of this style. 
 
 Cystotome. One is a necessity two would be almost a luxury. 
 Those in the market are mostly modifications of Von Graefe's. 
 It would be better if they were the original model, for it is a splendidly 
 conceived instrument. The outline of the blade is very suggestive 
 of the side view of a goose's head (Fig. 33) It will be observed 
 that the back of the head of the goose is well rounded, and that 
 the throat, from beak to neck, is a light concavity. Now, what 
 passes in this country as the Graefe cystotome is commonly an 
 ugly, angular affair, something like that shown in Fig. 34, being 
 a mere spike, or peg. The back of the head is a right angle that 
 
 FIG. 33. 
 
 FIG. 34 
 
 FIG. 35. 
 
 FIG. 36. 
 
 catches in the incision and in the iris; and the throat is another 
 angle in which rust and bacteria can accumulate. The idea seems 
 to prevail that only a scratching point is required in a cystotome 
 that a cutting edge is a superfluity; and, doubtless, many a bungling 
 capsulotomy is the result. A mere point does not cut, it simply 
 tears. The point punctures the anterior capsule, and, unless there 
 is an edge, and a sharp one at that, to make an incision, the alleged 
 capsulotomy is nothing but an indiscriminate laceration. Knapp's 
 cystotome is an example of an incisive one, but it too is objectionable 
 by reason of its angularity. Someone has given to the Graefe 
 cystotome a small cutting extension backward which adds to its 
 efficiency. The author has used for the past ten years a cystotome 
 on the Graefe principle, only the head of the goose is larger, and the 
 trenchant part is prolonged a little way into the neck (Fig. 35)
 
 KNIFE NEEDLE. 67 
 
 Continuing the simile, the tip of the beak is on a lower level than 
 the top of the head. In other words, the back of the blade is a 
 parabola. This disposition of the point makes it easier to introduce 
 and to push beneath the iris than if it were on a level, as is the Graefe 
 cystotome, or actually in advance of the rest of the blade, as in the 
 Knapp (Fig. 36). From the back of the head to the tip of the beak 
 is 2 mm. The center of the crescent that constitutes the blade is 
 i mm. wide, or even 11/2 mm. The shank measures 22 to 25 mm. 
 The objects in having it larger than the Graefe are to make of it a cut- 
 ting instrument of greater significance, thereby enhancing the pre- 
 cision with which it can be guided and inspected, and, in a measure, 
 to forestall the ravages of those who afterward put it in order. 
 One grinding will often reduce a smaller cystotome to a bare remnant, 
 and leave no semblance of its former shape This instrument 
 is not so large, even at the beginning of its career, as to make its 
 size an objection. Of course, it is not presumed that the entire 
 edge of the blade will engage in the capsule at any one operation, 
 but it is there, and ready to cut, if called upon. Contrary to what 
 has been said relative to the length of blade in the cystotome, I 
 have noted, time and again, both in operating upon pigs' eyes and 
 upon the human subject, that the tiny spike of the pseudo-Graefe 
 instrument, especially after a few improvements (?) at the hands of the 
 sharpener, failed to so much as touch the capsule in places. With 
 the anterior chamber empty, and the lens bulging forward, its 
 anterior convexity is rather increased, so that, with an insignificant 
 blade, unless one takes pains to see that the point is applied, by 
 lifting the handle, the shank will rest on the summit of the lens, 
 in starting the capsulotomy, and the point be thus kept from reach- 
 ing the capsule. 
 
 Knife Needle. One of these would be thousands. Were this 
 article to specify the model, it would be that of Knapp. Not the 
 pigmy thing only 3 or 4 mm. in length one sometimes sees going 
 under this name, but a blade of respectable proportions, or about 
 8 mm. long and 112 mm. wide. Nor should it have a shoulder, 
 or offset, where knife and shank unite, as is most often the case. 
 This goes with a jerk through the incision made by the knife. 
 Pagenstecher's discission knife is also a first-class instrument, 
 and is well suited for discission by the way of the corneal base, or
 
 68 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 the conjunctival route, which is fast becoming the only method. The 
 advantages of this mode, together with a method of preparing old 
 worn Graefe knives for use in the operation, in place of needles, or 
 knife needles, is given in the chapter on Discission. 
 
 Stop Needles. The various types of discission needles, like the 
 long, straight, spear-pointed, the sickle, etc., have mostly fallen 
 into disuse. One among them, however, is still in favor. This is 
 the stop needle of Bowman. As it owes its prolonged life to its 
 value in the operation of dilaceration, it is best to procure a pair of 
 them. In view of the fact that in this procedure the needles are 
 passed through transparent cornea, they should be gotten up in 
 manner so slight and dainty as to insure a minimum of traumatism. 
 The little rhomboid terminations ought not to exceed 2 mm. in 
 length by i mm. in width. It is best to have the edges lightly 
 convex, as this not only helps in penetration, but also gives lee-way 
 for sharpening without spoiling. The size of the shaft between 
 rhomboid and shoulder should be 6 to 7 mm. long by 3/5 of a mm. 
 in thickness, and the larger, or upper, part of the shaft should not 
 leave off suddenly, leaving a square offset, but should taper but 
 rapidly into the lower part. By this arrangement there is no 
 sharp angle to catch dirt, no corner to injure the corneal epithelium, 
 and, most important, the sloping shoulder serves as a stopper to 
 keep back the aqueous. 
 
 Tattooage Needle. This is an instrument seldom needed except 
 in a large charitable clientele, and there they are supplied. Besides, 
 as the cases are not usually emergency ones, there would be time 
 enough to get the instrument after getting the patient. However, 
 the instruments for the procedure are described under Tattooage 
 of the Cornea. 
 
 Blunt Dissector. For shelling out tumors, extirpating the 
 lacrimal sac in short, for use wherever blunt dissection is indicated; 
 also for loosening the periosteum in total exenteration of the orbit, 
 the writer has had constructed a modification of Fenger's blunt 
 dissector. Its blade is lanciolate, lightly curved on the flat, has a 
 suspicion of transverse rounding out on the convex side, and a low, 
 longitudinal, median rib on the concave side. Its length is 3.5 
 centimeters, and it is 6 mm. wide at its middle. 
 
 Sharp Hooks (Plate II). One, or possibly two, of different pat-
 
 BLUNT HOOKS. 69 
 
 terns, would be ample in this line. This is an instrument whose 
 place, in certain emergencies, no other instrument can quite fill. 
 There are two well-known classes of the sharp hook, viz., that which 
 is very minute, and whose bend is short. This class, of which there 
 have been a number of modifications, goes back to Beer. Its 
 surviving representative is that which bears the name of Tyrrell, 
 and whose crook is precisely like that of a button-hook. The 
 other class is descended from the vectis, of Gibson, but is more 
 closely identified with Von Graefe. Here the bend is either angular 
 or but slightly curved and is much less acute. The first-mentioned 
 kind was destined solely for an iris hook, and as such it has chiefly 
 been used. If, however, it is given less of the backward bend, 
 that makes it like a button-hook, and the crook is opened out 
 somewhat, it makes an excellent instrument with which to deliver 
 rather tough cataracts that are loosened and are well forward- 
 generally more or less within the anterior chamber yet, that it is 
 not practicable to get out by pressure. The other hook has none 
 of the backward bend in beginning the crook, but goes off from 
 the shank almost at a right angle, and is very slightly curved. Its 
 appearance is more that of an old-fashioned dissecting tenaculum 
 in miniature. This is, by far, the most suitable instrument with 
 which to go fishing for luxated cataracts that lie deeper, that is, 
 behind the iris, and for the softer ones that are in the anterior 
 chamber. It can be dug deeper into the lens, and more readily 
 than the other, and if it becomes entangled in tissue that is not 
 wanted, it can be more easily extricated. For remarks on its ad- 
 vantages over other traction instruments in cataract operations 
 see chapter on the Immediate Accidents of Extraction. Suffice it 
 to say in this place that, although it is a simpler matter to scoop out 
 such lenses, along with other things, than to catch them deftly 
 on the hook without disturbing the other contents of the globe, 
 there can be little question as to which is the better method. Could 
 I have but one of these hooks, I would choose the one last described. 
 These hooks should be of the best steel, and exceedingly fine and 
 delicate. The length of the more curved one ought not to be more 
 than one mm., and that of the straighter should be i 1/2 scant. 
 
 Blunt Hooks. There are also two kinds of blunt hooks, but one 
 kind and one hook is enough for anybody. Their only difference
 
 DESCRIPTION OF PLATE II. 
 
 23. Bowman stop needle. 
 
 24. Tattooage needles, round form. 
 
 25. Tattooage needles, flat form. 
 
 26. Beard extraction hook. 
 
 27. Tyrell blunt hook. 
 
 28. Stevens squint hook. 
 
 29. Graefe squint hook, medium. 
 29'. Graefe squint hook, large. 
 
 30. Prince divulsor. 
 
 31. Silver spatula. 
 
 32. Tortoise-shell spatula. 
 
 33. Daviel spoon. 
 
 34. Bunge exenteration curet. 
 
 35. Pagenstecher extraction spoon. 
 
 36. Round curet. 
 
 37. Olive curet. 
 
 38. Saw-edge curet. 
 
 39. Beard exenteration knife-spatula. 
 
 40. Weber wire loop. 
 
 41. Snellen wire loop. 
 
 42. Grooved foreign body spud. 
 
 43. Flat foreign body spud. 
 
 70
 
 PLATE II. 
 
 _J
 
 SQUINT HOOKS. 73 
 
 is as to size. Both were designed as iris hooks, i.e., for catching 
 the pupillary border, not as was Beer's, for catching in the stroma. 
 The larger is attributed to Himly, and is about as lumbering a 
 thing as can well be imagined. The other is known, in this country, 
 as TyrrelPs. It is, truly, a tiny button-hook, seeing that it has not 
 only the form, but the blunt point, as well, and is much more 
 dainty than Himly's. In the sometimes difficult task of seizing 
 with forceps the funnel-shaped iris of aphakial eyes, for instance, 
 and for the extraction of some adherent and much shrunken cataracts, 
 Tyrrell's blunt hook will come nobly to the rescue. Its form and 
 its smooth, round point peculiarly fit it for its insertion and with- 
 drawal through the corneal wound. The mode of using it is 
 described under Agnew's Blunt Hook Operation. 
 
 Squint Hooks. There are three standard sizes of such hooks, 
 and at least one of each should be provided, for each size has its 
 appropriate uses. There is a vast difference in the crooks of 
 squint hooks. Some makers seem to think that all that is de- 
 manded is to give to a round rod of steel of definite size a given bend. 
 But those who understand the exigencies of the instrument know 
 that the correct fashioning of its working extremity is no mean job, 
 either as to the configuration of the bend or as to that of the metal 
 comprising the bend. The bend is far from a right-angle one, 
 as has often been stated. It may be best described as an arc of 
 a circle. True, the chord of the arc makes a right angle with the 
 long axile of the stem or shank. And it must be insisted upon that 
 the chord be that of a true circle not of a parabolic curve. In 
 the Graefe hook, which is the largest of the three sizes recommended, 
 the radius of the arc is 5 mm., its height, or rise, is 2 mm., and the 
 length of its chord, which, as said before, is at 90 to the stem, is 
 9 mm. In the intermediate hook suggested, I think, by Landolt 
 the chord measures 7 mm., and in the smallest, that of Stevens, it 
 measures 5 mm., the rise, and the radius being proportionately 
 less The sides of the hook are flattish, i.e., in cross section the 
 crook would represent an oval, whose short diameter is constant 
 in every part of the bend, being about 1/2 mm. for the largest and 
 the intermediate, somewhat less for the smallest. The long 
 diameter of the oval in the Graefe hook, gradually increases from 
 2/3 mm. at the center of the curve, to i 1/3 mm. at the free end, the
 
 74 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 same being true, though relatively less, as to the other two. The 
 extremities in all are smoothly rounded. This form gives a crook 
 that is readily inserted beneath a tendon, is not so slight as to allow 
 the latter to slip off easily nor so pronounced as to be difficult to dis- 
 engage The Graefe hook is adapted to the work of picking up 
 the tendons in enucleation, and that of holding the tendon, \vell 
 spread out, for the placing of sutures, etc. The medium hook 
 answers for the same purposes, but is better adapted to the picking 
 up of the tendons in tenotomies and advancements. The Stevens 
 hook is, preeminently, the hook for the partial tenotomy. 
 
 It is remarkable to what an extent the Graefe squint hook has 
 become an all-around handy instrument. As examples of its uses 
 are the following: 
 
 In extirpation of the lacrimal canal, if the hook is passed beneath 
 the sac as soon as that organ is oposed, the dissection is greatly 
 facilitated by working the hook up and down between cupola and 
 the nasal duct. In the removal of the corneal portion of a pterygium 
 it serves admirably as a divulsor. In the withdrawal of bits of 
 iron or steel from the interior of the eye through a wound or incision, 
 the hook may, on occasion, and with advantage, be inserted at the 
 opening, then put in contact with the tip of the magnet, instead of 
 introducing the tip itself. It is employed to express the lens in the 
 extraction of cataract, especially in the "Indian" operation. It 
 is frequently made to act as a retractor in holding apart the lips 
 of incisions. 
 
 Iris Spatula. The tortoise-shell spatula is an ideal instrument, 
 and the hard-rubber one but little inferior. Unfortunately, they 
 cannot be at least, they are not fastened to the metal handle in 
 a manner that will allow of their being boiled. They can, of 
 course, he made aseptic by other means, but there is a sense 
 of security in being able to boil all the instruments, for a 
 particular operation, that comes of no other method of disin- 
 fection, so that every one should be boilable. The best spatulas, 
 to my knowledge, that conform to this principle, are those 
 of silver and of gold. If of the last, in order to have the re- 
 quisite strength and elasticity the fineness of the metal should not 
 exceed 10 k. The blade, including the shank, is 3 1/2 centimeters 
 long, and is i 1/2 mm. wide throughout, and not more than 1/4
 
 CURETS. 75 
 
 mm. in thickness at the middle. It should be lightly curved on the 
 flat, and the edge thinned down to the point just short of trenchancy. 
 The extremity should be rounded and, if anything, there should be 
 less thinning of the edge at that point than along the sides, to pre- 
 vent wounding the iris in poking. It must be seen to that the 
 metal spatula does not have a wiry edge nor become nicked. 
 
 Extraction Spoons. Here too it is a pity we cannot con- 
 sistently enjoy the luxury of tortoise-shell, but we must content 
 ourselves with either solid or German silver. Two are required- 
 one for use behind the incision, the other to make pressure from 
 below; the first flatter and broader than the second. The name 
 spoon is really applicable to the model of this instrument only 
 so far as it concerns the external form, i.e., there is no bowl to 
 the spoon it is solid or plain. They are not intended for scoops 
 nor for curets. Earlier spoons had a concavity because they were 
 used to scoop or lade out something usually more or less of the 
 cataract. Its presence, however, in the expression spoons of to- 
 day is about as useful as the appendix or any other rudimentary 
 organ; and also, like the appendix, it is simply a place for things 
 to lodge. The outline of the spoons is like that of a pear, but, 
 unlike ordinary spoons, the broad end is the one that is free. Their 
 long axes measure about 8 mm. The smaller spoon measures 4 
 mm. at the widest place, and the larger 5. The smaller is a trifle 
 over a millimeter in thickness, the larger, a trifle under. The 
 back is a regular convexity, i.e., without a longitudinal rib, and 
 the front is perfectly flat. The edge is faintly rounded and smooth. 
 The broader spoon is the same as that of Weber, excepting that it 
 is not hollowed out, and the other, very similar to that of Graefe, 
 though, in addition to the concavity, the latter has a great curve 
 in the shank that supports it. In the shank of each of those here 
 described there is a gentle bend in its terminal third. 
 
 Curets. Called also Sharp Spoons. Every outfit should con- 
 tain several of them. One or two fair-sized ones for the curetment 
 of granulating pus cavities, for example. If t\vo, it were well to 
 have one of them fenestrated, as this kind is easier both to clean and 
 to sharpen. Obviously, it is not so well fitted for the double pur- 
 pose of scraping and scooping. Then, too, let one be circular and 
 the other oblong. Their greatest diameters should not exceed
 
 76 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 seven mm., nor the smaller four or five. The depth of the bowl 
 must not exceed 11/2 mm., and it is important that the edge 
 should have a moderate flare. Then, a small curet with finely 
 serrated edge for such work as the obliteration of the sac or cyst 
 wall in the operation for chalazion and for getting rid of little 
 islands of the uvea in exenteration of the sclera is invaluable. It 
 may be either round or slightly oval, measuring about 3 mm. 
 across. Without going too extensively into curets, one might 
 also venture on the acquisition of one for loosening the contents 
 of the globe in exenteration. The most suitable form for it would 
 be oblong and thin, and with a decided flare to the edge. For 
 this purpose the writer prefers his exenteration knife-spatula. 
 
 Exenteration Knife-Spatula. This is an improved instrument 
 invented by the writer 1 for the removal of the contents of the sclera 
 in the operation of exenteration of the globe (Plate II). As its name 
 indicates, it partakes in qualities and uses of both knife and spatula, 
 being a little too dull for a knife, and too sharp for a spatula. It 
 consists of two parts, a blade and a handle. The blade is double- 
 edged, is about 4.5 mm. wide at its broadest part, where it joins the 
 shank, and gradually tapers to the extremity, where it is neatly 
 rounded. Its length is about 2.5 centimeters. It is curved on the 
 flat for two-thirds of the distance from tip to base, to correspond to 
 the meridional concavity of the sclera, and transversely convex on the 
 outer surface to fit the equatorial concavity. Its inner surface is 
 flat. The edges, while not so keen as is the edge requisite in a 
 Graefe knife, are, nevertheless, tolerably trenchant. The rounded 
 end is blunt not bulbous so that puncture of the sclera may 
 be easily avoided The handle is of aluminum, to admit of boiling, 
 and blade and handle are united by a nicely modeled shank. 
 
 Wire Loop. This is sometimes referred to as Fenestrated 
 Spoon, which is a very poor name, yet one sees now and then a 
 wire loop so clumsy that it might well be thus designated. It is 
 needless to state that the object of this instrument is the delivery 
 of a cataract that is luxated or has dropped into the vitreous. 
 Seeing that it is employed at a time when there is a large corneal 
 incision through which the vitreous is either escaping or on the 
 verge of doing so, it is of the highest importance that a wire loop 
 
 1 Ophthalmic Record, July, 1905.
 
 LID RETRACTORS. 77 
 
 introduced to bring out the lens be so constructed as to cause the 
 minimum of displacement. It must, therefore, be made of wire 
 that is as fine as is consistent with the force exerted, and the spread 
 of the loop must not be needlessly wide. If the wire is stiff and 
 strong as it should be its diameter need tiot be more than 1/3 
 mm. The greatest width of the older Graefe loop, was at least 6 
 mm., and its total length was i centimeter. Weber modified the 
 loop by simply stretching it out, as it were, making it 4 mm. wide 
 and i 1/2 centimeters long, but leaving the same coarse wire. 
 Snellen, while adopting Weber's loop, reduced the size of the w r ire. 
 Next to the open sharp hook, this is the best instrument for ex- 
 tracting lenses that cannot be expressed, and, in inexperienced hands, 
 it is the very best. Snellen's modification of Weber's would be my 
 choice. 
 
 Lid Retractors (Plate VIII). For three score years the retractor 
 of Desmarres has stood alone. Its inventor called it an eUvateur, 
 because it was originally destined for the upper lid alone. The only 
 change that has been made is the accentuation of the bend, i.e., in 
 the present model the hook of the lid-holder is not so widely open. 
 The trough of the older retractor measures 11/2 centimeters across 
 the top; in the newer model it is only i centimeter. It is better 
 to have two of these, one for each lid of adults; a larger for the 
 upper lid, the length of the trough of the lid-holder measuring 
 1 6 to 17 mm., and a smaller for the lower lid, with trough only 
 12 to 13 mm. The smaller will also answer for the upper lid in 
 cases of small children. Those with heavily gold-plated lid-holders 
 and shanks are preferable, and their cost is not excessive. Fenes- 
 trated retractors have no special advantages over the solid. It is 
 always easy enough to turn the lids for inspection and treatment 
 of the cornea. 
 
 A very objectionable feature often noted in connection with the 
 handled instruments, such as lance keratomes, cystomes, spoons, 
 curets, squint hooks, and wire loops, is the extreme length of the 
 shank. A length of 35 mm. in this part is not uncommon, and even 
 40 mm. has been observed. To hold these properly by the handle 
 places the fingers too far from the working part, too far from the 
 eye operated upon, and from the patient's face. Twenty-two to 
 25 mm. is about the desirable length.
 
 78 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 So much for the instruments of uniform handles; now for those 
 with uniform rings and branches, or the 
 
 Scissors (Plate III). In commenting upon incongruous types of 
 scissors that one often sees in the oculist's kit, Landolt says, " When- 
 ever we are confronted, among ophthalmic instruments, with the 
 reminiscences of the grosser surgery from which ours sprang, it is 
 most often in case of the scissors." What was true at the time this 
 was written is true to-day. Not only are many of the scissors destined 
 for eye surgery conspicuously coarse and big, but many of them 
 yes, the majority are lacking in the quality of their steel, and 
 faulty as to the articulation of the blades. As with the scalpels, 
 it is mainly the terminal portion of the blades that is concerned 
 while they are in use. But, if the coaptation of the blades is not 
 perfect, it is just this part that suffers most. A defect that occurs 
 with exasperating frequency is the failure of the edges to overlap, 
 or pass each other, at the end of the blades, or "forking." This 
 comes of the greater wear in this location and of the sharpener 
 failing to adjust matters as he should. The instrument will have 
 a longer life, without undue shortening of its blades if these over- 
 lap very decidedly when new. Landolt thinks that the automatic 
 fastening is, in a measure, responsible for the inferior cutting 
 qualities of some scissors. Arguing that, because of one's ina- 
 bility to tighten the fastening when the scissors get loose, as can 
 be done with those that are joined by a screw, the only recourse is 
 to cramp the blades by pushing forward the thumb ring and pulling 
 back that of the finger. This may be true, but I have been unable 
 to detect any difference in the working of the two kinds. The 
 advantages are largely on the side of the automatic when it comes 
 to a question of keeping them free from rust and filth that much 
 is certain. 
 
 With regard to the rings these are supposed to accomodate, one 
 the thumb, and the other, the third finger up to the first joint. 
 They will then be large enough for any but digits of extra volume. 
 The problem is solved by letting the regulation pattern conform 
 to this principle and compelling the acromegalian to have his 
 scissors made to order. With respect to the branches, there is no 
 good reason why they, too, should not be standardized as to length, 
 seeing that the variations in the dimensions of the blades are not
 
 SCISSORS. 79 
 
 so great as to be in the way. With the thumb and ring finger 
 inserted as stated, and the middle finger resting upon the outside 
 of the adjacent ring, as is the correct position for holding the scissors, 
 the length of the branches should be such as to permit the tip of 
 the index to fall naturally upon the pivot of the blades. This 
 means, for the average hand, a measurement of about 5 centimeters 
 from the pivot to the junction of branch and ring. Any marked 
 increase of this length tends to cause wabbling, and any material 
 decrease restrains freedom of action through cramping the fingers. 
 The scissors used by the oculist are all so small that whatever 
 latitude is necessary in making the relatively slight differences in 
 strength need not affect the aperture of the rings nor the length of 
 the branches. It is merely a question of the weight of these parts 
 and of the proportions given to the blades. Those that have branches 
 4 mm. wide by 3 thick, and blades 31/2 centimeters long, 8 mm. 
 wide and i 1/2 mm. thick at the base are strong enough for any 
 of the usual work. The daintiest iris scissors have branches 
 2 1/2x2 mm., and blades 21/2 centimeters long, 5 mm. wide, and 
 i mm. thick at the base. It follows, therefore, that there are no 
 great differences in size after all. 
 
 A question that has often occurred to me is: Why do so many 
 pairs of scissors have sharp points? The instrument does not 
 advance by puncturing at two contiguous points, then uniting these 
 points by tearing the intermediate tissue! The cutting point is 
 that just where the edges intersect, which constantly moves forward 
 as the blades are closed. The tissue that is being divided is caught 
 in that angle. There can be no office for those needle-like extremities 
 excepting to do mischief. ' They should be abolished. The tips 
 would simply need to be blunted by slightly rounding them. It is 
 even doubtful if there is now any branch of surgery in which incisions 
 are made by first piercing the tissues with one sharp blade, then 
 closing down the other to effect the cut. Formerly this was not an 
 uncommon practice. It is at present confined to the trades. 
 Neither is there any more a place for the elbowed scissors, with 
 one blade probe-pointed, though they are still with us, emeritus, 
 as it were. But enough of generalities. Let us make a few 
 selections. 
 
 Strabismus Scissors. Those generally acknowledged to be
 
 DESCRIPTION OF PLATE III. 
 
 44. Strabismus scissors, small. 
 
 45. Stevens strabismus scissors. 
 
 46. Blunt strabismus scissors, medium. 
 
 47. Blunt scissors, curved, medium. 
 
 48. Sharp scissors, curved on the flat. 
 
 49. Enucleation scissors, medium. 
 
 50. Enucleation scissors, large. 
 
 80
 
 PLATE III. 
 
 45 
 
 44 
 
 49
 
 SCISSORS. 83 
 
 best adapted to squint operations are so small as to be only one 
 grade heavier than the iris scissors described a little way back. 
 They are lightly curved on the flat. To be more exact, the radius 
 of the curve is 4 centimeters, and the bend is regular. This is a 
 sharp enough curvature for any scissors in fact, it is about what 
 is proper for all of that character used in eye surgery. Yet one 
 often sees them with a curve having a radius of only 3 centimeters. 
 And, that the scissors may work smoothly and be easier kept in 
 order, it is essential that the curve maintain about the same radius 
 throughout. I say about the same, for it must be remembered 
 that this cannot be mathematically true of curved scissors, as the 
 curve of the inner blade must be a trifle greater than that of the 
 outer. This is shown by the fact that when the blades are closed 
 there is always a narrow, crescentic space between them. The 
 blades of the strabismus scissors are about 27 mm. long, and 5 
 mm. wide at the base. From here they taper to the extremity, 
 where the width of the two, with the scissors tightly closed, is one mm. 
 and the combined extremity is nicely rounded. Broad, clumpy 
 ends would better be rejected. In order to be strong enough, the 
 base of the blade should be i 1/2 mm. thick plus, and, at the end, 
 fully 1/4 mm. This form of scissors has a more extended range 
 of application than any other eye instrument, and one should possess 
 at least two pairs, though it were well to have the second pair just 
 a shade heavier not longer. Stevens' strabismus scissors are useful 
 but not notably better, for the work for which they were designed, 
 than are those just described; and it even seems that, by reason 
 of the peculiar narrowing down of their extremities, they "buckle" 
 easily and are difficult to maintain. 
 
 Enucleation Scissors. Having the last-named heavier scissors, 
 a special pair, for cutting the optic nerve, are not really necessary. 
 To sever it, together with the surrounding vessels and nerves, would 
 put no strain on scissors of this strength. Yet it is perfectly fitting 
 to get the extra pair. They should be but a trifle heavier than the 
 stronger strabismus scissors. Their blades might be 3 centimeters 
 in length, and their extremities a trifle broader. I have a pair that 
 I purchased in Vienna, while a student there, the branches of which 
 are 9 centimeters long and the blades 4 centimeters. The base of 
 the blades is one centimeter in width. They were regularly sold
 
 DESCRIPTION OF PLATE IV. 
 
 51. Small iris scissors. 
 
 52. Luer's iris scissors. 
 
 53. Straight blunt scissors. 
 
 54. Enucleation scissors with hemostatic clamp. 
 
 55. Canthotomy scissors. 
 
 56. Straight sharp iris scissors. 
 
 57. Sharp-pointed angular scissors.
 
 PLATE IV. 
 
 52 51 
 
 57
 
 SCISSORS. 87 
 
 for enucleation scissors. They look now as if they belonged to a 
 veterinary kit. 
 
 Terson, 1 of Paris, is the originator of a pair of enucleation scissors 
 that appeal strongly to one's sense of practicality and fitness (Fig. 
 37). The blades are perfectly smooth and slightly curved on the flat. 
 They are of precisely the same lateral dimensions, so that when 
 closed their borders are exactly even. Their extremities are broadly 
 rounded. Their most striking peculiarities lie in the fact that the 
 inner or concave blade is extremely thick, while the outer, or convex 
 one, is proportionately thin, and that neither blade is beveled or 
 
 FIG. 37. Terson's enucleation scissors. 
 
 cut away at the side corresponding to the edge. The thick blade 
 holds or pushes the globe forward at the time the optic nerve is 
 severed. 
 
 Straight Scissors. Two pairs of straight scissors are needed. 
 One extra strong pair, with blades 3 1/2 centimeters long and 8 
 mm. across the base, for canthotomy, cutting mucous grafts from 
 the lip, enlarging cutaneous incisions, etc. One blade should be 
 heavier at the end than the other, and neither must be sharp-pointed. 
 The second straight pair are built on delicate lines blades 27 mm. 
 long and scant 5 mm. across the base, and with the combined 
 rounded ends i mm. wide^ These are best for making straight 
 incisions in the conjunctiva and in a number of ways. 
 
 Iris Scissors. It is customary among oculists to have a pair 
 of extremely delicate, curved scissors exclusively for cutting the 
 iris. The smaller pair of strabismus scissors would do in an 
 emergency, though their points are a little too thick for cutting the 
 membrane close to the cornea. The blades of the regulation 
 iris scissors are about 2 1/2 centimeters long, 4 mm. across the 
 base, and taper down to a fine, not keen, point where the thickness 
 of the two superposed ends does not exceed 1/3 of a mm. Such 
 
 1 Annales d'Oculist, Dec., 1905.
 
 88 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 scissors are also useful in the excision of minute tumors of the con- 
 junctiva and about the lid margins. They have largely given 
 way to the 
 
 De Wecker's Forceps Scissors (Plate VII). Many of the merits 
 of this valuable instrument are discussed in the chapter on Iridec- 
 tomy. It is marvelously contrived, yet simplicity itself. The scissors 
 arrangement is peculiar in that the blades are not united by a 
 pivot. The fastenings are high up, one nearly midway of the 
 branches and the other at the top. The lower one is so constructed 
 that, in closing the wings with the fingers, it forces the branches 
 apart. This constitutes the spring that keeps the blades open 
 or opens them after closure. The blades are about 7 mm. in 
 length and about 11/2 mm. wide at the base. The ends of the 
 blades are made both blunt and sharp, or one blunted and the other 
 sharp For my part, I prefer to have them both blunt. The 
 scissors are set at an angle of 125 to the branches, or a reverse 
 angle of 55. The entire length of the branches, including the 
 button at the top, is a little more than ten centimeters, and their 
 greatest width 8 mm. These are the dimensions given the instru- 
 ment by De Wecker and by his instrument maker, Matthieu. 
 Common faults of it, as it appears in the shops, are heaviness, 
 too strong a spring, and want of proper coaptation in the blades. 
 The great advantage the forceps scissors possess over ordinary 
 iris scissors is that by the upright position in which the instrument 
 is held while making the excision of the iris, the hand is brought 
 close up to the site of operation, which adds immensely to precision. 
 Besides their legitimate office of cutting the iris, they are also valuable 
 for extending an insufficient corneal section in the operations for 
 cataract. 
 
 Other Forceps Scissors. Any than those of De Wecker are 
 seldom employed; yet there are times, as, for example, when one 
 has to deal with a dense membranous cataract, a closed pupil with 
 aphakia, that defies all other means of .establishing an opening, 
 when a tiny species of scissors, suitable for work in the anterior 
 chamber, becomes an absolute necessity Fortunately, these needs 
 are found in the Charriere capsule scissors or the Dowell iris 
 scissors. The first is patterned after the ingenius Desmarres' 
 capsule forceps; the second enjoys a most fitting model all its own.
 
 FORCEPS. 89 
 
 Its curved and forceps-like branches and its diminutive pivoted 
 blades make it superior to Charriere's as regards manipulation. 
 A fair-sized, not too peripheral, incision is required. This brings 
 us to the 
 
 Forceps This group is composed of many classes, and of all 
 the instruments comprising our selection, the greatest number going 
 under one common name will be representatives of the said classes. 
 As it is with the scissors, the great trend of instrument makers is to 
 manufacture eye-forceps that are too bulky and clumsy, to make 
 their springs too stiff, and to neglect properly tempering the steel, 
 especially in those with the more delicate extremities. 
 
 Fixation Forceps (Plate V). There are various kinds of forceps 
 used in ophthalmic surgery more or less for the purpose of steady- 
 ing, or fixing, the parts. By way of distinction, therefore, the name 
 is almost wholly restricted to that which is employed to immobilize 
 the globe in operations that involve it or its external muscles. 
 Among other kinds are the rat-tooth, mouse-tooth, advancement, 
 and lid forceps, etc., so, as each of these is well named, we may, 
 with propriety, restrict the term fixation forceps as stated. This 
 instrument is made either with or without a catch for locking the 
 jaws. The lockable kind is fast falling into disuse, especially for 
 operations under local anesthesia, in which the globe is opened, 
 because of their startling effect upon the patient in unsnapping 
 the catch. In narcosis this objection does not hold, but it is some- 
 times impossible to make the thing let go instantly, as, for example, 
 when the virtreous is escaping. The catch is useful at times, 
 however, therefore it is well to have one pair with, and one without 
 it. In all respects save those referring to the locking device, the 
 two instruments are alike. The best and most elegant forceps 
 of all classes, to my notion, are those made in Paris, and the dimen- 
 sions here given relate to these. The total length of the fixation 
 forceps is ii centimeters and 3 mm., and the greatest breadth 8 
 mm. The articulating portion of the jaws is 4 mm. in extent, 
 is provided with sharp, angular teeth that dovetail together, and is 
 slightly concave to fit snugly against the sclera. Those in which 
 the teeth cross each other, so as to project slightly from the jaws 
 where the forceps is closed, are surer to hold. When the teeth are 
 insignificant or worn down, the holding power is not to be depended
 
 DESCRIPTION OF PLATE V. 
 
 58. Fixation forceps without lock. 
 
 59. Fixation forceps with lock. 
 
 60. Rat-tooth forceps. 
 
 6 1. Mouse-tooth forceps. 
 
 62. Strabismus forceps. 
 
 63. Dressing forceps. 
 
 64. Median tooth iris forceps. 
 
 65. Forster capsule forceps. 
 
 66. Wecker capsule forceps. 
 
 67. Knapp capsule forceps. 
 
 68. Toilet forceps. 
 
 69. Correct cilia forceps. 
 
 70. Large cilia forceps. 
 
 90
 
 PLATE V.
 
 FORCEPS. 93 
 
 upon. As to the locking variety, it behooves one to see that the 
 catch works easily and smoothly. In case the hold seems insecure, 
 it can be made firmer by picking up the conjunctiva and tissue 
 beneath in a rather large fold and giving it a twist. 
 
 Beard's 1 Fixation Forceps, with the collaboration of Mr. V. 
 M tiller, an instrument maker of Chicago, the writer, a few years 
 ago, set about attempting to improve upon the models of this in- 
 strument in general use. The chief aim was to produce a fixation 
 forceps that would not necessitate the awkward bend at the wrist, 
 and the placing so much in evidence of the hand that steadies the 
 eye in such operations as extractions and iridectomies. The 
 first product of the effort was an effective, though rather too com- 
 plicated affair, whose jaws emerged from one end of a tube by pressure 
 
 FIG. 38. 
 
 of the forefinger upon a knob at the other end. This was abandoned 
 in favor of the model shown in Plate VII and Fig. 38. This is an 
 adaptation of Mathieu's forceps-scissors to the needs in question. 
 The scissors blades are left off, and in their place are the members 
 of the forceps. Instead, however, of moving in the same sense as the 
 scissors, the lower portions of the instrument are given a quarter 
 turn, so that they are set in a position at right angles to that of the 
 scissors. Thus it is not necessary, in fixing the globe to turn the 
 tips of the fingers holding the forceps to such extent that they point 
 toward the operator (Fig. 39), and the forceps hand is got out of 
 the way and out of the light (Fig. 40). 
 
 Rat-tooth and Mouse-tooth Forceps. These two kinds are, 
 as their names would imply, distinguished only by their size except- 
 ing that, rarely, the larger has a couple of extra teeth. The general 
 proportions of the rat- ooth forceps are the same as those of the 
 fixation class. The jaws, however are not extended laterally, but 
 are flush with the extremities of the branches. The teeth are very 
 strong and about i mm. in length. There are usually three teeth, 
 so arranged that the one, in the center of one jaw, fits nicely between 
 
 1 See Ophthalmic Record, Feb. 1907, for more desirable text on this forceps.
 
 94 
 
 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 the two in the other jaw, and, when closed, the extremity of the 
 forceps is smooth, i.e., the teeth do not project. The mouse-tooth 
 forceps is but a smaller type of the same instrument, though it never 
 has more than three teeth. It measures 10 1/2 centimeters in 
 length and 6 mm. where broadest. The larger kind can be very 
 well dispensed with, and its place be taken by the catchless fixation 
 
 FIG. 39. 
 
 forceps. But the smaller is an absolute necessity. Indeed, rather 
 than invest in one of each kind, it would be wel to get two of the 
 mouse-tooth. When the mouse-tooth forceps is defective, it is 
 usually as regards the teeth. They lack size and strength or they 
 do not interlock perfectly. 
 
 Dressing Forceps. These are exact counterparts of the mouse-
 
 FORCEPS. 
 
 95 
 
 tooth forceps excepting that, instead of teeth, the inner aspect of 
 the jaws presents a series of transverse serrations. A mistake often 
 seen in the make-up of this forceps is that only the terminal tips 
 of the jaws come in apposition without undue pressure upon the 
 branches. There should be contact for two or three mm. without 
 
 FIG. 40. 
 
 squeezing. This is the most suitable forceps to aid in removing 
 sutures. It also makes a good, all-around, toilet-forceps, and is 
 valuable for handling the thread in advancement operations. One 
 is a plenty. 
 
 Iris Forceps. There exist a great number of varieties of this 
 instrument, yet there are but two in ordinary use, and they are all
 
 96 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 that one needs to procure. These are distinguished only by the 
 disposition of their teeth, and are known as median-toothed and 
 back-toothed. In general construction, the median-toothed is 
 like the mouse-tooth forceps, the only difference being in the size 
 and shape of the extremities. The terminal thirds of the branches 
 are cut down to about 1/3 the dimensions of the mouse-tooth, and 
 they are made to end in a gentle curve that lies in the same plane 
 as the flat of the branches. This curve extends for one centimeter 
 from the end of the forceps, and it has a radius of about 6 mm. 
 There is considerable diversity in the inclination of the chord of the 
 arc that constitutes the curve, with reference to the axis of the forceps. 
 As it is with the blades of the lance-keratomes, so should it be with 
 this inclination, i.e., it should be the same in the several forceps. 
 A convenient angle for the chord is 45. That is, the grand angle 
 is 135. The roughening on the branches that serves to give it a 
 safe hold to the fingers is situated lower down than it is in the mouse- 
 tooth forceps. This is the forceps for all uncomplicated iridectomies. 
 For iridectomies in cases where there is posterior synechia, or 
 for hose in aphakial eyes, etc., the back-tooth iris forceps is the more 
 serviceable. Here the teeth, instead of being situated between the 
 opposing ends of the branches, arise from the back, or convex, 
 edges of the branch terminals. In the one instance the bite of the 
 teeth is at right angles to the axis of the forceps, and in the other, 
 parallel with it. In one, the teeth are flush with the ends of the 
 blades, in the other flush with the back edges of the blades, and on 
 one side with the end also. It is a serious fault in this variety to 
 have the teeth at a iittle distance from the end of the branches on 
 both sides, for in atlempting to seize the iris that membrane 
 might be pushed down, out of reach of the teeth, by the free end 
 of the forceps. The back-tooth forceps often have five teeth two 
 fitting the interspaces of three. Forster's are thus. Sometimes 
 there are more than five. Again, the teeth are directed somewhat 
 backward and project in interlocking; or they are made bayonet 
 fashion, i.e., are made to occupy a plane still farther back than 
 the posterior edge of the jaws. Such arrangements have very 
 doubtful advantages and some serious drawbacks. The projecting 
 teeth make them difficult to insert without catching, and, with the 
 long, sharp, projecting teeth, there is danger of wounding the lens
 
 FORCEPS. 97 
 
 if the latter is present. Indeed, these more savage instruments 
 are only fitted for 
 
 Capsule Forceps. For the occasional thickened capsules, and 
 for those of adherent lenses, a forceps is needed for tearing the 
 membrane off and extracting it arrachement. Those that bear 
 the name of De Wecker serve the purpose well. They are some- 
 thing between the ordinary back-tooth forceps and those exaggerated 
 ones just mentioned in that their teeth occupy a very slight offset 
 at he back of the jaws. This forceps can be made to do very well 
 in place of the back- ooth forceps. Like all the small toothed 
 forceps they must be closely watched to see that the teeth are neither 
 broken off nor out of line with their notches. 
 
 An important point in the selection of iris and capsule forceps, 
 if not, indeed, as regards that of all the ophthalmic forceps, is to 
 make sure that the springs by which they open are not too stiff. 
 "In order to manipulate an instrument with the greatest delicacy 
 and certainty, said manipulation must, like the simple hold between 
 the fingers, call for the least possible force. In other words, the 
 strength which we must exert to hold our iris forceps shut destroys 
 just that much of the nicety and precision in handling the instru- 
 ment and of the daintiness of touch. While insisting upon it 
 that the springs be soft, let it not be understood that the branches, 
 or members, themselves should be flexible. On the contrary, 
 they must be firm and rigid. This principle is illustrated by 
 examining certain forceps and noting that the extremities of their 
 jaws open, instead of closing, when their (too weak) branches are 
 pressed upon. 
 
 Rotary Iris and Capsule Forceps. To this class belong those 
 of Liebreich and of Mathieu, and their advantages are explained 
 in the chapter on "Operations Upon the Iris." 
 
 Toilet Forceps. For making the toilet of the eye after iridecto- 
 mies and extractions the dressing forceps are not well adapted, being 
 too straight and too big. Hence, the small, curved toilet forceps 
 of De Wecker. are recommended. This is nothing more nor less 
 than ordinary iris forceps, deprived of their teeth and supplied, 
 instead, with the fine crosswise roughening similar to the dressing 
 forceps. Like it, too, there should be contact of the jaws for a 
 short distance from the ends of the branches say for about i mm. 
 7
 
 98 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 Cilia Forceps. A scientifically wrought cilia forceps is not 
 always to be had. Most of them are bad. Landolt says, " I can- 
 not fancy what evil genius pursues this little instrument. It seems 
 to be fated to bear a form that is neither graceful nor suited to its 
 purpose. Time and again, and unceasingly, cilia forceps are 
 fabricated that have jaws as big as shovels, heavy enough to crack 
 nuts, and, in shape, suggestive of the hoofs of a horse placed base 
 to base" (Plate V, No. 70). It is precisely this horse-foot construc- 
 tion that constitutes the objection most frequently found in cilia 
 forceps. That is to say, the area of the opposing surfaces of the 
 jaws is too great or it reaches too far from the tip. Hence, in at- 
 tempting to pull out a fine hair, through squeezing together the 
 branches the proximal edge of the broad articulating facet acts as 
 a fulcrum, to pry open the distal parts of the jaws, and the hair 
 is let go. An effective cilia forceps would be about 85 mm. long, 
 8 mm. wide in the broadest places, and the branches should be of 
 good thickness (Plate V, No. 69). The roughening for the fingers 
 should be carried to within 1.5 cm. of the extremity of the jaws. 
 The latter should not be more than 2 to 2.5 mm. wide, by 1/2 mm. 
 deep, and should have their articulating surfaces elevated i mm. 
 above the inner planes of the branches, and be perfect with respect 
 to coaptation. To interpose a peg or pin between the branches in 
 such a way that it will not permit of their being bent inward by too 
 much pressure of the fingers is a good idea. Moderate pressure in 
 epilation gives better results than does excessive. 
 
 Advancement Forceps. To those who feel the need of forceps 
 for clamping and holding the tendon in squint operations, I would 
 recommend Prince's advancement forceps. Their jaws are set 
 at an angle, in the plane of the flat of the branches, consist of one 
 spiked member and one correspondingly perforated one or, in 
 technical phraseology, of one male and one female member. For 
 the rest, the instrument is identical with the locking fixation forceps. 
 This is a simpler and more effective tendon-clamp than is that of 
 De Wecker. 
 
 Trachoma Forceps. This subject is treated of in the chapter 
 on the "Surgical Treatment of Trachoma." 
 
 Lid Forceps and Clamps (Plate VI). In this class are included 
 not only all the forceps used for holding and fixing the lid, but also
 
 FORCEPS. 99 
 
 the lid damps. In fact, the two instruments cannot be separated 
 into distinct classes, as one merges into the other. True, there are 
 lid forceps and lid clamps, pure and simple, but more often it is a 
 combination of forceps and clamp. The modern lid forceps spring 
 from " Jager's T forceps. The original is still in use, as it deserves to 
 be. Of course, it needs a locking attachment. This should be either 
 the sliding catch or the old-fashioned screw, for in these the force 
 of the grip can be regulated. The spring catch does not admit 
 of any adjustment, either as regards grip or thickness of lid. Du- 
 jardin's T forceps, on the same principle as Jager's, are too savage, 
 because of their teeth. Lid clamps are usually some modification 
 of that of Desmarres, i.e., the essential features are a plate to go 
 beneath the lid, a ring, whose circumference coincides with the 
 outer border of the plate, and a slide, or a screw, to lock the branches. 
 Knapp and Snellen enlarged the plate and left off that part of the 
 ring corresponding to the free border of the lid. In order to still 
 further enlarge the field for operating within the ring, Warlomont 
 has devised an expansible plate that spreads out like a fan. This 
 is placed, unexpanded, into the upper fornix, when, by turning a 
 screw on the end of the handle, the moveable parts of the plate can 
 be made to flare so as to put the cul-de-sac upon the stretch. The 
 ring coincides with the expanded plate. This is evidently an im- 
 provement over the older models when it is a question of the more 
 extended entropion operations, for example, as greater scope is 
 afforded for free incisions. But for smaller operations, like chalazion, 
 etc., the others are just as good, and they are far simpler and easier 
 as to their keeping. For chalazion, Wilder's clamp is handy. 
 (See " Chalazion.") For fixing or steadying the lid and for clamp- 
 ing it to prevent hemorrhage in restoration of the free border, as 
 also in median tarsorrhaphy, and to fix it in electrolysis of the cilia, 
 the lid forceps invented by the writer 1 (Plate VI, No. 79) is an 
 efficient instrument. The branches, being attached at the ex- 
 tremities of the jaws, are out of the way for work on either side of 
 the clamp. 
 
 Hemostatic Forceps. One must have two or three of the 
 lightest pattern Tate's or Halstead's model. Those with long 
 branches measuring 9.5 centimeters from the pivot to the extremity 
 
 1 Ophthalmic Record, Jan., 1905.
 
 DESCRIPTION OF PLATE VI 
 
 71. Prince advancement forceps. 
 
 72. Prince expression forceps. 
 
 73. Knapp expression forceps. 
 
 74. Noyes expression forceps. 
 
 75. Kuhnt expression forceps. 
 
 76. Warlamont adjustable lid clamp. 
 
 77. Beard lid forceps. 
 
 78. Desmarres lid clamp. 
 
 79. Wilder chalazion forceps. 
 
 80. Hunt chalazion forceps. 
 
 1OO
 
 PLATE VI. 
 
 ^ -^al
 
 FORCEPS. 103 
 
 of the rings are less in the way than the short, or dwarf, kinds, as 
 the latter necessitate placing the hand that holds them close to the 
 seat of operation. The jaws, from pivot to end, should not exceed 
 2.5 centimeters. The working extremity of the jaws should be 2 
 mm. wide, and slightly rounded. The branches are best if light 
 and elastic. Those with a series of notches for the catch are con- 
 venient, simple, and effective. 
 
 Needle Forceps. Those constructed upon the principles em- 
 bodied in the still highly approved instrument devised by Sands, 
 of Xew York, are the favored of all eye surgeons. The circular 
 jaws of the Sands forceps have mostly been discarded for the more 
 desirable duck-bill jaws, and instead of deep grooves for receiving 
 
 FIG. 41. Stephenson's needle forceps. 
 
 the needle, thus limiting the number of positions in which it can 
 be placed, the surfaces of the jaws are either simply roughened 
 or else they are lined with meta softer than steel, such as copper. 
 It has been urged that, without the grooves, curved needles are more 
 apt to be broken. This is contrary to my observation. Some clever 
 genius some say Knapp, some De Wecker, some Weiss thought 
 to turn the free end of the lever tow r ard the handle, whereas, in 
 the Sands model, it is toward the jaws. This arrangement puts the 
 hand that holds the instrument further away, and permits not only 
 greater freedom of movement, but more room for handling the 
 other implements concerned in the operations. The snap catch is 
 to be preferred to the slide, as its manipulation is easier and causes 
 less joggling. It adds to steadiness and leverage if a transverse 
 plate is attached on the side opposite the catch, whereon to rest 
 the forefinger. This plate is lightly guttered to fit the index. The 
 closer the lever, or the catch, to the jaws, the less unsteadiness in 
 letting go of the needle, hence those needle forceps that, like 
 hemostatic forceps, have the catch at the ends of the handles are 
 objectionable. It would really seem more scientific to employ 
 a simple grip forceps, without a catch, whenever practicable, as
 
 DESCRIPTION OF PLATE VII 
 
 81. Liebreich rotary iris forceps. 
 
 82. De Wecker's forceps scissors. 
 
 83. Sand's needle forceps, with duck-bill. 
 
 84. Knapp's needle forceps. 
 
 85. Noyes iris scissors. 
 
 86. Dowel scissors. 
 
 87. Todd tendon tucker. 
 
 97. Beard fixation forceps. 
 
 98. Halsted mosquito hemostatic forceps. 
 
 104
 
 PLATE VII. 

 
 BLEPHAROSTATS. IOy 
 
 the shock and twisting consequent upon the unlocking are doubtless 
 pernicious. Needle forceps without any form of lock or catch are, 
 however, of doubtful value in any kind of eye surgery. The great 
 objection being that they cannot be so deftly turned about in the 
 hand to assume the various requisite positions without dropping 
 the needle from their grasp. In order to obtain more freedom 
 and ease of handling, one often shifts the hand back to the extremity 
 of the handle. This is a movement of which the catchless forceps 
 will not admit. Moreover, there are certain advantages in using 
 a needle-holder that can be conveniently handed to the operator 
 ready "loaded" by an attendant. A good model of the simpler 
 forceps is shown in Fig. 41. 
 
 Blepharostats (Plate VIII), or eye speculums, as they are popu- 
 larly called, can be quickly disposed of. There is no end to their 
 variety, but, since the appearance of the Mellinger speculum, most 
 of the others have been relegated to the scrap-heap. Practically all 
 of its predecessors had branches, of greater or less length, pivoted 
 at one extremity, carrying lid-holders of divers configuration at the 
 other, and bearing, somewhere between the branches, a more or less 
 complicated locking, or setting, device. As a result of the increasing 
 divergence of the branches in the opening of these blepharostats, 
 the tendency is to pry the lids farthest apart at the free end of the 
 lid holders. Gaupillat dared even put pivoted lid-holders on, to 
 obviate this defect. Then, the catches, ratchets, screws, levers, 
 and things with which the locks were operated contrivances more 
 cantankerous, especially at critical moments, it were difficult to 
 imagine. Both these faults were done away with at once in the 
 Mellinger instrument. Its branches remain parallel in all stages 
 of separation, and its locking is accomplished in a truly automatic 
 manner. The tighter the lids grip the holders, the more rigid the 
 branches, yet no degree of gripping can interfere with instant closure 
 of the blepharostat. Moreover, the lids can be forced apart by 
 simply pressing upon the ends of the slides. The first of these 
 blepharostats were unnecessarily heavy and big, and the length of 
 the handle or lever portions of the branches was out of proportion 
 to that of the arm portion. Some years ago the writer suggested 
 the lengthening of the handles and the shortening of the arms, thus 
 affording more leverage for the operator's fingers, and less for the
 
 DESCRIPTION OF PLATE VIII. 
 
 88. Jaeger lid spatula. 
 
 89. Mules repositor. 
 
 90. Mellinger-Beard blepharostat solid lid holders. 
 
 91. Mellinger-Beard blepharostat fenestrated lid holders 
 
 92. Landolt nasally operated eye speculum. 
 
 93. Irrigation retractor. 
 
 94. Small Desmarres retractor. 
 
 95. Desmarres retractor. 
 
 96. Terson enucleation shield. 
 100. Conical dilator. 
 
 1 08
 
 PLATE VIII.
 
 BLEPHAROSTATS. Ill 
 
 patient's lids; and also the lightening and reducing of the whole 
 mechanism so as to make it more delicate and compact. Two years 
 ago he set about making an improvement in the lid- holders and in 
 the spring, especially designed for cataract operations. One 
 objectionable feature of the majority of lid-holders had been a 
 bar that rested beneath the lid. Many and many an eye has been 
 sacrificed to this, particularly in operations for the extraction of 
 cataract, by its catching in the wound. Another was that the 
 cilia and the ducts opening in the lid border were suffered to pollute 
 the site of operation. The Landolt model has not the bar, but it 
 has the other objection. Only the old, solid lid-holder of Weiss, 
 (or Laurence) was free from both. Yet in all other respects, the 
 Weiss blepharostat is a very clumsy affair, the lid-holders being 
 merely two straight gutters, adapted neither to the curve of the 
 free border nor to the convexity of the globe. Gaullipat and Lang 
 overcame one of these defects by making the bottom of the trough 
 convex, in order to fit the concavity of the lid-margins. In addi- 
 tion to this curve the blepharostat shown in Plate VIII, No. 90, has 
 another at right angles to the first, by which the inner wall of the 
 gutter is made to conform to the convex surface of the globe, and the 
 outer wall to that of the outer surface of the lid. Moreover, the inner 
 wall of the trough is made decidedly lower than the outer, so that 
 its rim will not press up in the fornix, as such pressure tends to 
 produce spasm of the orbicularis and to restrict the rotation of the 
 globe when the patient attempts to look downward, the very direc- 
 tion in which he should look during most operations. The impor- 
 tance of this feature will be appreciated when it is remembered that 
 the conjunctival sacs of mariy of the cataract subjects are shrunken 
 and the cul-de-sacs shallow. The comfortable way in which 
 the lids are held apart with this form of blepharostat reduces the 
 inclination to squeeze, and the eye can be rolled upward repeatedly 
 without risk of eversion of the corneal flap. The shape of the lid- 
 holders renders them a trifle less easy to put in place than some others, 
 but this is not to be considered in comparison with the readiness 
 and safety with which the instrument may be removed. I first 
 thought that it would be needful that one should have a pair of such 
 blepharostats a right and a left with a smaller, straighter trough 
 for the lower lid. This was found to be an error. Indeed, the
 
 112 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 manner in which the present form depresses that lid gives unusual 
 opportunity for manipulation of the fixation forceps. The whole 
 appliance is made of solid nickel, hence easily kept bright. The 
 arms, being flat, can be easily bent, in the fingers in order to adapt 
 the blepharostat to the varying prominences of eye and temple. 
 This obviates any need of the jointed arms which were also a part 
 of the very ingenious Gaupillat blepharostat of some twenty years 
 ago. 
 
 With regard to the spring, it was discovered that its loose ends 
 could become jammed in the slot through which glide the slides, 
 and that so tightly as to make any movement of the arms impossible. 
 Besides, the springs were made of steel, which soon got rusty and 
 out of true. At my suggestion, the Messrs. Miiller, who made 
 the modified instrument, put on spiral springs of non-corrosive 
 material, and with the wire at their extremities soldered into a 
 continuous circle. The spring has barely sufficient strength to 
 keep the grooves of the lid-holders applied to the free borders and 
 not strong enough to stretch the eye open too forcibly. 
 
 Jager's Lid Spatula. This well-known and serviceable im- 
 plement must be in every oculist's outfit. 
 
 Lacrimal Probes and Sounds are discussed in the chapter 
 relating to the surgery of the lacrimal apparatus. I believe, how- 
 ever, that Weber's conical sound is not mentioned there. This is 
 
 a valuable instrument, but rather than have the "double-header" 
 kind, I would choose two distinct instruments, having the top 
 portion merely for a handle (see Fig. 42). 
 
 Sewing Needles. Aside from a very few special kinds, the 
 ophthalmic surgeon habitually employs the various grades of 
 regularly curved needles. The radius of the main extent of the 
 curve of the finest needles is about i centimeter. From this they 
 gradually increase up to about 1.7 centimeters, which is about the 
 radius of the coarsest. The length of the needle corresponds to 
 about 1/3 the circumference of a circle. More highly curved, or 
 those including more than 1/3 of the circumference of the circles
 
 MANIPULATION OF INSTRUMENTS. 113 
 
 they represent, are not, as a rule, desirable. A special needle, 
 for use in advancement operations, is described under "Muscular 
 Advancement." All needles are supposed to have sharp edges as 
 well as sharp points, and their eyes should be smooth and rounding 
 where the thread strain falls, and a large as practicable. The 
 so-called self-threaders are all right for most operations, but for 
 those in which it would-be disastrous to break the thread, they are 
 not to be trusted, for they cut the strands, thus causing both ir- 
 regularity and weakness. 
 
 A certain number of ordinary probes and cotton carriers, pref- 
 erably silver, and our selection is complete. 
 
 Manipulation of Instruments. In this connection, Landolt, 
 with characteristic terseness, remarks, " Just as, by the mere act 
 of grasping a foil and putting himself on guard, the classic fencer 
 is distinguished from the pretended swordsman, so is a surgeon 
 of correct training, the moment he touches an instrument, dis- 
 tinguished from the autodidactic operator. The last may succeed, 
 for example, in extracting a cataract without losing the eye his 
 work, as a whole, may be attended with fairly good results but 
 no one will deny that, in point of perfection of results and number 
 of successes, the advantage will always lie on the side of right 
 training." 
 
 How obtain this training ? Assuredly not standing around oper- 
 ating tables and " looking on !" One would as well try to become an 
 expert billiard player in the same way. A start can be made under 
 the instruction of one fitted to teach. Not necessarily a finished 
 nor a famous operator. Surgery, in this regard, is like music 
 not all who excel in imparting a knowledge of the art are adepts in 
 its execution, and vice versa. Having been grounded in the elemen- 
 tal principles, constant practice is indispensable. In the beginning 
 only upon the fresh eyes of animals fixed in a mask and upon those 
 of the cadaver. Later, upon those of the live human eye, but 
 always, during periods when sufficient opportunity is not afforded 
 for this, keeping up, at least, the work on the animals' eyes. Then, 
 to train the fingers to that suppleness and precision of movement 
 that are of inestimable value to the eye surgeon, all manner of odd 
 moments are utilized. It suffices for this simply to go through 
 with, over and over, the different motions appropriate to the more
 
 114 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 important surgical measures, either with the instruments pertaining 
 thereto, with purely make-believe articles, such as pens or pencils, 
 or with imaginative ones, holding nothing. While those move- 
 ments pertaining to the wrist and forearm are not to be neglected, 
 -those of the fingers come first. In addition to nimbleness and 
 guidableness, the fingers must possess delicacy and sensitiveness of 
 touch. These are attained both by systematic exercises, similar 
 to those given the blind in teaching them to read, and in acquiring 
 knowledge of many external things, and by the scrupulous care of 
 the hands, particularly of the skin thereon. The avoidance of 
 needless wetting of the hands with solutions that destroy the epider- 
 mis, by wearing suitable gloves when engaged in any work or exercise 
 that would otherwise lead to roughness of the skin, etc. The 
 great advantages to be gained from ambidexterity are too well recog- 
 nized to be dwelt upon here. It is becoming so universal for 
 ophthalmic surgeons to be ambidextrous that it now looks almost 
 like a confession of inferiority for one to stand at the left side of 
 the patient, for instance, in making a corneal section for cataract 
 of the left eye. 
 
 Modes of Grasping Instruments. A great deal depends upon 
 degree of pressure exerted by the fingers upon the object held. Too 
 tight a grip tends to tremor, lack of motility, and general awkward- 
 ness; too light a one, to want of precision and to actual escape 
 of the instrument from the fingers. The happy mean, then, would 
 be to grasp light enough to insure the greatest freedom of move- 
 ment consistent with a secure hold. After this comes the exact 
 position of the fingers relative to the part grasped. This varies 
 both as to the character of the instrument and as to the use it is 
 being put to at the moment. First, as to the instruments with 
 handles. Much has been said about the "penholder fashion" of 
 holding eye instruments. This is a poor illustration. A penholder 
 is held steadily by the tip of the thumb, the pulp of the index, and 
 the inner side of the first phalanx of the medius. The motion im- 
 parted to the pen is mainly that of the forearm. No turning, or 
 rotation of the implement is practised or required. Obviously, 
 it is quite another matter when it comes to guiding the objects under 
 consideration. The great factors in the manipulation of the 
 handled instruments are the thumb and the index. Between these
 
 MODES OF GRASPING INSTRUMENTS. 
 
 the handle is grasped, and by them it is rotated solely, as concerns 
 its long axis, and partly as regards the other axes. To these ends, 
 the two are placed more 
 directly opposite, even in 
 the so-called pen-holder 
 grasp, than they are in 
 writing many times di- 
 rectly opposite, with 
 their pulps applied and 
 the medius plays a de- 
 cidedly secondary part FIG. 43 -Pen-holder 
 in both holding and guiding (Fig. 43). Its functions are to 
 lightly support the grasp and to give an occasional touch in guid- 
 ance. Rotations of the handle, on its transverse axes, are accom- 
 plished in great measure 
 by turning the entire fore- 
 arm, though it is surprising 
 to what an extent trained 
 fingers can effect these 
 movements also. The 
 wrist- joint i.e., whole- 
 hand movement is called 
 
 FIG. 44.-In extraction right. j nt() requisition much less 
 
 often in ophthalmic than it is in general surgery. Upper-arm 
 movements are to be limited, but in no way restricted. 
 
 Detailed specification as to the exact manner of holding and 
 directing each of the in- 
 struments with handles 
 would, without practical 
 demonstration, be only 
 tedious and confusing. 
 More can be ascertained 
 relative to the grasp by 
 looking at the accompany- 
 ing illustrations, than by 
 written descriptions (Figs. 
 
 FIG. 45. In extraction left. 
 
 44 and 45). Besides, many points in the manipulations, peculiar 
 to individual operations, are given in connection with the technic
 
 u6 
 
 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 FIG 46. Fiddle-bow. 
 
 of the procedure as it occurs in the body of this book. For the 
 
 rest, the reader must look to other sources. 
 
 A word, however, as to the "fiddle-bow" method of holding the 
 
 scalpel, as shown in cut (Fig. 46). The name, while a little more 
 
 appropriate than that of "penholder" to the grasp in point, only 
 
 describes it in part. For 
 here the index is usually 
 placed on the upper side 
 of the handle, near the end 
 that carries the blade. The 
 pulps of the second and 
 third fingers are placed side 
 by side about midway of 
 the handle, on one side, 
 and the thumb on the 
 
 other side, just opposite. The little finger is best left free. This 
 
 mode is specially conformable to incisions that are made from left to 
 
 right, as regards the operator, or from right to left w r hen executed 
 
 with the left hand. 
 
 The handling of instruments other than those with handles is 
 
 also treated of further on, 
 
 where occasion demands. 
 
 The method of holding the 
 
 scissors is given elsewhere in 
 
 this chapter. A word here as 
 
 to turning them over while in 
 
 the hand. This is a maneuver 
 
 that is in frequent requisition 
 
 with curved scissors. The 
 
 index is removed from its 
 
 position with tip resting on 
 
 the pivot, and dropped back 
 
 tO place it Opposite the medius. FlG " 47--Manner of holding keratome. 
 
 These two serve then to hold the scissors, while the third finger and 
 thumb are removed from the rings. This is done in the order named, 
 and the third finger, on emerging, gives the ring that it just left 
 a push to turn it in the direction of the thumb; this, in turn, on 
 coming out, pushes the other ring toward the third finger, and the
 
 THE CARE OF INSTRUMENTS. 
 
 latter is at once inserted. The thumb is then put into the remain- 
 ing ring, and the tip of the index put back in its place on the pivot. 
 The handling of iris and capsule forceps is peculiar in that it 
 rests almost exclusively with the fingers (Fig 48). The pulps of 
 index and medius are placed on one branch, one at either 
 extremity of the roughened area, and the thumb in the middle 
 of the other roughened area. The jaws are advanced into the an- 
 terior chamber by a sort of pulling backward on the part of the 
 index and a pushing for- 
 ward on that of the me- 
 dius, the thumb being, 
 meanwhile, the pivot, so to 
 speak, on which the instru- 
 ment turns. In withdraw- 
 ing the jaws, precisely the 
 reverse occurs. This is 
 one place where the mid- 
 dle finger is called upon 
 
 FIG. 48. Manner of holding iris forceps. 
 
 for some fine work. 
 
 The Care of Instruments. First as to the receptacles in which 
 they are kept or in which they are carried. A great deal has been 
 said in ridicule and disparagement of the ornate cases, all lined 
 with silk and velvet; covered with morocco, and garnished with the 
 name of the owner in flourishes of gold, the idea being that they 
 were unfit for holding surgical instruments because of one's inability 
 to wash and scrub them; that they should be manufactured only 
 of materials that will bear being boiled or immersed in powerful 
 antiseptic solutions. Now, while it is true that those fancy things 
 are somewhat out of harmony with the recognized principles under- 
 lying modern surgery, it is, after all, really only a matter of taste 
 or fashion whether one keeps his instruments in boxes bedecked 
 with beautiful stuffs or in those of hard wood and metal unadorned. 
 The box in neither case is of itself antiseptic, nor are the instru- 
 ments presumed to be ready for use the moment they are taken 
 from the box. If the decorated box will not bear soaking in strong 
 antiseptic liquids, no more will the others. The silk and velvet 
 and the leather can be washed clean with naphta and disinfected 
 with formalin, and that is sufficient for any.
 
 1 1 8 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 Granting, then, that one is at liberty to choose the material for 
 his instrument cabinets and his instrument boxes, I, for one, would 
 select hard wood. The rarer and finer and harder the wood, the 
 better. A glass shelf or two might be allowed in a cabinet, but 
 there should be no grand array, flauntingly exposed to view in 
 plate-glass show-cases, suggestive of a pathologic museum. For 
 the most part, these should be made up of very shallow drawers, 
 of the same wood as the rest. The location of the drawers is such 
 that none is inconvenient because of being too near, or too far 
 from, the floor. Each drawer has its lock, and, in additions, a 
 device to prevent it from being drawn clear out of the cabinet. 
 In these, however, only the instruments in constant use should be 
 kept. For the handled instruments there would be racks of the 
 corresponding wood or of ebony, and each notch therein should be 
 fitted to, and set aside for some particular instrument, and the 
 different objects should be arranged according to their characters, 
 i.e., the retractors, the spoons, the hooks, the knives, he needles 
 each group shou d have its allotted space. The scissors and 
 straighter forceps would have their drawers and racks, and be 
 held in their places by delicate springs. The jaws of the forceps 
 w T ould be kept closed by the action of the spring that serves as a 
 rack. All articles, such as blepharostats, odd-shaped forceps, etc., 
 and those not easily damaged, would be loose in the drawers, or 
 in separate compartments therein. For the more particular odd 
 ones, their individual compartments in the drawers should have 
 hinged or sliding covers. There will always be a certain treasured 
 assortment to be guarded apart, to be spared the vicissitudes of 
 ordinary handling good new, or newly repaired, knives and 
 scissors and the like. And none shall be left in boxes standing 
 about for thoughtless ones to overturn or meddle with. Super- 
 posed trays, with racks, etc., are apt to be the cause of more harm 
 than of good to the instruments, by falling, tipping, jamming and 
 crushing. For transporting small selections of instruments for 
 appointed operations, at hospitals or other places, a series of small 
 boxes, each containing from one to four or five articles, is better than 
 putting all or any considerable number into one container. If 
 a box be let fall, or if one is lost, the consequent damage or loss 
 will, in this way, be minimized. The more delicate or more
 
 TO PROTECT FROM RUST. 1 19 
 
 valuable the instruments, the fewer in a box. Knives are placed 
 in the racks edge downward. An exception is made as regards 
 lace-knives, which are placed pointing to the left. These boxes 
 can be put together in a leather bag or, what is bet.er, stuck around 
 in the different pockets of one's clothing. The rounded nickel 
 boxes with racks, and holding springs projecting from the under 
 side o their lids are splendidly adapted to carrying in the pocket. 
 For the non-cutting instruments all that is needed is the plain 
 nickel box, with rounded corners i.e., without racks or springs. 
 A layer of absorbent cotton is put in first, then the instruments, 
 then enough cotton laid on top of them to prevent rattling about. 
 If forceps are put into such a box, each should have a section of 
 rubber tub ng slipped over its branches to keep its jaws closed. 
 Before boiling, the rubber must be removed, else a tarnished 
 streak will appear at the place it occupied. Also, in boiling, the 
 delicate ends of instruments should be wrapped in, or wound 
 with, absorbent cotton, to protect them from injury. All knives 
 should be clamped in racks before boiling. 
 
 To Protect From Rust. If steel instruments are put away dry 
 they seldom rust. Especially is this true of those that are kept in 
 dry buildings and of those in daily use. Such as are out of present 
 use or are being kept for any reason would better be given a coat 
 of cocoa butter, vaselin, or lard. This refers not only to the 
 plain steel instruments but also to those plated with nickel; for 
 steel in these is often exposed in places. A propos of nickel plating, 
 it should cover all steel instruments except the blades of knives, 
 the edges of scissors, and tjie jaws of forceps. The custom of 
 leaving it off iris forceps and a few others is inexplicable. After 
 using, these instruments are washed first with cool water to remove 
 blood, etc., then immersed in very hot water, and, lastly, wiped with 
 soft linen, then dipped in benzin or gasoline, and allowed to dry 
 spontaneously. This last process has the effect of leaving upon the 
 metal an insensible coating of oil which effectually prevents rust. 
 While it is no more than proper that the water should be sterile in 
 each instance, it is not necessary to use any antiseptic. These are 
 only or use preparatory to the operation. It need hardly be ex- 
 plained that the reason the instruments are not put directly into 
 the scalding water after being used is because blood, or other albu-
 
 I2O INSTRUMENTS AND THEIR MANAGEMENT. 
 
 minoid substances with which they are soiled would be thus coagu- 
 lated and made difficult to get off. 
 
 It has been asserted in many quarters that the process of boiling 
 both corrodes and dulls steel instruments. This is not borne out 
 by experience and observation. If one's experience is that his 
 instruments have suffered in this manner he has probably failed 
 to observe that it was due to something else than the mere boiling. 
 Most often it is because they have remained w r et for a time after 
 having been taken out of the sterilizer. Sometimes it is the result 
 of impure water used for the boiling. As an extra precaution 
 against rust, it is well to put a little bicarbonate of soda into the 
 water, 5 to 10 grains to the ounce. Of all the kinds of moisture 
 to which instruments are exposed, there is none more corrosive 
 than that from sweaty hands. Therefore, after handling only, it 
 were better if the article were washed in hot water and dried. 
 Wiping without previous wetting would not suffice to remove the 
 salts deposited on the metal from the evaporated perspiration. 
 Seeing, how r ever, that this will rarely be done, let it be urged, at 
 least, that they be thoroughly wiped. 
 
 Our instruments are put through hot water after cleansing with 
 the object of insuring rapid drying, and not that one may dispense 
 with the wiping of them. The drying is as essential as the washing, 
 and the time to do it is while the instruments are fresh and hot from 
 their bath. It is of special importance that attention be given 
 to all angles, joints, etc., to make sure that no moisture remains in 
 them. 
 
 Care of Points and Edges. The worst enemies of these are 
 careless and untrained attendants about hospitals and offices, and 
 conscienceless and unskilled workmen in the repair shops. The 
 first knock them about, rattle them together, and jab them into 
 things, and the second grind them out of all form and substance, 
 and deprive them of their temper or rightful hardness. Hence, 
 the less these persons are intrusted w r ith our sharp instruments, the 
 better off we shall be. Certainly, as concerns the more delicate 
 and responsible articles it were decidedly to the advantage of those 
 most interested, i.e., the patient and the operator, if the surgeon 
 himself took sole charge of their care and maintenance, even to the 
 sharpening of them. He who is not already schooled in such matters
 
 TESTING. 121 
 
 can usually acquire the requisite training without difficulty. If 
 he cannot be an expert, he can at least become enough of a dab. 
 
 Unless a knife or a needle meets with some accident, as a fall or 
 a jam, whereby the edge or the point is positively damaged, no 
 grinding upon them is ever necessary. They are then never dull 
 in a gross sense. All they need, even after having been repeatedly 
 used, is honing and polishing. These are best accomplished by 
 means of a fine strop and the best of rouge pomade. Pastes contain- 
 ing gritty substances, as, for instance, pumice or emery no matter 
 how finely these substances are powdered are ruinous, and ought 
 scrupulously to be avoided. If a point be broken or turned, or 
 if a blade be nicked, the proper remedy is cautious grinding on 
 a whet-stone of good quality, with the liberal use of vaselin or 
 cold water. The great desiderata are to obtain the maximum 
 of keenness or of trenchancy with the minimum loss of substance 
 and to preserve the correct model of the working part of the 
 instrument. 
 
 Testing. The most suitable material on which to test the degree 
 of sharpness of eye instruments is known as French trial kid. This 
 means the thinnest and most delicate tanned kid preferably of an 
 animal that has not gone to the full term of gestation and not 
 split goatskin nor the still more objectionable shagreen, which is 
 made from horses' hides. The instrument is commonly tested with 
 the kid stretched over a drum. I prefer to dispense with the drum 
 and manipulate the leather with the fingers The point of a knife 
 or a needle, to be right, must pass through the kid without a jog 
 or audible tick, and almost without sensible resistance. Kera- 
 tomes, bistouries, cataract knives, and knife-needles should have 
 their entire edges tried, from point to heel. In severing the kid 
 they should not emit a distinct sawing or ripping sound. This 
 indicates a too-pronounced serration, which is only appropriate to 
 the larger scalpels and to the grosser instruments generally. A 
 single puncture or incision is sufficient, as repetitions only result 
 in loss of harpness. 
 
 To try scissors they are closed down tightly, making a cut in the 
 kid, then removed from it with blades still closed. If the points 
 hang or catch the leather in the least the condition of the instrument 
 is faulty. Either there is dullness at the extremities of the blades
 
 122 INSTRUMENTS AND THEIR MANAGEMENT. 
 
 or else there is a tendency to fork. Both are bad, for the reason that 
 the very tips of the blades constitute in the scissors the only parts 
 that actually engage the tissues. Wantonly opening and shutting 
 scissors, when they are not in real use, is highly pernicious, as it 
 spoils their edges, produc'ng roughness and grating. This can be 
 made to disappear, when not too far gone, by passing the edge of 
 the thumb-nail or other smooth object of similar hardness along each 
 blade, pressing from the 'flat, or articulating side, toward the bevel. 
 
 A BALANCE FOR KNIFE TESTING. 
 
 SMITH, PRIESTLY, Birmingham (Ophth. Review, Aug., 1903), has 
 devised a simple instrument to determine by actual measurement the 
 pressure which we have to employ to cut or puncture the leather of the 
 test-drum. It resembles a see-saw in miniature. One arm of the beam 
 carries a small drum covered with the thin white kid (shagreen) sold for this 
 special purpose; the other is marked with a scale indicating grammes, 
 and carries a sliding weight which gives to the drum an upward pressure 
 varying from o to 18 grams. 
 
 To test the point of a knife the drum is placed in a horizontal plane, the 
 point gently pressed against the leather, and the weight moved until the 
 knife persistently punctures the leather instead of depressing the beam. 
 All punctures should be made in the transverse diameter of the drum so as 
 to be at the same distance from the fulcrum. 
 
 To test the edge, the drum is placed on edge, vertically, and the knife, 
 passed through a slit in the leather, is pressed downward without thrusting 
 or sawing. Using a given piece of leather for all, a number of knives may 
 be compared and placed correctly in order of merit. We can measure 
 the effect on a given knife of immersion in boiling water, of antiseptic 
 fluids, or of use, and compare various models of puncturing or cutting 
 instruments. 
 
 Good Graefe knives, new or newly sharpened, puncture at a pressure of 
 i to 2 grams. They cut at from 10 to 14 grams, and with a tight 
 leather some of them at 8 grams. As a rule, they cut more easily near 
 the point. Cataract needle-knives cut at 14 to 1 8 grams. Cystotomes, 
 new, punctured at 4 to 8 grams; resharpened, at 10 to 18 grams.
 
 CHAPTER III. 
 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 THE LACRIMAL APPARATUS. 
 
 Dilating the Punctum. Probes or sounds and the canulas of 
 lacrimal syringes up to one millimeter in diameter may be passed 
 through the undivided punctum by first stretching this opening 
 somewhat. The measure usually suffices to reestablish the 
 punctum when superficially closed. 
 
 The Most Suitable Instrument is the conical probe or stylet of 
 Landolt (Plate VIII, No. 100), a modification of Bowman's "di- 
 rector." The kinds commonly on sale by the dealers in surgical 
 instruments have cones that are too long, slender, and sharp. Their 
 excessive length and slenderness are objectionable because they 
 necessitate a maximum of entrance into the canal with a minimum 
 of dilatation of the punctum. The point of the excessively long 
 ones might bring up against the lacrimal fossa ere the stretching was 
 sufficient. Their sharpness of point is objectionable for the reason 
 that it is apt to wound the walls of the canal, causing false tracts, 
 etc. The cone, then, should not exceed two centimeters in length, 
 gradually tapering from a diameter of two millimeters at the shank 
 to that of one-third of a millimeter at the point. The latter should 
 be neatly rounded or, better still perhaps, have an olive-shaped bulb 
 whose greatest diameter could be one-third to one-half a millimeter. 
 Every eye surgeon, doubtless, has noticed with what facility a tiny 
 bulbous extremity on knife or probe will enter the punctum. The 
 dilator or stylet should have a handle to itself, i.e., not at one end 
 of a handle that it shares with another instrument at the other end. 
 These double instruments, of which a number have been made, 
 do not conform to correct ideas of modern aseptic surgery. 
 
 To Dilate the Punctum, the patient may lie on a table, but it 
 is better that he sit in a low chair. A towel is put over his hair. 
 The operator stands behind the chair for the lower puncta, and 
 offers his chest as a support for the patient's head. Supposing it 
 
 123
 
 124 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 is the right lower punctum, the left thumb is placed midway of 
 the lower lid, pressed down tight on the lower rim of the orbit to 
 slightly evert the punctum and put it on the stretch toward the 
 temple to resist the inward pull of the probe. This pressure by 
 the thumb helps also to steady the patient's head. The patient 
 is told to look upward, the probe, anointed with sterile vaselin, is 
 inserted vertically, then immediately turned to the horizontal and 
 pushed along the canaliculus till the dilatation is deemed sufficient 
 and thus held for a few moments. When the progress of the cone 
 becomes a little difficult, slight rocking of it on its long axis will aid 
 its further entrance. If syringing or probing is to follow the dilata- 
 tion, an assistant stands by, holding the lacrimal probe or syringe, 
 as the case may be. When it is time to withdraw the dilator, this 
 is resigned to the assistant, the operator takes the probe or syringe, 
 places the tip of the canula at the punctum, and, still holding the 
 lower lid down and out and patient looking steadily up, the as- 
 sistant withdraws the dilator, and before the opening has time to 
 contract, the canula or probe is introduced. Treatment of the 
 lacrimal canal with dilator and syringe will often result in closure of 
 the punctum within a very few hours because of the rawness and 
 fissuring induced about its rim. To prevent thi ; whenever practi- 
 cable during the early period of handling a smooth stylet dipped in 
 vaselin should be inserted a little way two or three times a day. 
 
 Probing the lacrimal canal is resorted to mainly for ex- 
 ploration and for rendering it patulous throughout. It should be 
 seen to that the tip of the probe is nicely rounded in no way sharp 
 nor angular. The latter are common faults with small probes. 
 
 FIG. 49. 
 
 The probes most commonly employed are those devised by Sir 
 Wm. Bowman nearly fifty years ago (Fig. 49). They consist of 
 three double-ended instruments, i.e., six probes, made of silver, 
 each bearing midway a shield to indicate the direction of any bend 
 or curve that may be given to the probe while in use. The shield 
 also bears the figures denoting the sizes. The diameters of those 
 of to-day are graduated by one-half millimeter from one-half up 
 to three millimeters.
 
 PROBES. 125 
 
 There are various other forms of the lacrimal probe, notable 
 among them the series devised and successfully managed by Theo- 
 bald, of Baltimore. It comprises sixteen instruments graduated 
 by one-fourth millimeters from one-fourth to four millimeters. 
 Most eye specialists do not avor those that exceed four or five 
 millimeters. Whether the upper or the lower route be selected 
 as the better way from punctum to sac would seem to be largely 
 
 a matter of individual choice. Much can be said in favor of either, 
 though the lower canaliculus is favored by the majority and is the 
 one now in question. Bowman's probes are always serviceable, 
 though i he bulbous tips go best (Fig. 50). 
 
 The writer 1 employs a series of gold sounds that he devised 
 several years ago, represented actual size in the accompanying illus- 
 tration (Fig. 51), and finds them both serviceable and easy of ma- 
 nipulation. Nos. i and 2 it was thought best to have made of ten- 
 
 A/ '9 2. 
 
 FIG 51. 
 
 carat gold, as this has greater s rength, hardness, and elastic ty than 
 the finer metal, to say nothing of the lesser cost; whereas, Nos. 3 
 and 4, being of larger size, and destined for other service namely, 
 only in cases where Bowman's operation has already been per- 
 formed are made of fourteen-carat gold. The working end of the 
 instrument is spindle-shaped and is surmounted at the tip by a 
 small guiding bulb whose diameter is considerably less than that of 
 
 1 American Journal of Ophthalmology, Oct., 1901.
 
 126 OPERATIONS UPON THE APPENDAGES OF THE EYE 
 
 the spindle. The diameter of the shaft is also much less than that 
 of the spindle, and owing to this fact the friction, instead of being 
 all the way along, is practically confined to the enlarged portion 
 only, yet the effect is that of a probe of the diameter of said en- 
 largement; hence, traumatism and discomfort are both minimized. 
 They are especially useful for systemic treatment, as for example, 
 of stenosis from swollen lining, from cicatricial bands, etc., since they 
 pass both backward and forward .through the narrow places with 
 great ease, and can be insinuated cautiously and certainly into such 
 places with the view to local dilatation. Indeed, one of the chief 
 advantages in the employment of these sounds is one's ability, 
 owing to the peculiar form of the instrument, to feel along, as it 
 were, for obstructions, and thus to locate and deal with them by 
 passing the spindle back and forth through thenv-a procedure not 
 possible with rigid sounds or those that are cylindrical and of uniform 
 or nearly uniform diameter throughout. 
 
 In the manufacture of these sounds the strictest attention should 
 be given to minute detail of form. To mention a few points, for 
 instance, the bulb on No. i and the entering or guiding bulb on 
 No. 2 should not exceed 3/5 millimeter in diameter, and both should 
 be neatly rounded. Then, where bulb joins spindle and where 
 spindle joins shaft, there should never be abrupt curve, but one 
 part should be made to pass into the other by almost insensible 
 degrees. The size of the spindle ranges from two-thirds of a 
 millimeter in diameter up to two millimeters. The bulbs, from 
 one-third to two-thirds of a millimeter, and the length of spindles 
 from five millimeters for the smaller, to eight millimeters for the 
 larger. The shaft, like the tips, varies from one-third to two- 
 thirds of a millimeter in diameter and is eight centimeters in length. 
 At the distal extremity is a flat shield or heart-shaped plate by 
 which one may always know the direction of the bulb after having 
 bent the shaft in any desired manner. As to the wire for the smaller 
 sounds, it cannot be too springy, but ought not to be of greater 
 thickness than 2/5 of a millimeter; that of No. i could well be just 
 short of that. The two smaller sounds are introduced without 
 previous dilatation of the punctum. No. 3 can be used only 
 after dilatation, whereas No. 4 is employed in cases where 
 Bowman's operation has already been performed. The one in
 
 PROBES. 127 
 
 the illustration marked "original sound" was made from the 
 temple wire of an old pair of spectacles, and it was this which, used 
 in an emergency, was the forerunner of this series of sounds. 
 The shield was put on to make it conform to the others, and it is 
 still of great use. Its original spherical extremity was made oblong 
 or olive, thus reducing its lateral diameter. 
 
 To pass the probe or sound through the lower canaliculus, 
 the punctum having been dilated or the canaliculus slit, as the case 
 may be, the position of patient, that of the operator and the holding 
 of the lid are the same as for dilating the punctum. The instru- 
 ment, previously greased with vaselin, is put into the punctum 
 vertically, then instantly depressed to the horizontal and pushed 
 along the canaliculus until the end is solidly against the lacrimal 
 bone. Here it is held snugly while the probe is again approached 
 to the vertical, hugging closely the brow, and pushed down into the 
 nasal or bony portion of the canal. It is well to remember that the 
 direction of this portion of the canal is downward and inward, so 
 that while hugging the inner wall of the lacrimal sac or bone with 
 the end of the probe, throughout the elevation of the shaft, the in- 
 strument should all the while be pushed down and in. Moreover, 
 the elevation must be stopped short of the perpendicular, else the 
 tip may tend to puncture the tissues outside of the lacrimal fossa 
 of the nasal duct (Fig. 52). It was formerly taught that the 
 bony canals inclined the probes in the opposite direction, and the 
 study of the openings as found in the average skull is in favor of 
 this theory. Actual demonstrations on the living subject prove 
 the contrary, notwithstanding, and there can be no question that 
 the passing of the probe into the nasal duct is facilitated by holding 
 to this view. Whereas he who adheres to the opposite belief and 
 inclines his probe to, or beyond, the median line, on elevating it 
 will find greater difficulty and will be more apt to poke the in- 
 strument down into the orbit or somewhere external to the lacrimal 
 fossa. 
 
 Where there has been inflammation of the canal, there is most 
 apt to be an abnormal constriction just where the canaliculi meet. 
 This may be so tight and solid as to cause the belief that the probe 
 has reached the inner wall of the sac and is ready to descend, which 
 would result in a "false passage." Therefore, when the horizontal
 
 128 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 progress of the probe is stopped, if it feels as if it were against a 
 springy cushion or anything yielding, particularly, if on watching 
 the inner commissure of the lids, it moves with the probe it has 
 not entered the sac and the lid should be lightly drawn outward 
 
 FIG. 52. 
 
 and the probe forced, with a drilling and oscillating motion, till it 
 brings up solid and firm before elevating. If a reasonable trial of 
 these means is not attended with success, it will be necessary to 
 introduce the smallest probe-pointed knife and push it through the
 
 THE LACRIMAL CANAL. 1 29 
 
 stricture. (For method, see Bowman's operation.) To withdraw 
 the probe, pull up and out until the tip has reached the sac, then 
 depress to the horizontal and finish. 
 
 Threading the Lacrimal Canal. This refers to what is said to 
 be an effective manner of treating persistent dacryocystitis and various 
 forms of stenosis of the canal, reported to the Ophthalmolcgical 
 Society of the Netherlands, meeting of 1907, by Prof. Koster. 
 This surgeon passes a silk thread through the entire lacrimal tract, 
 makes a knot at the upper end, or disposes of it by sticking it to the 
 skin of the lower lid to keep it from entering the canal, coils the 
 lower portion and leaves it in the nose. For the insertion of the 
 thread he employs a series of hollow probes, of different sizes, each 
 having a solid probe that passes easily through it. The latter has 
 an eyelet at its distal extremity. The canaliculus is slit open. The 
 hollow member is passed into the canal until its lower end rests 
 on the floor of the nose, then slightly withdrawn. The thread is 
 put through the eyelet of the solid member, and this is in like manner 
 passed and left with its threaded end touching the floor of the 
 nose. A small blunt hook is used to draw the thread out of the 
 inferior meatus. The thread is now held while both the solid 
 and the hollow probes are pulled out. By partially withdrawing 
 the thread and treating it with remedies, it is made to serve as the 
 medium for their application. The silk is left in situ for weeks 
 or even months, if need be. Here one could probably find a sure 
 preventive of the persistent and rapid closure of the punctum 
 referred to, and avoid frequent opening with probe or stylet, but 
 it would be desirable to pass the thread through the undivided 
 punctum. In this case the canula might be dispensed with and a 
 very small probe with an eyelet to carry fine thread say size o or i, 
 be used alone. 
 
 Syringing the lacrimal canal is indicated for nearly all phases 
 of acute and chronic catarrhal and suppurative diseases to which 
 it is subject. Indeed, eye specialists in general are pretty well 
 agreed that the syringe furnishes the best means for the conservative 
 handling of these affections. 
 
 There are several forms of syringe employed for the purpose, 
 mostly some modification of the old Anel model. The illustration 
 (Fig. 53) shows one which my colleague Wilder and I planned and 
 
 9
 
 130 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 had made for the staff of the Illinois Charitable Eye and Ear In- 
 firmary, as well as for our private use. The cylinder is of glass 
 with fenestrated metal casting of nickeled brass. The advantages of 
 a cylinder that enables one to see its contents are obvious. The 
 piston-head is packed with asbestos or rubber to admit of boiling, 
 and is made to fit tight or loose by turning the handle. The canulas 
 are made to shove, not to screw on and are of three forms. One, 
 conic, for forcing melted paraffin or other liquid, as emulsion of 
 plaster of Paris or starch, into the sac to facilitate extirpation. One, 
 large silver canula for use after the canaliculus has been slit, 
 the invention of the late H. O. Tansley, of New York. This has 
 
 FIG. 53- 
 
 a blind tip, but its sides are perforated with a number of tiny open- 
 ings for a distance of one and a half to two centimeters therefrom. 
 Lastly, two small silver ones for the unopened canaliculus, of 
 equal diameter, but different as to length. The tips of all are made 
 smooth and rounding. The rings of the old model are left off both 
 barrel and piston and, instead, the head is made projecting or flange- 
 like, to afford a finger purchase and of hexagonal or octagonal shape 
 to prevent rolling when laid down, while the handle is in the form 
 of a button. The glass cylinder is fitted at either end with a soft- 
 rubber washer held tightly by screwing down the heads of the metal 
 casing. The Tansley canula is a most valuable adjunct in cases 
 where Bowman's incision has been made, as it performs the 
 office of a probe as well as that of a catheter. By its closed tip the 
 injected liquid is made to wash or bathe the sides or lining of the 
 canal, instead of being shot straight through into the nasal cavity. 
 Having been once introduced, it may be left in position while the 
 syringe is disconnected and refilled as many times as are desirable
 
 THE LACRIMAL CANAL.
 
 132 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 for thorough irrigation. One must be careful not to push the nozzle 
 of the syringe too forcibly into the hollow cone of the canula for 
 such treatment, as they cannot be readily separated. The Tansley 
 attachment- is best made with a light curve and with a shield or 
 facet on the socket to indicate its direction. Every bent canula 
 should have such a guide. 
 
 To Syringe the Lacrimal Canal when the Punctum is 
 Intact. The positions of surgeon and subject are the same as 
 for probing. The first step is dilatation with the conical stylet. The 
 assistant stands ready with the loaded syringe fitted with one of the 
 smallest canulas. The exchange of instruments is made as described 
 under " Dilatation"; the operator lays the barrel of the syringe across 
 the patient's nose so as to point the right-angled curve of the canula 
 perpendicularly, or nearly so, at the punctum. The syringe is held 
 between the first and second fingers of the right hand (for the 
 right eye) placed beneath the ring on the barrel, while the thumb is 
 ready on the piston. It is well to start with such a grasp of the 
 syringe that it will not be necessary to make any change therein, 
 on account of the position of the fingers or the direction of the 
 canula, until it is emptied. As the stylet leaves the punctum, the 
 tip of the canule is slid in, at the same time the whole instrument 
 is elevated, watching that the point does not slip out and holding 
 the lid slightly everted and stretched toward the temple throughout 
 (Fig. 54). Now the patient is made to lean slightly forward, to pre- 
 vent the injection from running into the throat, and the piston is 
 pressed slowly and steadily down (Fig. 55). If there is a feeling of 
 undue resistance to the descent of the piston, either there is stenosis 
 of the canal or the opening of the canula is engaged in a fold of the 
 lining membrane. It is unwise, even dangerous, then to force 
 matters, as to do so one risks the rupture of the canal wall and 
 driving the liquid, together with infective secretions, into the sur- 
 rounding tissues and exciting suppurative cellulitis, with all its dire 
 consequences. In this event it is best slightly to withdraw the tip 
 and see that the guide is right before proceeding. 
 
 Lacrimal Stenosis of Infants. It is not uncommon to find 
 epiphora and mucocele in the newly-born and in older infants. The 
 obstruction is usually in the nasal duct itself or at its outlet into 
 the lower meatus. Fortunately, these cases yield much more readily
 
 THE LACRIMAL CANAL.
 
 134 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 to treatment than do similar affections in older subjects, but the 
 remedial measures should be instituted as early as possible. Often 
 the closure is merely epithelial, and a single passing of the olive- 
 tipped gold sound, described on page 125, will suffice to effect a cure. 
 It is necessary, of course, to pass the sound all the way down till 
 it enters the nasal cavity. This can be accomplished in most 
 instances under local anesthesia, after first dilating the punctum 
 and holding the child's head between one's knees in the regulation 
 manner. Sometimes a few syringings with a mild antiseptic 
 solution will be needed after once the sound is passed. 
 
 Bowman's Operation; Incision or Slitting up of the Can- 
 aliculus. The objects sought in this procedure are the evacuation of 
 an abscess of the lacrimal sac that threatens to break externally, the 
 relief of congenital atresia or stenosis from traumatism or inflamma- 
 tory processes, foreign bodies, such as short hairs, fragments of 
 the beard of grain, and the so-called dacryoliths, or "tear-stones," 
 in the canaliculi, and rarely, the dislodgment of a foreign body 
 that has entered the lower orifice of the nasal duct; to make prac- 
 ticable the employment of the larger probes and of thorough cathe- 
 terism and for curettage of the sac. Yet other indications are 
 sometimes found, such as eversion of the inferior punctum and new 
 growths. 
 
 There are three good reasons why an abscess of the lacrimal 
 sac should not be permitted to rupture through the overlying in- 
 tegument the obliterating adhesion, the ugly scar, and the hazard 
 of a fistula. 
 
 The operation is not made so often as it formerly was, for the 
 reason that the use of the syringe for treatment of ordinary dacryo- 
 cystitis has largely supplanted the method of systematic and 
 progressive probing that was once so poular. But a single instru- 
 ment is required, viz., some one of the various modifications of 
 the Weber canaliculus knife. Agnew's (Plate I) is the one 
 preferred by the writer. Its probe point has not the long, slender, 
 easily broken neck of the Weber model. The edge of its blade is 
 slightly convex, which gives better cutting power than if it were 
 straight, and it has a long shank of tough, malleable iron that can 
 be bent to meet the exigencies of an overhanging brow. 
 
 Cocain or any local anesthetic is of little value for the opera-
 
 BOWMAN'S OPERATION. 135 
 
 tion unless previously injected deep into the canal, and it hardly 
 justifies the use of general anesthesia. Previous dilatation of 
 the punctum is unnecessary and only adds to the patient's 
 discomfort. 
 
 The operation upon the lower canaliculus, the one usually 
 chosen, is performed with patient and operator in positions described 
 for passing a lacrimal probe, and the method is much the same. 
 Given the right, lower canaliculus to incise, for instance, the napkin- 
 covered head of the patient is pulled back and pressed against the 
 operator's chest. The contents of the sac are expressed when 
 possible. The knife is held in the right hand. The left thumb is 
 laid heavily on the right cheek or malar bone, for the three-fold 
 purpose of slightly everting the lower lid, stretching it tightly toward 
 the temple, and fixing the patient's head. An assistant holds the 
 patient's hands and he is requested to look upward during the entire 
 operation. The knife is inserted vertically at the punctum, then 
 lowered to the horizontal, with the edge looking upward and back- 
 ward. Having proceeded thus far, it is good practice to pause for an 
 instant, see that the position of the blade is just right, take a firm 
 hold upon the handle, bear hard outw r ard on the lid, to make taught 
 the canaliculus, push the knife straight inward until the point stops 
 against the inner wall of the sac, then, while holding it there, 
 bring up the handle, hugging the brow, through an arc of ninety 
 degrees or more, owing to the length of the cut. The plane of 
 the incision, instead of being vertical, is inclined toward the operator. 
 The extent of the incision must be regulated by the peculiarities 
 of the case or the end to be attained. If this be to admit of the use 
 of somewhat larger probes or canulas than can be readily passed 
 through the normal punctum (a la de Wecker) the length of the cut 
 need not exceed three or four millimeters; in other words, an enlarge- 
 ment of the punctum. If a greater opening is desired, the incision 
 may extend to the caruncle. According to v. Arlt, this means 
 about three-fifths of the length of the canaliculus, or it may reach 
 the common duct. In no case, unless for phlegmon of that cavity, 
 is it advisable to extend a free incision into the sac for fear of per- 
 manently disabling the internal canthal ligament. If it is desired 
 to pass the knife through the whole length of the lacrimal canal, 
 as the handle nears the vertical the edge of the blade is turned slightly
 
 136 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 toward the front and pushed down into the bony portion, as per 
 the directions just given for probing. The knife is brought out and 
 the operation is finished. 
 
 As the tendo oculi lies in front of the lacrimal gland, it is quite 
 practicable to pass the blade through the sac and nasal duct, in 
 order to divide strictures without seriously, or at all, wounding 
 it, provided the edge is not turned too much forward. In the hori- 
 zontal progress of the knife through the canaliculus, the anatomy of 
 the parts must be borne in mind, i.e., that the anterior half of 
 the lacrimal fossa belongs to the superior maxilla and is thick and 
 firm, while the posterior half belongs to the thin, yielding lacrimal 
 bone. Hence, if the blade were thrust inward with great force, 
 unless it were directed toward the anterior half of the fossa, it 
 could perforate the bone and enter the nasal cavity. 
 
 Stilling's practice of multiple division of strictures of the deeper 
 portions of the canal, for which he designed the knife that bears 
 his name, has been supplanted by systematic and graduated probing. 
 Stricturotomy, as a prelude to forced dilatation of both the mem- 
 branous and the bony portions of the lacrimal canal, however, is 
 still extensively practiced. 
 
 The correct location for the slit is in the posterior superior wall 
 of the canaliculus, hence the necessity for directing the knife with 
 edge slightly backward. Were it along the top or superior wall, it 
 would be unsightly and, worse still, the function of this part of the 
 canal would be destroyed. Even when placed in the most favorable 
 position possible, be it long or short, this incision greatly interferes 
 with the drainage of the conjunctival sac. The suction of the 
 lacrimal sac, caused by the alternate contraction and relaxation 
 of the orbicularis and Horner's muscle, through nictitation, is 
 spoiled by the slit, and this alone is a frequent cause of epiphora. 
 The fact that gravity puts the burden of draining of the conjunctival 
 sac mainly upon the lower canaliculus is a strong argument in 
 favor of slitting the upper one and preserving the lower whenever 
 practicable. 
 
 Should the surgeon prefer to wield the knife with the right hand 
 for both eyes and the left canaliculus is to be divided, an assistant 
 stands behind the patient to hold the head, and the operator in 
 front. Otherwise it is behind for the right eye and in front for
 
 BOWMAN'S OPERATION. 137 
 
 the left. The rest of the method is the same as for the right eye, 
 save, of course, that the inclination of the cut is away from the 
 operator. In making the operation upon either of the upper 
 canaliculi, as also in dilating and probing them, the surgeon's 
 position, be he ambidextrous or not, is in front of the patient, for 
 both eyes. It goes without saying that the inclination of the 
 blade or the position of the slit is here backward and downward. 
 
 Bandaging is not required after slitting of the canaliculus. 
 The subsequent care of the case comprises merely bathing with 
 very hot water or antiseptic washes and the appropriate use of sound 
 or syringe. 
 
 Removal of a triangular section of the posterior wall of the 
 lower canaliculus, as first practised by Critchett, of London, for 
 eversion of the punctum, with epiphora, seems to have fallen into 
 disuse. This consisted, first, in slitting up the canaliculus as far as 
 the caruncle, in the usual way. Second, a vertical snip with scissors, 
 extending down two or three millimeters from the punctum, on the 
 inner aspect of the lid. Third, the joining of this with the inner 
 end of the first incision, or the resection of the triangle thus formed. 
 The idea was that the secretions of the eye would thus be provided 
 with an open drain. In effect, it proved to be a delusion, as lacrimal 
 drainage is not accomplished through gravity. Moreover, such a 
 piling up of conjunctiva! growth took place about the site of the 
 operation as to effectually block any sort of outflow. Arlt pro- 
 duced a form of epicanthus to relieve epiphora in cases of eversion 
 of punctum where the orbicularis was paretic. 
 
 In closing this subject, there is one injunction the observance of 
 which cannot be too strongly insisted upon, viz., as a rule, avoid the 
 use of the syringe immediately after that of the probe or knife. This is 
 to prevent the unpleasant or serious results of forcing the injected 
 liquid into the cellular tissue. This rule may be departed from in 
 cases that are familiar because of a number of previous probings 
 where the passing of the instrument has been such as to insure 
 freedom from traumatism, but the syringing should be done very 
 cautiously. When probe and syringe are both to be employed in 
 a given case, if practicable, the probe should follow the syringe. 
 If not, it were better to let at least twenty-four hours elapse be- 
 tween the two acts.
 
 138 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 Incisions of the anterior exterior wall of the lacrimal 
 sac have been made in cases of dacryocystoblenorrhea, for curet- 
 ment, as when that portion of the tractus is filled with granulations, 
 to give access to the cautery for its obliteration, and for the evacua- 
 tion of pus in phlegmonous inflammation. Opening of the anterior 
 wall of the sac is done after the following manner: for the right 
 side an assistant holds the patient's head, as in slitting the upper 
 canaliculus. The operator stands in front. The third finger of 
 the left hand is placed on the skin at the outer commissure of the 
 lids and the palpebral fissure is stretched outward, while, with the 
 index, the tendo oculi is located. A sharp bistoury or Beer's 
 knife is held penholder fashion in the right hand, edge downward. 
 The point is placed just beneath the middle of the inner canthal 
 ligament, with the handle leaning slightly toward the temple. 
 The blade is then pushed back, in, and slightly down, until the 
 point touches the bone at the posterior wall of the sac. The knife 
 is now withdrawn, extending the outer wound slightly downward 
 and outward, taking care not to cut the posterior wall of the sac. 
 The incision may be extended to any desired length, by means of 
 a blunt, curved bistoury, blunt scissors or even a Weber canaliculus 
 knife. For upward lengthening, scissors are preferable, the outer 
 blade being placed beneath the tendo oculi and the inner one, in the 
 sac. To get at the interior of the sac, the wound is held open by 
 retractors, the Miiller Speculum, or simple strabismus hooks. 
 
 There is apt to be considerable hemorrhage, so much, in fact, 
 that where the sac is to be obliterated by the cautery, many opera- 
 tors have chosen to make the operation in two sittings. At 
 the first the opening is made, the cavity packed with gauze, 
 dressing applied and left thus for twenty-four hours. At the 
 second, the cautery. In this way the walls of the sac are dry and 
 in the best possible condition for the finishing process. One may 
 choose between the thermic cautery as the galvano or Paquelin 
 and the chemic, as the nitrate of silver or mitigated stick. 
 
 Relatively few modern surgeons, however, have recourse to the 
 incision of the anterior exterior wall of the lacrimal sac, preferring 
 extirpation for the first two conditions and the slitting of the canal- 
 iculus for the third. This last demands a complete section from 
 punctum to sac or, at least, to the common duct and, in addition,
 
 SEALING OF THE PUNCTA. 139 
 
 the subsidiary passage of the knife through the nasal duct, as al- 
 ready described. This is followed by expression of the pus by way 
 of canaliculus or nose. Agnew, of New York, preferred the canal- 
 iculus or conjunctival incision to the external or cutaneous one, 
 even to get at the sac, for its obliteration. Others, as A. Tersen 1 
 for example, for curettage of the sac, first slit the upper canaliculus 
 and then made use of his slender, curved, fenestrated curet (Fig. 
 56). Many and valid objections to this sort of treatment at once 
 present themselves. 
 
 FIG. 56. 
 
 The immediate after-treatment consists in frequent bathing with 
 hot water. The water is previously boiled and is applied as hot as 
 can be tolerated by the skin by means of pieces of gauze or wads of 
 absorbent cotton. The patient sits erect and holds beneath his 
 chin a bowl, containing the water, which he dabs on continuously 
 for only a few minutes at a time. There can be no objection to 
 making the liquid into a mild antiseptic solution. After twenty- 
 four to thirty-six hours, daily or twice-daily syringing is begun. 
 For this the Tansley blind-ended canula and a twenty-five to fifty 
 per cent, solution of argyrol are most commendable. 
 
 Sealing of the puncta, by touching them with the electric 
 cautery, in cases characterized by discharge from the lacrimal 
 canal as a preliminary to such operations as extraction and iridec- 
 tomy is sometimes done. After the danger of infection has passed, 
 if the openings are not re-established by sloughing out of the eschar, 
 dilatations with the stylet of Landolt may be instituted. Haab once 
 advised, for the above purpose, inserting a slender electrode into 
 the canaliculi for a distance of five or six millimeters and searing 
 the mucous membrane. Rather a drastic step unless attended 
 with extirpation of the sac, in which event it would serve to make 
 the operation complete. 
 
 Ligation of both canaliculi, first proposed by Quackenboss and 
 later by Buller, 2 of Montreal, or of the common duct, as practised 
 
 1 Bull, et Mem. Soc. franc, d'opht., 1893. 
 3 Montreal Med. Jour., Mar., 1902.
 
 140 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 by the writer, preparatory to operations that necessitate opening of 
 the eyeball is, perhaps, next to the radical procedure of absolute 
 removal of the sac and the fiery obliteration of the canaliculi, the 
 best means of preventing infection from the lacrimal canal. Some 
 operators advise tying of each canaliculus separately, but a single 
 ligature applied to both is better. It is advisable, for example, 
 when extraction is to be made and there exists a state of the tear 
 passage that would endanger the result and which, from lack of 
 time, the patient's consent, or other cause, it would be impracticable 
 to remove. The time for the operation is the moment preceding 
 the extraction, and it is performed in the following manner: the 
 contents of the sac and canaliculi are thoroughly expressed. The 
 canal may be syringed with a mild antiseptic w r ash. Wood, of 
 Chicago, mentions having previously injected a solution of argyrol, 
 letting remain what would. Two No. i Bowman probes are 
 passed into the sac one through the upper, the other through the 
 lower canaliculus and held there by an assistant, as guides. They 
 are held somewhat apart, so as to mark the outermost bounds of the 
 canal above and below. A half-curved needle of small dimensions, 
 armed with No. 2 or 3 silk thread is passed in just below the lower 
 probe, and close to the inner canthus, deep enough to clear the union 
 of the canaliculi at the back, and out just above the upper probe, 
 and securely tied. The fibres of the tarsal ligament are necessarily 
 included, and so much the better, as they assist in the compression 
 of the canal. Braided silk thread, boiled in paraffin, makes a 
 more suitable ligature than cat- or silkworm gut, as it is not so harsh 
 and irritating to the skin and does not work loose. It is best not 
 to leave it double, i.e., both strands in unless it is doubled and 
 twisted after having been put through the eye of the needle. The 
 ligature may be removed in four or five days or after sufficient 
 healing of the corneal section. If there is any resulting stenosis 
 of the canal, which is not likely, it can be relieved afterward by 
 dilating the punctum and passing a small, olive-tipped probe. 
 
 Electrolysis of the Nasal Duct. We all have cases of epiphora 
 in which the chief or sole obstruction to drainage is an obstinate 
 stenosis of the bony portion of the canal. Usually, by applying 
 great force, a small probe will pass into the nose, but each time it 
 is almost like making an opening through bony tissue. Stricturotomy
 
 EXTIRPATION OF THE LACRIMAL SAC. 14! 
 
 is useless or worse. Here is where electrolysis finds an application. 
 Indeed, we have here a form of operative treatment that will often 
 enable us to relieve obstinate epiphora, and in a surprisingly short 
 time, when nothing else would be of any avail. The toughest 
 strictures seem to melt like wax before the electrically charged sound. 
 For a description of the method and the instrument, I here give a 
 translation from Baudry. 1 
 
 "Preliminary Dilatation of the Lower Punctum with the 
 Conical Stylet. An antiseptic injection is useful to disinfect the 
 field of operation. A convenient supply of electricity is necessary. 
 The electrolytic sound of Lagrange (Fig. 57), Xo. i or 2, is passed 
 into the nasal canal. The upper part of this sound is covered with a 
 
 FIG. 57. 
 
 casing of non-conducting material, to protect the canaliculus and 
 sac, while the lower portion, uninsulated for a distance of two 
 centimeters, is in contact with the nasal canal. The sound is 
 connected with the negative pole of a battery furnished with the 
 galvanometer aperiodique (of Chardin) or any practical one, the 
 positive electrode being inserted, wrapped in a wad of cotton, satu- 
 rated with salt solution, in the inferior meatus of the nose, and held 
 immovable. The current is regulated by a rheostat (Bergonie's is 
 mentioned}. The current passes slowly and steadily from noughts 
 up to 5 milliamperes, remains at this for three to five minutes, 
 then returns again by insensible degrees to noughts. 
 
 These sittings, which are not at all painful, are repeated two, 
 three, or four times, according to the case. As soon as the sound is 
 removed, anther antiseptic injection is made." 
 
 Extirpation of the Lacrimal Sac. This is a comparatively 
 recent surgical measure. True, nearly two hundred years ago 
 Planter tried an excision of the sac combined with an attempt to 
 establish a permanent fistula connecting the conjunctival sac 
 
 '"Technique Operatoire," 1902.
 
 142 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 with the nasal cavity, a form of operation that has been recently 
 revived. Little was done in the way of actual removal of the sac, 
 even following Berlin's important paper on the subject at the 
 Heidelberg Congress of 1868, till within the past 25 years. During 
 this period the procedure has gained advocates in a sort of arithmeti- 
 cal progression. There are two routes by which the sac is got at, 
 one by way of the conjunctiva, or the mucous, the other by way 
 of the skin, or the cutaneous. In the last decade the first has 
 practically given way to the second. 
 
 Mucous Route. Probably a fair representative of this class is 
 the method of Van Hoffmann, contributed to the Heidelberg 
 Congress of 1896. The first step consists in slitting up, after 
 Bowman, of both canaliculi, which are then carefully dissected out 
 their entire length, or as far as their common duct. The loosened 
 canaliculi are grasped by broad-jawed forceps and drawn forward, 
 while the incisions made in slitting them are joined by separating 
 skin from conjunctiva around the inner canthus. This makes an 
 opening from punctum to punctum, or one about 12 mm. long. 
 Through this one works carefully inward, between canthal ligament 
 in front and Horner's muscle behind, to expose the body of the sac. 
 Having freed this front and back, it is pulled downward and the 
 dome is dissected around. The whole is then pulled out at the 
 wound, while, with blunt dissection, the sac is loosened from its 
 bony bed. Lastly, when only the nasal portion remains fast, this is 
 severed with small blunt-pointed scissors, as low down as possible, 
 strong traction being meantime made upon the sac. The only 
 points claimed in favor of the mucous route are freedom from 
 excessive bleeding, and absence of visible scar. When one con- 
 siders how little these figure in the most approved cutaneous route, 
 and puts this against the difficulties and inconveniences of the 
 mucous route, the advantages are mainly on the side of the former. 
 
 Cutaneous Route. The form of extirpation here alluded to 
 is that first done by von Graefe, in which the sac is removed 
 without intentional incision of its walls, except at the entrances of 
 the common and the nasal ducts, and is, by the writer at least, 
 preferable to that form by which the anterior wall is opened before 
 dissecting out is begun. Seeing that, in order to be most com- 
 plete and successful, not only the sac, but also the canaliculi and the
 
 INDICATIONS. 143 
 
 lining of the nasal duct should be removed, the operation would 
 better be called "extirpation of the lacrimal canal." 
 
 There is considerable diversity of opinion among ophthalmic 
 surgeons both as to the indications for this operation and as to 
 its gravity. The elder Knapp, 1 for instance, considers it too radical 
 a measure to be resorted to unless other modes of treatment have 
 failed. Among these he even numbers the repeated openings of the 
 anterior wall and thorough cauterization extending over weeks 
 and months because they are less terrible to the patient and freer 
 from the dangers of suppuration and orbital cellulitis. Whereas, 
 the younger Knapp 2 considers the operation much less formidable 
 and resorts to it often, as in chronic suppuration of the canal that 
 does not yield readily to antiseptic treatment in recurrent abscess, 
 in dilatation of the sac, whether the contents can be expressed or 
 not, and in lacrimal fistula. The operation is undoubtedly grow- 
 ing in popularity, and the indications for making it are broadening 
 more and more. It may be confidently asserted that it affords the 
 quickest, surest and most satisfactory means of curing most of the 
 really bad chronic cases. 
 
 Indications. Among these may be classed all those trouble- 
 some affections of the lacrimal passage in which more conservative 
 methods either cannot or may not be effectively carried out, such as 
 
 1. Chronic dacryocystitis with mucocele and excessive distention 
 of the sac. 
 
 2. Chronic suppuration of the canal with recurrent, phlegmonous 
 inflammation, or caries of neighboring bony structures, or fungosi- 
 ties, and with or without fistula. 
 
 3. Incurable obliteration of some portion, as of the nasal duct, 
 through disease or traumatism, with troublesome epiphora. 
 
 When the status, as per either of the first two classifications is 
 present, some form of quick riddance, either by obliteration or 
 extirpation, becomes imperative under the following conditions, 
 viz. : (i) If an operation that necessitates the cutting into the globe, 
 wounding of the cornea, or opening of Tenon's capsule is demanded 
 for the eye which is involved, as, for examples, extraction, pter- 
 ygium, strabismus and enucleation. (2) If there exists, on the side 
 
 1 Norris and Oliver, " System," pp. 902 and 903. 
 
 2 Arch, of Oph., July, 1903.
 
 144 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 of the diseased lacrimal passage, a defect of the cornea that renders 
 it peculiarly vulnerable to infection, such as an ulcer, a cystoid 
 cicatrix, or partial staphyloma. (3) If the patient is or is soon to 
 be so circumstanced that prolonged conservative treatment is out 
 of the question. 
 
 Extirpation is usually done under complete narcosis, though I 
 have frequently made the operation without an. anesthetic, with 
 comparatively little inconvenience to the patient and very decided 
 advantage to the operator. Anesthesia, by the Schleich process I 
 do not approve of, for it interferes with that nice differentiation of 
 tissue that is one of the greatest requirements for the success of 
 such surgery. Cocain solution put into the opening is useless 
 for the relief of pain, and worse than useless because of its effect on 
 the blood-vessels. 
 
 Following the lead of those who inject solidifying solutions into 
 the sac I have, in a few instances, tried with satisfaction the filling 
 of the sac with melted paraffin (Wilder) that congeals at a temperature 
 considerably higher than that of the body say at 110 to i2oF. 
 To obviate too free entrance of the paraffin into the nose and throat 
 it should not be too hot, but somewhat thick like cold molasses. 
 Where degenerative changes in the wall have not been too great, 
 the difficulties attendant upon the shelling out of sac are appreciably 
 lessened by having it thus made into a firm tumor. One of our 
 internes, recently serving in the Illinois Eye and Ear Infirmary, 
 Dr. Fullenwider, suggested the use of fine, dental plaster w r hich 
 seems to answer yet better than the paraffin. Those substances, 
 the paraffin melted (previously boiled) and the plaster, made into 
 a thin emulsion with sterilized water to which a little salt is added, 
 are injected through the dilated punctum by means of the syringe 
 described on page 129, using the conical canula. C. R. Holmes, 
 of Cincinnati, uses a thick paste of starch colored with iodin, and 
 Valude, of Paris, has recommended spermaceti. One must be 
 careful not to use undue force in the performance, else a rupture 
 will occur and the material be driven into the adjacent tissues. 
 Should this occur in the use of a non-absorbable material and steps 
 be not at once taken to remedy, either a permanent deformity or a 
 subsequent operation will be the result. Therefore, if the surgeon 
 is aware of such an accident before closing the external incision,
 
 PREPARATION. 
 
 145 
 
 the material should be dissected out. The patient should be prone 
 upon his back and all ready for the operation of extirpation. The 
 inferior nasal meatus is tamponed with vaselined cotton to prevent 
 blood or other fluid from entering the nose, throat, and larynx. 
 
 All pus or other fluid is first thoroughly expressed from the sac and 
 canaliculi, the cavity washed out and the liquid again expressed. 
 If paraffin is put in, it is then hardened by applying crushed ice or 
 
 FIG. 58. Broeckaert paraffin injector. 
 
 a cooling spray, as of chlorid of ethyl, to the overlying skin. If 
 plaster, a few minutes is given for it to set. This throwing in of a 
 hardening substance serves to make a mould not only of the sac, 
 but also of the canaliculi, and does away with the need of inserting 
 probes for purposes of orientation. Probably a less uncertain 
 method of filling the sac, and one as well calculated to facilitate the 
 extirpation, is that of Jocqs, of Paris, which consists in making a 
 small opening in the anterior wall as soon as the sac is reached and 
 packing the entire organ with absorbent cotton. Another feasible 
 plan is to fill the sac with cold paraffin, of relatively low melting-
 
 146 
 
 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 point, by means of one of the powerful injectors made for that 
 purpose (Figs. 58 and 59). 
 
 One of the good points mentioned by Czermak in this connection 
 is the occlusion of the lids during the operation in purulent cases 
 with strips of adhesive plaster. He reasons thus: through the 
 action of the retractors in holding open the wound, the palpebral 
 fissure gapes, the corneal epithelium dries and exfoliates or cracks, 
 
 and discharge from the puncta coming 
 in contact with it might result in 
 serious infection. This, of course, 
 would prevent the use of probes 
 passed into the sac as guides. 
 
 Anatomical Notes. The inferior 
 nasal quadrant of the orbital rim is 
 formed by a sharp ridge on the nasal 
 process of the superior maxillary bone. 
 Midway of this ridge is a prominent 
 convexity which is the anterior lacrimal 
 crest. Immediately behind this is the 
 lacrimal groove or that portion of the 
 lacrimal fossa belonging to the supe- 
 rior maxilla. The other, or posterior 
 part of the fossa, is formed from the 
 delicate lacrimal bone, and is bounded 
 at the back by a slight ridge the 
 FIG. 59. Beck-Mueller paraffin posterior lacrimal crest. The fossa 
 
 ends below in a short, round bony 
 
 canal, leading to the inferior meatus of the nose. Fossa and canal 
 lodge, respectively, the lacrimal sac and the nasal duct (see 
 Fig. 60). A sharp oval is marked on the drawing to show the 
 place of attachment of the anterior branch of the tendo oculi, or 
 internal canthal ligament. This branch is bifid, one prong for 
 each tarsus. Back of this, with only thin fascia intervening, is 
 the upper extremity, or cupola of the lacrimal sac (see Fig. 61), 
 behind which, likewise, is the posterior branch of the tendo 
 oculi, and behind that is the muscle of Homer. The last two 
 are attached to the posterior lacrimal crest. Separating this 
 whole mechanism from the deeper structures of the orbit is a
 
 THE TECHNIC. 
 
 147 
 
 stronger fascia, the septum orbitale. The opening of the united 
 canaliculi is seen between the branches of the tendo oculi. The 
 .cupola of the lacrimal sac rises to about the level of the upper edge 
 of the tendo oculi. Fig. 62 shows the arrangement of the blood- 
 vessels of this vicinity. This drawing makes clear why the incision 
 should not lie to the nasal side of the rim of the orbit; and why 
 
 FIG. 60. i, Anterior lacrimal crest. 2, Lacrimal groove. 3, Posterior 
 lacrimal crest. 4, Attachment of tendo oculi. 
 
 one should be careful, in loosening the cupola, lest copious bleeding 
 be caused by wounding the vessels that connect the facial and the 
 ophthalmic systems. Different subjects vary greatly as to the 
 depth at which lies the lacrimal sac. 
 
 The Technic. First step. With a convex-edged scalpel an 
 incision is made over the sac, beginning just beneath the tendo 
 oculi and extending about two and one-half centimeters down and 
 out, following the natural sulcus that marks the inferonasal rim of
 
 148 
 
 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 the orbit (Fig. 63). In case the subject is one of those in whom the 
 sac is not deeply situated a shorter incision would suffice, but there 
 is no drawback to one of the length here specified, and the task 
 is perceptibly lightened by having a generous opening. So situ- 
 ated, the incision avoids the larger blood-vessels i.e., the branches 
 of the facial artery and vein called angular and the scar is least 
 conspicuous. The tissues are deliberately divided, layer by layer, 
 first the skin, second superficial fascia, third orbicularis, and fourth 
 
 
 
 FIG. 61. i, Anterior branch of tendo oculi. 2, Lacrimal sac. 3, Posterior branch 
 of tendo oculi. 4, Hornsr's muscle. 5, Septum orbitale. 
 
 the deeper fascia, so as to come with discrimination down onto 
 the anterior wall of the sac, and keeping all the while close in behind 
 the anterior lacrimal crest. Caution is required in dividing the last 
 layer or the sac may be opened. Diligent sponging is kept up and 
 the lips of the deepening and broading wound are held well apart 
 by squint-hooks or Desmarre's retractors, or if an assistant is not 
 available, by Muller or Eversbusch speculum (Fig. 64). 
 
 Second step. When the smooth, red membrane composing the 
 offending organ is exposed, blunt dissection or very careful cutting
 
 THE TECHNIC. 
 
 149 
 
 around with dull-pointed scissors is begun: first, loosen the outer 
 or lateral side, then the inner or median side, then the back, which 
 lies deep in its fossa, then up about the cupola. The shelling-out 
 of the sac is greatly facilitated by passing a strabismus hook behind 
 it as soon as its body is exposed. This can, by alternately pulling 
 gently upon it and working it up and down, be made to assist 
 
 7 
 
 FIG. 62. i, Supra-orbital artery and vein. 2, Nasal artery. 3, Angular artery. 
 4, Facial artery. 5, Infra-orbital artery. 6, Branch of superficial temporal artery. 
 7, Malar branch of transverse artery of the face. 8, Superior palpebral artery. 
 9, Anastomoses. 10, Inferior palpebral artery, u, Facial vein. 12, Angular vein. 
 13, Branch of superficial temporal vein. 14, Lacrimal sac. 15, Internal canthal 
 ligament. 15', External canthal ligament. 16, Lacrimal artery. 17, Ligament of 
 the tarsus. 18, Tarso-orbital fascia. (After Testut.) 
 
 materially in the loosening process. Scrupulously avoid cutting 
 the sac, the canaliculi, the tendo oculi, the inferior oblique muscle, or 
 making an opening in the tarso-orbital fascia or septum orbitale. 
 This last is about the gravest accident that could happen during 
 the operation in question, as it could lead to septic cellulitis of the 
 orbit, to loss of sight through necrosis of the cornea, or through 
 strangulation of the optic nerve, or infection of the choroid, or 
 to death itself, by ascending meningitis or by thrombo-phlebitis
 
 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 of the sinuses of the dura. Should, by any chance, a wound be 
 made in this fascia, the opening should be thoroughly disinfected 
 and tightly closed with silkworm or catgut sutures before continuing 
 
 FIG. 63. Incision for lacrimal extirpation. After the incision is open 
 the whole is retracted and drawn upward and inward. 
 
 the extirpation. In working deep in the lacrimal fossa, remember 
 the frailty of the lacrimal bone composing the posterior half of 
 that depression. 
 
 Third step. After the sac is loosened from all attachments, save 
 
 FIG. 64. 
 
 the common and nasal ducts, proceed to divide those with the 
 scissors. First the former. Here, if much traction is made upon 
 the sac while in the act, the puncta are apt to be inverted or drawn
 
 THE TECHNIC. 15! 
 
 inward, and in cutting off the canaliculi one risks making button- 
 holes of the lids and skin about them. Having freed the upper 
 portion, it is grasped with broad fixation forceps and held up while 
 the scissors are passed down into the nasal opening to divide the 
 lower end or, as preferred by the writer, to loosen and remove it 
 as far as the nasal cavity. Profuse hemorrhage is rather to be ex- 
 pected, though the above described manner of making the incision, 
 
 FIG. 65. Extirpation of lacrimal sac. Deep fascia opened showing sac. 
 
 together with firm pressure of its inner lip against the bones of the nose, 
 the use of a broad Desmarres retractor beneath the inner lip of the 
 incision to compress the vessels against the nasal bone (Fig. 65), 
 torsion of the larger spouting vessels, the instillation of i-iooo 
 solution of adrenalin chlorid, or copious douches of very hot water, 
 or, better still, hot sublimate solution will serve to keep the bleeding 
 easily within bounds. Every trace of the sac must be got rid of. 
 It often happens that its walls are so tender that, in spite of the most
 
 152 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 cautious handling, they are torn. I have found that in such in- 
 stances the fingers may with advantage be substituted for the 
 forceps, to hold it, after freeing its upper end. If it is highly de- 
 generated and amorphous, one cannot always hope to get it out in- 
 tact, but must be content to sponge out the cavity as dry as possible, 
 search for detached islands of the walls and mucous lining, pick 
 them up with the forceps and excise them with the scissors. A 
 thickened, tough sac can easily be shelled out entire. Where carious 
 bone is present it is scraped away with a hard, sharp curet, no 
 matter if it be that of the inner wall of the fossa or lacrimal bone, 
 whereby an opening is made into the nasal cavity. Any granular 
 masses also undergo curettage, and this sort of cleaning out is 
 carried down into the nostril. As a proper finish, a small olive- 
 tipped electrode is used to cauterize the nasal end of the canal. 
 This last, however, must not be done so long as the inflammable 
 gases from the anesthetic are near about, else an explosion will ensue. 
 
 Once in a while cutting of the internal canthal ligament is an in- 
 evitable part of the operation, as w r hen a fistulous opening has been 
 established above it, though the writer prefers leaving it intact 
 whenever possible. The incision is then extended up through the 
 ligament. After the fistula has been dealt with i.e., its tract has 
 been excised and before closing the external wound, it is best to 
 unite the severed fragments of the ligament by a catgut suture. As 
 much of each canaliculus as practicable, without buttonholing at 
 the punctum, is removed, and if there are any misgivings as to the 
 capacity of what remains to make trouble, they may be obliterated 
 by searing their linings with a delicate galvano-cautery, as per 
 Haab. 
 
 The opening having been cleansed and the bleeding stopped, it 
 is closed by three or four pretty deep silk sutures, between and 
 beyond which, if needed, smaller and shallower ones may be in- 
 serted. One cannot be too precise in approximating the lips of the 
 incision. Provided the extirpation has been complete, no tent nor 
 drain is put in. This is done only when there is some doubt as to 
 thoroughness. 
 
 The dressing consists of the usual wet sheet of cotton, the 
 thick, dry pad, and the wet netting, monocular bandage; and 
 sufficient pressure must be kept up to cause obliteration of the
 
 OBLITERATION OF THE SAC. 153 
 
 cavity. It is essential that a ball of cotton be placed immediately 
 over the wound, between the wet layer and the dry pad, to insure 
 such obliteration. The sutures are removed just as early as the 
 condition of the wound will allow. If this be in forty-eight hours, 
 all the better. Where a tent is required as a drain or to induce 
 healing by granulation from the bottom of the .opening, a strip of 
 iodoform gauze answers the purpose. The wound is closed at 
 either extremity and the gauze is left projecting from the middle. 
 The bandage is changed daily so is the tent if used until per- 
 manent closure is effected. 
 
 Obliteration of the Sac. This measure is indicated when, 
 through long-standing suppurative disease, with numerous exacer- 
 bations, much scar tissue with extensive adhesions, thickening of 
 the periosteum, bone lesions, fistulas, and fungosities exist. The 
 incision is made as for extirpation, except that it includes the front 
 and outer wall of the sac and, if necessary, the internal canthal 
 ligament. After widely separating the lips, the cut in the front 
 wall is extended into the nasal duct. As much as practicable of the 
 sac is dissected out, the rest, together with the fungosities and the 
 carious bone, removed by scraping with a strong, sharp curet, and 
 lastly, the entire cavity is rather deeply seared with the thermo- 
 cautery. Iodoform gauze packing, the ordinary pad, and bandage 
 compose the dressing, all of w T hich are renewed daily under antisep- 
 tic irrigation, until the wound heals from the bottom. Later it may 
 be necessary to repeat the operation one or more times. 
 
 Fistula of the lacrimal sac will sometimes require an opera- 
 tion for its cure, when the indications for obliteration or extirpation 
 of the canal are lacking. A tiny fistula that pours out simply tears 
 will usually disappear by the simple operation of opening up the 
 nasal part of the canal by probing, preferably without slitting up 
 the canaliculus, with, perhaps, stimulation of the. tract by means 
 of the galvano-cautery. A pus fistula may yield to Bowman's 
 operation, the use of the syringe and the Tansley cannula with 
 potent antiseptics. Failing in this, recourse may be had to the 
 more radical measure of incision and excision of the tract and 
 closure by sutures. 
 
 In conclusion, a watchword that will bear repeating is, always 
 the conservation of the lacrimal canal whenever possible.
 
 154 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 Extirpation of the lacrimal gland, taken all over, is an 
 operation frequently performed, yet in the life of even the busiest 
 ophthalmologist in general it is resorted to very rarely. True 1 
 classifies the surgical measures here considered, epigrammatically, 
 as follows: 
 
 The extirpation . of the whole gland is an operation of reserve 
 (extremity) . 
 
 The extirpation of the palpebral gland is an operation de choix 
 (option). 
 
 The extirpation of the orbital gland is an operation de necessite. 
 
 The indications, are neoplasms, chronic inflammations, de- 
 generations, and persistent, external fistula of the gland, also annoy- 
 ing epiphora remaining after the permanent obliteration of the 
 lacrimal canal. 
 
 Like extirpation of the sac, that of the gland is not a measure to 
 be adopted lightly. Diseases and some benign tumors of this 
 organ (as those from syphilis) are often amenable to other means of 
 treatment. An external, or cutaneous, fistula, if it cannot be 
 healed in the usual way, may sometimes be converted into an in- 
 ternal or conjunctival one, when the former tract either disappears 
 spontaneously or is easily dealt with by excision. Lastly, an 
 epiphora that has been profuse before, and for a short time after 
 extirpation of the lacrimal sac, will often cease altogether or become 
 so scant as to cause no inconvenience. With the passing of the 
 irritation from the affected drainage division of the apparatus, 
 the overactivity of the secretive part subsides. 
 
 Before proceeding to describe the surgery of the parts, permit 
 a word as to their anatomy. The lacrimal gland is a double organ, 
 consisting of a larger superior portion, the orbital gland, and a 
 smaller inferior portion, the palpebral gland, or, as it has also been 
 called, the accessory lacrimal gland and gland of Rosenmuller. 
 
 The former, surrounded by a fibrous capsule, occupies a depres- 
 sion in the bone, under the supero-temporal roof, or angle of the 
 orbit. Situated above and to the outer side of the levator palpe- 
 brae superioris tendon, its inner border almost touches the outer 
 fibres of the superior rectus, and its outer comes near the upper 
 fibres of the externus. In size and shape it is very like an average 
 
 1 Arch, d'opht., T. xiii, p. 280, 1893.
 
 EXTIRPATION OF THE PALPEBRAL GLAND. 155 
 
 lima bean. It is an acinose gland, and when stripped of its 
 capsule, it appears as a grayish, red mass of closely packed lobules. 
 
 The lower, or palpebral gland, only about one-half the size of 
 the upper, is composed of rather scattering lobules, lying just 
 external to the outer third of the upper conjuctival fornix. The 
 lowest lobule is usually found in the immediate vicinity of the outer 
 canthus. It may be above, level with, or even below it. The 
 outer fibres of the levator tendon pass between the orbital and 
 palpebral lacrimal glands. Each gland has separate and common 
 ducts all emptying into the outer half of the fornix conjunctive 
 about four millimeters above the convex border of the tarsus. 
 
 Removal of the whole gland has been accomplished through the 
 fornix or transition part of the conjunctiva. It is done by first 
 making a free canthotomy, everting and stretching upw r ard the lid, 
 till the superior border of the tarsus (now, of course, the inferior) 
 is about opposite the bony rim of the orbit, then making an incision 
 just below and parallel with the tarsus, from the junction of its 
 middle and outer third and extending beyond its temporal extremity. 
 The same incision enables one to get at and shell out both glands, 
 but the operation is a difficult one. The conjunctival opening, 
 therefore, is limited in its use mainly to the removal of the pal- 
 pebral gland. 
 
 Extirpation of the Palpebral Gland. Cocain anesthesia 
 suffices. When the lid is drawn up, as above described, and the 
 patient is made to look far downward, as he should throughout the 
 operation, the imprint of the lobules can be seen. Should the 
 patient be unruly, or should the eye roll involuntarily up, an as- 
 sistant grasps, with strong forceps, the tendon of the superior rectus, 
 as per Angelucci, a trick that works like a charm to steady both 
 patient and globe, as well as to hold the latter down. A little 
 adrenalin solution, painted on to the spot will cause immediate 
 blanching, when the incision can be made and the gland exposed 
 with but slight bleeding. As advised by Panas, a strong probe 
 may be passed down behind the everted upper lid to bring the 
 gland into better reach of hand and sight. 
 
 The incision is best made with a small scalpel having a highly 
 convex edge. The wound is held open with the smallest-sized 
 retractors or the tiny strabismus hooks of Stevens, and the gland
 
 156 OPERATIONS UPON THE APPENDAGES OF THE EYE. 
 
 is loosened first above, then below, by blunt dissection or cutting 
 with stub-pointed scissors. When the lobes are in view and fairly 
 freed from surroundings, they are drawn out and severed from 
 their posterior attachments by cutting with the scissors, from the 
 nasal side and ending at the temporal. At this end there is apt to 
 be some hemorrhage, but it is easily controlled by styptics, clamping, 
 or torsion. 
 
 Extirpation of the Palpebral Portion, together with the de- 
 generative effect entailed upon the ducts of the orbital gland, will 
 occasionally suffice for the relief of epiphora. It is well known that 
 atrophy of the conjunctival sac, following trachoma, results in the 
 drying up of the source of the tears, hence the actual cautery has 
 been applied (Chibret and Bettermieux) to the retrotarsal folds 
 and the mouths of the ducts, with a view to the discouragement 
 of further lacrimal secretion or the induction of atrophy of the 
 gland. One ought to avoid unnecessary opening of the orbital 
 fascia, fearing cellulitis, and know how to distinguish the glandular 
 tissue from that of the orbital fat. The first-named is pink and of 
 firmer consistency, the second, yellow and softer. A couple of fine, 
 absorbable sutures are put in to tolerably close the conjunctival 
 incision, or they may be omitted, and the conjunctiva and skin of 
 the canthus are sutured together as per description see "Cantho- 
 plasty." Canthotomy is often dispensed with in extirpation of 
 the palpebral lacrimal gland. The levator tendon is to be scrupu- 
 lously shunned, because of possible ptosis. A safer, easier, and 
 generally preferable method for the extirpation of the larger gland 
 is by way of the external incision. 
 
 The Operation for Extirpation of the Orbital Lacrimal 
 Gland. The supercilia are lathered and smoothly shaved with a 
 razor. For the most part, general anesthesia is demanded. The 
 exact mid-line of the stumps of the outer half of supercilia is chosen 
 for the site of the cutaneous incision, so that most of the scar will 
 be hidden. The convex scalpel is held in the right hand while the 
 indicated line of the eyebrow is stretched over the rim of the orbit 
 by manipulation of the left thumb and index. After cutting 
 the skin from midway of the eyebrow to its outer extremity, the 
 cut is continued just over the outer rim of the orbit to a point about 
 on a level with the outer canthus. It is then deepened until the
 
 EXTIRPATION OF THE ORBITAL LACRIMAL GLAND. 157 
 
 periosteum is reached, then pulled downward and held open by 
 some form of retractor. A quite fitting instrument for the purpose 
 is the lid speculum of Landolt (Plate VIII). The tarso-orbital 
 fascia, or septum orbitale, is next incised opposite the front border of 
 the gland, and from three to four millimeters beneath the edge of 
 the orbital rim, taking care to keep the inner end of the incision as 
 far as practicable toward the temple, in order to keep out of the 
 way of the levator and its nerve. The gland is laid bare, loosened 
 with curved, dull-pointed scissors, w r orking now closed and held 
 pen-fashion for blunt dissection, again cutting the stronger fasten- 
 ings of the gland first below, then above the latter being all the 
 while slowly and steadily drawn forward, until it comes away 
 entire. At this stage, the lacrimal artery is tied, hemostatic 
 forceps applied to other bleeding vessels, and every means resorted 
 to for the prevention of deep hemorrhage. (See Gifford, 1 " Extirpation 
 of the lacrimal gland, causing atrophy of the optic nerve, through 
 hemorrhage into the orbit.") Great care must be exercised to pre- 
 vent injury to any of the external eye muscles or to their nerve supply. 
 The cavity is washed out with sublimate solution and the opening 
 in the tarso-orbital fascia is closed with fine gut sutures. The lips 
 of the outer wound are put into the nicest possible apposition and 
 held together by a few carefully placed, interrupted sutures of paraf- 
 fined silk. The usual monocular bandage is applied, excepting 
 that the pad of dry cotton is larger and extends up higher on the 
 forehead. The patient is put to bed and kept quiet and the eye 
 regularly inspected. The silk thread is removed as soon as the 
 healing of the wound will permit. If signs of infection appear, the 
 incision must be at once reopened, at least that portion of it involved 
 by the threatening process, cleaned out, and vigorously treated with 
 strong antiseptics. 
 
 1 Am. Jour, of Ophthalmology, Vol. vi, p. 268.
 
 CHAPTER IV. 
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES OF 
 
 THE EYE. 
 
 Strabismus. This is a very old word, of Greek origin, whose 
 more modern and preferable English synonyms are squint and 
 heterotropia; and all three are terms that refer to an abnormal 
 position of the globe whereby its visual axis fails to meet that of 
 its fellow exactly at the fixation point. Whatever the determining 
 or "exciting" causes of squint whether errors of refraction, ambly- 
 opias, unawakened fusion centers, etc. it is certain that faulty 
 muscles are in most cases the predisposing the real cause. 
 The vast majority of eyes remain free from strabismus, no matter 
 what the state of 'the vision, the refraction, or other physical conditions. 
 Of the squinting eyes, approximately only about one-third are 
 amenable to treatment other than surgical. It is of the utmost 
 importance, then, that one should study well each separate case, 
 in order to determine the nature, the degree, and the contributing 
 factors as regards both the eyes and the possessor of them; and 
 that surgical methods should not be resorted to saving when reason- 
 able trial of all other appropriate means has failed to remedy the 
 defect. Then only is an operation indicated. 
 
 Kinds of Squint. The deviation of the eye is spoken of as 
 lateral, or horizontal, when it turns out or in; as vertical, when up 
 or down, and as oblique when it is a combination of the two. When 
 the eye turns inward, the squint is said to be convergent (esotropia) ; 
 when outward, divergent (exotropia) ; when upward, sursumvergent 
 (hypertropia) , and when downward, deorsumvergent. In pure 
 horizontal deviation inward the eyes are in the position of positive 
 convergence, because the lines of fixation intersect in front of the 
 eyes; and in horizontal deviation outward, they are in that of negative 
 convergence, because the lines of fixation, if prolonged backward, 
 would meet behind the eyes. At a matter of fact, however, in most 
 instances the squint is a mixture of the lateral and the vertical 
 varieties. 
 
 158
 
 KINDS OF SQUINT. 159 
 
 All squints are divided into two grand classes, depending upon 
 whether the eyes are or are not, under certain conditions, able to 
 assume their normal relative positions. The older and less rational 
 terms to denote the two classes were non-paralytic and paralytic. 
 Non-paralytic strabismus was called concomitant. The later and 
 better terms are comitant and incomitant. The first includes all 
 those in which the direction of the eyes might, through the influence 
 of the will, the effect of artificial lenses, the action of drugs, narcosis, 
 etc., become normal in any part of the field of fixation. To the 
 second belong all the others, whether the squint be due to paralysis, 
 paresis, from any cause, or to congenital shortness of a muscle. 
 A further classification of squint is into constant monolateral, 
 alternating, and intermittent. .In the first class the deflection is 
 always confined to the same eye; in the second, it is first of one 
 eye and then of the other. In the third, the squint is absent part 
 of the time and, when present, may be either monolateral or alter- 
 nating. By far the most common form of squint is the convergent. 
 
 A still further classification is into primary and secondary squint. 
 The former comprises all save those unfortunate cases in which 
 deviation of an opposite kind has followed the too free severance of 
 a muscle from the globe (overtenotomy) or the prolonged wearing 
 of the full correction for excessive hyperopia. 
 
 Then there is that state of the ocular muscles in which there is 
 more or less tendency of an eye to wander, and actual squint is 
 prevented only by a corresponding degree of conscious or uncon- 
 scious muscular effort. This is referred to as latent squint or 
 suppressed squint. It is also the dynamic strabismus of Von Graefe, 
 and the heterophoria of Stevens. 
 
 The same general surgical principles are applicable to all forms 
 of squint latent or manifest yet they must be variously modified 
 to answer the demands of individual cases. 
 
 With rarest exception but one eye squints, while the other fixes, 
 and the two are designated as squinting eye and fixing or working 
 eye. The fact that the squint is confined to one eye does not imply 
 that but one eye is concerned in the defect. As first pointed out 
 by Bonders, and since abundantly verified, strabismus is usually 
 a bilateral affection. Nor does it follow that the fixing eye is pos- 
 sessed of a better muscular system than the squinting one. Often
 
 l6o OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 the reverse is true. Greater visual acuity, a lesser refractive error, 
 etc., having determined it to do the work. As concerns the cases 
 here in point, viz., those that ultimately require surgical measures, 
 it may be assumed, for all practical reasons, that the defect is purely 
 a muscular one, and that the muscle usually concerned is that one 
 away from which the eye turns, or its fellow of the other eye; or, as is 
 most often the case, both of them. That is, these muscles are in- 
 efficient or abnormally weak, rather than that their opponents are 
 overactive or too strong. The last mentioned, however, was the 
 original idea, and upon it was based the primitive operation of 
 strabotomy. To this day the Germans call the muscle toward 
 which the eye deviates the Shielmuskel the squint-muscle and 
 refer to the one truly at fault as merely the antagonist. Every 
 close and experienced observer, in studying the conditions of the 
 muscle or muscles actually involved in the squint, must have been 
 aware of the anomalies so often present anomalies of development, 
 of attachment to globe, adhesion to the fibrous capsule, etc. 
 
 The different surgical means that have been devised for the cure 
 of squint may be thus denominated and arranged according to 
 their origin: 
 
 f a. Myotomy. 
 
 1. Strabotomy \ , ~ 
 
 [ b. Tenotomy. 
 
 2. Tendon advancement, or prorrhaphy. 
 
 3. Capsular advancement. 
 
 f a. Folding or tucking. 
 
 4. Tendon shortening \ , 
 
 D ( b. Resection. 
 
 5. Tendon recession. 
 
 6. Operations upon the check ligaments. 
 
 7. Tendon lengthening. 
 
 These various measures are employed either singly or combined; 
 as, for example, a muscular with a capsular advancement, to which 
 may be added a tendon resection, or a tendon folding, and so on. 
 
 i. Strabotomy, or the cutting of an ocular muscle, for the cure 
 of strabismus, like the entire surgery of squint, is of comparatively 
 recent date. The first to conceive of such a thing was the gifted 
 English charlatan oculist "Chevalier" John Taylor, 1 in 1738; 
 
 1 De Vera causa strabismi, Lisbon, 1739.
 
 VON GRAEFE'S METHOD. 161 
 
 though he did not carry his idea into effect, contenting himself 
 merely with a u fake" operation, viz., snipping the conjunctiva of 
 the affected eye, then closing the fixing eye by means of adhesive 
 plaster. Of course, the operated eye immediately became 
 "straight." By the time the plaster was removed the operator was 
 paid and gone to other fields. We have some muscle snippers in 
 our own time who could give the smooth Chevalier pointers. 
 
 A similar suggestion to that of Taylor, i.e., the division of a 
 muscle to correct a squint, was made by Eschenbach, of Rostock, 
 in 1752. Yet, singular to relate, for a hundred years from the 
 time of Taylor's hint no attempt was made to put the notion into 
 actual practice. This was left to be first done, but only upon the 
 cadaver, by Stromeyer, of Hanover, in 1838, and by Dieffenbach, 
 of Berlin, upon the living subject in 1839. Dieffenbach's early 
 operation was essentially a myotomy which concerned the muscle 
 toward which the eye deviated, and as such was both defective and 
 formidable. It consisted in a free opening of conjunctiva and 
 Tenon's capsule, drawing forward the Shidmuskel the supposed 
 faulty muscle and the complete severance of its body. Naturally, 
 in an era when asepsis was unknown the consequences were often 
 dire. Septic orbital cellulitis and, moreover, secondary squint, 
 with all its lamentable attendant defects, were so common that 
 after a year or so the procedure fell into dissuse. About this time 
 (1841) Bonnet, of Lyons, published the results of his anatomical 
 researches, w r hich had been conducted with special reference to the 
 relations of the ocular muscles and the various ramifications of the 
 fibrous capsule of the eye, and their bearing upon the surgery of 
 squint. This led to subconjunctival myotomy, which lessened 
 somewhat the dangers of infection, and later, mainly through the 
 efforts of Jules Guerin (Nantes and Angers, about 1845) to tne I GSS 
 harmful and simpler operation of tenotomy, and still later (about 
 1849) even to subconjunctival tenotomy. By these means not only 
 was infection still further barred, but secondary strabismus be- 
 came a less frequent sequel. The operation was taken up with a 
 vim by A. v. Graefe in 1853, an d by George Critchett, of London, 
 in 1857, and improved and refined till, at their hands, it reached 
 practically the status in which it is found to-day. 
 
 Von Graefe's Method. The tendon is fully exposed by either
 
 1 62 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 a horizontal incision through conjunctiva and capsule of Tenon, 
 passing over the insertion, or, as was most often preferred, by a 
 vertical incision between the insertion and the cornea. The con- 
 junctiva is undermined toward the neighboring canthus with 
 blunt scissors, the Graefe strabismus hook is inserted beneath the 
 tendon, he latter lifted somewhat and severed from the sclera with 
 blunt scissors as close as practicable to its attachment. The hook is 
 reinserted to search for any uncut fibres of the tendon, which, if 
 found, are also divided. Lastly, the conjunctival wound is closed 
 by a fine suture. 
 
 Von Arlt, of Vienna, made tenotomy after the manner of v. Graefe, 
 save that he picked up the exposed tendon with the mouse- 
 tooth or toothed fixation forceps, instead of with the hook, but 
 used the hook in finding and severing remaining fibres. This 
 surgeon was most circumspect in determining the position and 
 extent of his incision through the membranes, choosing a small 
 horizontal one over the center of the tendon for the lower degrees of 
 strabismus and a freer vertical one over the insertion for the higher 
 grades. If it was feared that the separation of the muscle from the 
 globe was extreme, the aponeurosis of the tendon was included by 
 the suture which finally closed the vertical wound; if not, only the 
 conjunctiva was included. 
 
 Critchett's Subconjunctival Tenotomy. With strong mouse- 
 tooth forceps, pressed firmly upon the globe over the lower border 
 of the tendon, just behind its insertion, a horizontal fold of con- 
 junctiva and underlying capsule of Tenon is picked up and cut 
 crosswise with blunt-pointed scissors close to the forceps, if possible 
 dividing both membranes at one snip, though it may be necessary 
 to pick up the capsule in a similar fold and incise it separately. 
 Thus a vertical wound opening is made. The lower border of the 
 tendon is now brought to view by gently lifting with the forceps the 
 fold of membrane still retained in its jaws and touching the wound 
 with the sharpened point of a cotton sponge. A delicate, flattened 
 Graefe hook is then inserted, point up, beneath the tendon, pushing 
 it snug up to include all the fibres, the forceps relinquished by the 
 left hand for the hook, which is slightly raised. One point of the 
 delicate blunt-pointed scissors is passed beneath the tendon close 
 to its attachment and the other beneath the conjunctiva, and the
 
 SNELLEN'S SUBCONJUXCTIVAL TENOTOMY. 163 
 
 tenotomy accomplished by successive snips of the scissors, cutting 
 from the heel to the point of the hook. As in the Graefe method, 
 stray fibres that have escaped the scissors are sought and divided. 
 If still greater effect is desired a subconjunctival incision is made 
 vertically in Tenon's capsule, a little back of the point where the 
 tendon was cut. Unless there is a tendency of the conjunctival 
 wound to gape, no suture is employed. 
 
 SnellenV Subconjunctival Tenotomy. The Utrecht master 
 has given an invaluable procedure. The conjunctiva and capsule 
 are picked up by strong mouse-tooth forceps in one horizontal 
 fold, as in the Critchett operation, not over the border of the tendon 
 but over its center, and, if possible, the tendon itself is contained 
 in the bite, which is made a little back of the insertion. The entire 
 fold is lifted and cut athwart by the blunt scissors close to the 
 forceps, on the corneal side, and the wound peered into to see whether 
 or not the tendon has been nipped. If not, its center is caught up 
 in a longitudinal pleat in which a tiny, perpendicular buttonhole is 
 cut. Still holding up the fold, a small hook is introduced, point up- 
 ward, at this hole, and the upper half of the tendon severed by 
 cutting with the blunt scissors from heel to point of the hook 
 beneath the membranes and between the hook and the insertion. 
 Still holding with the forceps, the hook is placed, point downward, 
 under the lower half of the tendon, and that, in like manner, is 
 divided. After the example of v. Arlt, if greater effect is desired 
 the incision in Tenon's capsule is extended, subconjunctivally, 
 both above and below. The conjunctival wound may, according 
 to the judgment of the operator, be closed by a thread, or its edges 
 simply cleansed and approximated by means of the forceps. Snel- 
 len, in beginning his operation, sometimes grasps the tissues in the 
 opposite sense, i.e., over the center of the tendon, but into a verti- 
 cal fold. 
 
 George T. Stevens, of New York, has somewhat modified Snel- 
 len's method into a partial tenotomy and has devised a set of deli- 
 cate strabismus instruments (Plates II and III). Whatever may be 
 said concerning the modification, it is certain that the implements 
 leave little to be desired along this line. The present writer adopted 
 the Snellen operation and the Stevens instruments more than fifteen 
 
 1 Klin. Monatsbl. f. Augenh., 1870, S. 26.
 
 1 64 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 years ago, and has since employed them in preference to others. 
 The following constitutes the 
 
 Author's Mode of Making the Snellen Tenotomy. Assuming 
 that we have to do with a case of convergent squint of the right eye, 
 the eye is prepared and anesthesia local or general is produced. 
 Local anesthesia is preferable. The patient lies on a -table, at the 
 head of which the surgeon stands. The blepharostat is put in place 
 and the conjunctival sac thoroughly irrigated with warm boric 
 solution, the remains of which are sponged away. If the eye is under 
 local anesthesia, as is the rule, the patient is instructed to look all 
 the while to the extreme right. The outlines of the tendon and in- 
 sertion of the internus can now be indistinctly perceived. If they 
 are about in their normal positions, the mouse-tooth forceps is 
 placed in contact with the globe, with jaws separated some six or 
 eight millimeters, and just below the center of the tendon in such a 
 way as, when bearing firmly down and closing the forceps, to form 
 a vertical fold three or four millimeters in height, composed of con- 
 junctiva, capsule, and tendon. Holding the forceps tightly, the 
 fold is slightly lifted, and with the Stevens scissors, with their con- 
 cavity directed toward the operator, one essays by a single sturdy 
 snip to cut through all three layers of the fold close to the forceps, 
 thus making in each a small horizontal incision. 
 
 The forceps, still holding fast, is slightly tilted away from the 
 operator to cause the wound to gape. If the attempt has succeeded, 
 the bare shining sclera is seen at the bottom of the wound. If 
 necessary, the tip of a cotton sponge is applied to the opening to 
 clear away the blood. The scissors are now exchanged for the 
 Stevens hook, which is inserted, point downward, beneath the lower 
 half of the tendon, close up to its insertion. The fold held till 
 now by the forceps is let go, the membranes below the cut are seized 
 with the forceps and pushed downward so as to expose the point of 
 the hook, behind which, by tilting it, they are caught. Now, 
 making traction outward and upward with the hook, held in the 
 left hand, the lower half of the tendon is severed from the globe 
 close to its attachment, cutting carefully with the scissors from the 
 heel toward the point of the hook. Those who make complete 
 tenotomies will here, of course, divide the entire half of the tendon. 
 It is the writer's invariable practice, however, except in the opera-
 
 ACCIDENTS AND COMPLICATIONS. 165 
 
 tion of tendon recession, to leave both borders of the tendon, or at 
 least its lateral fibrous expansions, intact. The section is, therefore, 
 stopped a millimeter or so short of the lower edge of the tendon. 
 The hook is held beneath the uncut border, the scissors are exchanged 
 for the other hook, which, in turn, is placed beneath the upper 
 half of the tendon, the first hook is removed, the membranes pushed 
 beyond its point with the forceps, and, again taking the scissors, 
 the upper section of the tendon is made precisely as had been the 
 lower that is, sparing the border. The result of the procedure is 
 a small horizontal incision in both membranes and a vertical button- 
 hole in the tendon, which separates all of its more central fibres 
 from their former attachment. The eye is again douched with the 
 warm boric solution, as it has been several times during the opera- 
 tions with the double purpose of cleanliness and to prevent dryness 
 of the corneal epithelium, and the membranes are carefully re- 
 arranged. No suture is put in. 
 
 I make this operation only as the first step in muscular advance - 
 ment, never as a single surgical measure. The advancement proper, 
 as described further on, is then proceeded with. 
 
 Accidents and Complications, Immediate and Consecutive. 
 While the operation of tenotomy, as performed to-day, is one of the 
 safest of surgical procedures as regards any serious instant mishap 
 or any grave sequel that threatens actual loss of the eye, yet these very 
 things have happened, to experienced surgeons as well as to the 
 tyro, in this branch of his art. Not only are these greater dangers 
 to be avoided by every possible means, but there are a number of 
 lesser untoward happenings to be guarded against. Among the 
 immediate are: 
 
 Hemorrhage from the conjunctiva and Tenon's capsule. The 
 larger vessels of these membranes are, as a rule, plainly visible and 
 can be avoided by cutting to one side of them. This is particularly 
 true of the capsule, where a large vein is seen to extend longitudi- 
 nally over the centre of tendon and muscle, and it is through wound- 
 ing of this that the worst hemorrhages come. The most to be dreaded 
 from the bleeding is a large hematoma, which is in the way, and 
 tends to complicate the healing process. Because of their secondary 
 relaxing effect upon the walls of the blood-vessels, I am very sparing 
 in the use of such things as cocain and adrenalin. Indeed, I have
 
 1 66 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 practically abandoned the last, and as to cocain, limit both strength 
 and quantity to the minimum that will produce anesthesia, and 
 attempt to make the operation under the primary effect : one minim 
 of a 2% to 4% solution dropped onto the site of the tenotomy twice, 
 or, at most, three times, with two-minute intervals; then a wait of five 
 minutes after the last drop before beginning the operation, is the rule. 
 Subconjunctival injections of these solutions I never resort to, 
 not so much because of the danger, which is slight, but because of 
 the inconvenience occasioned by the ensuing infiltration. Another 
 source of hemorrhage is indiscriminate cutting about with the 
 scissors beneath the conjunctiva and Tenon's capsule. All such 
 dissection is absolutely uncalled for, and pernicious, save in cases 
 where one encounters cicatricial tissue, as from a former operation. 
 It were also easy, by thus snipping, to wound the deeper layers 
 of the orbital fascia, exposing the fat and risking what is perhaps 
 the gravest accident that ever occurs after tenotomy of a rectus, 
 viz., septic orbital cellulitis. 
 
 Perforation of the sclera in severing the tendon has often 
 occurred, and is a casualty as inexcusable on the part of the operator 
 as it is serious for the operated, yet nothing but the greatest watchful- 
 ness will prevent its happening to even the most skilled and expe- 
 rienced surgeon. To avoid it one should never use pointed scissors, 
 never pull up the tendon strongly and cut obliquely from behind 
 its insertion close down to the sclera, and never cut too much 
 under cover of overlying membranes. Whenever possible the bite 
 of the scissors should be squarely at a right angle to the long axis 
 of the muscle. 
 
 Tenotomy of the wrong muscle or upon the wrong eye is 
 to be guarded against. To tenotomize the corresponding muscle 
 of the eye not intended were less harmful than pardonable, seeing 
 that squint is usually the result of a binocular defect. Should the 
 opposite muscle of either eye be cut, however, it should be at once 
 picked up and reattached to the globe by one of the various suture 
 methods employed for advancement, though the cut end of the 
 muscle should, of course, be drawn up only far enough to meet 
 the stump from which it had been severed. 
 
 Of the consecutive accidents, by far the most common come mainly 
 from a too complete section of the tendon. They are :
 
 ACCIDENTS AND COMPLICATIONS. 167 
 
 1. Retraction of the caruncle, leaving only a dark hole where 
 this little body should be. 
 
 2. Lack of motility of the globe in the direction of the operated 
 muscle. 
 
 3. Exophthalmos, with its attendant widening of the palpebral 
 fissure, or proptosis. 
 
 4. Secondary squint, or the ultimate deviation of the globe in the 
 contrary direction to that for which the tenotomy was made. 
 
 Knowing the cause, the preventive is obvious and readily avail- 
 able; yet, having once occurred, the remedy, whilst it may be quite 
 manifest, is not so easy of application. To my mind the proper 
 thing to do, whether secondary strabismus exists or not, *is to try to 
 restore the relation of the muscle to the globe, even, if need be, at 
 the cost of re-establishing the original squint at the same time. 
 This would be a big choice of the two evils and could then be dealt 
 with more intelligently and scientifically. To widen the palpebral 
 fissure of the other eye for the proptosis, for example, as has been 
 recommended, and even practised, is preposterous. If, on the other 
 hand, one is at once aware of having gone too far in any direction, 
 he ought, then and there, to make an effort to set matters aright. 
 If, for instance, he thinks the capsule has been too greatly pushed 
 back, or too freely opened, or knows that the tendon had been too 
 extensively divided, or that the extreme lateral fibres have been 
 cut on one or both sides, a small, absorbable suture should be so 
 put in as to correct the error. Even after the lapse of two or three 
 days, if it is evident that a blunder has been made along this line, it 
 is not too late to try to rectify the consequences; for, while union 
 may be firm, there being no -scar tissue as yet, the parts may be still 
 separated without difficulty. Aside from the bad results of a com- 
 plete tenotomy may be mentioned those of extensive incisions in the 
 conjunctiva and in Tenon's capsule. This is especially true if 
 they are made in the vertical sense. This alone leads to retraction 
 of the caruncle, slow healing, extensive adhesions, granulomata, 
 and other complications. Whether or not one chooses the 
 better direction for these incisions, i.e., the horizontal, he should 
 see to it that there is not undue gaping of the cut edges of the 
 membranes. 
 
 If exuberant granulations spring up, or a polyp occurs, at the site
 
 1 68 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 of the tenotomy, a drop of cocain solution and a snip of the scissors 
 constitute an effectual remedy. 
 
 In warding off other sequels, such as conjunctivitis, tenonitis, 
 etc., absolute cleanliness of the eye, the instruments in short of 
 everything concerned is the best safeguard. Add to this perfect 
 occlusion of the eye and the strictest quietude of the patient after 
 the operation, and about all is done that can be. Often too little 
 attention is paid to the dressing of the eye after this sort of 
 operation. In view of the fact that so many of the subjects are 
 children, one should be all the more exacting in these respects. 
 I find that the use of the wet netting bandage, and flexible collodion 
 to fix it, makes an excellent dressing in every way. (Described in 
 chapter on Dressings.) Extensive adhesions and scar tissue after 
 tenotomy are to be avoided chiefly because by their action in 
 binding the tendon and tension on the check ligaments they restrict 
 the movements of the globe. They are usually the result of un- 
 necessary traumatism at the time of the operation, mostly through 
 futile and aimless poking and gouging with hooks, slashing with 
 scissors, and mangling with forceps. 
 
 There is no advantage in a subconjunctival tenotomy over one 
 that is made with the tendon in plain view; much to the contrary. 
 In the first place, one's work is more uncertain, being out of sight, 
 and precision is the key-note to success. In the second, it has been 
 proven that there is less apt to be unfavorable reaction after the 
 open method, seeing that bacteria and blood can be much more 
 thoroughly got rid of. 
 
 As to dosing the effect of a tenotomy; to assert that so much cutting 
 in a given manner means so many degrees of permanent rotation of 
 the globe away from the muscle attacked has always seemed to the 
 writer to be the acme of absurdity. Granting that a tendon can 
 be set back a specific distance, what assurance have we that it will 
 remain in that position? It is pretty certain that if the borders 
 of the tendon are both left intact and if the tenotomy has been ac- 
 complished with the minimum of traumatism, the ultimate result 
 will be nil. After the complete tenotomy it would seem to be merely 
 a question as to how much, or how little, harm is done. The 
 result is purely problematical. If the tendon has not been too 
 greatly loosened from its sheath, it may creep back to its place again
 
 TENDON ADVANCEMENT. 169 
 
 or it may recede to a greater or a lesser distance, depending upon 
 wherever it can find an attachment or can come to rest. To divide 
 the tendon all from one side leaving a single border uncut tends 
 to produce torsion of the globe. 
 
 Probably the least doubtful way of obtaining a definite degree of 
 effect is to make section of all but the outermost fibres of the tendon, 
 then resort to one of the several guy-threads such as have been 
 invented by Graefe, Knapp, Griining, and others. These consist 
 mostly in passing a ligature through the episcleral or scleral tissue, 
 close to the cornea on the opposite side to that whereon the tenotomy 
 occurs, whereby the globe is pulled into extreme duction, when the 
 ligature is coiled upon the temple or nose as the case may be, and 
 there fastened with collodionized cotton. The ligature is a source 
 of both pain and danger. 
 
 Another somewhat less positive but much safer method is to 
 make section of the entire tendon, drop it back the desired distance, 
 and fix it there by a thread. This operation will be described later 
 under " Curb Tenotomy." 
 
 Were I asked to name the indications for tenotomy of a rectus 
 muscle, I should say buttonholing the center of the tendon at the 
 time an advancement is made on its antagonist to prevent, by 
 weakening it, the cutting out of the thread used in the advancement, 
 and complete tenotomy only in case of abnormal shortness of the 
 muscle, as it is found in certain cases, as, for example, congenital 
 strabismus then always with the curb suture just alluded to. 
 These are, in my opinion, the only two indications. 
 
 2. Tendon Advancement. Dieffenbach, of Berlin, attempted 
 advancement of the retracted muscle for the secondary squint that 
 occurred after one of his myotomies as early as the year 1842, 
 but the results were not gratifying. Guerin, 1 of Nancy, was the 
 first to make practicable such a procedure. He, too, was incited to 
 make the operation by a desire to relieve secondary squint, many 
 instances of which were all about the ugly fruits of the (then) new 
 fad of muscle-cutting. Just the precise technic these surgeons 
 adopted I have not, as yet, been able to ascertain. One of the 
 first published descriptions of an advancement operation is that of 
 
 1 Ann. d'oculist., vol. xxii, 1849.
 
 i yo 
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 Albrecht von Graefe 1 . It is substantially as follows: Supposing we 
 have to do with a divergent strabismus of the right eye (Fig. 66). 
 The conjunctiva and Tenon's capsule are incised over the insertion 
 of the internus, and its tendon completely severed from the globe. 
 The membranes are then opened over the insertion of the externus, 
 its tendon lifted on a hook, a ligature is passed through the middle 
 of the tendon, close to its attachment, from the scleral side outward. 
 The ligature, which includes about 1/2 the width of the tendon, 
 is tied and given to an assistant. While traction is made with the 
 
 ligature toward the cornea, 
 the operator gently pushes 
 the hook toward the outer 
 canthus; from 1/2 to 3/4 
 the width of the tendon is 
 divided by the scissors, 
 mm. behind the 
 The degree of sec- 
 proportioned ac- 
 
 FIG. 66. Graefe's "faden operation." 
 
 some 2 
 thread, 
 tion is 
 
 cording to the resistance 
 the muscle is supposed to 
 offer against rotation to the 
 other side. The eye is 
 
 now turned into extreme adduction, and the ligature is fastened 
 to the nose by diachylon plaster (or other adhesive), care being 
 taken to so place the thread that it will not infringe upon 
 either lid border, i.e., exactly in line with the closed palpebral 
 fissure. If the bridge of the nose is not sufficiently high to hold the 
 ligature clear of the cornea, it is built up by means of the diachy- 
 lon plaster. Such is von Graefe's famed "Faden-operation" 
 (thread operation) that has been so much criticised and ridiculed. 
 As a matter of fact, it is not by any means one of the poorest of the 
 many clever devices of this genius in ophthalmology. It embodies 
 the partial tenotomy of the stronger muscle and the (intended) 
 advancement of the weaker, and provides an ingenious and practical 
 means of holding the globe in a favorable position for the reattach- 
 ment of the advanced mucle. True, von Graefe abandoned it because 
 of injury to the cornea sustained by certain of the operated through 
 1 Arch. f. Ophth., iii, No. i, 1857, p. 342344.
 
 TENDON ADVANCEMENT. 
 
 171 
 
 contact of the ligature. But with the ligature anchored at the in- 
 sertion, with vertical buttonholing of the tendon, careful fastening 
 of the ligature on the nose by collodionized cotton, and with modern 
 methods as to antisepsis and dressings, this source of danger would 
 cease to be a factor; yet there would still remain the discomfort to 
 the patient, for the pain was said to be severe during the several days 
 the ligature was left in. Where the operation chiefly failed was 
 that the internus (in the case cited) was expected to advance of its 
 own accord and take its new hold upon the globe, instead of re- 
 tracting as it always does. Had this been brought forward and 
 sutured before the guying, the 
 history of the procedure might be 
 a very different one. This was an 
 attempted advancement without a 
 single suture. 
 
 About this same time George 
 Critchett, 1 of London, devised his 
 multiple suture operation, which is 
 the parent of most modern advance- 
 ment methods (Fig. 67). It may 
 be thus briefly described: A 
 vertical incision about 1/2 inch long, is made between the cornea 
 and the insertion of the tendon to be advanced, through conjunctiva 
 and Tenon's capsule. This is opened up, the tendon is laid bare 
 and lifted on a strabismus hook, seized near its middle with clamp 
 fixation forceps, and severed, from the globe flush with the sclera. 
 If need be, a small strip is trimmed off the cut end of tendon. 
 While an assistant holds the 'forceps, three separate sutures are 
 passed downward, through the tendon, after having picked up a bite 
 in the overlying membranes, one near each border and one at the 
 middle. The first two threads are carried forward, beneath the con- 
 junctiva, to emerge near the upper and lower limbus, respectively, 
 close to the vertical meridian, while the third is given a similar hold 
 exactly in the horizontal meridian, coming out at the limbus. The 
 middle suture is tied first, to hold the muscle in its proper place, 
 then the other two. When occasion demanded it, a fourth suture 
 was put in. This operation, very slightly changed, is still the 
 
 1 Med. Times and Gazette, Nov., 1857. 
 
 FIG. 67. Critchett's advance- 
 ment operation.
 
 172 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 favorite method with many ophthalmic surgeons. At the hands of 
 the majority, the fixation forceps has given way to some form of 
 tendon clamp, and the anchorage of the needles is deeper. 
 
 Landolt, 1 of Paris, modified Critchett's operation in several im- 
 portant respects, chief among which was the omission of the central 
 suture which he considered, and justly so, to be in the way of a 
 positive and efficient advancement. Landolt 2 thus described his 
 method in 1897: " Conjunct! val incision close to and parallel 
 with the corneal limbus. No conjunctival bridge for a meridional 
 suture is left, since the muscle then becomes inserted not a the 
 corneal margin, but further back, corresponding to the conjunctival 
 incision. The conjunctiva is not detached far beyond the insertion 
 of the tendon. A small and somewhat flattened hook is passed 
 under the muscle, either according to von Graefe's method or, 
 better, after grasping the muscles with a pair of forcepss and cutting 
 a small hole. In this manner the whole muscle is brought flat on 
 the hook, whereas, in the first mode, the relaxed muscle may be- 
 come folded lengthwise or the hook become entangled in Tenon's 
 capsule or the muscle fibres. An assistant now draws the muscle 
 forward and away from the globe with the hook, and the operator, 
 with the squint forceps, grasps the muscle at a point 1/3 of its 
 breadth from its margin, together with the surrounding connective 
 tissue and Tenon's capsule, behind the hook, and then passes a fine 
 curved needle through this entire fold. After this is done on both 
 sides of the muscle, it is pulled up by the four threads and cut be- 
 tween the threads and the hook. The tendinous stump is detached 
 close to the eyeball. This is a small resection, which enhances the 
 effect of the advancement in moderate degrees of strabismus. In 
 simple insufficiency or small degrees of strabismus, the muscle is 
 detached without resection. In strabismus of high degree, the 
 sutures are introduced far behind the insertion for a more extensive 
 resection. This done, the operator sees if the sutures are well 
 applied. If they are not, he reapplies them, which is very easy, 
 since the inferior surface of the muscle is now exposed. Then one 
 needle is passed for a few mm. through the episcleral tissue, close to 
 
 1 Comptes rendfis de ma clinique pour 1'annee, 1878. 
 
 2 Knapp's Archives, vol. xxvi, No. i. 
 
 3 Specially designed by Landolt for use on the ocular muscles, whose 
 teeth are placed obliquely to the long axis of the instrument.
 
 TENDON ADVANCEMENT. 
 
 173 
 
 the corneal limbus above, while the other is passed similarly below, 
 the muscular plane. The assistant grasps the eyeball over the 
 antagonistic muscle with a fixation forceps and rotates it toward the 
 muscle to be advanced. Thus the operator can tie both sutures 
 without much traction on the enclosed tissues. It is advisable to 
 half tie both sutures before completely tying one. Thus the pre- 
 ponderance of the first suture over the second is avoided. To 
 prevent confusion, white silk is used for one and black silk for the 
 other suture. The muscle, with its covering conjunctiva, not un- 
 frequently rests upon the corneal margin, where, of course, it 
 cannot insert. If the advanced 
 piece should encroach far on 
 the cornea, it may be divided 
 by a cut into two halves, as I 
 have done for years, and both 
 halves will then lie at the 
 corneal margin. Generally the 
 advanced muscle retracts 
 enough to furnish a more 
 favorable insertion. After the 
 sutures are tied, the eyes are 
 irrigated with an aseptic solution and both are bandaged. In con- 
 vergent squint the effect of the operation is increased by paralysis 
 of accommodation. Therefore atropin is instilled into both 
 eyes as long as there is any tendency to convergence. Exclusion 
 of light, rest, and occlusion of the eyes have the same effect. The 
 binocular bandage remains at least five days, for the healing of the 
 wound. In convergent squint it is reapplied for several days 
 more for the above reasons. Then it is replaced by correcting 
 convex glasses. The sutures need hardly ever be removed before 
 the sixth or seventh day. In divergent squint, accommodation and 
 convergence assist the operation. As soon as the advanced muscles 
 are firmly attached, one eye is left free. After one or two weeks 
 the methodical exercise of convergence may be commenced." 
 
 The father of the single-suture advancement was Adolf Weber, 1 of 
 Darmstadt, who, in 1873, contrived an ingenious though impracti- 
 cable procedure (Fig. 68). After uncovering, picking up, and dividing 
 
 1 Lit. Verzeichniss, No. 6, p. 415. 
 
 FIG. 68. Weber's single suture 
 operation.
 
 174 
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 the tendon as did Critchett, he used a triple-armed suture that 
 was threaded and inserted in the following manner: A fine, curved 
 needle was put on at each end in the ordinary way, but at the middle 
 the thread was doubled upon itself and passed thus through the eye 
 of a somewhat larger needle. While an assistant lifted the tendon, 
 the middle needle was passed through the center of the tendon from 
 the scleral side, thence, also from within outward, through the distal 
 conjunctival flap, the loop pulled through, and the needle removed. 
 The other two needles were carried forward beneath the conjunctiva, 
 one above, the other below the cornea, and brought out near the 
 vertical meridian. They were then carried back and passed through 
 the loop from the corneal side. The assistant then released the 
 tendon from the forceps and the muscle was drawn up by the 
 traction on the two ends of thread held together. When the 
 muscle had been brought forward sufficiently the two threads 
 were made into a rather large knot close against the loop so that the 
 
 suture could not slip. 1 This 
 measure possesses three points 
 of great merit, in that it is 
 simple, easy of execution, and, 
 best of all, the tendon is drawn 
 forward exactly in the hori- 
 zontal meridian. Unfortun- 
 ately, it has two fatal faults, 
 viz., the thread, although 
 
 double, traverses the thickness of the tendon at only one place, 
 in consequence of which not only is it more likely to cut out, but, 
 moreover, the center of the tendon is pulled forward in a point, while 
 the lateral portions are thrown toward each other in plaits not 
 spread out as it should be. 
 
 DeWecker 2 for a time practised a modification of Weber's 
 operation (Fig. 69). Instead of holding the tendon by fixation 
 forceps he, of course, used his own double advancement hook. The 
 real change, however, consisted in the curious mode of disposing of 
 
 1 Haab, in his "Augenoperationen," Munich, 1904, mentions having seen 
 Horner make the Weber advancement save that, instead of putting both 
 ends of thread through the loop from the corneal side, he passed one end 
 from either side and tied them so as to include the loop in the knot. 
 
 2 Ann. d'oculist, t. 70, 1873, 22 5- 
 
 FIG. 69. DeWecker's modification of above.
 
 THE PULLEY OPERATION OF PRINCE. 175 
 
 the thread. The loop was drawn far through and cut. Thus there 
 were two threads which the surgeon proceeded to tie not each end 
 to its fellow, but each to the opposite end of the other thread. 
 
 It will be seen by the foregoing descriptions that the thread finds 
 its anchorage above and below the cornea save in the Critchett 
 operation, where there is, in addition, a thread anchored between 
 the cut end of the tendon and the cornea. There is another class 
 of advancement methods wherein the only hold of the suture (or 
 sutures) , outside of that in the tendon, is between the latter and the 
 cornea. A few of the more prominent of these will be described. 
 
 The Pulley Operation of Prince. 1 This is a procedure which, 
 modified by its author at certain stages of its existence, has stood 
 the test of nearly a quarter of a century, and is both efficient and origi- 
 nal (Fig. 70) . Its early name, however, is hardly applicable to its pres- 
 ent form. As he first made the operation, and as I had the pleasure 
 of seeing him perform it in 1884 while on a visit to Dr. Agnew at the 
 Manhattan Eye and Ear Hospital, N. Y., while I was house 
 surgeon to that institution, was thus: 
 A vertical thread was put firmly in the 
 episcleral tissue close up to the cornea on 
 the side next the tendon to be advanced 
 quilted in for a distance of about 6 
 mm., and the ends, for the moment, left 
 hanging free. He then exposed the 
 tendon, clamped it with his advance- 
 ment forceps, and severed it close to 
 
 FIG. 70. Prince s first, or 
 
 the sclera. While an assistant held the " pulley " operation, 
 
 forceps, a double-armed thread was 
 
 passed, from within outward, through the tendon, thus leaving 
 a loop in its under side. Then, while the aid drew the tendon 
 forward, one end of the double-armed thread was laid at right 
 angles across the buried thread at the corneal margin and the 
 latter was tied snugly over it. In this way was formed the pulley. 
 Lastly, the two ends of the other thread were knotted and drawn 
 taut, advancing the tendon. In order the more readily to 
 distinguish the threads the vertical one, or pulley, was white, the 
 other black. The yielding of the outside portion of the pulley 
 1 St. Louis Med. and Surg. Journal, 1881.
 
 176 
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 and the bunching of the tendon into a cone, seeing that the traction 
 was all from a single point, after a number of years, caused the 
 author of the measure to very materially change and improve the 
 method (Fig. 71). The pulley thread was omitted, and what had 
 been the second stage of the operation, i.e., the exposing and picking 
 up of the tendon, became the first. The double-armed thread was 
 put into the tendon as before, whereupon one of the needles was 
 made to traverse the tissue alongside the cornea, as had the old 
 pulley needle, all that was left to do being to knot and draw the 
 thread until the desired turning of the globe was achieved. 
 
 FIG. 71. Prince's second 
 operation. 
 
 FIG. 72. Verhoeff's advance- 
 ment operation. 
 
 Verhoeff, 1 of Boston, has devised a one-suture mode similar, 
 in most respects, to that of Prince, but with one essential difference. 
 This has reference to the fastening of the tendon to the sclera. In the 
 Prince operation the pull of the two threads is straight toward the 
 cut end of the tendon, whereas, in that of Verhoeff, the greater portion 
 of the tendon's width is tied down tightly to the underlying tissue 
 strapped down, as it were (Fig. 72) . The procedure is thus described : 
 A vertical incision is made in the conjunctiva, about 3 1/2 mm. 
 from the cornea, and that membrane undermined up to the limbus. 
 The tendon is exposed, lifted and held with the Prince advancement 
 forceps. The flap of conjunctiva next to the cornea is retracted, one 
 needle of a double-armed fine thread is passed, vertically, for a 
 distance of 6 to 8 mm. through the episcleral tissue, one mm. from the 
 cornea. At its point of exit the needle is again plowed for a short 
 distance horizontally toward the tendon. The lower needle is 
 
 1 Oph. Record, 1901.
 
 WORTH'S ADVANCEMENT. 
 
 177 
 
 made now to take this same horizontal course. Both needles are 
 then passed through the tendon, from the scleral side, at a greater 
 or lesser distance behind the forceps, according as much or little 
 effect is needed. The assistant pulls the muscle forward the requi- 
 site distance and the thread is drawn up and tied. That portion 
 of the tendon contained in the bite of the forceps is cut off, the free 
 end placed beneath the conjunctiva, and the wound in this membrane 
 closed by a fine suture. The conjunctival thread is removed on the 
 fourth day; that in the tendon on the eighth. With proper needles 
 and deftness, a very solid support can be got for the suture in this 
 anchorage, representing, as it 
 does, three sides of a rectangle, 
 and for the lower degrees of 
 squint it must be an excellent 
 procedure. For the higher de- 
 grees, one would suppose it 
 necessitates considerable resec- 
 tion of tendon; ergo, shortening 
 of the muscle. 
 
 In this class belongs also the 
 operation of Worth. 1 This sur- 
 
 FIG. 73. Worth's advancement operation. 
 
 geon proceeds as follows: A 
 
 vertical incision about 1/2 in. long is made through conjunctiva 
 and Tenon's capsule, its middle close to the corneal margin. 
 These membranes are retracted to expose the tendon. If the 
 angle of the squint is of high degree, the incision is made 
 curved, with its convexity toward the cornea, in order to allow 
 the membranes to retract more freely. Prince's advancement 
 forceps is introduced, with the toothed blade lying on the con- 
 junctiva, and thus closed. The tendon and its underlying attach- 
 ments are divided with scissors close to the sclera. Two needles, 
 each threaded with a double strand of tolerably thick thread that 
 has been previously boiled to remove the extra coloring matter, 
 then steeped in a sterilized mixture consisting of three parts of white 
 beeswax and five parts of white vaselin, are employed. While an 
 assistant holds up the tendon and superposed membranes, one of 
 the needles is passed inward at A (Fig. 73), through conjunctiva, 
 
 1 "Squint," London, 1903.
 
 178 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 capsule, and muscle, and brought out at the under side of the tendon. 
 It is again passed through muscle, capsule and conjunctiva, and 
 brought out at B. The bite of the thread thus encloses about the 
 lower fourth of the muscle with its tendinous expansion, capsule, and 
 conjunctiva. The other needle is similarly entered at A', passed 
 through conjunctiva, capsule, and tendon, and brought out at the 
 under side. It is then again entered beneath the tendon and brought 
 out through the conjunctiva at B', this bite enclosing the upper 
 fourth of the tendon. Both sutures are inserted, before proceeding 
 further, in order that they may be symmetrically placed. The 
 ends of the thread from A' and B' are then knotted tightly at C. 
 The end bearing the needle is then entered at D, passed through con- 
 junctiva, capsule, and tendon, and carried beneath the lower blade 
 of the Prince forceps nearly to the corneal margin. The needle is 
 here passed through the tough circumcorneal fibrous tissue and 
 brought out at G'. The two ends of thread are then loosely tied, 
 with a single hitch, at H. The first suture is then similarly com- 
 pleted. The anterior part of the tendon, capsule, and conjunctiva 
 are then removed by the scissors just behind where they are 
 grasped by the forceps. The gap is then closed by tightly tying 
 each suture at H H, so that the cut end of the tendon is brought 
 nearly up to the corneal margin at G G'. The longitudinal position 
 on the muscle of the knotted loops A, B and C, and A', B', and C' 
 varies according to the degree of rotation desired. 
 
 The hold on the tendon in this operation afforded by the knotted 
 arrangement of the sutures insures extraordinary solidity, but it is 
 a question whether or not a certain amount of necrosis would not 
 ensue from strangulation. As for the rest, the anchorage near 
 the cornea, which is of even greater importance, is relatively 
 slight much more so than in either the Prince or the Verhoeff 
 operations. Moreover, the operation would seem to be needlessly 
 complex. 
 
 The Beard Advancement Operation (Figs. 74 and 75). The 
 first published account of this procedure appeared in the A merican 
 Journal of Ophthalmology for March, 1889. Within the past three 
 or four years several articles in the ophthalmic literature of Great 
 Britain and the continent of Europe have been brought to my no- 
 tice, in which the writers told of original methods very similar to, and
 
 THE BEARD ADVANCEMENT OPERATION. 
 
 I 79 
 
 in one case viz., Dr. H. Lindo Ferguson 1 practically identical with 
 this, though it is a pleasant reflection that they all lack priority. 
 
 In most instances the first part of the operation consists in the 
 making of the neatest possible buttonhole, as per description on 
 page 164 of the tendon of the muscle opposite to that which is to be 
 advanced. The sole object of this partial tenotomy is to cause a 
 temporary breaking of the power of 
 that muscle, so that the advanced 
 tendon may have a relatively undis- 
 turbed period during which to make 
 its new insertion. The tiny scissors 
 and hooks of Dr. Stevens, of New 
 York, are employed. 
 
 The patient is told to look far 
 to the opposite side; with mouse- 
 tooth forceps the conjunctiva, and 
 only this membrane, is picked up 
 in a vertical fold, well back of the 
 insertion of the muscle; with small, 
 straight scissors, slightly blunted 
 at the points, a snip is made across 
 
 FIG. 74 Beard's advancement oper- 
 ation. The tiny dotted oval is to 
 represent spot where tendon was at- 
 tached. The double dotted line shows 
 where thread is anchored to sclera. 
 The tendon is never laid bare as this 
 drawing would indicate. 
 
 the fold, exactly over the center of the tendon, and the incision 
 thus begun is carried forward horizontally till it reaches the 
 margin of the cornea. Then the episcleral tissue forward of the 
 insertion of the tendon, if there be enough of it, is in like manner 
 incised, so that a furrow is opened, whose bottom is the naked 
 sclera, and along which the cut tendon is to slide. By so doing, one 
 reaches the tendon by positive 'stages, neatly and discriminately, and 
 avoids giving it an unguarded snip, which is possible with too 
 heroic cutting. The tendon, lightly covered by its aponeurosis, 2 
 being now well in view, is slightly lifted by the forceps, and a 
 medium-size squint-hook inserted beneath it, as close as can be to 
 the insertion. No advancement force s is put on to mangle the 
 tendon an assistant holding the hook until the suture is placed. 
 
 1 Transactions of the Ophthalmic Society of the United Kingdom, vol. 
 xvii, p. 336. 
 
 2 In striving for marked effect one must be careful to avoid undue 
 advancement of Tenon's capsule. This means tightening of the check 
 ligament on that side and consequent restriction of motility.
 
 i8o 
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 This last is of No. i braided black silk, boiled in equal parts of 
 paraffin and vaselin, and is double-armed i.e., has a needle at 
 each end. The needles are as fine as will barely carry the thread, 
 and are straight two-thirds of the way from eye to point, from thence 
 slightly curved. As a necessary precaution, the needles should be 
 tested to see that they are quite sharp, and their points be examined 
 under a magnifying glass to make sure that they are without flaws. 
 
 FIG. 75. 
 
 Both needles are passed downward through the tendon (see Fig. 74), 
 at a distance from its insertion proportionate to the degree of effect 
 desired, one near the upper, the other near the lower border, and 
 the loop or stitch thus formed is drawn down snugly upon the 
 tendon. Then, taking the upper needle in the holder, the con- 
 junctiva and anterior capsule are lifted by the forceps, and the 
 needle passed beneath these membranes without entering them, 
 carried well forward, then plunged into the episcleral and super- 
 ficially into the scleral tissues, and plowed along until a point is
 
 THE BEARD ADVANCEMENT OPERATION. l8l 
 
 reached opposite the vertical meridian of the cornea, or beyond, 
 and fully four to five millimeters from the limbus, where the needle 
 is brought out. The lines of anchorage should be divergent, 
 not horizontal. Merely placing the suture beneath the mem- 
 branous covering of the globe will not suffice; a much firmer 
 support is required. Notwithstanding the sharpness of the needles, 
 no little exertion is needed to force them through the dense fibrous 
 tissue, and in doing so the globe must be steadied. To grasp the 
 conjunctiva and capsule, to this end, will not do, as these membranes 
 will tear; so I take hold with strong broad-jawed forceps of the 
 tendon at its insertion, even including the hook as held by the 
 assistant. Precisely the same is done by the other needle below. 
 Xo\v, obviously, if the ends of the thread were here tied, the suture 
 would lie across the cornea; instead, however, the upper needle is 
 again placed in the holder and passed from behind, under the 
 loop or stitch that lies vertically on the tendon (see Fig. 74), and one 
 must be quite sure that the needle passes under the thread, and not 
 through, even the least strand or fibre of it; for this would cause 
 a snarl in drawing up the suture, and do away with one great feature 
 of this operation that of a perfect sliding suture. To make sure, 
 we had better include a little of the tendon here, or else leave the loop 
 standing up a little, so that we may see clearly what we are doing. 
 It is better to make an invariable rule of using the upper thread for 
 this step as, in the first place, the knot does not lie beneath the 
 sensitive upper lid, and, in the second, the removal of the suture is 
 made simpler and easier. One now proceeds to divide the tendon. 
 The thread is gotten out of the way of the scissors; if need be, 
 held out of the way by an assistant with a strabismus hook; for to 
 cut it in two were awkward in the extreme. The hook beneath the 
 tendon is taken by the operator, and the tendon is completely 
 severed; next, the stump of tendon at its insertion is seized by 
 the forceps and cut off even with the sclera. The latter step 
 serves two very important purposes it removes an obstacle to the 
 sliding forward of the tendon, and prevents an unsightly lump at 
 the site of the operation. Then, as to the tying and tightening of 
 the suture, several points must be observed. One should have 
 his assistant rotate the eye toward the operated muscle by means of 
 fixation forceps. It is essential that the loop across the tendon
 
 1 82 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 should remain tightly drawn down; to insure this, and at the same 
 time obviate any tearing up of the track of the suture where it lies 
 deeply imbedded under the conjunctiva, take hold of the upper 
 end of thread with the dressing forceps, and the lower one with 
 the fingers, just where it emerges above and below the cornea, 
 and pull, not back in the direction of the advancing muscle, but 
 away from it (in Fig. 75, toward the nose). This insures drawing the , 
 muscle forward in a straight line. Having in this way drawn the 
 muscle well forward, the assistant "takes up the slack" of the end 
 of the thread which passes beneath the loop, gives it to the operator, 
 who lets go with his dressing forceps, and ties the suture. 
 
 The tension being equal on all the thread-bearings, the advancing 
 tendon is drawn neither up nor down, but comes forward in a 
 straight horizontal line. One may leave the suture tied in a long 
 bow-knot, after Prince, the shorter end of the thread being always 
 the one which controls the loop, so that after the lapse of twenty- 
 four hours, if, for any reason, there is occasion for modifying the 
 effect upon the eye, the last part of the knot may be untied, and the 
 suture either tightened or slackened, as desired; and in any but 
 dispensary practice this will do excellently. On first removing the 
 bandage, whether one wishes to shift the suture or not, the long ends 
 and loop of thread, which have been till now fixed by the dressing 
 just outside the nearest canthus, are, before rebandaging, cut off 
 close to the knot. The suture is allowed to remain in the eye from 
 six to nine days the dressing being renewed during the time 
 at intervals of about forty-eight hours. Both eyes should be 
 bandaged, and absolute rest in bed for at least forty-eight hours 
 must be insisted upon. 
 
 I have abundantly proven that the pull of the suture in the tendon 
 is not only to move and hold the muscle forward, but also to keep 
 the tendon spread out flat. This is easily demonstrated by a model 
 even with the flimsiest material to represent the tendon. 
 
 Some few of my confreres, on reading as to the technic of the 
 advancement operation herein detailed, have conceived a notion 
 that it is complicated and difficult. This impression has doubtless 
 arisen from my having dwelt at such length upon the minutiae of 
 the operation, which alone insure success. As a matter of fact, it is 
 one of the simplest of procedures. It is, moreover, one of the
 
 CAPSULAR ADVANCEMENT. 183 
 
 safest. There is usually some superficial reaction, but in all my 
 experience I have seen but a single case which promised trouble. 
 This was that of a dispensary patient, who reported on the fourth 
 day after the operation with septic tenonitis at the site of the in- 
 cision. The process was promptly arrested before any damage 
 resulted. My experience with the operation refers to a great 
 number of cases, many of which I have had under observation for 
 from five to twenty years, and I can affirm that the results have 
 been most gratifying, both to patients and to operators. I would, 
 therefore, confidently and heartily recommend it to the profession. 
 The day of the tenotomy, pure and simple, as a rational remedy for 
 the cure of strabismus is past. Its mangled victims have too long 
 paraded their horrors, such as the paralyzed muscle, the secondary 
 squint, the retracted caruncle, and the ghastly exophthalmos. 
 
 3. Capsular Advancement. In the hope of doing away with 
 the annoyance caused by the cutting out of the thread and the 
 escape of the muscle in the advancement operation, at a time when 
 it was the custom to completely denude the tendon, DeWecker 1 
 proposed his advancement capsulaire, which, even at the hands of its 
 inventor, enjoyed but an ephemeral existence. The idea was that, 
 by advancing the adjacent check ligament or, in the plural, as 
 the French put it, les ailerons capsulaires, or lateral capsular expan- 
 sions of the tendon, the muscle would be supported and strengthened, 
 and the end would be accomplished without touching the tendon. 
 Here is how he proceeded: First, the excision of a semilunar or 
 pyramidal-shaped piece of conjunctiva, base toward the cornea, 
 over the insertion of the tendon, about 10 mm. high and 5 wide, 
 and a corresponding portion of Tenon's capsule; then detached the 
 tendon from its capsular sheath all around, undermined the con- 
 junctiva up to and around the neighboring half of the cornea, and, 
 lastly, drew the capsule forward and secured it by two sutures ar- 
 ranged much as are the outer threads in the Critchett advancement, 
 the difference being that the tendon was left untouched, as it was not 
 expected to move, but merely to allow the capsule to slip forward over 
 it. The effect was dosed by the dimensions given to the excised 
 portions and the size of the bite of the thread in the capsule. De- 
 Wecker practised making of this operation for several years. The 
 
 1 Annal d'oculist, t. xc, p. 188, 1883.
 
 1 84 
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 writer saw much of this gifted surgeon's work in the years 1885 
 and 1886, during which time he met Herman Knapp, who made a 
 long visit to Paris in the latter year. Knapp became impressed by 
 DeWecker's enthusiasm over the measure and, on returning to 
 New York, " made the operation a few times. The effect proving in- 
 sufficient, I at once modified it in such a way that it was in reality 
 a tendino-capsular advancement." 1 Knapp told of his modifica- 
 tion at the meeting of the American Ophthalmological Society in 
 1886, and the first published account of it appeared in the transac- 
 tions of this society for that year. 
 DeWecker very soon abandoned 
 the original operation and 
 adopted what is practically 
 Knapp's modification (Fig. 76). 
 Here is Knapp's description 
 of it in Norris and Oliver's sys- 
 tem, page 876: "The conjunc- 
 tiva is vertically incised over the 
 insertion of the tendon, and 
 undermined around the cornea 
 to the vertical meridian; 
 
 Tenon's capsule opened with the scissors at the lower line of the 
 insertion line of the tendon, a strabismus hook slipped beneath 
 the tendon and the capsule incised over the tip of the hook on 
 the upper side of the tendon. Three or four sutures are applied, 
 one through the conjunctiva and the lower edge of the muscle, 
 passing under the conjunctiva obliquely forward, then two or three 
 millimeters through the outer layers of the sclera immediately before 
 emerging on the conjunctiva near the vertical meridian. The second 
 suture is on the upper side, and pursues a course analogous to the 
 first. The third suture is passed through the conjunctiva and the 
 middle of the muscle, advanced under the hook, which during the 
 application of all the sutures raises the tendon, thrust through the 
 middle of the tendon near its insertion, then through the superficial 
 layers of the sclerotic to emerge on the conjunctiva near the cornea. 
 If a large effect is desired, a fourth suture is applied at the side of, 
 and similar to, the third. The sutures are tied in the same way as 
 'Quoted from Knapp in Norris and Oliver, p. 876. 
 
 FIG 76. Knapp's musculo-capsular 
 advancement.
 
 TENDON SHORTENING. 
 
 in Critchett's advancement. The operation, in fact, is the same 
 as Critchett's without excision of a piece of tendon. The sutures 
 remain in five or six days. The operation acts by shortening 
 (tightening) the check-ligaments and the muscle by folding them. 
 They remain folded and attached to their new position on the 
 sclerotic by means of cicatricial tissue, which is formed by an ad- 
 hesive inflammation due to the irritation set up by the sutures." 
 
 4. Tendon shortening, for the cure of the various forms of 
 squint has been, and still is, extensively practised. As has been 
 stated, this is accomplished in two ways: (a) by folding of the tendon 
 upon itself and fixing it so, or tucking; and (b) by the excision of a 
 portion of the tendon tenonectomy. 
 
 a. Folding or tucking of the tendon is the outgrowth of 
 DeWecker's capsular advancement, treated of in the preceding 
 section, and, as there asserted, it was Herman Knapp, of New York, 
 who was the originator of the measure under the name of tendino- 
 capsular advancement. 
 
 Kalt 1 proposed a modification 
 of Knapp's method, which con- 
 sisted in omitting the tendon 
 from the thread, but putting it 
 in capsule only, as did DeWecker 
 in his capsular advancement. 
 The sheath of the tendon was 
 not loosened, but to avoid folding 
 the tendon he severed the 'latter 
 from the globe and allowed it to 
 advance with the capsule. 
 
 Lagleyze, 2 of Buenos Ayres, reports excellent results obtained with 
 a folding operation of his own, (Fig. 77.) made as follows: After 
 having excised a flap of conjunctiva overlying the tendon, he incises 
 Tenon's capsule, inserts one strabismus hook beneath the tendon and 
 another beneath the fleshy part of the muscle. He then proceeds to 
 suture by means of a double-armed thread. One needle is made to 
 pass through the body of the muscle from its scleral surface, i mm. 
 from its border and, in emerging, to include the capsule and con- 
 
 FIG. 77. Lagleyze's folding 
 method. 
 
 1 Soc. d'opht., 2 mars, 1891. 
 
 3 Arch, d'opht., xii, p. 668, 1892.
 
 1 86 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 junctiva; the other needle follows the same course near the other 
 border. The loop of thread thus rests on the fleshy portion of the 
 muscle. The needles are then carried forward and the ends of 
 thread given secure anchorages near the cornea. In proportion as 
 the thread is drawn up, the strabismus diminishes. The thread 
 is removed at the end of 12 days. Obviously, this operation 
 can be made applicable only to the lower degrees of squint. 
 
 So numerous have been the original folding, or tucking, operations 
 that have been given to the world since those just mentioned, and, 
 as only a somewhat elaborate or detailed description in each instance 
 could give an adequate idea of its merits and merit they have, 
 almost without exception it is inexpedient to more than refer to 
 some of them here. 
 
 Colburn, 1 of Chicago, some twelve years ago gave what he 
 called an " advancing tuck operation." 
 
 Savage, 8 of Nashville, devised a muscle-tucking operation more 
 than ten years ago. Again, 3 about one year ago the same surgeon 
 published another tendon-folding measure. 
 
 It seems that a classification of these procedures is made into the 
 "shortening tuck," i.e., where the fold is made at or behind the 
 insertion of the tendon; and the "advancing tuck" where the same 
 is formed between the insertion and the cornea. 
 
 Todd,4 of Minneapolis, and Clark, of Columbus, have not only 
 given tucking operations, but each has invented an ingenious tucking 
 instrument. Todd's is a kind of two-tined fork, or bident, one 
 prong of which is placed beneath the tendon and there clamped by 
 turning a nut on the handle to rotate the instrument backward 
 makes the shortening tuck, and forward, the advancing tuck (Plate 
 VII, No. 87). The Clark device is a triple squint hook, the middle 
 member of which is made to move up or down by turning a knob on 
 the handle. When the three members are on the same level, the 
 instrument appears only as a rather broad hook. To apply it, the 
 middle portion is placed somewhat below the other two, introduced 
 beneath the tendon, while the other two rest on top of the tendon. 
 
 1 Oph. Record, April, 1902. 
 
 Oph. Record, March, 1893. 
 
 3 Oph. Record, Nov., 1903. 
 
 T 4 ph- Record, vol. xi, p. 73, 1902, and Annals of Oph., Oct., 1904; also 
 Journal Am. Med. Assn., Jan. 7, 1905.
 
 TENDON SHORTENING. 187 
 
 The middle is then made to rise, whereby a fold of the desired height 
 is formed. In each case the folds of tendon are sewn together by 
 animal sutures to prevent unrolling. 
 
 Bruns, 1 of New Orleans, is also the author of a clever folding 
 operation, and has contrived a modification of the Clark hook to 
 meet the requirements of the proceeding. 
 
 A truly cavalier folding operation is that of Trousseau. 2 Given 
 a convergent squint, for example, after moderate tenotomy of the 
 internus, an aid rotates the globe far inward, the tendon of the 
 externus is grasped by fixation forceps and drawn away from the 
 globe. A long, curved needle and substantial thread are passed 
 into the episcleral tissues near the cornea, through the tendon, 
 then beneath the body of the muscle, finally through it and out. 
 The eye is then rotated to the outer angle and the suture tied. The 
 thread remains from 6 to 12 days. In 27 cases the results were 
 satisfactory in 21. 
 
 Other European originators of 
 folding operations are Brands and 
 Fosters The latter's is very like the 
 Schweigger resection operation in all 
 save that, of course, the tendon is not 
 divided. 
 
 There is one feature wherein the FIG. 78. J. F. Noyes' shortening, 
 folding methods are unique if they 
 
 do not succeed in correcting the deviation, they cannot leave it 
 greater than it had been before. 
 
 The strabismus operation of J. F. Noyes,* of Detroit, has been 
 referred to as a folding operation (Fig. 78). It was, in truth, a 
 shortening operation not, however, by folding nor by resection of 
 the tendon, but by dividing and lapping it. The whole width of the 
 tendon was cut through at a distance from its insertion that varied in 
 accordance with the degree of squint; the distal end was placed 
 beneath the stump, and the two sewed together. 
 
 b. Shortening by excision of a part of the tendon resection 
 
 1 Oph. Record, June, 1904. 
 
 2 Annal d'oculistique, Jan., 1903. 
 
 3 A. F. A., 1902. 
 
 4 Versammlung. der Niederl. Ophthl. Gesellsch., Dec., 1901. 
 s Trans, of the Am. Oph. Society, 1874, p. 273.
 
 1 88 
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 tenonectomy as an adjunct to the rest of the procedure has been 
 employed, in some measure, by almost every ophthalmic surgeon 
 who ever made a veritable advancement operation, but as a single 
 measure it has not been given wide application. For my part, 
 I believe it to be a measure that deserves more consideration in the 
 professional mind than it enjoys in this country, at least. Surely, 
 it is as much to be commended as is the operation of tendon folding. 
 Yet were its popularity commensurate with the number of different 
 modes that have been proposed for the performance of it, its place 
 in ophthalmology were assured. On the continent of Europe 
 resection does not go abegging. 
 
 One of the first to give 
 prominence to such muscle 
 shortening was Vieusse, 1 
 who cut the tendon a short 
 distance behind its inser- 
 tion, abscised from the 
 posterior portion what was 
 requisite for the case, and 
 united the cut ends by two 
 sutures. 
 
 Probably the most ex- 
 tensively practised of any 
 resection to date is that of Schweigger 2 (Fig. 79). After tenotomy 
 of the opposite muscle a horizontal incision is made through conjunc- 
 tiva and capsule, over the center of the tendon to be excised. A flat, 
 curved hook is inserted beneath the tendon and shoved back and forth 
 to free and spread it out. A second hook is then inserted, but from 
 the opposite side. While one hook is pushed up snug against the 
 insertion, the other is pushed backward till from 8 to 10 mm. of the 
 tendon are exposed. With the help of an aid, the amount of tendon 
 to be resected is measured off with a tiny tape, something like a 
 strabometer also Schweigger's invention bearing a mm. scale 
 whose zero is in the center, and the points marked by slight nicks in 
 the edge of the tendon. Two double-armed catgut sutures are ready. 
 These are put in, one or two mm. back of the posterior nick; the 
 
 1 Record d'opht., 1875, p. 330. 
 ' A. F. A., 29, p. 165, 1894. 
 
 FIG. 79. Schweigger's resection operation 
 for squint.
 
 TENDON SHORTENING. 189 
 
 needle of one suture is drawn through close to the upper border, 
 carried beneath to a point slightly below the center, then up through. 
 Now, a needle of the second thread is drawn through near the lower 
 border, carried up under, and out just above the center. Each 
 suture is tied, thus ligating the entire tendon. The four threads 
 are held by an assistant, the tendon is cut at the posterior nick, 
 the stump is lifted by forceps, the four needles passed through it 
 from the scleral side, close up to the insertion, the tendon is cut off 
 at the other nick, thus completing the resection, the sutures are 
 drawn so as to butt one end of tendon against the other, and tied. 
 The outer wound is closed with silk thread. 
 
 Another such shortening measure is the "Myectomy" of L. 
 Miiller, the main points of which are thus: The operation is made 
 under narcosis to relax the muscle. Bilateral tenotomy of iheShiel- 
 muskel. Vertical incision of conjunctiva 4 mm. from the cornea, 
 and the wound well retracted to lay bare the tendon. The latter was 
 lifted on the hook at a distance behind the insertion corresponding 
 to the length of the piece to be excised, which, in divergent squint, 
 this surgeon states, would be from 6 to 8 mm., and for convergent, 
 somewhat less The proposed section is so measured on the tendon 
 by means of small compasses, and so marked as to leave a 2 mm. 
 stump at the insertion. Close behind the piece to be resected are 
 placed the sutures of rather coarse silk, one near the upper, the 
 other near the lower border, each including about 1/4 of the width 
 of the tendon, and tied. The ends bearing the needles are cut off 
 close to the knots. While an aid holds the threads, the tendon is 
 cut at the distal mark, and two other silk threads are put into the 
 stump close to the sclera and in the same way as were the other two, 
 cutting off the needle ends. The tendon is now cut at the proximal 
 mark and the opposite ends of the thread are tied in surgeons' 
 knots, at the same time approximating the ends of tendon. The 
 outer wound is closed by five sutures, and the buried threads are 
 left in for all time. 
 
 In comparing resection with advancement, Miiller affirms that 
 the latter finds no analogue in surgery, and is a very imperfect 
 procedure, for the reason that one does not know how much the 
 yielding conjunctiva will, during the first 24 hours, permit the muscle 
 to retract. Consequently, one must always aim for a primary
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 over-effect without knowing how much of it will disappear. More- 
 over, he believes it of the greatest importance that the original point 
 of insertion be left intact, to prevent an oblique attachment, which 
 could occur through sliding about of the advanced tendon. 
 
 It is evident that the foregoing remarks do not refer to that form 
 of advancement in which a solid anchorage is obtained for the thread 
 in episcleral or in scleral tissue. 
 
 The Beard Shortening Operation. Fig. 80 illustrates an 
 operation devised by the author 1 some time ago, which is adapted 
 to certain cases where shortening of the muscle, and not advance- 
 ment, is desired; though I 
 must admit I have rarely 
 found occasion to practise it. 
 The tendon of the opposite 
 muscle is buttonholed, as if 
 for the advancement opera- 
 tion. Here also the suture is 
 a double-armed one, the 
 needles being of a half-curved 
 variety and very sharp. The 
 primary incision is the same as 
 in the advancement, though 
 here the tendon is laid bare. 
 In this operation the advance- 
 ment forceps must be used. This instrument fixes the tendon mid- 
 way of the parallelogram included between the vertical lines (Fig. 
 80), which, of course, varies in length according to the degree of 
 shortening needed. The tendon is then divided at the point occupied 
 by the line near the cornea, and the forceps given to an assistant. 
 Catching hold of the stump of tendon with mouse-toothed forceps, 
 the needles are passed down through the insertion, hugging the 
 sclera, one near the upper, the other near the lower border. They 
 are then carried beneath the tendon, without crossing the thread, 
 and brought out correspondingly from below, and far enough back 
 of the fixing forceps to insure a firm hold; the loop, however, is 
 not drawn down, but is left very long, as shown in the drawing. 
 Here the operator takes the forceps from the assistant and cuts the 
 1 American Journal of Ophthalmology, March, 1889. 
 
 FIG. 80.
 
 TENDON RECESSION. IQI 
 
 tendon at the point indicated by the other vertical line, thus resecting 
 a portion. The long loop and the two ends of thread are then tied 
 in one knot, and the cut ends of the tendon nicely butted together. 
 If the surgeon prefers, the loop may be cut and the ends tied sepa- 
 rately. The thread may be absorbable or not, as the operator chooses. 
 The wound in the membranes is closed by one or two fine sutures. 
 The points claimed for this over certain other shortening operations 
 lie in the facts that the thread embraces and supports the united 
 ends of the tendon, both in front and behind, so that they are 
 kept in nice apposition, and not inclined to stand up in a pout, 
 and that the operation is simple and easy of execution. 
 
 Among others who have designed practicable resection operations 
 are Driver, 1 Coates, 2 Baraquez,3 Prince,* and Stevens. s 
 
 5. Tendon Recession. In the writer's opinion, there is but 
 one class of squint cases wherein the surgical treatment calls for an 
 actual setting back of the muscle toward which the eye deviates, 
 viz., that in which the muscle is abnormally short. This is found in 
 certain instances of congenital squint, and, exceptionally, in the case 
 of middle-aged or elderly subjects with acquired squint in whom the 
 defect has been of many years' duration. I refer particularly to 
 those in which the length of the muscle is so inadequate that not 
 only is the eye incapable of voluntary rotation in the opposite 
 direction, but also refuses to so turn under fixation forceps, even 
 with the subject in complete narcosis. The condition is exceedingly 
 rare, the writer having encountered it not to exceed six or eight 
 times in as many hundreds 'of operated cases. To attempt advance- 
 ment of the antagonist without a recession of this short muscle would 
 result in the production of an unwarrantable degree of exophthalmos, 
 and still greater limitation in the motility of the globe. Indeed, 
 advancement of the opposite muscle is not needful save in a certain 
 percentage of these cases, the recession alone being sufficient. The 
 ordinary complete tenotomy is not applicable because of the un- 
 certainty as to what would ultimately become of the severed muscle. 
 What is wanted is something that will limit the extent to which 
 
 1 Kl. Mbl. f. Aug., p. 133, 1876. 
 
 2 Lancet, May, 1878. 
 
 3 Bolletin de Clin. oft. de Santa Cruz, No. 2, p. 17, 1885. 
 
 4 Journal of the Am. Med. Assn., Oct. 13, 1888. 
 s N. Y. Med. Jour., p. 345, 1889.
 
 IQ2 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 the cut muscle will recede. This is found in a suture arranged 
 after a given fashion. The first, to my knowledge, to use such a 
 suture, was A. E. Prince, of Springfield, 111., back in the early 
 "eighties." I have not at hand this article on the subject nor 
 do I recall the exact technic. Prince called it "tenotomy with a 
 control suture." A little later, Colburn, of Chicago, made a similar 
 tenotomy and named the thread " restrain suture." In the American 
 Journal of Ophthalmology for March, 1889, the writer published his 
 method of making the operation under the caption "curb tenotomy." 
 It is substantially as follows: The tendon is exposed by a horizontal 
 incision through conjunctiva and capsule, whose center is over the 
 middle of the insertion. The tendon is caught upon a small flattish 
 hook, which is shoved back to free the muscle from its sheath. 
 A double-armed thread of No. i braided silk is put into the tendon 
 2 or 3 mm. behind the insertion by passing a needle down through 
 close to each border, and the loop thus formed pulled down snug. 
 The needles are then carried beneath Tenon's capsule, one above, 
 the other below, just in line with the loop, given a good bite, and 
 brought out through both capsule and conjunctiva. While the 
 operator holds the thread, an aid rotates the eye far outward (it 
 being the internus) in order to still further loosen the tendon from 
 its surroundings; the globe is set free and the suture so tied as to 
 leave a slight convergence. The same suture closed the opening in 
 the membranes. Of course, the tendon does not reunite to the globe, 
 but to its aponeurosis. In about half my cases all the gain was 
 cosmetic; the rest showed increased motility in both lateral 
 directions. 
 
 6. Operations Upon the Check Ligaments. Ailerons Capsul- 
 aires, of the French, and Bindenflugels of the Germans. The studies 
 of Motais, Kalt, and others have demonstrated that it is possible to 
 enhance the power of an ocular muscle by judicious division of 
 the adjacent check ligament, just as Landolt has shown that proper 
 advancement of a lateral muscle may cause extension of the field 
 of fixation in both directions. At a result of his researches Motais 
 has given certain rules for such capsulotomy. Supposing an 
 internal squint: Turn the eye outward, incise conjunctiva and 
 the tissue beneath it from near the cornea to the center of the tendon, 
 thence the mucosa along its whole length in front of the muscle.
 
 TENDON LENGTHENING. 193 
 
 Now feel along the outer surface of the capsule with closed, blunt 
 scissors, and, back some 9 or 10 mm. (15 mm. if it were on the outer 
 side) the instrument encounters a pretty firm resistance. This is 
 the ligamentous expansion of the capsule. The scissors are opened, 
 and this tissue is cut with short snips of the scissors. 
 
 The same writer also gives instructions how to proceed in case 
 the ligament is to be cut in the middle of its course or at its union 
 with the periosteum of the orbit. At the same time, he strongly 
 cautions against attempts at these operations by those who are not 
 thoroughly versed in the anatomy of the parts. He might also have 
 added that, like the single operation of strabotomy, the final result 
 is problematical. Moreover, the danger of orbital cellulitis must be 
 ever present. 
 
 Parinaud 1 also gives a method for setting back the check ligament. 
 Given a convergent squint, the eye is put in extreme abduction by 
 forceps. A horizontal fold of conjunctiva is picked up over the in- 
 sertion and cut athwart with the scissors so as to make a vertical 
 incision 10 or 15 mm. long, and at the distance of about 7 mm. from 
 the cornea. The conjunctiva is undermined back to the caruncle, 
 the sheath of the tendon is exposed and the capsule cut along its 
 upper borders. Through the opening thus made blunt scissors are 
 thrust and the fascia is cut upward, curving a little backward, for 
 a distance of 10 mm. The same is done below the muscle. The 
 conjunctival wound is closed by suturing. A capsular advancement 
 on the other side, and even tenotomy on the same side, may ac- 
 company the procedure. 
 
 In another place Parinaud 2 recommends setting back the capsule 
 in every case of convergent squint when spontaneous lessening of 
 the deviation, once begun, had ceased to progress; especially in 
 those where the wearing of glasses had caused the defect only 
 partially to disappear. 
 
 7. Tendon Lengthening. Sidney Stephenson, of London, 
 according to an article in the Lancet of September 23, 1905, was the 
 originator of this class of squint operations. Realizing the ex- 
 tremely uncertain effect of simple tenotomy, it occurred to him 
 that a more strictly scientific proceeding would be to lengthen the 
 
 1 Note a 1'acadamie des sc., 14 avril, 1890. 
 
 2 Bull, et mem. de la soc. franc, d'opht., p. 291, 1893.
 
 194 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 tendon of the rectus muscle without at the same time interfering 
 with its actual insertion into the sclerotic coat of the eyeball. In 
 this way he hoped that the dosage of tenotomy might be rendered 
 more or less certain instead of being, as in the old operation, an al- 
 most unknown factor. He described the method of operating and 
 exhibited several patients upon whom the operation had been per- 
 formed, at the Ophthalmological Society of the United Kingdom in 
 1902. Briefly, the steps of the operation are as follows : A vertical 
 or curvilinear incision is made with scissors over the insertion of the 
 internal rectus muscle and the latter is exposed as fully as might be 
 and carefully separated from the overlying conjunctiva by a few 
 snips of the scissors. After a small squint-hook has been passed 
 beneath the tendon a fine, well-boiled, silk suture is inserted through 
 the lower border of the tendon close to the sclera. The lengthening 
 of the tendon might be effected in several ways, of which the two 
 most practical alone need be described: i. (Fig. 81.) A long ob- 
 lique incision is made with scissors, commencing at the lower border, 
 
 FIG. 81 FIG. 82. 
 
 near the scleral insertion, and terminating at the upper border of the 
 muscle some distance from its tendinous attachment to the eyeball. 
 The two ends of the tendon are then united by a couple of points of 
 interrupted suture. 2. (Fig. 82.) The lower half of the tendon is 
 cut through some little distance from the scleral insertion and the 
 incision is carried along the center of the tendon, midway between 
 its upper and lower border, finally to be brought out at a right angle 
 to its former course. The free ends left by this step-like incision 
 are united by sutures. The lengthening of the tendon as carried out 
 by either of the foregoing methods should be directly proportionate 
 to the linear measurement of the squint; in other words, in a strabis- 
 mus of five millimeters an attempt to lengthen the tendon by just
 
 TENDON LENGTHENING. 195 
 
 that amount should be made. The final step, after the tendon 
 sutures have been tied and cut off short, is to close the conjunctival 
 incision neatly with several points of interrupted suture. The 
 operation of tendon lengthening may or may not be combined 
 with tenectomy and advancement of the antagonist muscle. 
 Stephenson remarks, in passing, that an agent has recently been 
 placed at our disposal that acts even better in inducing local an- 
 esthesia and hemostasis in those cases than cocain and adrenalin 
 applied separately to the eye. The new combination has received 
 the name of "eusemin" and consists of cocain, adrenalin, and chlore- 
 tone dissolved in physiologic salt solution. Applied to the eye 
 before and during the performance of the operation, eusemin 
 renders the work at once simpler and more speedy. He further 
 says that the operation of muscle lengthening is by no means easy 
 to do, but he is convinced that it is more exact and scientific than 
 the ordinary tenotomy, and the results can be foreseen and graded 
 with considerable accuracy. 
 
 The technical difficulties of tendon lengthening led the writer to 
 find a simpler substitute and he made use of a device adopted by 
 orthopedic surgeons viz., the so-called "artificial tendon." This 
 procedure is explained, and as applied to the internal rectus muscle 
 is described as follows: 
 
 "The tendon is exposed as in the former case and two sterilized 
 silk threads are passed through the tendon about three millimeters 
 from its scleral insertion one through the upper and the other 
 through the knver border of the muscle. The threads are then 
 knotted, one long end armed with a small curved needle being left 
 attached to each. The tendon, thus securely held, is next divided 
 vertically on the outer side of the knot that is to say, about midway 
 between the latter and scleral insertion of the tendon. The threaded 
 needles are then passed between the distal and the proximal portions 
 of the divided tendon in such a way as to bridge over the gap left 
 between the two. Lastly, the two sutures are tied together. An 
 even simpler way of forming the artificial tendon is to use two 
 needles on one length of silk. If advancement of the antagonist 
 muscle has formed part of the operation, the sutures should not be 
 adjusted until the first operation has been completed. If, on the 
 contrary, muscular elongation is alone contemplated, then before
 
 196 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 the threads are tied the eyeball should be strongly abducted so as to 
 leave a distinct interval before inserting the silk threads of the artifi- 
 cial tendon." 
 
 Landolt 1 has recently proposed a method of muscle elongation. 
 He designed it for those inveterate cases of convergent squint 
 in which there is marked contraction of the internal rectus, accom- 
 panied by changes in its structure and the loss of elasticity. The 
 tendon is laid bare by a horizontal incision over the center, 
 and stretched flat upon a strabismus hook. While an assistant 
 rotates the globe outward the rectangle represented by the tendon is 
 bisected diagonally. The apex of one of the right- angle triangles 
 thus formed is united by suturing to that of the other. Another 
 way mentioned is to divide the tendon by a series of cuts in the form 
 of steps, and joining the last step on one side to the corresponding 
 one on the other. By a curious coincidence, Landolt has hit upon 
 precisely the same idea as did Stephenson. In this connection 
 the following question suggests itself, viz., may not the result of 
 such operations, in cases w r here the eyes are capable of binocular 
 single vision, be a serious disturbance of the muscle balance, owing 
 to the peculiar manner in which the ends of tendon are united ? 
 
 Verhoeff 2 has suggested a form of tendon lengthening which is 
 
 presumed to find its application only 
 in the lowest degrees of strabismus. 
 
 It consists in laying bare the tendon 
 FIG. 8^. FIG. 84 , . . , , . , . , , 
 
 of the muscle toward which the globe 
 
 is deflected, buttonholing it in the vertical sense and, in addition, 
 making a series of nicks in its edges. It is through scratching out 
 of the tendon consequent upon the opening of these cuts that the 
 effect is obtained. Figs. 83 and 84 show the cuts closed and open. 
 This is nothing else than a form of partial tenotomy, and Haab 3 
 significantly observes, in referring to the measure, " Ob diese Oper- 
 ation bleibendere Resultate erzielt als die partiellen Tenotomien, 
 welche friiher schon von verschiedenen Autoren vorgeschlagen und 
 ausgefiihrt wurden, muss die Erfahrung lehren." 
 
 While, as before stated, some degree of vertical deviation is 
 common in connection with horizontal squint, operations upon 
 
 1 Archiv. d'Ophtal., January, 1905. 
 
 Mbl. F. A., Band xli, 1903. 
 
 3" Augen-operationslehre," p. 278,1894.
 
 TKXDOX DISPLACEMENT. 197 
 
 the muscles that rotate the eye upward or downward are seldom 
 indicated. Correction of the lateral deviation usually corrects the 
 vertical also. At all events, and generally speaking, no attention 
 need be given to any hypo- or hypertropia until there is full redressal 
 of the eso- or exotropia. Then, if a vertical squint persists, it is 
 time for its surgical treatment. Its cause may be looked for either in 
 one of the vertical recti or in one of the obliques. The vertical recti 
 in such cases lend themselves readily to the same operative measures 
 as do the other two straight muscles. The obliques do not. Indeed 
 these are hardly amenable to surgical interference of any kind. 
 The inferior may be tenotomized, and the writer has twice performed 
 the operation, and with gratifying results; but the undertaking is 
 both laborious and risky. 
 
 From time to time more or less complete tenotomies of the superior 
 and the inferior rectus muscles have been advised for the cure or 
 as aids to the cure of horizontal squint. Stevens, of Xew York, 
 fora time, seemed 'truly ardent in his advocacy of such measures. 
 Ever since the early investigations of Landolt, in regard to the 
 ocular movements, it has been known that the vertically acting 
 recti were, in addition, by their dual contraction, decided adductors 
 of the globe thus being the normal antagonists of the combined 
 obliques. Landolt also pointed out that normally directed eyes 
 are, relative to the long axes of the recti muscles, already in a state 
 of convergence. Moreover, that, under certain abnormal conditions, 
 the vertical recti could become abductors. Given, for instance, 
 narrow central insertions of their tendons, especially if the globe be 
 of large size, as in certain myopes, and the lateral muscles are lack- 
 ing in tone, and we have what the writer once described as pivotal 
 attachment, where there was convergent squ'nt in near vision and 
 divergent for distance. Here the muscles and their insertions bore 
 the same relations to the globe that two shafts with their pivots, 
 or cranks, would bear to a wheel. The moment the rotation, in 
 either direction, carried the pivot-like attachment beyond the center 
 of motion the deviation became markedly manifest. 
 
 Quite recently, Jackson, 1 of Denver, in a paper entitled " Lateral 
 Displacement of Tendon Insertions for the Cure of Strabismus," 
 recommends tenotomy of the inner half, to three-fourths, of the 
 
 journal of the Am. Med. Assn., Aug. 19, 1905.
 
 198 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 tendons of the superior and inferior recti, or even complete tenotomies 
 of them, and their reattachment to the sclera in a more favorable 
 manner, by suturing. He has practised lateral displacement by 
 partial tenotomy on the superior and inferior recti muscle chiefly 
 for the correction of excess of convergence, and describes his method 
 of operating. He claims this operation is followed by no diplopia 
 and by no more reaction than ordinary complete tenotomy. Jackson 
 considers lateral displacement of the tendon insertions of the superior 
 and inferior recti, in connection with tenotomy of the internus, as 
 an effective and reliable operation for high degrees of convergent 
 squint. He begins with a complete tenotomy of the internus, 
 and through the same conjunctival opening the scissors are intro- 
 duced and the nasal one-half to three-fourths of the tendon of the 
 superior or inferior rectus is divided at its insertion. He strips 
 the edge of the tendon back one-half inch or more from the insertion 
 by means of a strabismus hook. He cites a case where this opera- 
 tion was performed successfully for a high degree of squint, and 
 explains that no protrusion of the eyeball or other bad result has 
 been observed. 
 
 Now, while there are, now and then, instances wherein, after care- 
 ful study of the muscular anomalies that are present, one is convinced 
 that there is undue tension upon one edge of a broad tendon, and 
 that unquestionably, a well-directed partial tenotomy is indicated. 
 But to make anything like regular practice of this kind of strabotomy 
 is to enter upon delicate ground and to invite indiscriminate 
 intervention in the matter on the part of muscle-snippers. As 
 said before, it is my belief that it is only exceptionally that one need 
 consider the vertical muscles as factors in a squint, at least to the 
 extent of attacking them surgically. And often even when they 
 seem to be directly responsible for the defect, they are only indirectly 
 so, i.e., merely because of a lack of balance or a want of dynamic 
 adjustment on the part of the other two recti. In the pivotal 
 attachment, just alluded to, had the internus and the externus been 
 properly in rein, so to speak rightly toned there would probably 
 have been no squint in either direction. 
 
 Advancement for Secondary Squint. A goodly percentage 
 of the squints with which one has to deal are of this variety, and, 
 while the surgical measures appropriate to some of them might
 
 ACCIDENTS AND OTHER SEQUELS. 199 
 
 come under the head of a form of advancement, others constitute 
 a class by themselves, and the surgeon must resort to special methods 
 to meet the demands of the individual case. This class is charac- 
 terized not only by exaggeration of the exophthalmos, retraction 
 of the caruncle, etc., but by that of extent of adhesions and scar 
 tissue as well. If one fears that it will be difficult to obtain a firm 
 forward anchorage for his suture he would better weaken the opposing 
 tendon by a large transverse buttonhole. Then comes the task 
 of procuring the needed raw surface near the cornea with which the 
 tissue to be advanced is to unite. In the worst cases this can be 
 obtained only by a laborious dissection. This can best be accom- 
 plished by the use of very small mouse-toothed forceps and scissors, 
 beginning well back where the tissue is looser, and trying to open up 
 a wide path toward the cornea in the horizontal meridian. If 
 one encounters an island of scar so firmly incorporated with the 
 sclera that it cannot be separated, it may be freshened with a small, 
 very sharp, finely serrated curet. Now the muscle, or the remains 
 of it, must be searched for. If nothing having the semblance of 
 a tendon and aponeurosis can be found if all is united in one mass 
 with the conjunctiva a sort of pyramidal flap, with its apex 
 toward the cornea is formed by diverging incisions of the united 
 membranes, putting the regulation advancement suture or sutures 
 in near the apex, bringing the whole flap forward and securing it 
 just as one would a tendon. In this way the deformities, at least, 
 (and usually at most) can be corrected. Yet it is remarkable 
 how much control is sometimes obtained by the reinstated muscle 
 over the movement of the globe. 
 
 Accidents and other sequels consequent upon advancement 
 a-e, in many respects, identical with those attending tenotomy 
 aready given. Care must be exercised to prevent operating on 
 tfe wrong eye, cutting or breaking the thread, etc. The thread 
 shuld be braided, not twisted, and ought to be previously examined 
 as o strength and evenness, as well as to see that there are no little 
 breiks in its strands. The use of so-called self-threading needles 
 is p-ejudicial since they are apt to cut and make weak places. The 
 cuttng out of the sutures can best be avoided by using thread of 
 ontymedium fineness and by giving it the proper hold in the tissues. 
 Mar'festly one cannot depend upon the numbering printed or
 
 200 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 written upon the spools or skeins of thread by the manufacturers; 
 what is No. i in one make is No. 2 or No. 3 in another, and so on. 
 Thread that has been treated with a preparation of wax or paraffin 
 is vastly preferable for several reasons. It does not snarl, it does 
 not make a track for bacteria, and, being nonabsorbent, is easier 
 drawn through the tissues. It holds better because bacteria do not 
 proliferate around it and soften the parts. If, at the first dressing, it 
 is discovered that the thread has escaped from some part of its 
 fastenings, the fault may, in some instances, be remedied by the 
 judicious placing of a single new thread in such a way as to counteract 
 it. If merely too much dropping back of the tendon has occurred, 
 without cutting out of the suture, I have been able, at times, in the 
 one suture method, to pull the thread up tight again, twist it into 
 a pedicle, and ligate it. Of course, if the thread is left in a bow knot 
 at the time of the operation, the matter is simple enough. 
 
 Advancing capsule and conjunctiva with the tendon. If this 
 be done in too comprehensive a manner, it leads to restriction of 
 motility by tightening the check ligament in the one instance, and 
 to advancement of the caruncle and obliteration of the semilunar 
 told in the other. 
 
 Wounding and bruising of the parts should not only occur in 
 the minimum degree, but should be kept as well forward as practi- 
 cable so as not to interfere with what Landolt calls the normal unrolling 
 of the operated muscle upon the globe; in other words, the true 
 advancement effect is nullified in proportion as the adhesions reach 
 backward. 
 
 Enophthalmos after advancement operations has been referred 
 to as an objectionable feature. It is usually insignificant, yet i 
 affords an additional argument for operating upon both eyes in tre 
 higher degrees of squint in order to prevent an apparent different 
 in the width of the palpebral fissures. 
 
 GENERAL CONSIDERATIONS ON ADVANCEMENT. 
 
 Age of Subject. A squint operation would not, as a rule/ be 
 justifiable prior to the age when it could be ascertained whefher 
 or not other than surgical measures could avail. There are ex- 
 ceptions, however, to this rule, as, for example, cases of congfiital
 
 CHOICE OF METHOD. 2OI 
 
 strabismus with unnatural shortness of the muscle or muscles. 
 If this were suspected, it could be differentiated from spasmodic 
 squint by placing the patient under ethyl chlorid, nitrous oxid, or 
 similar anesthetic, and testing the rotation of the eye with forceps. 
 Then, too, there is that class where, without any brevity of muscle 
 in the direction of the deviation, motility in the opposite direction is 
 so very limited, and the degree of deflection is so high, that it is a 
 foregone conclusion, particularly if the patient belongs to the lower 
 and irresponsible station of life, that it is merely a question as to 
 whether one operates at once or leaves a permanent squint. 
 
 Choice of Method. Where there are so many effective modes 
 this would seem to be largely a matter of individual preference. 
 If one has happened upon or selected a method with which he has 
 become familiar, and been uniformly pleased, he is not apt to 
 exchange it for another. There are a few squint operations for 
 which their authors do not claim universal application, yet any 
 measure that is capable of causing 25 to 30 degrees of redressment 
 of a squint is sufficient for all cases, provided both eyes are operated 
 upon. There are relatively few instances wherein the deviation 
 exceeds 50 degrees, and if it is better, as is pretty well agreed, since 
 the affection in question is a binocular one, that the corresponding 
 muscle of both eyes be operated, then the need of bilateral interfer- 
 ence is all the more urgent. In practice, however, we cannot 
 always count upon an opportunity of making a second operation, 
 but may often wish to make a single sitting suffice. If one has 
 scruples against tenotomy as a means of curing squint, he would, 
 then, prefer an operation that, all things else being equal, would 
 give the maximum of effect. But are all things else equal ? The 
 maximum of effect could doubtless be obtained by most any of the 
 shortening processes, either folding or resection, but would the 
 result be in every way as good as after a true advancement ? The 
 advocates of the latter would say, "No!" They believe that to give 
 the muscle the greatest power or leverage over the globe, it should be 
 given an attachment forward of its original one, and it is in this that 
 a veritable advancement mainly consists; that, while there are most 
 excellent measures among the shortening operations, their sphere is 
 limited to the lower degrees of squint. Admitting that they who 
 prefer advancement are right, what kind of an advancement can
 
 2O2 
 
 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 be reckoned upon to give the greatest and best effect ? For it 
 must be remembered that permanent over- effects, or secondary 
 squints, do not occur after advancement operations except where 
 too much tenotomy has accompanied the operation. Two little 
 effect, even after both eyes have been operated, is frequent. 
 Moreover, to get very decided permanent effect one must strive 
 for yet more decided primary effect, i.e., over-efect; for some 
 dropping back of the tendon is inevitable. As to the degree 
 
 of primary effect, one must 
 be guided by his judgment 
 knowing, as he ought, 
 the angle of the squint 
 and other peculiarities of 
 the case in hand. In 
 divergent and paralytic 
 squint, it goes without say- 
 ing that the over-effect 
 must be specially pro- 
 nounced. The forms of 
 advancement that will give 
 the maximum turning of the 
 globe with the minimum 
 
 FIG. 85. -Anchorage obtained in the spaces 
 a and b, i e., on the corneal side of the nearer 
 vertical tangent of the limbus, affords a more 
 positive advancement than one obtained in the 
 space c. 
 
 resection or obliteration of 
 tendon are those whose sutures begin to take their proximal anchorage 
 beyond the nearer vertical tangent of the cornea (Fig. 85). 
 
 The anchorage must be beyond the tangent; it will not do to be 
 merely even with it. This is not to imply that those methods wherein 
 said anchorage is between the cornea and the operated muscle 
 are necessarily inferior. Doubtless there are good measures and 
 bad ones in both classes. Given an equally g^od one on either side, 
 it becomes simply a question as to whether or not one wishes to in- 
 crease the turning of the globe at the expense of the tendon. Given 
 two equally good measures in either class, it becomes largely a 
 question as to which is simpler. From reading the descriptions one 
 would conclude that there are needlessly complicated procedures in all 
 the classes, but descriptions are apt to be misleading in this respect. 
 
 Most all the single suture advancement operations have the 
 merit of drawing the muscle straight forward. This is not true,
 
 ORTHOPIC AND FUSION TRAINING. 203 
 
 however, of those wherein the thread is knotted in or tied to the 
 tendon. It can be done with the multiple suture methods that have 
 a meridional thread, by tying this first, but this, again, is in the way 
 of a full effect. A certain vertical deflection of the muscle is difficult 
 to avoid in the two suture modes. Another advantage of the single 
 suture is that it facilitates removal. It is a curious fact that there is 
 more dread and flinching on the part of the average patient relative 
 to the taking out of the thread than to the making of the operation 
 itself. One has merely to grasp the knot with the forceps and cut 
 the suture. If the knot is not held by the forceps one risks attempt- 
 ing to pull it through the stitch canal. 
 
 A great deal has been said about the advantage of this or that 
 advancement procedure in that the arrangement of the suture or 
 sutures in the tendon tends to prevent its cutting out. From an 
 abundant experience with his own method, both as performer and 
 onlooker, the writer has long since come to the conclusion that it is 
 far easier for the average surgeon to obtain a firm hold for the 
 thread in capsule and tendon than in the globe; and this with regard 
 to an operation where the suture is not tied fast to the tendon by 
 "surgeon's knots." It may be that more is lost than gained by 
 these ligations of the tendon. 
 
 The object of the accompanying tenotomy being only for its 
 temporary effect, the writer often omits it in the lower degrees of 
 squint, but, owing to the fact that the greater the rotation the greater 
 the resistance of an unweakened opponent, tenotomy has come to be 
 an auxiliary in all whose' angle is above 25 degrees. If advance- 
 ment of the corresponding muscle of each eye fails to correct the 
 squint, rather than make a tenotomy to complete the cure, a second 
 advancement is made in case of the first eye operated. I consider 
 advancement preferable to tenotomy for every form of squint, latent 
 or manifest, where surgical measures are at all indicated. 
 
 Orthoptic and fusion training are instituted at the earliest 
 moment after operating in order to enhance the result. Binocular 
 single vision, however, is not the rule in these cases. But, as 
 Landolt has pointedly said, the best that the most skilled can do is 
 to put the eyes approximately right and rely upon Nature to do the 
 rest. So, by these exercises we strive still further to assist Nature. 
 
 The length of time one should wait before making a similar
 
 204 OPERATIONS UPON THE EXTRINSIC MUSCLES. 
 
 operation on the fellow eye must be regulated by circumstances. 
 In children, and all those where there is hope of gaining the end by 
 the help of other means, from six months to a year is not too long. 
 As regards older subjects, and those with high and incorrigible 
 amblyopia, it is useless to wait longer than a month or so. 
 
 Anesthesia. Wherever feasible one should make the operation 
 under local anesthesia, and it is the writer's custom even in case of 
 small children from 7 to 12 years of age although they are pre- 
 pared for narcosis, to begin under cocain. If they bear it uncom- 
 plainingly, well and good; if not, they are narcotized. A pretty 
 large percentage of these little ones can be operated without being 
 put to sleep. The suggestion of Eales, 1 of making the tenotomy 
 and first step of the advancement under cocain, and then giving 
 ethyl chlorid or some such anesthetic for the sewing seems a 
 plausible one. The subconjunctival injection of cocain is not free 
 from danger, and makes a mess of the tissues concerned. Three 
 or four drops of a 4% solution made from a good quality of cocain 
 produces perfect anesthesia in most eyes, though it is well to put a 
 drop or two into the wound as soon as the conjunctiva is incised, 
 both for the tenotomy and for the advancement. 
 
 As to safety, advancement ranks about as high as any operation 
 that is made on the eye. In all my experience I have never seen but 
 a single eye that gave me serious alarm thereafter. This was a dis- 
 pensary patient who was allowed to go home directly from the operat- 
 ing-room, but with instructions to report on the second day. He 
 did not return till the end of the fourth day. The bandage was 
 filthy, the dressing was off the eye, and there was septic tenonitis 
 at the site of the advancement, with a deep infiltration in the nearest 
 segment of the cornea. The suture was at once removed, the man 
 put under treatment in the hospital, and the eye made a complete 
 recovery. 
 
 A neat and effective advancement, though safe and simple as to 
 detail, is by no means easy of execution, the great difficulty lying 
 in the deep anchorage required for the sutures in the globe. The 
 older the subject, the more difficult this becomes. To pierce the 
 superficial layers of the sclera for the requisite distance without 
 going through and in such a way that the tunnel of the needle will 
 
 1 Brit. Med. Jour., Jan., 1888, p. 349.
 
 ANESTHESIA. 
 
 205 
 
 not be ripped open in drawing the suture through is the key to the 
 situation. Fine needles, of proper shape and irreproachable sharp- 
 ness, together with steadying the globe by holding with fixation 
 forceps the tendon at its attachment, go a long way toward lessen- 
 ing the labor of this step; though nothing but practice will give the 
 necessary skill. This can be attained to a tolerable degree by 
 operating upon pig's eyes in a mask. 
 
 To give the lines of anchorage a highly divergent direction serves 
 three important purposes: i. It prevents the thread in its back- 
 ward course to the loop from overlying the cornea. 2. The ad- 
 vancement can be more posi- 
 tive, i.e., it allows the tendon 
 to be drawn quite up to the 
 cornea. 3. Any dropping 
 back or cutting of the thread 
 is minimized in proportion 
 to the degree of divergence, 
 hence magnified in propor- 
 tion as the lines of anchorage 
 approach parallelism. On 
 the other hand, the solidity 
 and security of the anchor- 
 age is increased in propor- 
 tion as its lines become more 
 nearly horizontal, for the 
 reason that the strain of trie 
 
 VM. 
 
 FIG. 86. The anchorage cannot be long. 
 Essential that distal portion should be deep. 
 
 thread is thus distributed along the sides of the stitch canal, whereas, 
 the more divergent the lines, the more the strain is concentrated at 
 the distal extremity of the canal. These points are illustrated by 
 Fig. 86; aa indicate the further ends of the scleral anchorage, situated 
 at five mm. from the cornea on the vertical meridian. This insures 
 a maximum advancement without contact of the thread with the 
 cornea. Now, in order to give greater firmness to the hold of the 
 thread in the sclera it is not inserted along the lines ea, but is made 
 to follow the lines ca. Still greater lateral strain in the anchorage 
 would be obtained by following the lines c'a, or to make them 
 actually parallel, but this would add greatly to the difficulties of the 
 operation. It would also shorten the anchorage.
 
 CHAPTER V. 
 OPERATIONS UPON THE LIDS. 
 
 EVERSION. 
 
 Eversion of the lid consists in turning it so as to expose its 
 conjunctival surface, together with the retrotarsal folds, and to 
 accomplish which the essential feature implies the inverting of the 
 stiffening plate of the lid, viz., the tarsus. The ends sought in 
 everting the lids are manifold, such as examination and topical 
 treatment of the conjunctiva, the removal from it of foreign bodies, 
 the excision of tumors of the tarsal plates and the making of various 
 other operations. Although the performance seems a simple affair, 
 it is really one involving considerable sleight, and the constant need 
 of the procedure gives it importance. Moreover, the fact that the 
 eye, naturally a sensitive organ, is rendered all the more so by the 
 affections requiring eversion, makes it incumbent on the operator 
 to be deft in its execution. The novice is hardly expected to do the 
 thing without awkwardness, but that so many of the older and more 
 experienced eye surgeons should perpetually exhibit this quality in 
 the little act is truly surprising. 
 
 Method for the Upper Lid. (Fig. 87). Standing or sitting in 
 front of the subject, the operator rests the tips of the fingers of his 
 right hand upon the brow; with the thumb and index of the left 
 hand he takes hold of the lashes, tells the patient to look all the while 
 far downward and to refrain from squeezing. He pulls the lid well 
 down on the stretch and slightly away from the eyeball, places the 
 right thumb on the skin opposite the upper border of the tarsus, 
 pressing it downward and backward rather slowly and steadily 
 at first, till, feeling that he has the plate well in hand, he gives a 
 quicker down and back impulse to the upper border and an equally 
 quick forward and upward one to the free border, ending the move 
 in turning the tarsus completely upside down (Fig. 88). The right 
 hand is removed as is the left forefinger, but the left thumb remains 
 to hold the lid everted, by pressing the lashes back against the 
 
 206
 
 METHODS FOR THE UPPER LID. 
 
 207 
 
 globe and having for solid support the rim of the orbit above 
 (Fig. 89). If, as is sometimes the case, the lashes are wanting, a 
 
 FIG. 87. 
 
 stiff probe or similar instrument is used to press the convex border 
 of the tarsus down and back, till the free border pouts very de- 
 cidedly, when with the left thumb it is adroitly shoved up, rolled
 
 208 
 
 OPERATIONS UPON THE LIDS. 
 
 back, and held, possibly with the probe left in situ to help (Fig. 90). 
 This instrumental eversion is useful also where the patient is touchy 
 or the orbicularis is spasmodic, but it is best, as a rule, to rely upon 
 the fingers alone. In fact, to be able to make a neat eversion with 
 the left hand unaided by the right is a most convenient acquire- 
 
 FIG. 88. 
 
 ment, for the reason that it is so often desirable to have an instru- 
 ment in the right, all ready for use. To do it, the office performed 
 by the left thumb and index is precisely as described for the two 
 hands and in lieu of the right thumb, the upper border of the tarsus 
 is manipulated by the left middle finger.
 
 METHODS FOR THE UPPER LID. 
 
 2OQ 
 
 Epilation of the margins of the lids is advisable as regards 
 any hairs that are in the way of proper application of remedies, as 
 in blepharitis or for trie-temporary riddance of any that offend by 
 
 FIG. 89. 
 
 touching the cornea, or conjunctiva, and is done by means of the 
 cilia forceps (Plate V). 
 
 The chief requirements of this instrument concern the jaws, 
 which, to be right, are rather broad two to three millimeters 
 slightly rounded at the corners and of faultless coaptation. The 
 14
 
 210 
 
 OPERATIONS UPON THE LIDS. 
 
 depth of the articulating surface is about one and one-half milli- 
 meters and the width, of course, the same as that of the jaw itself. 
 The shanks are sufficiently rigid to withstand the necessary pressure 
 
 FIG. 90 
 
 without bending toward each other, as this would cause the tips 
 of the jaws to open, save at their posterior angles, and to let go the 
 hair.
 
 THE METHOD. 211 
 
 Lindsay Johnson 1 recommends putting a minute quantity of 
 cobler's wax, or resin, between the opposing jaws of the forceps, and 
 gently heating for a second. The material will spread evenly over 
 the blades and insure a firm grip on the hair. It can be melted and 
 wiped off for cleansing or renewing. 
 
 The Method. Epilation, like eversion, while it can be done, 
 after a fashion, by the merest novice, has, nevertheless, its refine- 
 ments and is cleverly done only by those who have special training. 
 The forceps is held between the tips of the right thumb and index, 
 jaws up for the upper lid and down for the lower. The bulbs of 
 the left fingers are rested on the patient's brow, he is made to 
 look down for epilation of the upper lid, and vice versa. The left 
 thumb manipulates the upper lid, the left index the lower, slightly 
 everting by pressure, raising, depressing, etc. The jaws are placed 
 vertically astride the hair to be pulled and in contact with the skin 
 at its base, closed not too tightly and gentle, steady traction 
 made exactly in the line of the shaft of the cilium, to pluck it out 
 by the root. Quick jerks and sidewise pulls will not do, but result 
 in breaking off, not eradicating. The hairs, especially the tiny 
 ones, seem to require a little time in which to relinquish their 
 deeper attachments. The smaller the hair, apparently, the stumpier 
 the free end, hence those that are practically invisible to the 
 naked eye are almost as potent for harm when they touch the cornea 
 as are the larger ones. Focal illumination made by an assistant or 
 by the adjustable lens, attached to a head-band are valuable ad- 
 juncts. For locating the finer cilia the lid must be so managed 
 that the pupil, iris, or nearly closed palpebral fissure will afford a 
 dark background for the illumined hair. Strong convex spec- 
 tacles, or the binocular loop, worn by the operator will greatly 
 assist him. With all these appliances certain extremely fine hairs 
 will remain invisible and must be nipped for cautiously along the 
 whole length of the lid. When the resistance of one is felt or a 
 pimple is seen to rise around it the usual time is given for it to let 
 loose. 
 
 A wad of absorbent cotton that has been moistened with boric 
 acid or sublimate solution and well wrung is held on the brow 
 beneath the fingers of the left hand on which to wipe the forceps. 
 
 1 Ophthalmoscope, Nov., 1904.
 
 212 OPERATIONS UPON THE LIDS. 
 
 As the eye fills with tears, the lids are sponged dry from time to 
 time, for the forceps will not hold the cilia securely when they are 
 wet. 
 
 Electrolysis of the hair-follicles, something after the method 
 of Michel, 1 as an auxiliary to epilation, is the only sure means of 
 permanently eradicating the cilia, and is particularly applicable to 
 cases of trichiasis where relatively few hairs grow inward, or, as it 
 is termed, distichiasis. 
 
 The requisite implements are an electric outfit, capable of 
 furnishing a continuous current of from one to five milliamperes. 
 The negative electrode is fitted with a fine, sharp needle (gold or 
 platinum), the positive, with a sponge which is moistened with salt 
 solution. Provided there is a rheostat or controlling switch, one 
 may dispense with a galvanometer; indeed, the best means of regu- 
 lating the energy is to immerse the two electrodes in a vessel of water 
 and gradually turn on the current until the needle throws off a 
 stream of tiny bubbles, indicative of the decomposition of the 
 liquid. It is then ready for use. A valuable suggestion is that 
 of Jourdan, of Frankfort a/M., to apply shellac to the needle, then 
 to uncover the point by scraping. This greatly lessens the pain, 
 since it protects the sensitive skin. It also prevents punctiform 
 scars that might otherwise ensue. 
 
 In order to introduce the needle with precision the operator 
 wears strong, convex lenses or uses the binocular, stereoscopic 
 loop. The patient may sit or lie. A lid spatula is inserted beneath 
 the lid to steady it and to afford a purchase for holding and manip- 
 ulating with the thumb. Or, better still, the Beard lid-forceps is 
 clamped on (Fig. 91). The needle is pushed down alongside the shaft 
 of the hair, till the point is well within the follicle (three to four mil- 
 limeters) and the sponge electrode is applied to the adjacent temple 
 or forehead. As soon as a boiling up of gas occurs around the 
 needle, the sponge is lifted, or the connection button is released, 
 the needle withdrawn and the hair lifted out. Lifted is the word, 
 for if any traction is needed, it is a sign that the electrolysis has been 
 incomplete and, to be effective, must be repeated. The performance 
 is anything but agreeable to the victim, but the pain is much greater 
 if the needle is taken out without stopping the current. 
 
 1 St. Louis Clinical Record, Oct., 1875.
 
 CHALAZION. 
 
 213 
 
 Chalazion. The usual manner of removal is by incision and 
 curettage. The tumor is attacked from one of three directions: 
 
 1. Marginal Route. From the free border (Agnew). 
 
 2. Conjunctival Route. From the inner surface of the lid. 
 
 3. Cutaneous Route. From the external surface of the lid. 
 The first is preferable for the removal of the softer or cystoid varieties 
 particularly, when not situated in the extreme upper portion of the 
 superior tarsus. 
 
 FIG. 91. Electrolysis of cilia. 
 
 The only Instruments needed are a thin, sharp Beer's knife or 
 a straight, keen bistoury and a small, oblong sharp curet. A drop 
 of cocain solution is instilled. 
 
 The positions of surgeon and subject, as concerns the upper lid 
 (Fig. 92), are the same as for slitting and syringing the lower canalic- 
 ulus (p. 134). The lid is slightly lifted from the globe by catching hold 
 of the lashes with the right hand, the left forefinger is slid beneath, 
 with the palmer tip in contact with the tumor, the left thumb is put 
 in contact with it on the outside and it is held as one would a pea
 
 214 
 
 OPERATIONS UPON THE LIDS. 
 
 FIG. 92.
 
 CHALAZION. 215 
 
 in other words, as if the surroundings of the tumor did not exist 
 and this hold is maintained throughout the entire operation. The 
 lid is turned slightly away from the eye and the incision is made 
 exactly in the mid-line of the free border of the tarsus, the flat of the 
 blade corresponding to the flat of the lid, and the point aimed at the 
 center of the tumor. Having penetrated the chalazion, the knife 
 is rocked slightly, to insure free opening of the wall, and, in with- 
 drawing, the soft contents are squeezed out by pressing together the 
 left finger and thumb. Still grasping the tumor, the tiny serrated 
 curet is introduced, the unexpressed contents laded out and the 
 walls of the cavity well scraped. The left finger and thumb 
 feel the movements of the curet and are a guide to its work. As the 
 instrument is removed, they are approached to hold the opposite 
 sides of the opening tightly together and thus held for a few moments, 
 else it would fill with blood and tend to disparage the result. The 
 materials for applying a compressive bandage are ready at hand, so 
 that as the lid is let go, the occluding pad, with its facing layer of 
 wet cotton, is applied, and the simple bandage (p. 15) tied over it. 
 This can be done in such a way that there will be no let up in the 
 pressure upon the site of the chalazion, hence no possibility of a 
 blood tumor forming. Twelve hours is long enough for the bandage 
 to be worn, after which simply bathing the eye with hot water is 
 sufficient. The advantages of Agnew's method are simplicity and 
 the leaving of neither a visible scar of the skin, nor an irritating one 
 of the conjunctiva. 
 
 Wilder, of Chicago, has invented a lid-clamp, shaped like the 
 letter U (Plate IV, No. 79). With this he surrounds the chalazion, 
 then injects a few drops of cocain solution through the border of the 
 lid into the tumor. The clamp serves both to keep the cocain 
 from entering the general circulation and to prevent hemorrhage, 
 while the cocain renders the cutting and curetting painless. A 
 drop of the solution previously put on the underlying conjunctiva 
 also helps to do away with the pain of the clamp. 
 
 Removal from the inner surface of the tarsus, although the favorite 
 mode with a few operators, is chiefly indicated when the inflam- 
 matory process has gone so far in that direction as to have produced 
 either a spontaneous opening or the sprouting up of granulation 
 masses. An incision is not necessary in most instances, merely
 
 2l6 OPERATIONS UPON THE LIDS. 
 
 eversion of the lid, cocain and a drop of adrenalin, and thorough 
 curettage. A clamp and sutures are uncalled for. Other indica- 
 tions than those just alluded to hardly exist for the method in ques- 
 tion, seeing that either the marginal or the cutaneous modes offer 
 superior results. In truth, large chalazions, extirpated from the 
 conjunctival side, have been followed by troublesome trichiasis. 
 
 The cutaneous opening is resorted to by many as a customary 
 procedure, and has certain advantages. For the hard, fibroid 
 chalazions and those softer ones whose seats are high up in the 
 superior tarsus, this is by far the best method. 
 
 The instruments needed are a lid clamp (Desmarre's, Plate VI, 
 is probably the most suitable, but Snellen's also answers well) small, 
 mouse-tooth forceps, small scalpel or bistoury, Steven's strabismus 
 hooks, small, blunt scissors, needle forceps, and a fine curved 
 needle, carrying No. i braided silk thread. Narcosis would be 
 admissible only in case of a child, either in years or nerves. 
 
 A drop of cocain solution is put into the eye to make it tolerant 
 of the clamp. The plate of the latter is slid beneath the lid, the ring 
 made to encircle the chalazion and the screw tightened. This ap- 
 pliance insures hemostasis and steadies the field of operation. 
 The hard, rubber lid spatula may be substituted for the clamp, 
 but it must be held by an assistant. A transverse incision is made 
 (that is, parallel with the free border) over the tumor and extending 
 a short distance beyond it at each end through integument and 
 orbicularis, down to the tarsus, and held open by the little strabismus 
 hooks. The fibres of the muscle are pushed aside, the tumor seized 
 with the forceps, or a minimum-size, short tenaculum does equally 
 well, and dissected with knife and scissors much as one would shell 
 out a sebaceous cyst. If practicable, the conjunctiva beneath the 
 chalazion is left intact, but no part of the abnormal growth is left 
 behind in order to avoid making a hole clear through, as to do so 
 would do no special harm. The opening is cleansed, but not until 
 after the removal of the clamp and the stanching of the blood is the 
 suture introduced. One suffices, and it is taken out after twenty- 
 four to thirty-six hours. The dressing may be the regulation 
 bandage, a patch, or adhesive strips. 
 
 Canthoplasty. Technically, this word signifies an operation for 
 the correction of an anomalous condition of the commissure
 
 CANTHOPLASTY. 21 7 
 
 usually the outer of the lids and is to be distinguished from canthot- 
 omy or tarsodialysis, which means merely a cutting of the canthus. 
 According to its common acceptation, however, the term is used in 
 both senses, yet with this difference; simple incision of the canthus, 
 without the addition of sutures, is called provisional canthoplasty; 
 and the more finished operation, wherein there is external tenotomy 
 oculi and the divided conjunctiva and skin are stitched together or 
 yet further elaborated, is known as definitive canthoplasty. 
 
 The. first is applied, for example, to the temporary elongation of 
 the palpebral fissure that is made preliminary to exenteration of 
 the orbit, to the enucleation of a globe of extra size, to the extraction 
 of cataract where the conjunctival sac is much shrunken, and to 
 relieve pressure, as in phlegmon of the orbit, in the intense chemosis 
 of gonorrheal ophthalmia, and in panophthalmitis. 
 
 The second, to permanent extension of the outer commissure for 
 the correction of blepharophimosis, for anchyloblepharon, and for 
 the damaging lid tension in chronic trachoma. It is also an im- 
 portant part of many operations for entropion and is occasionally 
 the sole measure adopted for the cure of spastic entropion. It may 
 be stated in passing that canthotomy, pure and simple, is seldom 
 practised nowadays, as even in most of the instances just given it is 
 followed by sutures. C. R. Agnew, of New York, in 1875, was the 
 first to demonstrate the immense value of canthoplasty as a thera- 
 peutic measure in inflammations of the conjunctiva and cornea, 
 such as the more severe phases of phlyctenular and interstitial 
 keratitis and trachoma. 
 
 Agnew's method, a modification of that devised by Von Ammon 
 in 1839, the one chiefly in vogue, is here described. 
 
 The instruments comprise large and small straight, blunt scissors 
 (Plate IV, Nos. 53 and 54), mouse-tooth forceps, needle-holder, 
 and two or three fine curved needles. General anesthesia only when 
 absolutely necessary. Local anesthetics help slightly. The patient 
 lies on the table. 
 
 First Step. The outer commissure is held moderately open by 
 the left thumb and index, one blade of the large scissors is slid into 
 the outer cul-de-sac as far as it will readily go, its edge exactly be- 
 neath the angle of the lids and in line with the closed palpebral fissure. 
 The other blade is closed down until it touches the skin, a good grip is
 
 2l8 OPERATIONS UPON THE LIDS. 
 
 taken on the handles, so that the blades will not "buckle," and with 
 one firm snip the cut is made. This should be from one to one and 
 a half centimeters long, according to the demands of the case. 
 Although the cut is usually made in a perfectly horizontal direction, 
 it would seem that in many individuals the scar would conform 
 better to the natural topography about the outer canthus if it were 
 given a somewhat downward inclination. One should bear in 
 mind that a part of the accessory lacrimal gland lies in this region 
 and strive not to injure it wantonly. There will be some bleeding, 
 but it usually ceases spontaneously. 
 
 Second Step. Division of the external canthal ligament. The 
 free border of the upper lid is grasped by the left thumb and index, 
 pushed slightly up to open the spaces between the severed skin and 
 conjunctiva, the small scissors, closed, are put into the upper 
 opening to feel for the ligament. The lid is now pulled forward and 
 toward the nose, so as to make the ligament taut, when the scissors 
 are opened slightly, the blades are pushed up astride the ligament 
 and it also is cut with a single snip. Some authors state that the 
 conjunctiva is unavoidably incised in dividing the ligament; such 
 is not the case, for with delicate scissors and a little care, neither 
 the skin nor the conjunctiva need be wounded. If the snip is suc- 
 cessful the lid at once gives way under thumb and finger. If it 
 fails thus to yield, another and more careful effort must be made. 
 The same procedure is repeated on the lower section of the ligament. 
 
 Third Step. Placing and tying the sutures. An assistant opens 
 wide the extended commissure. It will be observed that the cut in 
 the skin is longer often very much so than that in the conjunctiva. 
 Now, all the descriptions of the operation that I have ever read and 
 all the many cuts that I have seen illustrative of it, teach that the 
 angle of the conjunctival opening is joined to that of the skin. 
 This is precisely what Agnew insisted should not be done. And 
 with good reasons, to wit, because of the inequality in the length 
 of the angles alluded to, thus to unite them, means the obliteration 
 of the external cul-de-sac; not only this, but the conjunctiva is so 
 stretched to meet the skin at this point, that an unseemly bridle or 
 band results that is particularly noticeable when the globe is in 
 adduction. Instead, therefore, following Agnew, after picking up the 
 conjunctival angle with the needle, it is carried outward as far as it
 
 CANTHOPLASTY. 
 
 219 
 
 will go without any stretching and is joined to the upper lip of the 
 incision (Fig. 93). Another suture is placed to unite the lower skin 
 and mucous lips, and the operation is finished unless, perchance, 
 one chooses to put in a third or superficial suture to close the small 
 skin angle thus left unclosed. As each suture is put in, if it be not 
 tied at once, the two ends of thread are laid together on the temple 
 where an aid places a finger on them to insure keeping them to 
 themselves. They are 
 tied with the canthus 
 stretched open, in order 
 to see that they are true 
 and do not cut out of 
 the conjunctiva. 
 
 Several other ingenious 
 and effective varieties of 
 canthoplasty have been 
 devised and extensively 
 practised. Attention is 
 called to three: 
 
 i. Richet 1 resected a 
 dart of skin and tarso- 
 
 FIG. 93. Canthoplasty. 
 
 orbital fascia whose base 
 was the canthus and 
 
 whose point reached outward horizontally one and one-half centi- 
 meters. A median horizontal incision was made in the outer wall 
 of the external conjunctival cul-de-sac thus laid bare, and the cut 
 edges were stitched to those of the skin. 
 
 2. David Prince, 2 of Jacksonville, III, made a cutaneous incision, 
 beginning on a level with, and three or four centimeters from the 
 commissure, down and in, parallel with the lower lid border, one- 
 third to one-half of the length of the latter; then from this point 
 out and up back to the level of the canthus, but several millmeters 
 further toward the temple. The curved angle of skin thus marked 
 out was dissected up from apex to base. A third incision joined 
 this base and the canthus, the upper lip of which was undermined 
 for a centimeter or more toward the brow, a double-armed suture 
 
 1 Trait, d'anat. med. chir., 1851. 
 
 2 Am. Jour, of the Med. Sciences, 1866, p. 381.
 
 220 OPERATIONS UPON THE LIDS. 
 
 was put through the point of the curved flap outlined by the first two 
 incisions; it was tucked up into the pocket made by the undermining 
 of the upper lip of the horizontal incision, the suture brought out 
 through the skin beneath the supercilia and tied over cylinders of 
 buckskin or other material. The remaining angular opening was 
 closed by sutures, which completed a clever method for combining 
 canthoplasty with correction of moderate ectropion of the lower lid. 
 
 3. Chalot (V.) 1 makes an incision through the skin only, extending 
 from the canthus outward one and one-half centimeters. This 
 he crosses with a vertical skin incision, made flush with the canthus, 
 the two forming a capital H , supine, against the canthus. The 
 two angles he dissects or undermines, exposing a bridge of conjunc- 
 tiva. This is incised above and below, turned outward, and sutured 
 to the angle of the cutaneous incision. 
 
 Tarsorrhaphy, or as it is sometimes termed, blepharorrhaphy, is 
 an operation having for its object the occlusion of all or a portion 
 (total tarsorrhaphy, or partial tarsorrhaphy) of the palpebral 
 fissure. It is called external, median, or internal, respectively, as it 
 concerns the corresponding division of the fissure. Internal tar- 
 sorrhaphy is sometimes erroneously called median, after the German 
 fashion, as, for example, in A. Duane's translation of Fuchs' text- 
 book (D. Appleton & Co.), p. 727, 1892. Like canthoplasty, the 
 end sought may be a permanent one (definite tarsorrhaphy) or 
 temporary (provisional tarsorrhaphy). 
 
 Some form of the operation is indicated in lagophthalmos (pa- 
 ralysis of the seventh nerve with ectropion) , in neuro-paraly tic keratitis 
 (paralysis of the fifth nerve), in reducible exophthalmos, as of 
 Basedow's disease or the proptosis after injuries, in paraphimosis, 
 and in certain surgery undertaken for the restoration of the lids and 
 conjunctiva, to hold them in position during the healing process. 
 
 Total tarsorrhaphy, literally speaking, either temporary or 
 permanent, is not admissible, since in the first instance it means 
 difficulty of reopening the outer canthus should this become 
 desirable later, and in the second, retention of the secretions of the 
 eye. A more or less extensive median operation is better in both 
 instances. 
 
 External tarsorrhaphy. Occlusion of the outer portion of 
 
 1 Trait. Elem. de Chir. et de Med., Paris, 1900, 3d edition, p. 711.
 
 EXTERNAL TARSORRHAPHY. 
 
 221 
 
 FIG. 94. External tarsorrhaphy. 
 
 the fissure, as first practiced by Walther, was frequently resorted 
 to previous to the invention of the median method. It was done 
 by "scalping" the lids or excising strips of skin containing the 
 follicles of the cilia (Fig. 94) from 
 the outer canthus for varying dis- 
 tances inward, owing to the degree 
 of closure desired and uniting the 
 raw edges by sutures. The method 
 is still resorted to, at times, as a 
 permanent feature, especially in 
 connection with operations for the 
 correction of ectropion of the lower 
 lid, from laxness, and with eversion 
 of the punctum; but it should never 
 be done if one expects later to undo 
 the work. 
 
 Fuchs is the author of a method 
 of external tarsorrhaphy that could 
 be converted into internal, and 
 which is characterized by great solidity of the union produced be- 
 tween the lids (Fig. 95). Briefly, it is thus: beginning at the outer 
 canthus and extending inward the desired distance, an intermar- 
 ginal incision is made, whereby the lid is split for a depth of five 
 
 or six millimeters into tarsal 
 and cutaneous leaves. At the 
 inner end of the slit a vertical 
 incision is made in the skin 
 half that extends to the bot- 
 tom of the slit to allow the 
 latter to gape. Correspond- 
 ing incisions are made in the 
 upper lid with the addition of 
 a second perpendicular inci- 
 sion in the skin half at the 
 canthus. The upper extremi- 
 ties of the two vertical cuts are joined by an incision, and the 
 parallelogram thus outlined, and which contains the hair bulbs, is 
 excised. A double-armed suture is passed from within outward at 
 
 FIG. 95.
 
 222 
 
 OPERATIONS UPON THE LIDS. 
 
 the middle of the denuded portion of the upper tarsus and, in the 
 same manner, through the skin flap of the lower lid and tied over a 
 cylinder of some appropriate material. In closing the lids and 
 knotting the thread the inner surface of the loosened skin flap is 
 made to coapt with the raw surface of the upper tarsus. To com- 
 plete the operation, a few, fine, superficial sutures are put in. 
 
 Internal tarsorrhaphy was introduced by V. Arlt, for eversion 
 of the punctum. It consisted in the resection of a horseshoe-shaped 
 strip of skin around the lac lacrymale close to, and surrounding the 
 
 inner canthus and unit- 
 ing the upper and lower 
 halves by sutures, thus 
 preserving the puncta 
 and canaliculi a sort of 
 :v artificial epicanthus (Fig. 
 96) . The great Viennese 
 was not extensively imi- 
 tated in this respect. It 
 finds its chief indication 
 in those slight eversions 
 of the puncta that are so 
 productive of annoying 
 epiphora, and that are so unsatisfactory as to their treatment by 
 conservative means. All that is necessary is to close the semicircle 
 that constitutes the canthus itself or, what the French call "the 
 grand angle." This is accomplished by paring with delicate 
 curved scissors a very narrow strip, just where skin and conjunctiva 
 meet, rather inclining to the skin side, being scrupulous to avoid 
 wounding the canaliculi and to stop safely short of reaching the 
 puncta. The opposite raw surfaces are united by fine interrupted 
 sutures, which are removed at the end of two or three days. 
 
 Median tarsorrhaphy (Fig. 97), or the forced agglutination 
 (more or less extended) of the opposing surfaces of the lid borders 
 at or near the center of the palpebral fissure, was first done by Bow- 
 man; but to Panas is due the credit of devising the improved mode. 
 It is the most suitable operation, whether provisional or definitive, 
 and is made as follows : 
 
 The lids having been carefully approximated, one selects the 
 
 FIG. 96. Internal tarsorrhaphy.
 
 MEDIAN TARSORRHAPHY. 
 
 22 
 
 location and marks the extent of the proposed occlusion. The 
 best way is by means of tiny pricks with knife, to cause red points of 
 blood. If the eye has useful vision, the site of the operation is 
 so placed that in looking at distant objects the outer opening is 
 utilized, and at those close up, the inner one. This would make the 
 occluding bridge a trifle to the nasal side of the center, the point 
 that is preferable from an anatomical standpoint also. A lid 
 spatula is placed first in the lower fornix, for when the upper lid 
 is done first the bleeding interferes with work on the lower. The 
 lid is pressed firmly against 
 the spatula to steady it if 
 no clamp is used, and a thin 
 slice of the margin is re- 
 moved by means of the 
 convex scalpel. I have 
 found the Beard forceps 
 described on page 99 the 
 most convenient instru- 
 ment for steadying the lid 
 during this step. It is ap- 
 plied just as if for making 
 the intermarginal incision 
 for receiving a graft, the screw tightened, and the lid everted. The 
 raw surface prepared need not be more than four or five millimeters 
 long, though this must be regulated by the judgment of the operator. 
 Its width should include only the tarsal partion of the free border, 
 i.e., the adjacent cilia and their follicles 'are spared. An exactly 
 contiguous spot is pared on the upper margin. Two sutures are 
 passed in through the lower lid and out through the upper, the raw 
 areas put nicely in apposition and the thread tied firmly over a 
 short section of soft-rubber tubing or a cylinder of gauze or cotton. 
 It is best to reinforce the sutures by strips of adhesive plaster. 
 Over all, the usual dressing and bandage. The spring of the rub- 
 ber tubing will take up the slack of the thread caused by any 
 slight tendency to cut out; yet, to make surer, one may tie bow- 
 knots, so that they may be untied, in case of early separation of the 
 lids, and the sutures again drawn up. The thread is removed 
 after four or five days. 
 
 FIG. 97.
 
 224 
 
 OPERATIONS UPON THE LIDS. 
 
 In course of time the free portions of the lid borders, although 
 closed at first, become curved or concave, causing two elliptical 
 openings which serve admirably for vision the outer for distant and 
 the inner for near, yet not sufficiently wide to give rise to trouble 
 with the cornea (Fig. 98). 
 
 Exsection of the Tarsus. The cutting out of all or a portion 
 of a diseased tarsus was done as far back as the Middle Ages. It 
 was first undertaken for the relief of cicatricial entropion. To this 
 end, Saunders 1 in cases of shrunken and incurvated tarsi, removed 
 
 them entirely. In this con- 
 nection, the procedure has 
 been superseded by modern 
 methods, as described under 
 Entropion. The operation 
 is resorted to after fair trial 
 of other means of treatment 
 has failed to effect a cure or 
 when the circumstances are 
 such that the other means 
 
 FIG. 98. 
 
 cannot be consistently carried out. It is indicated in the severe 
 tarsal forms of vernal catarrh and in obstinate chronic trachoma 
 characterized by deep infiltration and hypertrophy and degenera- 
 tion of the tarsus, accompanied by persistent pannus and recurrent 
 corneal ulcers. (For description see page 356.) 
 
 C. Magnani, 2 of Smyrna, as a precaution against ptosis, after the 
 operation, before tying the threads to close the wound, opens it 
 wide and puts a double armed suture into the deeper portion of 
 Miiller's muscle, then carries the needles up and back (lid inverted), 
 and causes them to emerge from the skin near the cilia. He, then, 
 closes the wound, turns the lid back into position, and, lastly, ties 
 the external thread ends over a tiny glass bead. If the operation 
 is done after the manner here described, however, there is no 
 extra inclination to ptosis. It will be remembered that there is an 
 inherent tendency in many of these chronically inflamed lids to 
 both ptosis and entropion. 
 
 The usual dressing is applied, though whether to one or both 
 
 1 Treatise on Diseases of the Eye, 1811. 
 3 La Clinica Oculistica, Oct., 1903, p. 1460.
 
 OPERATIONS FOR EPICANTHUS RHINORRAPHY. 
 
 eyes is a matter which is left to the judgment of the operator. 
 If there are knotted threads touching the cornea, both eyes should 
 be bandaged, the better to insure immobility of the globes. 
 The sutures are removed on the fourth day. 
 
 Operations for Epicanthus, or Rhinorraphy. Von Ammon 1 
 first described this congenital deformity of the nose and disfigure- 
 ment of the inner canthi under the name it bears, and invented an 
 operation for the correction of the ocular part of the defect which he 
 
 FlG. 99. Knapp's Rhinorraphy. 
 
 called rhinorraphy. This consisted in pinching up a vortical fold 
 of skin on the bridge of the nose sufficient to rid the canthi of the 
 redundance, marking out the base of the fold in ink. excising it, 
 inserting silver pins, as in the operation for harelip, and closing 
 the opening by means of thread wound on to the pins, figure S 
 fashion. This is known as median rhinorraphy. 
 
 De Wecker 2 modified the operation l>y putting two or three large, 
 curved, threaded needles through the base of the pinch up fold, in 
 
 1 DarsteUungen, etc., 6, 1841. 
 
 2 Trait. Comp. d'oph., vol. i, p. 180. 
 
 15
 
 226 
 
 OPERATIONS UPON THE LIDS. 
 
 stead of outlining it. He then cut it out with scissors close to the 
 needles, and brought together the edges of skin with the threads. 
 
 Knapp 1 still further modified the procedure by removing a 
 diamond or rhomboid section of skin, long axis vertical, from the 
 center of the nose, undermining the edge for some distance, laterally, 
 closing with a number of fine interrupted sutures and reinforcing 
 with strips of gauze and collodion (Fig. 99). 
 
 Arlt 2 excised the two semilunar pieces of integument comprising 
 
 FIG. ioo. Arlt's lateral rhinorraphy. 
 
 the greater portion of the epicanthal folds themselves, and in" 1 ex- 
 treme cases a median ellipse from the nose also. This is known 
 as lateral rhinorraphy. The sutured wounds presented something 
 the form of an X (Fig. ioo). 
 
 The use of silver pins, as in the Von Ammon operation, is apt to 
 leave an ugly scar, as also are de Wecker's large needles and thread. 
 Knapp's small needles and thread, with the -auxiliary collodion 
 strips, is a decided improvement in this particular. V. Arlt's 
 
 1 Epicanthus und seine Behandlung, Arch. f. Aug. u. Orenh. 1 1 1 S SQ 
 8 Graefe-Saemisch, in, S. 443.
 
 OPERATIONS FOR EPICANTHUS RHINORRAPHY. 227 
 
 method is also a good one, and for it Knapp's small sutures and 
 collodion may be utilized. The extra scar is hidden by the specta- 
 cles which the subjects of epicanthus usually require. 
 
 I would suggest trying the omission of the rhinorraphy and, in 
 lieu thereof, the injection of paraffin, to build up the bridge of the 
 nose, which in these cases is flat, and careful and studied resection 
 of the epicanthal folds, free undermining of the cut edges, fine, in- 
 terrupted sutures, and the support of gauze, wet with flexible col- 
 lodion. Of course, every precaution must be taken to keep this 
 collodion from entering the palpebral fissures. None but those with 
 skill and experience in the prosthetic employment of paraffin should 
 attempt such use of it on account of the dangers from paraffin 
 embolism. It must be remembered, too, that the mass of paraffin 
 that is put into the tissues has a treacherous way of sometimes 
 changing its form and its location. The results of epicanthus 
 operations are seldom beautiful, whatever the method, because of 
 the usual accompanying congenital anomalies, such as ptosis, 
 microphthalmos, squint, etc.
 
 CHAPTER VI. 
 
 OPERATIONS FOR PTOSIS. 
 
 The original term for falling down of the upper lid was blepharop- 
 tosis, which, although more expressive as to the actual import of the 
 word, has quite properly been superseded by the abreviation 
 ptosis. This affection may be either congenital or acquired. Con- 
 genital ptosis is not uncommon, and, in a large proportion of the 
 cases, it is bilateral. It is often associated with epicanthus, microph- 
 thalmus, squint, and other connate defects. Acquired ptosis is, in 
 most instances, paralytic; that is, it is the result of paralysis of the 
 levator from disease or from traumatism. Distinctive forms of 
 ptosis are ptosis senilis, from slow progressive atrophy of the levator; 
 ptosis adiposa, and ptosis elephantiastic, or cutaneous ptosis, from 
 redundance and relaxation of the lid tissues; ptosis trachomatosa, 
 from the combined effects of the characteristic infiltration, the 
 blepharospasm and the ensuing shrinkage of the conjunctival sac 
 from trachoma; and ptosis hysterica, or pseudo-ptosis, from voluntary 
 or spastic contraction of the orbicularis. The dropping of the lid 
 is also distinguished as partial or complete. 
 
 Whether congenital or acquired, the vast majority of cases are 
 fit subjects for surgical treatment. This is divided into paliative 
 or provisional, and curative or definitive. The first consists in the 
 application to the lid of collodionized bands or strips of adhesive 
 plaster, the insertion of restraining sutures beneath the skin, and the 
 wearing of specially designed preventive spectacles, or artificial 
 spring supports, of thin metal or other material, affixed to the lid 
 borders, to act as antagonists of the orbicularis. These temporary 
 measures are seldom resorted to; for, when intervention of any kind 
 is called for, an operation that will give permanent relief is de- 
 manded, or operative treatment. 
 
 It is rather singular to note how little attention was paid to ptosis 
 in early times surgically, at least. By the ancients, the affection 
 was, in great measure, confused with entropion and trichiasis; and 
 
 228
 
 OPERATIONS FOR PTOSIS. 2 29 
 
 about the only operation adopted with reference to it was the ex- 
 cision of a horizontal ellipse of skin from midway of the fallen lid, 
 and varying in size with the degree of the ptosis. Xo material 
 change was made in the status of such surgery until 1880. True, 
 von Graefe 1 had made an attempt to improve it. He incised the skin 
 the entire length of the lid, opened wide the cut, and resected a strip 
 of the orbicularis, about one centimeter in width and as long as the 
 incision. The wound was closed without excision of skin. The 
 idea was to cause subcutaneous shortening of the lid, together with 
 the weakening of the power of the opponent of the levator, viz., the 
 orbicularis. Mention may also be made of the curious tentatives 
 employed by Denouvilliers and Gosselin, whereby they hoped to 
 make a lasting perforation in the fallen lid to serve as a window 
 through which the patient could see. During the last twenty-five 
 years, however, ophthalmic surgeons have been tremendously pro- 
 lific in the operative measure they have contrived for the correction 
 of this defect. So numerous are they that to attempt a description 
 of each is out of the question. We must, therefore, content our- 
 selves with detailing only a few of them. Most of the measures in 
 question have for object either 
 
 1. The linking of the lid directly to the frontalis muscle. 
 
 2. The advancement of the natural elevators of the lid, or 
 
 3. The inosculation of the skeleton of the lid with the superior 
 rectus muscle. 
 
 Moreover, each contemplates, or affects, a certain amount of 
 shortening of the entire lid. 
 
 The conspicuous manner in which the frontalis offers itself as 
 nature's substitute for the crippled levator in ptosis early led surgeons 
 to think of means for giving this muscle greater purchase over the 
 fallen lid. Hunt (1838) and later Morand, thought to achieve this 
 through more or less ingenious sliding or transposing, of skin flaps 
 about lid and brow. Others went deeper, with the idea of making 
 an actual anastomosis between the frontalis and the orbicularis. 
 Yautrin, for example, brought down a fragment of the frontal muscle 
 and attached it to the lid, while Darier tried engrafting a strip of 
 the orbicularis upon the frontalis. 
 
 The notion of putting the upper lid in closer touch with the frontal 
 
 1 Archiv. f. Oph., Bd. ix, 2, S. 57.
 
 230 
 
 OPERATIONS FOR PTOSIS. 
 
 muscle by means of deep cicatricial bands was first conceived by 
 Dransart. 1 The union was accomplished by means of sutures 
 connecting the lid and the superciliary region, and the method has 
 been called deep palpebro-frontal ligature. 
 
 Dransart employed buried, absorbable sutures (Fig. 101). He 
 made an incision along the upper border of the tarsus, opened wide 
 the wound, particularly above, where he carried the loosening up as 
 far as the supercilia. A needle, armed with catgut, was made to 
 transverse the tarsus, beginning about its middle, passing upward 
 deep into its substance, then through the fibres of the orbicularis to 
 
 FIG. 101. Dransart. 
 
 FIG. 102. Pagenstecher. 
 
 a point just below the supercilia. Here it is turned and passed 
 back through the same structures, alongside its first course, and was 
 brought out on a level with its entrance. Two other sutures were 
 introduced in the same way, parallel with the first, and all three 
 tied. The degree of tightening could be governed by that of the 
 ptosis, but the chief merit of the method was assumed to lie in the 
 three cicatricial bands or cords running from tarsus to frontalis. 
 The skin incision was closed and the buried sutures were left to their 
 fate. 
 
 H. Pagenstecher 2 modified Dransart's procedure (Fig. 102). The 
 operation consisted, merely, in the introduction of two subcutaneous, 
 double-armed sutures, running from near the free border to a point 
 above the supercilia, where they were tied in bowknots over sections 
 of rubber tubing. These were left in place to suppurate, and were 
 gradually tightened or drawn up from time to time, and made to cut 
 
 1 Annals d'oculist, vol. Ixxxiv, p. 88, 1880. 
 
 2 Internal. Congress of Ophthalmology, London, 1881.
 
 OPERATIONS FOR PTOSIS. 
 
 231 
 
 their way out. No incision was made, the originator relying for 
 his result upon the effect obtained by the cicatricial tracts uniting 
 lid and frontalis caused by the sutures cutting through the tissues. 
 
 De Wecker 1 went still further, and modified this operation by 
 removing a long oval of the skin and underlying muscle, whose lower 
 edge was four or five millimeters from the free border. (Fig. 103.) 
 For the rest, he proceeded as did Pagenstecher. 
 
 Hess 2 modified the Pagenstecher-De Wecker procedures thus: 
 Incision the whole length of the previously shaved supercilia, 
 through skin and subcutaneous connective tissue (Fig. 104). Dis- 
 section downward, between integument and orbicularis, to near the 
 
 FIG. 103. DeWecker. 
 
 Fio. 104. Hess. 
 
 ciliary border. Insertion of three double-armed sutures about mid- 
 way of the loosened flap, which are carried up beneath the skin, 
 brought out at a point on the brow two centimeters above the 
 primary incision, and knotted over sections of drain tube. The 
 upper half of the flap is by this means thrown into a horizontal fold, 
 the size or height of which corresponds to the degree of effect, the 
 loops of thread causing a depression that simulates the normal 
 sulcus. The sutures are removed at the end of the tenth day. 
 
 It would seem that this measure is likely to produce rather undue 
 shortening of the lid. 
 
 A phase of the Dransart method is that of Mules* (Fig. 105). In- 
 stead of silk or catgut sutures he employs gold or silver wire, which 
 is put in after the following manner: Incision along the free border 
 of the lid, as if for intermarginal graft, though not so deep. One of 
 
 1 Annal. d'pculist. t. 88, p. 29, 1882. 
 
 2 Oph. Society of Heidelberg, 28th Session, Aug. 1893. 
 
 3 Trans. Oph. Society of the United Kingdom, vol. xviii, p. 227.
 
 232 
 
 OPERATIONS FOR PTOSIS. 
 
 corresponding length in the middle of the shaved supercilia. Two 
 sutures of fine gold or silver wire, each armed with two needles, are 
 introduced at the bottom of the marginal incision, carried up under 
 the orbicularis to emerge from beneath the upper lip of the brow 
 incision, so as to include the frontalis. The tracts of each pair 
 of needles are six to eight millimeters apart. The lid having been 
 drawn up sufficiently, the sutures are tied. The cut in the eyebrow 
 is closed with fine silk sutures; that in the border is left to close of 
 itself. 
 
 Objections that have been offered to this procedure are liability 
 of the wire, after a time, to break or to be expelled, and injury 
 to the hair follicles of the cilia. To obviate these features, Bishop, 1 
 
 FIG. 105. Mules. 
 
 FIG. 106. Bishop. 
 
 of Cambridge, proposed substituting for the wire a fine wove-chain 
 of gold. A single strand of this is threaded into a four-inch abdomi- 
 nal needle. No incision is made (Fig. 106). The needle is first in- 
 serted above the supercilia, a little to the nasal side, passed down 
 beneath the orbicularis, close to the tarso-orbital fascia and tarsus, 
 brought out near the cilia, reinserted at the point of exit, carried 
 horizontally along near the free border, brought out external to the 
 median line, reinserted, passed upward, parallel with its downward 
 course, to emerge on a level with the point of first entrance. After 
 drawing up the lid the requisite degree, the needle is put deep into the 
 frontalis where it came out last, plowed horizontally along, and finally 
 brought out where it first entered. The ends are cut off and buried 
 beneath the skin. 
 
 Wilder 2 makes a similar operation to that of Dransart, though with 
 
 1 British Medical Journal, Sept. 26, 1903. 
 
 2 Annals, of Ophthalmology, vol. vii, No. i, 1898.
 
 OPERATIONS FOR PTOSIS. 
 
 2 33 
 
 some important differences and improvements (Fig. 107). The 
 primary incision extends for three and one-half centimeters along the 
 median line of the shaved eyebrow down to the periosteum of the 
 orbital rim. The lower lip is undermined and retracted until the 
 tarsus is exposed. Two double- 
 armed silk or catgut sutures are put 
 into the tarsus, one on either side of 
 its center, and each pair of needles 
 is carried upward a few millimeters 
 apart, but in their course, instead of 
 traversing the orbicularis, as Dran- 
 sart's do, they are quilted through 
 the tarso-orbital fascia and brought out so as to include the mus- 
 cular and connective tissue just beneath the upper lip of the brow 
 incision. The sutures are drawn up to the degree desired for the 
 elevation of the lid and tied. The sutures, or ligatures, are left to 
 be absorbed or encapsuled Thus, not only are there two cicatricial 
 cords connecting tarsus and frontalis, but there is also a shortening 
 
 FIG. 107. Wilder. 
 
 FIG. 108. Panas. 
 
 Y 
 
 FIG. 109. Panas. 
 
 of the septum orbitale which, in this instance, serves as an advance- 
 ment of the tendon of the levator (now really the frontalis). 
 
 Panas 1 is the author of what has been one of the most popular 
 operative modes for the relief of ptosis. This master in surgery, 
 recognizing the uncertainty of obtaining the desired cicatricial result 
 
 1 Maladies des Yeux, T.xi , p. 140, 1894.
 
 234 OPERATIONS FOR PTOSIS. 
 
 after the mere suture operation, devised a more strictly surgical 
 method, the essential feature of which is, according to its author, 
 the direct autoplastic fixation of the lid with the orbito- frontal muscle 
 (Figs. 108 and 109). Panas called the operation blepharopexy and 
 it may be described as follows: A lid spatula is put into the upper 
 conjunctival cul-de-sac. A horizontal incision is made midway be- 
 tween the eyebrow and free border of the upper lid, through skin 
 and orbicularis down to the tarso-orbital fascia. From this in- 
 cision branch two others, including skin only, one on either side, 
 vertically, or slightly inclining outward, till opposite the upper bor- 
 der of the tarsus, when they are given a direction yet more divergent, 
 which, in terminating the inner one near the punctum, the outer 
 close to the external commissure is almost parallel with the ends 
 of the first incision. The three points or flaps thus outlined are 
 dissected up. A cut is then made along almost the entire midline 
 of the shaved supercilia, comprising skin and the thick layer of 
 muscular fibres formed by the interlacing of the orbicularis and 
 the frontalis. The bridge of integument between the two hori- 
 zontal incisions, is tunneled through with a bistoury. The middle 
 flap overlying the tarsus is pushed up through the tunnel and 
 sutured to the superior lip of the upper incision by three stitches. 
 Superficial sutures are put in to close the remaining gaps. 
 
 The degree of effect is regulated by placing the primary incision 
 higher or lower, as the case may be, and by the extent to which the 
 buried flap is drawn up. If it is observed, in drawing up the flap, 
 that there is a tendency to ectropion before the sutures are tied, two 
 others are put into the tarso-orbital fascia, one on either side of the 
 middle flap, but not into the skin. These also are passed through 
 the tunnel and united to the upper lip of the brow incision near its 
 extremities. These last are supposed to lift the paralyzed lid in the 
 natural manner, i.e., by giving to it the movement of a rotary hinge, 
 upward and backward, revolving on an imaginary axis, which 
 passes through the two commissures. 
 
 The procedure, while successful to a degree, has certain serious 
 drawbacks. The considerable disturbance of the normal relation 
 of the parts, the obliteration of the physiologic sulcus, and the sub- 
 stitution for it of an inverted fold, the covering up of an epithelial 
 surface by a raw one, and the fact that the effect, after all, is obtained
 
 HUNT-TANSLEY OPERATION. 
 
 2 35 
 
 by what amounts to pronounced resection of the skin, are all ob- 
 jectionable features. 
 
 Hunt-Tansley Operation. Devised by Hunt and modified by 
 the late J. O. Tansley, of New York. It belongs in the same group 
 with the Panas operation, and 
 
 is mentioned here because it .^j^JT'Z'^P^I^ 
 
 <g^jg'_- ~^ ' 
 
 has attained considerable j&^ 
 popularity in some parts of V 
 the United States, particularly 
 in the East. Fig. no shows 
 the lines of incision. Two 
 horizontal, parallel incisions, 
 each one-half inch long, are 
 made through the skin, one 
 just below and the other just 
 above the middle of the eye- FIG. no. 
 
 brow, and the two are joined by tunneling under. From the lower 
 one two parallel incisions are carried downward, one-quarter inch 
 apart, to within one-eighth inch of the cilia. The vertical strip of 
 skin thus outlined is dissected loose down to its base, a double- 
 armed suture is put into its free end, and it is wrapped round a 
 
 cylinder of gauze or cotton 
 wet with warm normal salt 
 solution. From the at- 
 tached extremity of this 
 flap two cuts are made, one 
 outward, the other inward, 
 parallel with the free border 
 of the upper lid, to end at 
 points directly above the 
 canthi through skin and 
 orbicularis. The canthal 
 ends of these cuts are then 
 joined by an incision made 
 
 along the sulcus which corresponds to the upper border of the 
 tarsus. This also includes skin and orbicularis. The two triangles 
 of skin and the crescent of muscle so formed are dissected out, 
 leaving the tarsus exposed. Now, the needles attached to the 
 
 FIG. in.
 
 236 OPERATIONS FOR PTOSIS. 
 
 suture in the tongue of skin are passed upward through the tunnel 
 beneath the eyebrow, and the operation is completed by stitches, as 
 shown in Fig. in. 
 
 One of the latest phases of the Vautrin-Darier idea, referred to 
 further back, is the method of Freeland Fergus? of Glasgow. By 
 this measure a strip of the occipito-frontalis is, as it were, dovetailed 
 into the affected lid. It is briefly thus: Incision the whole length 
 of the eyebrow dow r n to the tendon of the frontalis. Dissection of 
 the skin, upward for a distance of two inches and downward al- 
 most to the free border of the lid. The upper lid of the w-ound is 
 strongly retracted to expose the frontalis, from which is formed 
 a flap or tongue three-quarters of an inch wide and two inches long. 
 Through this, near its lower or free end, are passed from below 
 two double-armed sutures. These are carried down to the bottom 
 of the pocket made in the lid, brought out, and tied on the skin just 
 above the cilia. The brow incision is closed by interrupted sutures. 
 
 This method certainly affords a means of directly coupling the 
 frontal muscle and the lid. Whatever is gained, however, must be 
 through the enhanced power of the muscle, as a whole, to raise the 
 lid. For it is not to be presumed that the transplanted tongue will 
 be endowed with separate or special qualities of contraction in the 
 vicarious office thus thrust upon it; nor that the tongue will be free 
 to slide up and down like a muscle in its sheath. The best that can 
 occur is that the lid will be held up by a more or less rigid band ex- 
 tending down from the forehead. And one can readily fancy 
 Aow such a measure could leave the motility of the tissues about the 
 brow more restricted than they had previously been. 
 
 2. Advancement, or shortening the levator, by making a 
 fold therein, was first suggested by Bowman in the first volume of 
 Moorfield's Hospital Reports, and first practised by Eversbusch, 3 
 of Munich (Fig. 112). Under general anesthesia, the plate of 
 Snellen's forceps is placed as high as possible beneath the upper 
 lid and the clamp set. A horizontal incision is made, halfway be- 
 tween the brow and the ciliary border, down to the fascia, the 
 latter exposed by separating the lips, a vertical fold, two and one- 
 half millimeters wide, is picked up in the center of the so-called 
 
 1 Brit. Med. Journal, March, 1901. 
 
 2 Zur Operation der congenitalen Blepharoptosis. 
 Augenh., Bd. xxi, S. 100, 1883. 
 
 Klin. Monatsbl. f.
 
 ADVANCEMENT, OR SHORTENING THE LEVATOR. 
 
 237 
 
 tendon, a small, double-armed thread is entered into each side of 
 the fold, carried downward between tarsus and orbicularis, and the 
 needles brought out two or three millimeters apart at the free 
 border. Two other sutures are similarly placed, one at either side. 
 The primary incision is sutured and, lastly, the three pairs of thread 
 ends, projecting from the edge of the lid, are tied over small sections 
 of rubber tubing. Both eyes are bandaged. 
 
 Snellen, 1 of Utrecht, is credited with at least two methods to 
 shorten the levator tendon: 
 
 FlG. 112. Eversbusch. 
 
 FIG. 113. Snellen, No. i. 
 
 1. By Resection. After exposing the fascia in the usual way, 
 by an incision parallel with the upper lid border, a cut was made 
 transversely through it (Fig. 113). Two or three catgut sutures 
 were passed through the upper edge of the tarsus from the front; 
 the cut end of the tendon was lifted, the sutures passed through it, 
 high up, from the back, a portion was resected commensurate with 
 the amount of shortening desired, the threads were tied and the skin 
 wound closed. Fuchs makes a resection somewhat similar to the 
 above. 
 
 2. By tucking without any incision, either of the skin or of the 
 conjunctiva, 2 by means of burrowing sutures (Fig. 114). At the 
 center of the insertion of the levator a thread is made to pass through 
 skin, tarsus, and conjunctiva. Then, with the lid everted, it is 
 carried upward between the conjunctiva and the fascia, again 
 brought out through the skin, the latter is lifted, the needle inserted 
 at about the same point whence it has just emerged, passed down 
 beneath the integument, and brought out where it first penetrated. 
 Two others are thus inserted, one on either side of the first, and their 
 
 1 Report of the German Oph. Society at Heidelberg, 1883. 
 
 2 Trans. Oph. Society of the United Kingdom. Oph. Review, Nov. 14, 
 1889.
 
 2 3 8 
 
 OPERATIONS FOR PTOSIS. 
 
 ends are knotted over bits of drainage tubing. Gruening, of New 
 York, had already made practically the same operation, though 
 with the aid of the ordinary skin incision. 
 
 De la Personne, 1 Angelucci, 2 and others have also modified 
 the Eversbiisch procedure. 
 
 Resection of the tarsus as a measure for the cure of ptosis 
 was revived by Sir William Bowman, as an adjunct to resection of 
 the orbicularis, as practised by his friend von Graefe. At a glance 
 this method would seem to stand in a class by itself, yet virtually 
 
 FIG. 114. Snellen, No. 2. 
 
 FIG. 115. Gruening. 
 
 it is but an advancement of the muscles normally concerned in 
 lifting up the lid. Bowman removed a portion of the tarsus and 
 the contiguous portion of the orbicularis. Galezowski went still 
 further and excised a strip that included the whole thickness of 
 the lid. A well-known modification of the Bowman operation is 
 that of Gillet de Grandemont.3 
 
 Gruening, 4 of New York, has, for some time, employed, with 
 satisfactory results, a modified form of De Grandemont's method 
 (Fig. 115). He uses it for almost any variety of ptosis, and performs it 
 as follows : An incision is made through skin and orbicularis muscle, 
 parallel with, and 4 mm. from, the free border. Skin and muscle 
 are dissected up and retracted. A portion of the bared tarsus, com- 
 prising its whole width, from inner to outer canthus, and the whole 
 thickness, including the adherent conjunctiva, is cut out. The 
 vertical diameter of the excised strip varies with the degree of ptosis, 
 though it is always wider in the middle, where it may measure 7 mm., 
 tapering almost to a point at either extremity. The tarsal wound is 
 
 1 Archiv. d'opht., vol. xxiii, p. 497, 1903. 
 
 2 Archiv. di Ottala. p. 489, 1904. 
 
 3 Bull, et mm. de la soc, Franc, d'opht., 1891, p. 80. 
 
 4 New York Eye and Ear Infirmary Reports, 1904.
 
 JOINING THE TARSUS WITH THE SUPERIOR RECTUS. 239 
 
 closed by three double-armed sutures. One needle is passed 
 horizontally through the tarso-orbital fascia, then both needles are 
 passed downward, through the remnant of tarsus, and brought 
 out at its free border, behind the lashes, where the suture is knotted. 
 Thus the lips of the tarsal wound are brought into apposition, and 
 the lashes are given a horizontal direction. The skin opening needs 
 no sutures. 
 
 3. Joining the Tarsus with the Superior Rectus. In cases 
 of ptosis not complicated with paralysis of the superior rectus, 
 the late Dr. Parinaud 1 (Fig. 116), after having everted the upper 
 lid, made a horizontal incision one and one-half centimeters long, in- 
 cluding the conjunctiva, and the upper border of the tarsus at its 
 
 FIG. 116. Parinaud. 
 
 FIG. 117. Motais. 
 
 middle; seized the conjunctiva with fixation forceps near the upper 
 corneal limbus, and rotated the globe far downward; opened up the 
 conjunctival incision, and exposed the tendon of the rectus, raised it 
 with forceps, passed a double-armed suture beneath it, including its 
 aponeurosis. Then each of the needles was passed upward, through 
 the adjacent conjunctiva, thence through the levator tendon, down- 
 ward between tarsus and skin, and brought out, seven millimeters 
 apart, at the free border. They were here tied over some soft 
 substance, and taken out after four to six days. 
 
 Motais, 2 of Angers, has given an ingenious and highly approved 
 ptosis operation, which embodies the Parinaud principle: a 
 
 'Ann d'oc, 1897, t. cxvii, p. 12.. 
 
 2 Bull, et mem. de la soc, d'opht, de Paris, Nov., 1898.
 
 240 
 
 OPERATIONS FOR PTOSIS. 
 
 meridional incision of the conjunctiva, beginning over the center 
 of the insertion of the tendon of the superior rectus, or about seven 
 mm. from the upper corneal limbus is extended through the retro- 
 tarsal folds, to end at the convex edge of the tarsus (Fig. 117). This 
 is opened and retracted, so as to plainly reveal the tendon, which is 
 then lifted upon a strabismus hook. The hook is worked back and 
 forth in such a manner as to loosen the tendon from its surroundings. 
 A fine, but strong braided suture, armed with two curved needles, 
 is passed in and out through the tendon near its insertion, so as to 
 include its middle third. To give the thread a solid hold, it has been 
 
 suggested that it be at once tied. This, 
 however, is apt to complicate matters in 
 removing it. With knife and fine blunt- 
 pointed scissors, a tongue is formed of 
 the portion embraced by the thread, its 
 free extremity cut flush with the sclera, 
 and the other left at the union of the 
 muscle fibres; i.e., it extends the entire 
 length of the tendon. It must be seen to 
 that the thread is firmly fixed in the end 
 of the tongue. If there be any doubt on 
 this point, the tongue is folded upon itself 
 and the suture again passed through. 
 The surgeon places the tip of his index behind the inverted lid as 
 a guide, and, with the scissors, makes a pocket between the anterior 
 surface of the tarsus and the fascia of the orbicularis. This pocket 
 is wide enough to receive the tongue and reaches almost to the 
 border of the lid. The needles are passed into the pocket, through 
 at its bottom, to emerge on the skin surface of the lid, near the 
 cilia, about 4 mm. apart, and are tied over a roll of antiseptic gauze 
 (Fig. 1 1 8). The conjunctival opening is closed with fine sutures. 
 It were well to have these of catgut and leave them to be absorbed, 
 thereby obviating any disturbance of the lid at the end of two or 
 three days. The thread attached to the tendon is removed at the 
 end of 5 days to a week. 
 
 Motais' procedure is founded upon the synergy of action existing 
 between the superior rectus and the levator. It follows, theoretically, 
 that, as a result of the engrafted tendon, natural movements are 
 
 FIG. 118. Motais.
 
 JOINING THE TARSUS WITH THE SUPERIOR RECTUS. 241 
 
 FIG. 119. Beard's method for ptosis. 
 Front view. 
 
 imparted to the lid. In other words, that in looking up, for example 
 
 the lid does not lag behind. 1 
 For a number of years 
 
 past I have practised, with 
 
 most gratifying results, a 
 
 method that combines the 
 
 principles of the Anagnos- 
 
 takis-Hotz entropion oper- 
 ation, the tucking of the 
 
 levator tendon of Evers- 
 
 busch, and a little of the 
 
 suture arrangement of 
 
 Pagenstecher 2 (Figs. 119 
 
 and 120). A lid horn is 
 
 put beneath the upper lid. 
 
 An incision is made along 
 
 the sulcus, rather in its upper slope than exactly in its bottom, 
 
 through skin and muscle, and extending the whole length of the 
 
 tarsus. The divided fibres of the orbicularis are undermined, both 
 
 above and below, exposing the 
 tarsus and its suspensory ligament. 
 Four curved, one-inch-long needles, 
 carrying two sutures (i.e., double- 
 armed) of No. 3 braided silk, boiled 
 in vaselin-paramn, are in readiness. 
 Each needle is passed through the 
 lower flap near its edge, from 
 within outward, then through a 
 horizontal fold of the tarso-orbital 
 fascia really the tendon of the 
 levator picked up by broad-jawed 
 fixation forceps, thence upward, 
 quilting, or, as Wilder says, 
 "gathering" the septum orbitale, 
 
 and brought out well above the supercilia. 
 
 A handy way of picking up the deep fascia at any chosen point, 
 
 'For further remarks on the Motais operation see Summary at end of 
 chapter. 
 
 2 Oph. Record. 
 16 
 
 FIG. 120. Beard's method for ptosis. 
 Sectional view.
 
 242 OPERATIONS FOR PTOSIS. 
 
 is to first dig the point of the needle in somewhat, in order to lift the 
 tissue, then grasp it, in the horizontal sense, with the jaws of the 
 forceps. The threads are so spaced that the loop left lying inside 
 the lower flap is about six to eight millimeters long, and its middle 
 marks the junction of the middle and end thirds of the tarsus. At 
 first I put the needle through the lower flap of skin and muscle 
 from the cutaneous surface, but soon found that this tended to fold 
 the flap horizontally, and to turn its edge outward. 
 
 The manner of tying the sutures is important. One pair of 
 thread ends is held between the left thumb and index, while, by 
 means of small, mouse-tooth forceps, the edge of the lower flap is 
 seized between the corresponding threads, pulled up and rolled 
 backward, and placed in apposition with the tarso-orbital fascia 
 just where the thread enters the fold therein. The two ends of 
 thread are, meanwhile, drawn up pretty well, but not tightly, and 
 tied in a single surgical knot over a short cylinder of firmly rolled 
 gauze or absorbent cotton. The same is done relative to the flap 
 and other suture. Before finishing the knots, it is seen to that the 
 edges of both skin flaps are directed backward; in other words, not 
 coapted one with the other, but that both are in contact with the 
 broad ligament of the tarsus. In this way the resulting cicatrix 
 is completely hidden by a normally placed and normally appearing 
 sulcus. 
 
 Lastly, the sutures are tightened as much as is needed for the 
 desired effect, and are tied in bowknots. In the extreme cases it 
 will be impossible for the patient to close the lids so long as the 
 sutures are in. As this is for only two or three days, during which 
 time a carefully applied dressing and bandage is worn, there is no 
 danger to the cornea. Nothing more is expected of the sutures than 
 to hold the operated parts in their new relations until primary union 
 is assured; that is to say, they are not left in position to suppurate 
 or to cut through. The tension of the threads may be altered at any 
 time within twenty-four to thirty-six hours, if one wishes to qualify 
 the primary results, by merely undoing the bowknot and loosening 
 or tightening the other one, as the conditions demand. In removing 
 the sutures, the rolls over which they are tied are pulled smartly up, 
 both threads are cut off close to the skin and withdrawn by seizing the 
 loop below. In this way no soiled portion passes through the tracks.
 
 SUMMARY. 243 
 
 I consider the Hotz idea, as embodied in this procedure, to con- 
 stitute, probably, one of its most salient advantages, and, taken all 
 in all, theoretically as well as practically, it seems to possess some of 
 the best points of other ptosis operations, and eliminates some of 
 their worst faults. It is adapted to all the ordinary forms of ptosis, 
 the degree of effect being governed by the height of the fold made 
 in the broad ligament of the tarsus, its distance from the upper 
 border of the tarsus, and, in some measure, by the distance of the 
 primary incision from the free border of the lid. 
 
 Narcosis is employed only when necessary. Cocain solution 
 injected into the skin is less of a help than a hindrance. It is 
 usually dropped into the open wound, but it is of doubtful benefit. 
 
 Summary. In the foregoing chapter an attempt has been made 
 to give, by describing example ptosis operations, an idea of some of 
 the many different methods, and to illustrate the guiding principle 
 in each instance. In the primitive operation of excising a segment 
 of skin mere shortening of the lid was the aim and the end. 
 Naturally, this can only be applicable to cases characterized by an 
 actual redundance of integument, i.e., cutaneous ptosis, or blepharo- 
 chalasis, for, in general, the lids of ptosic subjects are already too 
 scant. This is particularly true of congenital ptosis, in which the 
 lids are short, flat, and devoid of any sulcus in the skin. In the 
 operation of von Graefe the object was the weakening of the an- 
 tagonist of the levator or the orbicularis, and was manifestly 
 faulty in the premises. The Bowman- Gillet de Grandemont 
 methods are similar to von Graefe's in that they really amount to 
 subcutaneous shortening of the lid; but they are an improvement 
 in so far as they effect an advancement of the elevators of the tarsus. 
 As to the palpebro-frontal ligament of Dransart, as represented in 
 the original operation and in those of Mules, Bishop, Wilder, and 
 others, there is no denying that the results are positive, but they are 
 mainly due to shortening. There is no definite advancement of the 
 normal elevators, the lifting of the lid is relegated almost wholly 
 to the frontalis, which is but a poor substitute, and besides, a 
 foreign body is left in the tissues; not the least objection to this is 
 that it is sometimes extruded. They would seem to be superior to 
 those other methods that are employed for putting the lid in more 
 direct connection with the frontalis, whereby tongues or strips of
 
 244 OPERATIONS FOR PTOSIS. 
 
 muscle are transplanted. The frontalis owes its power of lifting the 
 eyebrow to the fact that its attachment is essentially to the skin; 
 hence, procedures that call for deep or extensive incisions and 
 other traumatism in the superciliary region must result in scars that 
 inevitably limit the natural movement of the parts. Then, too, 
 these engrafted fragments will atrophy, and the effect obtained will 
 diminish with the lapse of time. The palpebro-frontal ligaments 
 are peculiarly suited to cases in which both the levator and the 
 superior rectus are powerless. In the mode of Pagenstecher, of 
 gradually tightening ligatures, the object was the coupling of the 
 lid to the frontalis by means of cicatricial cords, and looked to a 
 determinate result through a most precarious and irregular medium, 
 viz., the exciting of an inflammatory or suppurative process. In 
 the procedure of Eversbusch and his followers the object sought is 
 the shortening or advancement of the levator, and its futility as a 
 systematic, all-around process would appear to lie in the fact that the 
 muscle concerned is, in the great majority of cases, either absolutely 
 inert or of extremely insignificant force. While, therefore, the 
 sphere of these measures is thus limited, they are theoretically suit- 
 able only for a certain small number of cases in which 1 the levator is 
 fairly potent, as in trachomatous ptosis. But, as a matter of fact, 
 they have a much wider range of usefulness, of which more anon. 
 The Motais-Parinaud measures are happily imagined and rest 
 upon a physiologic as well as a scientific basis. Yet they depend 
 for their success upon the integrity of the superior rectus; and in a 
 large percentage of cases of ptosis there is paralysis or marked 
 insufficiency of the muscle. Theoretically considered, the very pro- 
 nounced drawing forward of the superior rectus that would be req- 
 uisite for the correction of an extreme ptosis by these methods 
 would result in undue tension diplopia -and, possibly, vertical 
 squint. They would find their best application, then, to the lower 
 grades of ptosis in which the superior rectus is of nor.mal strength. 
 According to Terson, 1 of the considerable number of operations 
 of this kind that have been recently performed, some have been 
 followed by good results, and others not only by failure, but by 
 corneal complications the latter even leading to anterior staphy- 
 loma. Moreover, the eye is said to be more prone to remain open 
 
 1 Encyclopedic Francaise d'ophtalmologie, vol. v, p. 498, 1906.
 
 SUMMARY. 245 
 
 during sleep after the Motais-Parinaud methods than after other 
 operations for ptosis. 
 
 Shoemaker, of Philadelphia, in the Annals of Ophthalmology, 
 Oct., 1907, makes certain pertinent remarks as to the Motais opera- 
 tion from the theoretic standpoint. For instance, he says, "Motais 
 claims to supply a perfect physiological substitute for the levator 
 by such a transplantation of the superior rectus tendon. This is not 
 actually the case, but the lid after the Motais operation is held in its 
 new position by anchorage to a fixed point on the eyeball, so that 
 there can be no elevation or movement of the lid through the trans- 
 planted portion of the superior rectus independent of the eyeball." 
 Did the writer of these words bear in mind how slightly, even in 
 the normal eye, the levator can act independently of the elevators of 
 the globe ? Shoemaker further says that the tongue or slip of the 
 superior rectus is perfectly inextensible if made of tendon, as was 
 the intention, and that if made ten millimeters long, as Motais 
 specified, it would reach into the muscle and be apt to part upon 
 the slightest tension. Yet he thinks the possible effect to be 
 derived from the operation is great, and when little or no effect is 
 obtained he believes the cause of the failure lies in transplanting 
 the slip among the fibers of the orbicularis, instead of securing it 
 to the tarsus, and that this is particularly apt to occur when the 
 stitch is tied on the skin, as the tendon is then drawn away from 
 the tarsus. To be sure that the slip is attached to the tarsus he 
 would suggest the open method, as follows: 
 
 The first stage of the operation remains unchanged except that 
 in passing the double-armed thread through the prepared tendon 
 slip, pass the needles from above downward, placing the loop on 
 the upper surface. Then make a horizontal incision through the 
 skin of the lid and the orbicularis muscle down to the tarsus a little 
 below its upper margin. Undermine the orbicularis fibres by 
 pushing them upward or backward, exposing the tarsus to its upper 
 margin. Buttonhole Miiller's muscle and the conjunctiva and 
 through this opening carry the sutures with the piece of tendon, and 
 fasten the latter directly to the surface or edge of the tarsus precisely 
 as we do the tendon to the sclera in an ordinary advancement. 
 Having dipped each needle into the tarsus and brought tarsus and 
 tendon slip into direct contact, restore the orbicularis fibres, carry
 
 246 OPERATIONS FOR PTOSIS. 
 
 the needles through them and the skin, and tie. Close the wound 
 in the lid with two or more stitches. 
 
 He thinks permanent paralysis of the superior rectus is not 
 necessarily a contraindication to Motais operation, but may be 
 rather an advantage, and he sees no reason why, in such a case, 
 the whole tendon should not be transplanted and put to some use. 
 A positive contraindication would be a thin, poorly developed 
 superior rectus. 
 
 The laying bare of the tarsus, as proposed by Shoemaker, doubt- 
 less has its advantages. Not the least of these being the greater 
 facility i't affords for the definite and precise disposition of the 
 transplanted tongue. My colleague Wilder has been the first, I 
 believe, to put Shoemaker's idea into execution. This he has done 
 of late in several instances, and expresses himself as well pleased 
 with the outcome. In addition to adopting Shoemaker's proposal, 
 Wilder has added a feature of his own. He reasoned, and rightly, 
 that the little tongue gives hardly more than a single point of sup- 
 port to the lid, and even thought that he observed, in a case that had 
 been operated upon by the Motais method, that the free border of 
 the upper lid showed a sort of notch corresponding to the point of 
 attachment of the tongue. To avoid this, as well as to serve as 
 auxiliaries to the delicate tongue in holding up the lid, he places a 
 slowly absorbable suture in the ligament of the tarsus on either side 
 of the buttonhole through which the tongue is drawn, and in such 
 a manner as to slightly fold said ligament. He thus combines with 
 the Motais measure something of that of Eversbusch or a slight 
 shortening or tucking of the levator tendon. 
 
 Objections to, or criticisms of, a measure on purely theoretical 
 grounds, no matter how cleverly conceived nor how logically 
 argued, are not necessarily valid nor conclusive. Many reports 
 have been made in ophthalmic literature of most excellent results 
 obtained with the Motais operation. Notable among those made 
 in this country is that of H. D. Bruns, of New Orleans. 
 
 The present writer has performed it in eight cases. Two of these 
 were trachomatous ptosis of high degree. In one the lid had fallen 
 completely. Since the upper borders of the tarsi had undergone 
 trachomatous degeneration, they were excised at the same time, 
 thus allowing the anchorage of the tongue to be made at the middle
 
 SUMMARY. 247 
 
 of the tarsus instead of at the upper border. The outcome of these 
 cases was so singularly gratifying that I wondered if it were not 
 best oftener to combine the operation with a slight excision of the 
 tarsus. I have recently seen a recommendation to that effect by a 
 French author. In the operations just referred to it was necessary 
 first to make a free canthotomy, in order the better to manage the 
 upper lid, there having been considerable atrophy of the conjunctiva.. 
 
 In addition to the two cases just mentioned, my eight included 
 five of congenital ptosis and one from traumatic paralysis of the 
 levator. The results in all of them are far and away the best I have 
 ever obtained in this affection. As concerns the last case operated 
 it was feared for a time that either the tongue had broken, or the 
 suture had pulled out of it, but this fear proved to be groundless. 
 The manner in which the free border of the upper lid keeps out of 
 the way of the pupil, as the subject looks further and further up- 
 ward, is truly beautiful to contemplate. As regards annoying 
 diplopia, upward squint, inability to keep the lids closed during 
 sleep, etc., I have not observed any of these. It is true, however, 
 that one can, soon after the operation, demonstrate hypertropia. 
 According to this phase of the subject, one would naturally conclude 
 that cases of bilateral ptosis, having both eyes operated, would be 
 more likely to escape this complication than would the monolateral 
 ones. 
 
 I find that in congenital ptosis the lack of power in the superior 
 rectus is main y due to non-use, for these subjects have no oc- 
 casion to rotate the globe upward. By careful examination it can 
 usually be demonstrated that there is limited function in the muscle. 
 No matter how little there is, the Motais operation is the one, in my 
 opinion, that should be chosen.. After the lid is once raised the 
 superior rectus develops more and more its proper function. Herein 
 lies the explanation of a unique and most gratifying feature of the 
 Motais method, viz., the constantly increasing enchancement of 
 the effect for weeks and even months after the operation. 
 
 A little study is invited of the accompanying drawing (Fig. 121), 
 which is a tolerably accurate representation, in vertical, median sec- 
 tion, of the tissues concerned in the surgery of ptosis. This will dem- 
 onstrate that any measure which folds or in any way shortens the 
 broad ligament of the tarsus, not only advances the levator and
 
 248 
 
 OPERATIONS FOR PTOSIS. 
 
 Muller's muscle, but also tightens up, or advances, the levator por- 
 tion of the tendon of the superior rectus. It follows that, as single, 
 constant measures, the class of operations treated of under the second 
 category, viz., the advancement of the natural elevators, are, perhaps, 
 those deserving of the greatest confidence. Granting that those in 
 the first class the linking of the lid to the frontalis are as effective 
 
 FIG. 121. Lev., Levator muscle. S.R., Superior rectus muscle. S, Sclera. 
 U.F., Upper fornix. M, Muscle of Miiller. I, Iris. C, Cornea. L, Lens 
 I, Scleral portion of superior rectus tendon. 2, Levator portion. 3, Conjunctival 
 portion. L.T., Levator tendon. S.O., Septum orbitale. F, Frontal muscle. S-C, 
 Super-cilia. E, Expansions of the levator tendon. T, Tarsus. The lids are 
 represented closed. 
 
 in lifting up and holding the lid, the feat is accomplished in an 
 unnatural manner; that is, the lid is pulled straight up, not rolled 
 back and up, normally, like the visor of a helmet; moreover, the 
 forehead is corrugated in the act, thus adding another deformity. 
 We have noted the limitations of those in the third class. 
 
 All who have had much experience in this branch of ophthalmic
 
 SUMMARY. 249 
 
 surgery will agree that the results of ptosis operations, taken all in 
 all, are far from brilliant. " It is only with precise appreciation of 
 the peculiarities of the individual case, that one may hope to succeed 
 in this delicate, and special surgery of the lid" (Terson). A correct 
 diagnosis as to the character of the ptosis and a nice estimate as to 
 its degree, are pre-requirements to a fortunate issue. The high 
 degrees of congenital ptosis, with inert superior rectus, are the 
 most difficult with which to contend. It is in these that, according 
 to the writer's observation, the greatest good is to be looked for 
 from those surgical measures that do not rely for their success upon 
 a single feature or principle, but upon a well-considered union of two 
 or more. In this manner one is not obliged so to exaggerate a 
 particular step as to risk, for example, the production of unsightly 
 and harmful lagophthalmos, but is enabled to obtain a maximum 
 effect with a minimum disturbance of any one of the several parts 
 involved. For the milder forms of partial ptosis all the measures 
 that have just been described readily give satisfactory results in 
 good hands and in well-selected cases. After all, it is here, just 
 as with surgery in general, that subtle something known as personal 
 equation is a tremendous factor. A chosen few seem to be lucky, 
 whatever the methods they select.
 
 CHAPTER VII. 
 ENTROPION. 
 
 Entropion, or turning inward of the lid upon the globe, is of 
 two kinds functional and organic. The evil results of the condi- 
 tion have reference, mainly, to the damaging effects upon the cornea 
 and conjunctiva caused by the contact of the misplaced eyelashes, 
 or trichiasis; though the deformity, and the pressure, and the 
 rubbing of the warped and shrunken tarsi upon the globe, in the 
 worse forms of organic entropion, are alone sufficient reasons for 
 surgical intervention. 
 
 Functional or spastic entropion usually concerns the lower 
 lid only, and occurs most often in elderly persons in whom the 
 palpebral integument is lax or superabundant. It is then known 
 as senile entropion, and a common cause is the wearing of a bandage. 
 Not infrequently, however, it affects the lower lid of younger sub- 
 jects, when it is accompanied by inflammations of the skin and of 
 the conjunctiva. This form of spasmodic turning in has been 
 called acute entropion. Whatever the cause or the age of the indi- 
 vidual, they are treated about alike; that is, for the transient or less 
 obstinate varieties simple mechanical means are successfully 
 employed, and for the more stubborn, surgical measures are 
 required. 
 
 If from bandaging, and it is not practicable to leave off the dress- 
 ing, a strip of rubber adhesive plaster five or six centimeters long, 
 by one to one and one-half wide is applied vertically. About one 
 centimeter of the upper end is first made to adhere just below the 
 cilia, pulled downward slightly, to draw the free border away 
 from the eye not so much as to produce a decided ectropion then 
 fastened throughout the rest of its extent. If there is any lacrima- 
 tion, the tears soon loosen the plaster, in which event it is better to 
 gently evert the lid and to paint flexible collodion over the region 
 of the lower half of the orbicularis, taking care to close the eye and 
 otherwise protect it from the ether.
 
 FUNCTIONAL OR SPASTIC ENTROPION. 
 
 251 
 
 A more efficient way is to cut a small strip of gauze or other 
 suitable fabric, lay it on the part, and glue it down by smearing 
 on the collodion (Fig. 122). As with the plaster, the upper end is 
 made fast first, allowed to dry, then drawn down, and the whole 
 made to stick. If the entropion persists in spite of the continuance 
 
 FIG. 122. Applying collodionized gauze for spastic entropion of lower lid. 
 
 of such treatment for a reasonable time after the exciting cause has 
 been removed, some form of operation is resorted to as a choice of 
 two evils; for, while lid abscess and even phlegmon of the orbit are 
 known to have resulted from the sort of surgery in question, the 
 trifling risk therefrom, as compared with the sure harm to the cornea 
 and conjunctiva that will follow the prolonged friction of the lashes,
 
 252 ENTROPION. 
 
 is not to be considered. If the entropion be still purely spastic, 
 one of the safest and most effective remedies is canthoplasty, with 
 free division of the external canthal ligament the cantholysis of 
 Agnew as described in its proper place. 
 
 One may also have recourse to one of the suture operations. 
 These, of which a number have been devised, consist in inserting a 
 thread or -a series of threads, vertically in the tissue of the lower 
 lid, that through the tying or through the consequent cicatrizing 
 will correct the entropion. The forerunner of most of them was 
 that of Hippocrates, who passed a ligature through a horizontal 
 fold of the skin just beneath the free border, and allowed it to 
 suppurate out. Gaillard 1 entered from one to three curved needles, 
 carrying silk thread into the skin just beneath the lashes, that 
 penetrated to the tarsus, followed its anterior surface, thus including 
 skin and orbicularis, and emerged, straight below, some fifteen 
 millimeters or more from the point of entrance, according to the 
 degree of redressal required. They were tied tightly and left till 
 their spontaneous release. 
 
 Arlt 2 modified Gaillard's method (Fig. 123) so that, in accordance 
 with present ideas, it might be thus described: 
 
 Two No. 3 braided black silk sutures, previously boiled in 
 vaselin-paraffin and otherwise aseptically prepared, are needed, 
 each of which is armed with two curved needles. With left finger 
 and thumb a horizontal fold of the skin large enough to correct 
 the defect is picked up beneath the affected lid. One pair of the 
 needles is made to penetrate the base of the fold on the same level, 
 two or three millimeters apart, and about the same distance (three 
 millimeters) from the free border one on either side of the junction 
 of the middle with the outer third of the lower lid. They are passed 
 downward between tarsus and muscle, and brought out as in the 
 Gaillard operation. The other pair is similarly introduced, astride 
 the junction of the middle and inner thirds of the lid. In tying, a 
 cylinder of some soft material is placed beneath both knots and under 
 both loops, whilst a large probe or other round instrument is pressed 
 against the tarsus to make it cave inward. A bandage is applied 
 until the sutures are removed at the end of forty-eight hours. 
 
 1 Bull, de la Soc. med. de Poetiers, 1844. 
 
 2 Die Krankh. des Aug., iii, S. 368, 1856.
 
 SNELLEN'S SUTURES. 
 
 2 53 
 
 Snellen's 1 Sutures. The eye is cocainized. The edge of the 
 lid is seized with a pair of T forceps, or with the fingers, and everted 
 enough to open the cul-de-sac, in the bottom of which the needles 
 are started (Fig. 124). One needle of a double-armed suture is 
 here passed (convexity downward) directly through the whole thick- 
 ness of the lid, just external to the lacrimal punctum, and the other 
 
 FIG. 123. Arlt's suture for entropion. FIG. 124. Snellen's suture for entropion. 
 
 through about four millimeters further outward, while the resultant 
 loop is drawn down into the fornix. The point of each needle is 
 then inserted at its place of exit from the skin, passed upward be- 
 neath the latter not beneath the muscle one parallel with the other 
 (their convexities backward) , and brought out two millimeters below 
 the cilia. One or two other threads are placed in precisely the 
 * Cong, internal, d'oph., Paris, 1863.
 
 I 
 
 * 
 
 same manner. The lid is turned outward, ovn .1 round Instrument 
 of some kind, and the uUire are tied ovn ylind< i .m<i i h m 
 three or four days, the eye being bandaged meanwhile. 
 
 Stellwflg's sutures (Fig. 125), like Snellen's, began by loop ftl 
 the bottom of the lower fornix, but instead of passing In i through 
 the lid, were directed up and forward belum. the turiUl and iln 
 orbictilarls, to emerge from the skin near the cilia. 
 
 's suiure for c tropi^n 
 
 Graefe, 1 in some CAvSe^ of spastic eniropion, picked up a small 
 vertical fold of skin, i\\o or throe millimeters wide, near the center 
 of the free border, passed a thread through its upper end. tied it, 
 AtU^eut one end olY short. This was repeated directly bek>W, 
 over the rim of ihe orbit, and the two long ends of thread were 
 
 1 Heidelberg Cong.,
 
 - - -.. : ' - ::: -. ::L-.L T - T> ?: \ 
 
 - .. - - : -- r- --..~ . > . 
 
 i -: :"-".:. 
 
 ' - - ' - .._.-- ' -_- 
 
 ' 
 
 
 ellipses, triangles, etc., of 
 
 fashion of the ararirrs, is still pract> : :: a Emited extent, for 
 
 functional cutimiiuM as wefl as for the cieatricial variety. The 
 
 opening is either dosed by suturing or v to heal by graauia- 
 
 tkai (Desmarr 
 
 Another primitive cure is linear cauterization o: n along 
 
 the border. Both these meas:.~ irratior. 
 
 The mere fact that they do away with the entropion in most in- 
 stances does not render them free from censure, and 
 easily pushed to such an extreme ..- - - - n of one 
 
 blemish for another, such as lagophthalmos. unseemly so 5 
 ectropion. It is doubtful if sheer redundance of skin is . 
 true cause of entropion. but it is certain that the removal of it will 
 pull the lid away from the eye so might many an odd comrivuru 
 
 ORGANIC OR CICATRICIAL KNTROP1ON. 
 
 UPPER LID. 
 
 This form, unlike the functional, consists not so much in the 
 malposition as in the malformation of the lid. the chief factors in 
 which are the warping of the tarsus, through the transformation of 
 this body into cicatricial tissue, and the atrophy and consequent 
 shrinkage of the conjunctival sac. 
 
 The causes are diseases such as chronic inflammations and ul 
 cerations, beginning in the conjunctiva, the results of infection, 
 burns, and other injuries. The greatest of all agents, both as to its 
 capability and its frequency, in the production of cicatricial i-ntropion 
 is chronic granular conjunctivitis, or trachoma. The counirii's 
 bordering on the Mediterranean Sea have from the times of their 
 earliest history been peculiarly subject to this atlliction, hence,
 
 256 ENTROPION. 
 
 they early began to devise surgical means for the relief of trichiasis, 
 which is the greatest evil of entropion. 
 
 This form differs in another respect from functional entropion, 
 viz., that it more generally concerns the upper lid. In dealing with 
 entropion from trachoma, therefore, it is well to keep in view the 
 manner of its production; in other words, the clinical characteristics 
 of the disease which produces it, as constituting the rationale 
 for its best and most progressive surgery. The features that have 
 a special bearing may be stated thus: 
 
 1. Principal Seat. The upper conjunctival fornix. 
 
 2. The intense photophobia, which is the earliest factor in the 
 causation of entropion. Through it an abnormal development of 
 the orbicularis ensues, especially of the palpebral or inner zone of 
 the muscle which rema'ns after the acute stages of the disease have 
 passed. By its action the tension of the lids upon the globe becomes 
 excessive, the friction is increased, and the protecting, sharp, inner 
 angle, containing the musculus ciliaris of Riolani, disappears, the 
 free border becomes whetted down, by absorption, to a feather edge, 
 and the underhanging skin contains the lashes. 
 
 3. The atrophy of the entire conjunctival sac and the whole of 
 the tarsi that are responsible for the shrinkage and distortion of 
 these parts a process that, once well under way, seems never to 
 come to an end until death. 
 
 Nos. 2 and 3 are, probab'y, both concerned in the bringing 
 about of the varying degrees of ptosis that are so often associated 
 with entropion. The levator gradually yields to the prolonged 
 antagonism of the powerful orbicularis and to the obliteration of 
 the upper fornix, through atrophy of the conjunctiva, and becomes 
 permanently disabled. 
 
 Incipient, or slight cicatricial entropion, when the cause of 
 it is no longer active, can rarely be corrected by one of the opera- 
 tions described for the functional kind. Here tissue has been 
 destroyed that must usually be replaced. 
 
 The first important operation of which there is a definite account 
 is that described in the medical works of jEtius, written in the 
 sixth, and those of Paulus /Egineta, in the seventh century of 
 the present era. Briefly, it was as follows: The free border was 
 divided vertically, from canthus to canthus, into two leaves the
 
 ORGANIC OR CICATRICIAL ENTROPION. 
 
 257 
 
 anterior, composed of the skin holding the cilia and their follicles; 
 
 the posterior, of the tarsus and conjunctiva. An ellipse of 
 
 integument, the length of the palpebral fissure, was removed just 
 
 above the roots of the lashes, and the latter, with their loosened 
 
 bridge, slid up and fixed to 
 
 be out of the way. This is 
 
 the identical operation that 
 
 was revived by G. Jasche 1 
 
 and that, modified by v. Arlt, 2 
 
 had such a tremendous 
 
 though ephemeral vogue, 
 
 under the name of "Verab- 
 
 schiebung des Wimperbo- 
 
 dens nach Jasche-Arlt," or, 
 
 in English, transplantation of 
 
 the eyelashes (Figs. 126 and 
 
 127). 
 
 The great faults of this procedure were: (a) want of a fixed point 
 
 above for the upper edge of the flap; (b) lack of support from 
 
 below, so that the cilia gradually descended until they again rested 
 
 on the eyeball; and (c) no attention was paid to the incurvation of 
 
 the tarsus; nor (d) to the 
 atrophy of the conjunctiva 
 and restoration of the free 
 border; (e) to the relief of lid 
 tension; (/) to drawing up 
 the loose underhang of the 
 cilia; nor (g) the counteract- 
 ing of the tendency to ptosis. 
 The need (a) was found by 
 Anagnostakis,3 of Athens, who 
 chose the upper border of the 
 
 FIG. 126. Jasche-Arlt, No. i. 
 
 FIG. 127. Jasche-Arlt, No. 2. 
 
 tarsus (Fig. 128). He made a 
 
 cutaneous incision the length of the tarsus, only three millimeters 
 from the free border, opened it up, and resected a strip of the 
 orbicularis overlying the upper border of the tarsus, and to the 
 
 1 Med. Ztg. Russlands, No. 9, 1844. 
 
 2 Graefe-Saemisch, Bd. iii, 1874. 
 
 3 Annal. d'oculist. t. xxxviii, p. 5, 1857.
 
 2 5 8 
 
 ENTROPION. 
 
 FIG. 128. Anagnostakis 
 
 latter stitched the lower lip of the skin incision. The upper lip was 
 not included in the sutures. This method failed in all the other 
 
 requirements save (a). 
 
 Hotz, 1 of Chicago, modified 
 this proceeding by making the 
 primary incision higher up 
 and parallel with the upper 
 tarsal border, to give a normal 
 sulcus with the scar at its bot- 
 tom (Fig. 129). He passed 
 the sutures through the upper 
 lip of the skin incision also 
 before tying, and, most im- 
 portant of all, insisted upon 
 the resection of the lower 
 fibres of the orbicularis thus 
 partly fulfilling indication (e) . 
 To Hotz is really due the credit of perpetuating the principle ad- 
 duced by Anagnostakis, and which is so necessary a part of the 
 advanced entropion operation. 
 Moreover, as regards the incep- 
 tion of the idea, Hotz owes noth- 
 ing to the Greek surgeon. 
 
 The first to see, and partly to 
 supply, the second want sup- 
 port from below as well as the 
 first to make marginal blepharo- 
 plasty, was Spencer-Watson. 2 
 This surgeon, after splitting the 
 lid border as per the old Greek 
 method, made as if to remove 
 the ellipse of skin, but left the 
 outer end attached, as he did 
 also the inner end of the cutan- 
 
 U--J j. .LI ! FIG. 120. Hotz. Border fibres excised. 
 
 ecus bridge containing the cilia, 
 
 as nourishing pedicles. He then caused the two flaps thus formed 
 
 1 Archives of Ophthalmology, vol. viii, p. 249, 1879. 
 3 Med. Times and. Gaz., vol. xlix, 1874.
 
 ORGANIC OR CICATRICIAL ENTROPION. 
 
 259 
 
 FIG. 130. Spencer- Watson's entropion 
 operation. 
 
 to exchange places, and fixed them in their new relations by fine 
 sutures (Fig. 130). 
 
 Gayet 1 split the free border and dissected up the long strip of 
 skin, with external pedicle, 
 which he transplanted back 
 of the cilia without sliding up 
 the skin containing them, thus 
 partly meeting requirement (d) 
 or restoration of atrophied 
 tissue (Figs. 131 and 132). 
 
 A further improvement was 
 that made by Dianoux 2 who, 
 in addition to the bridge con- 
 taining the lashes, formed a 
 second of integument, above 
 and adjacent to the first. The 
 two were then transposed and 
 
 sutured. Both were fed by double pedicles, and as soon as practica- 
 ble those of the intermarginal. strip were cut (Figs. 133 and 134). 
 
 Waldhauers made the 
 Jasche-Arlt operation, and 
 rather than throw away the 
 excised segment of skin, he 
 covered with it the denuded 
 lower portion of the tarsus 
 graft without a pedicle, after 
 Le Fort- Wolfe. 
 
 Van Millingen,4 of Con- 
 stantinople, under the name 
 of tarso-chiloplasty, still 
 further improved the methods 
 in question by substituting 
 for the intermarginal skin graft one of mucous membrane taken 
 from the inner lining of the lip. A broad strip of this tissue 
 furnishes the requirements mentioned under both (b) and (d). 
 
 1 Annal. d'oculist. t. Ixxxii, 1879. 
 3 Annal. d'oculist, No. 2, p. 132, 1882. 
 3 Klin. Monatsbl., 1897, pp. 47-54. 
 Oph. Review, p. 309, 1887. 
 
 FIG. 131. Gayet's entropion operation.
 
 260 
 
 ENTROPION. 
 
 FIG. 132. Gayet's entropion operation. 
 Lid averted. 
 
 The originator of tarsoplasty in this connection was Streatfield. 1 
 
 His operation consisted in the removal of a large horizontal wedge 
 
 of tissue from the upper lid, 
 which was composed of skin, 
 orbicularis, and a small part 
 of the center of the tarsus. 
 No sutures were employed, 
 the wound having been left 
 to heal by granulation in 
 order to increase the effect 
 of the operation (Fig. 135). 
 Thus was the third requisite 
 (c) to the success of this 
 branch of surgery provided. 
 It occurred to Snellen, of 
 Utrecht, to combine this 
 guttering of the tarsus with 
 the Anagnostakis 2 method, 
 the only difference being 
 
 that double-armed sutures were used, starting in, through, coming 
 
 back to the lower skin flap, and tying over glass beads. Chroniss 
 
 added canthoplasty and, about the same time, Agnew subjoined 
 
 external tenotomy or can- 
 
 tholysis to this procedure, 
 
 and by these means the 
 
 second requirement of (e) 
 
 was obtained. 
 
 Panas* made a similar 
 
 operation to that of Snellen 
 
 with two or three highly 
 
 significant differences, viz., 
 
 the careful dissecting up of 
 
 the lower skin flap as far 
 
 down as possible not to cut 
 
 through and make a buttonhole, the passing the sutures through 
 
 1 Royal London Hospital Reports, vol. i, p. 125, 1858. 
 1 Van Gils Beitrage, Utrecht, 1870, p. 90. 
 
 3 Rec. d'opht., 1875. 
 
 4 Arch, d'opht., p. 208, 1882. 
 
 FIG. 133. Dianoux's entropion operation.
 
 ORGANIC OR CICATRICIAL ENTROPION. 
 
 261 
 
 the line of cilia beneath the entire flap (not through it), and the 
 fastening them by collodion to the brow (Figs. 136 and 137). 
 This dissection and the draw- 
 ing up of the lower flap, 
 partly meet requirement (/). 
 The point wherein it fails of 
 the condition is the fact that 
 the threads push the ciliary 
 strip up instead of pulling it up 
 and putting it on the stretch. 
 
 A. Pagenstecher 1 made an 
 incision just below the upper 
 border of the tarsus, opened 
 
 it Up Wide, exposed the tarso- FlG '34 -Dianoux's entropion operation. 
 
 orbital fascia, which was caught up in a horizontal fold, and 
 through it were passed the sutures that traversed the two lips of 
 the cutaneous incision. As a complete operation for entropion the 
 proceeding fell far short, yet it served to obviate the droop of the 
 
 upper lid and thus met requirement (g) . 
 A resume, then, of the fundamental 
 principles of the modern operation for 
 entropion of the upper lid, the measures 
 devised in accordance with them and 
 their authors would stand something 
 like this: 
 
 (a) Fixed anchorage for sutures that 
 hold up the flap containing the cilia: 
 the tarsus and the tarso-orbital fascia. 
 Anagnostakis. 
 
 (b) Support of same from below: 
 transplantation of tissue. Spencer- 
 Watson. 
 
 (c) Correction of incurvation of 
 tarsus: counter-grooving. Streatneld. 
 
 FIG. 13^. Streatneld s groove. 
 
 (</) Replacing of tissue, to atone for 
 
 shrinkage of conjunctiva, and to restore the angle of the free border: 
 intermarginal grafts. Spencer- Watson, Gayet, and Van Millingen. 
 1 Klin. Beob., 1861 ; and A. f. Oph., xxxvi, 4, S. 265.
 
 262 
 
 ENTROPION. 
 
 (e) Relief of overtension of the lids and accompanying blepharo- 
 phimosis: canthoplasty, cantholysis, and resection of the border 
 fibres of orbicularis. Chronis, Agnew, Hotz. 
 
 (/) Redressal of the underhang of the skin at the free border, 
 and the turning up (not pulling up] of the cilia: dissection of 
 lower lip down to the cilia. Panas. 
 
 (g) Obviation of accompanying ptosis: tucking of levator 
 tendon. Pagenstecher. 
 
 FIG. 136. Panas entropion operation. 
 
 FIG. 137. Panas entropion operation. 
 
 The scope of any given operation for cicatricial entropion and 
 trichiasis of the upper lid will be determined by how many of the 
 six features here enumerated it will be fit for it to embrace. To 
 put it another way, the extent of the surgical interference needed 
 for the relief of a specified case will be governed by the number of 
 abnormal conditions that are concerned in the production or main- 
 tenance of the entropion and the trichiasis. If, for instance, only 
 partial absence of the angle of the free border is responsible for 
 the trouble, the simple insertion of an intermarginal graft might 
 furnish the remedy. If entire absence and nothing more, a Hotz 
 operation would be added to this with, perhaps, canthoplasty. If
 
 ORGANIC OR CICATRICIAL ENTROPION. 263 
 
 complicated with incurvation of the tarsus, counter-grooving must 
 be joined with the other steps, and so on. As a matter of fact, the 
 instances are exceedingly rare that are not all the better for giving 
 one's patient the benefit of the whole category. For, if all the 
 phases mentioned are not present in the particular case, owing 
 to the never-ending progressiveness of the affection on and on for 
 years after all apparent traces of the primary disease have vanished 
 what the several parts of the operation do not accomplish in the 
 way of actual cure, they will achieve as preventives. Another 
 element that must be taken into consideration in defining the limits 
 of an operation for entropion of the upper lid, especially when caused 
 by trachoma, is the age of the subject. Those who come to us 
 suffering from this disorder represent every period of life between 
 ten and seventy years. I have known three generations of a single 
 family to be under treatment at the same time. Naturally, in 'view 
 of the perpetuity of the degenerative changes of the tarsus involved, 
 one must strive for greater effect in cases of children and the younger 
 adults whose lives are before them than in those of the middle-aged 
 and the elderly, if it is hoped that the best results of one's work are 
 to endure till the end. 
 
 How great, then, should be the effect ? More than twenty years 
 of service as surgeon to the Illinois Charitable Eye and Ear In- 
 firmary, an institution whose outdoor and hospital clientele com- 
 prises some 12,000 new patients annually of whom a large propor- 
 tion were, a few years ago, admitted because of entropion from 
 trachoma have given the writer exceptional opportunities in this 
 line of surgery, both as participant and observer. Unlike those 
 whom we treat in private practice are these wards of the State. 
 When their troubles recur they come back or are sent back to us, 
 and it is almost a daily occurrence to see one return with an ag- 
 gravated type of entropion, who a few years before, had been 
 operated upon and "cured" of the same trouble in the same lids. 
 It sometimes happens, too, that the recurrence is more pronounced 
 than had been the first form. Certainly, the difficulties of the second 
 attempt at restitution are in no way lightened by what was done at 
 the first. On the other hand, it is much to be doubted if a well- 
 made operation for cicatricial entropion has ever been followed by 
 too great an effect. Many a one has resulted in lagophthalmos
 
 264 ENTROPION. 
 
 from undue shortening of the lid, but not from too great an eversion. 
 Presumably this last is possible, but it seems to be only theoretic- 
 ally so. 
 
 Wherein most operators fail is not that they do not obtain cor- 
 rection of the deformity, for the merest tyro among them succeeds 
 in this, but that their correction does not last. In the pursuit of this 
 branch of plastic surgery, therefore, it would not go amiss to take 
 this as a maxim excessive immediate effect is necessary in order to 
 insure permanent correction. 
 
 Technic of the Operation. The following description em- 
 bodies the author's conception as to the surgical requirements of 
 a pronounced cicatricial entropion of the upper lid, and also the 
 details of his manner of procedure. The operation may be per- 
 formed with or without narcosis. If dispensed with, cocain solution 
 is dropped into the conjunctival sac. The infiltration anesthesia of 
 Sleich is effective in preventing pain, but the swelling of the tissues 
 it produces is highly prejudicial to nice results. The patient is 
 prone upon a table. If both eyes are in need of the operation and 
 the patient can or will submit to their occlusion for a few days, it 
 is decidedly to his advantage, as to time, suffering, and inconveni- 
 ence, to make the two operations in one sitting. One or two trained 
 assistants are needed. 
 
 First step. The canthotomy (p. 217). Free division of the 
 external canthal ligament is indicated. 
 
 Second step. Making of the intermarginal incision that is to 
 receive the graft. The lid is grasped, everted, and held back by 
 the Beard lid forceps (Fig. 138) or by the tips of the fingers placed 
 upon the eyelashes. Where the latter exists in sufficient numbers 
 and length, one may dispense with the forceps. This instrument 
 has proven most serviceable, as it effectually fixes the lid and pre- 
 vents bleeding while the making of the cut is in progress. The 
 scalpel, with extra convexity near the extremity of the blade, held 
 as shown in Fig. 46, is employed. The incision extends from the 
 outer limit of the free border to, but not including the punctum. 
 
 Where many fail is in making this cut too short and too shallow. 
 If the entire free border is involved I do not hesitate to carry the 
 incision past the punctum, i.e. , to the inner canthus. An insignifi- 
 cant shallow incision will not retain the graft which, to be effective,
 
 ORGANIC OR CICATRICIAL ENTROPION. 
 
 265 
 
 should sink in till its epithelium is lower than the surrounding lid 
 margin. The position of the incision is in the posterior portion of 
 the substance of the tarsus, rather hugging the boundary between 
 tarsus and conjunctiva; it is about four millimeters in depth, and is 
 made to gape widely that one may judge of its capacity. The 
 lid is now turned back into place. 
 
 FIG. 138. Making the inter-marginal incision for mucous graft. 
 
 Third step. The Cutaneous Incision. A broad lid spatula is 
 pushed into the upper fornix and held by an aid (Fig. 139). With 
 the same scalpel an incision is made through skin and muscle just 
 below, and parallel with, the upper border of the tarsus, except near 
 the extremities where it takes a horizontal direction, extending some- 
 what beyond the vertical line of the canthus in either direction. 
 Its distance from the free border varies with the width of the 
 tarsus. 
 
 Fourth step. Dissection of the Flaps. The lower lip of the 
 incision, with its attached portion of the orbicularis, is lifted and
 
 2 66 
 
 ENTROPION. 
 
 undermined, and the tarsus cleanly denuded down to the point 
 where the cilia are seen to cross between it and the muscle, like 
 
 FIG. 139. ''Altogether operation." 
 
 black stitches in a seam. For this dissection it is best to use the 
 back of the knife-point, and the flap is thus loosened the entire
 
 ORGANIC OR CICATRICIAL ENTROPION. 
 
 267 
 
 length of the free border. When the cilia are reached, in careful 
 dissection, one feels the point of the knife vibrate as it chatters in 
 passing over them. Buttonholing at this stage is to be avoided. 
 The upper lip of the incision, with its underlying muscle, is 
 loosened and pushed upward, so as to expose the tarso-orbital 
 fascia (Fig. 141). 
 
 Fifth step. Resection of the 
 Border Fibres of the Orbicularis. 
 The instruments are small, mouse- 
 tooth forceps and delicate, blunt- 
 pointed scissors. The upper edge of 
 the muscle clinging to the lower flap 
 is seized with the forceps and neatly 
 excised from end to end in one long 
 strip, the surgeon and the assistant 
 meanwhile taking care of the skin 
 edge to see that it is not nicked and 
 notched. 
 
 Sixth step. Counter-grooving of 
 the Tarsus. The operator steadies 
 the tarsus on the spatula, notes the FIG. 140. Beard's method for 
 
 line Of greatest prominence of the entropion. The heavy black lines 
 
 show the incisions. 
 
 horizontal ridge corresponding to 
 
 the gutter on the inner surface, and with the same scalpel 
 incises it. The two cuts- needed for this purpose are so inclined 
 that they meet at or near the posterior surface of the tarsus. If 
 the conjunctiva should be slightly wounded in the act, it is of 
 little consequence, though it were better to avoid it. The size of 
 the wedge will depend upon that of the tarsus. The incisions 
 will, of course, not go far beyond the ridge, which is often not so 
 long as the tarsus. The thickness of the wedge is usually about 
 two millimeters. 
 
 Wilder has devised an apparatus for excising the wedge of tarsus. 
 It consists of a pair of small scalpels fixed in a holder. One move- 
 ment suffices for the excision. The appliance is also used by its 
 originator for cutting the cutaneous intermarginal graft for restora- 
 tion of the lid border. 
 
 Seventh step. Inserting the Sutures. One may use the ordinary
 
 2 68 
 
 ENTROPION. 
 
 curved needles and holder or Reverdin's needle with handle. The 
 needles should be small, fine, and sharp. Large ones cause needless 
 traumatism. No. 2, braided, black, silk thread, boiled in paraffin, 
 makes an excellent suture, of which three are put in, the first one 
 midway of the tarsus and the other two, one on either side five 
 or six millimeters away. Each needle is passed from below, through 
 
 the lower flap just far enough 
 from the edge to insure a firm 
 hold for forty-eight hours, then 
 through a small, horizontal fold 
 of the tarso-orbital fascia, picked 
 up in the forceps, just above the 
 convex border of the tarsus, 
 thence high up beneath the 
 superior flap, and brought out 
 through the muscle and skin but 
 a short distance below the super- 
 cilia. To make the fold or tuck 
 in the fascia, slightly dig the 
 needle into it just where the 
 crest should be, pull it up and 
 grasp the base of the raised part 
 with the mouse-tooth forceps, so 
 as to form a horizontal pleat and 
 pass the needle through, close 
 to the jaws of the forceps (Fig. 141). 
 
 Eighth step. Tying the Sutures. Here the closest attention to 
 the detail of every maneuver is of the greatest moment. The lips 
 of the intermarginal incision will now be found tightly glued together 
 by fibrin. They are parted with the points of the closed scissors and 
 all shreds cleaned out. So, too, as regards the flaps of the external 
 opening. They are lifted up, and all blood, etc., removed from 
 under them, so that they may slide over tarsus and fascia. The 
 central suture is tied first. A double turn is made in the thread and 
 the lower end given to the aid, while the operator holds the upper 
 between thumb and index. The edge of the lower lip of the cut 
 is grasped with the mouse-tooth forceps near the thread to be tied, 
 and drawn up, turned backward and placed in contact with the 
 
 P'IG. 141. Beard's method for entropion. 
 Shows course of sutures.
 
 ORGANIC OR CICATRICIAL ENTROPION. 269 
 
 fascia just where the thread enters the latter, or against the fold, 
 simply pushing up the other flap with its edge also turned backward, 
 just as described for the ptosis operation. While the flap is being 
 thus held, the operator pushes down (or backward, as regards the eye) 
 with the forceps on the weakened tarsus, to make sure that it bends 
 with its concavity outward, closing the newly-made groove, and now 
 surgeon and assistant pull together on the ends of thread and draw 
 it tight, when the former takes both ends and completes the knot. 
 Were the tarsus not pressed down in its middle this way, it might 
 hump or buckle up, i.e., with its concavity downward and actually 
 increase the deformity it was the aim to correct. The sutures, to 
 complete the canthoplasty, are here put in and tied as per description 
 under " Canthoplasty." 
 
 Ninth step. Making and Placing the Graft. A wad of cotton 
 wet with warm boric acid is laid over the lids. The patient's lower 
 lip is turned out and gently washed with warm salt or boric solution 
 not scrubbed and rubbed, so as to hurt the epithelium and a small 
 cotton sponge dipped in boric solution and tightly squeezed is 
 pushed down into the pocket between lip and gums. A pair of large 
 straight scissors, the same as are used for the canthotomy, answer 
 best for cutting out the graft. The lip is caught between the thumb 
 and index, rolled over the medius so as to evert well, the scissors 
 opened very wide, the base of the blades placed firmly on that part 
 of the mucous membrane that usually lies opposite the margins of the 
 gums and, bearing down with the scissors while holding up with the 
 middle finger from below, along ellipse is excised with one snip of the 
 shears that will fill the intermarginal incision. The piece will 
 include not only the entire thickness of the mucous membrane, but 
 a number of lobules of adipose tissue will be found attached to it. 
 Turn it over, face down, upon the nail of the left thumb (or upon the 
 rubber glove or gauze cot covering the same) and with the small 
 scissors, carefully trim off all the adipose, paring it down to the 
 submucous connective tissue. 
 
 A very thin, flabby graft is useless. It must have body as well 
 as breadth. In respect to the latter dimension, as time goes on, 
 I am inclined to make the grafts wider than of yore. In extreme 
 cases, they would measure hardly less than seven or eight millimeters 
 at the middle.
 
 270 
 
 ENTROPION. 
 
 Rinse it in i% salt or 4% boric acid solution at about 110 F., 
 and place it flatwise in the cut back of the cilia, making sure that 
 the epithelial surface is outward. The tips of tiny spindle-shaped 
 cotton sponges are well wrung out of boric solution and applied 
 about the edges of the graft, to drink up the slight oozing, the 
 lid being all the time held everted as directed for making the mar- 
 ginal cut. 
 
 The graft must be ample in exactly the same proportion as 
 
 is the intermarginal incision. If 
 the first piece excised falls short 
 of filling the cut, it is better to 
 take a second, sufficiently large, 
 to piece out, squaring and butting 
 together their ends. 
 
 No decided hemorrhage should 
 be taking place from the wound 
 when the graft is laid in, else a 
 clot will form beneath and inter- 
 fere with proper union. But a 
 slight bleeding, which is always 
 checked by laying in the graft, 
 is an advantage in that it helps 
 to fix and to hold the morsel in 
 position. Sutures would be both 
 useless and harmful, as when 
 quickly put in (i.e., not fussed 
 with too much) and stuck by 
 fibrin, there is no possibility of the graft letting go, except, possi- 
 bly, in removing the dressing (Fig. 142). 
 
 The latter consists, first, in the usual, thin layer of cotton wet 
 with warm, boric acid solution, carefully applied to the closed lids 
 (p. 15). There is a little point of considerable value that might 
 be mentioned in this connection; after every other operation treated 
 of in this volume, except the one now under discussion, the ap- 
 plication of the first wet sheet of cotton is made by sliding it on to 
 the lids from above, in order to smooth the lashes downward (see 
 dressing after "Extraction"). In this instance the reverse obtains, 
 viz., it is slid upward, for the reason that the primary effect of this 
 
 FIG. 142. Shows completed operation.
 
 ORGANIC OR CICATRICIAL ENTROPION. 271 
 
 operation is to turn the cilia upward, like the feathers in a strutting 
 peacock's tail, and such a manipulation of the dressing tends to 
 heighten the result. To avoid loss of time in the first removal of 
 the dressings, caused by prolonged soaking of the cotton, as well as 
 to prevent loss of the graft itself, through having become glued 
 firmly to the cotton, one may place next to the lids a piece of thin 
 soft gutta-percha tissue. Upon this, a good-sized pad of dry 
 cotton is built up and over all the wet netting roller is applied. 
 The patient is kept quiet in bed for forty-eight hours, when the 
 bandage is cut, the cotton removed by soaking with warm, boric 
 acid solution and all the sutures are removed. The identical 
 dressing is reapplied with renewal at twenty-four-hour intervals 
 for a week or more. It will not do to leave off the bandage earlier, 
 else the drying effect of exposure will cause the graft to perish and 
 drop out. Even after the final removal of the bandage, it is well to 
 keep the graft covered for a few days with a film of sterilized vaselin, 
 for fear of desiccation. Formerly the wound in the mouth was 
 closed by sutures, but of late nothing is done for it. It heals kindly 
 by granulation and, moreover, most of the subjects are operated 
 without narcosis, and are glad to be spared further "sewing." 
 
 Conclusions. In my practice the several procedures just 
 described, viz., canthoplasty, Hotz's method, counter-grooving of 
 the tarsus, tucking of the tarso-orbital fascia, and the insertion of 
 the post-ciliary mucous graft are nearly always combined in a 
 single operation, which at the Eye and Ear Infirmary has come 
 to be known as "the altogether." They are thus united not for 
 convenience, but because experience has taught that by so doing 
 the effect is greater, better, and more lasting. If the same were 
 done piecemeal, i.e., for instance, first the canthoplasty, the Hotz 
 operation a week later, and so on, the ultimate result would be 
 much less satisfactory. Each of the multiple factors concerned in 
 the entropion is attacked by an efficient foe and the defects are 
 righted in a rational way by judiciously apportioning the effect 
 among the several ills, rather than by giving too great prominence 
 to one or two (Figs. 143 and 144). 
 
 With regard to the choice of mucous or of skin grafts for the 
 restoration of the free border, ophthalmic surgeons are not in 
 accord.
 
 272 ENTROPION. 
 
 Knapp 1 prefers those of skin, claiming that it is the more suit- 
 able, inasmuch as the normal lining of the free border is dermal 
 and not mucous. If one will take the pains, however, to ex- 
 amine a few lids that have been subjected to the operation, 
 he will be readily convinced that the graft after a comparatively 
 short time, really takes the place of conjunctiva in that it lies in 
 contact with the cornea. 
 
 F.G. 143. Ths expression of face before "the altogether operation." 
 
 Others have urged as an objection to the mucous graft, that its 
 shrinkage is greater than one of skin. Such does not agree with my 
 observation. Indeed, an extended experience with grafts of the 
 three, recognized varieties, viz., those of Wolfe, Thiersch, and Van 
 Millingen, have led me to believe that the last are precisely those 
 that retain more nearly their original bulk, and for the past ten or 
 twelve years, I have resorted to "chiloplasty." The last bit of skin 
 I made use of to replace the border was put into that of the lower 
 lid where it lay in contact with the globe. Very soon an ugly ulcer 
 appeared on the cornea immediately under the graft. Although 
 not a hair could be found in the patch to cause the irritation, the 
 ulcer persisted in spite of treatment. Finally it was remarked, in 
 
 1 De Schweinitz, Diseases of the Eye.
 
 ORGANIC OR CICATRICIAL ENTROPION. 
 
 273 
 
 everting the lid, that, while the surrounding conjunctiva was 
 normally moist, the graft itself remained perfectly dry. This led 
 to the conclusion that the oily nature of the epidermis was a hin- 
 drance to proper lubrication, hence the ulcer. The piece was 
 excised, a graft from the lip substituted, and at once the ulcer 
 healed. 
 
 The more thoroughly the various steps of the operation have 
 been performed the uglier from a purely cosmetic standpoint 
 
 FIG. 144. The expression of face ten days after " the altogether operation." 
 
 are its early results. In a few cases so pronounced has been the 
 ectropion, that a crust has formed on the palpebral conjunctiva 
 from exposure to the air. This, with the large red grafts and the 
 inverted lashes, all go to make a picture not overly attractive, yet, 
 as before stated, I have never seen permanent hypercorrection. 
 But a short while and all unsightliness disappears. 
 
 A serious and not infrequent sequel of operations for cicatricial 
 entropion from trachoma is ulceration of the cornea. This occurs 
 even in cases that had previously escaped this complication. More- 
 over, these ulcers are apt to be centrally located, just where they 
 can do most harm to the vision, and heal least readily. One can- 
 not, therefore, use too many precautions with the view to their 
 
 18
 
 274 
 
 ENTROPION. 
 
 prevention; first, as to the choice of the case never one in which 
 the trachomatous process is still active; second, as to the preparation 
 of the eye make copious irrigation of the conjunctival sac with 
 warm mild antiseptics immediately beforehand; third, as to the 
 operation itself not needlessly to injure the corneal epithelium 
 by such things as too much cocain, broad spatula, or lid-clamps, 
 nor by going through the entire thickness of the lid with the needles, 
 thus pricking the cornea or leaving a loop of thread where it will 
 rub that membrane. The effect of the free and prolonged instillation 
 of cocain solution is unquestionably wrong in that it results in the 
 drying and exfoliation of the corneal epithelium. A very few drops 
 before beginning the operation is sufficient, and it should be seen to 
 that the eye is flooded from time to time with warm boric solution. 
 An additional safeguard would be the instillation of a few drops of a 
 25 to 50% solution of argyrol when about to apply the final dressing. 
 This preparation is not only an effective. antiseptic, but it is otherwise 
 harmless, and, besides, has the property of remaining in the con- 
 junctival sac for several days. 
 
 ORGANIC ENTROPION. 
 
 LOWER LID. 
 
 Cicatricial entropion of the lower lid does not lend itself so \vell to 
 the surgical methods described in connection with that of the upper. 
 Here the conditions are different. The transformation of the tarsus, 
 the absence of the width of the free border, disappearance of its 
 posterior angle, etc., do not figure so prominently as in the other case. 
 Lid tension, the tension of the border fibres of the orbicularis, strain 
 of the shrunken conjunctiva, and the blepharophimosis are the things 
 chiefly to be contended against. These, together with the anatomi- 
 cal peculiarity of the inferior tarsal plate that is, in being only 
 about one-half the width of the superior one necessitate a mode of 
 handling quite special. It is true, however, that absence of the free 
 border occasionally constitutes the main fault, and the placing of 
 an intermarginal graft the best remedy. 
 
 The prime indications are to release the lid from the binding 
 pressure of the contractile and shrinking tissues, by resection of 
 the border fibres of the orbicularis, by canthoplasty with cutting
 
 ORGANIC ENTROPION. 
 
 275 
 
 of the external canthal ligament, and by piecing out the conjunctiva 
 with grafts of skin or mucous membrane. These measures may, in 
 occasional instances, be supplemented by the judicious employment 
 of operations for the shortening of the 
 adjacent integument. 
 
 Among the best of these is that of 
 Panas 1 (Fig. 145). The resulting 
 cicatrix corresponds to the natural 
 topography of the region. It is ex- 
 ecuted as follows: two vertical in- 
 cisions, each about one centimeter 
 long, are made through skin and 
 muscle, one near the outer canthus, 
 the other near the inner, their upper 
 extremities close under the cilia. 
 Their lo\ver ends are joined by a 
 horizontal incision through skin only. 
 The flap thus outlined is dissected up 
 to the very roots of the eyelashes, everted and a strip of the 
 premarginal fibres of the orbicularis is excised. A parallelogram 
 is trimmed from the lower edge of the loosened flap, its width 
 
 proportional to the amount 
 of shortening demanded, 
 and the opening closed by 
 fine sutures. 
 
 V. Graefe gave a method 
 that has often done good 
 service (Fig. 146). Three 
 millimeters from and par- 
 allel with the free border, 
 an incision is made through 
 skin and muscle, extending 
 nearly the entire length of 
 
 FIG 145. Panas' operation for 
 entropion. 
 
 FIG. 146. Graefe's operation for entropion. 
 
 the lid. A triangle of skin, 
 whose base rests on the 
 middle of the first incision, and whose size is governed by the degree 
 of effect aimed at, is excised muscle not included. The strip 
 * Mem., These de Paris, 1873.
 
 276 ECTROPION. 
 
 of skin and muscle lying next to the margin are caught with forceps 
 and dissected from the tarsus until the cilia are exposed, taking 
 care not to buttonhole, and the attached fibres of muscle removed 
 with scissors. The two corners of skin are undermined and the 
 whole opening closed by small sutures. If still greater effect is 
 wanted, a triangular piece of the tarsus may be excised, base down- 
 ward, or in the opposite direction to that of the skin triangle (see 
 dotted lines in accompaning cut). 
 
 The curious operation for entropion of the lower lid that bears 
 the name Flarer-Stellwag 1 was made by "scalping" the lid, turning 
 the abscinded strip upside down and replanting it. 
 
 ECTROPION AND BLEPHAROPLASTY. 
 
 . The name ectropion which is the exact opposite of entropion, 
 refers to an eversion or turning outw r ard of the lid, either partial 
 or total. The degree of eversion varies between that slightest of 
 all partial forms, wherein the lower punctum loses its suction on 
 the globe by the merest separation therefrom, to that most extreme 
 of total ectropion, where, through extensive destruction of the in- 
 tegument surrounding the palpebral fissure and the subsequent 
 contraction, both tarsi are not only inverted, but drawn widely 
 asunder so as to expose the entire area of the conjunctival sac. 
 
 For convenience, we may separate the varieties of ectropion into 
 four grand divisions, which, given in the inverse of their importance 
 or frequency are, (a) Spastic, (6) Mechanical, (c) Atonic, and (d) 
 Cicatricial. 
 
 Spastic ectropion, muscular ectropion, acute ectropion, 
 are several names that denote the same condition, and affect 
 mainly the lower lid. Spastic ectropion has its beginning in some 
 sudden swelling of the conjunctiva or advancement of the globe that 
 tends to push forward the free or straight border of the tarsus. At 
 the same time the backward pull of the orbicularis, through normal 
 contraction upon the convex border, together with the continuance 
 of the outward push of the border, completes the eversion by over- 
 coming the action of the marginal fibres. The ectropion once ac- 
 
 1 FlarerrReflexioni sulla trichiasi, etc. Milano, 1828. Stellwag, v.c. : 
 Ein neues Verfahren ge'gen einwartsgekehrte Wimpern. Allgem. Wr. 
 med. Ztg., 1883, Nr. 49.
 
 ECTROPIOX AND BLEPHAROPLASTY. 277 
 
 complished, the latter fibres only serve to maintain it. This condi- 
 tion, when exaggerated, may be termed blepharo-paraphimosis. 
 
 Mechanical ectropion is really a less acute form of the above, 
 in which both lids may be involved, and, in cases of long standing, is 
 characterized by structural changes in all the tissues of the lids, 
 but more particularly the innermost. The active force is referable 
 to exophthalmos, ectasia of the globe from staphyloma, tumors, etc., 
 or to growths and chronic swellings, hypertrophy, etc., of the con- 
 junctiva onucons ectropion). The perverted action of the orbicu- 
 laris, alluded to, figures here also. 
 
 Atonic ectropion chiefly concerns the lower lid, and may be due 
 to (a) paralysis or paresis of the orbicularis paralytic ectropion or 
 (b) relaxation of all the tissues of the lid, with lengthening of the 
 free border senile entropion. As a complication of this form, 
 hypertrophic conjunctivitis of the lower lid and epiphora occur, and 
 can easily be mistaken for a purely mucous ectropion. 
 
 Cicatricial Ectropion. In this variety, the eversion is the in- 
 direct result of a burn, other injury, or disease that destroys all or a 
 part of the skin of the lids. The destruction that causes ectropion 
 rarely extends deeper than the superficial fascia, or, at most, the orbic- 
 ularis. When the deeper leaf, viz., the tarsus and conjunctiva, 
 is carried away, that is another affair. The principal agents in 
 bringing about the condition are the contraction of the scar and, 
 after the eversion is pretty well established, the anchylosis in the 
 external sulcus. The location and extent of the scar will determine 
 those of the ectropion. 
 
 As to the surgical means adopted for the correction of ectropion, 
 they will depend mainly upon the nature of the defect. For the 
 purely spastic -kinds, it will ordinarily suffice to remove that which 
 is most active in producing it. Treatment of the conjunctivitis, 
 or whatever the cause, putting on strips of adhesive plaster 
 to keep the palpebral fissure closed, and bandaging, if the condi- 
 tions will admit of this. If, however, there is strangulation from 
 the muscle-cramp, an immediate canthotomy (p. 217) with free 
 cutting of the external canthal ligament is needed. For the mechan- 
 ical form, as in the spastic, attention to the ulterior cause is often 
 the sole means, be it the ablation of anterior staphyloma, the re- 
 moval of a tumor of the globe, tarsus or conjunctiva, or the relief
 
 278 
 
 ECTROPION. 
 
 of a transient exophthalmos. Should it be from a more lasting but 
 benign and reducible exophthalmos, median tarsorrhaphy would likely 
 be the most eligible recourse (p. 222). Mucous ectropion of the 
 lower lid will, in most instances, yield to local medical treatment, 
 together with adhesive or collodionized strips to support the lid, 
 and bandaging. Failing in this, one \vould far better try one of the 
 simpler surgical procedures, such as the insertion of a Snellen 1 suture, 
 
 rather than the employ- 
 ment of more radical 
 measures, or resort to such 
 irrational and primitive 
 methods as cauterization 
 or excision of the offending 
 conjunctiva. 
 
 An excellent means of 
 holding up a sagging lower 
 lid for an extended period, 
 as well as for the better 
 closure of the palpebral 
 fissure in certain cases of 
 lagophthalmos, is by the 
 use of the contrivance in- 
 vented by the writer for the 
 coaptation of shin-wounds 
 in general surgery. 2 
 
 This consists of a strip of 
 tarlatan ribbon, near one 
 
 selvage of which is attached a row of tiny flattened hooks, similar in 
 shape to those employed in connection with "eyes." A strip of 
 this is fastened, by flexible collodion, hooks up, to the lower lid; 
 and another, hooks down, to the brow. The two are then laced, 
 with a suitable cord, the lids approximated as nearly as desired, 
 and the cord tied in a bowknot. 
 
 The Snellen Suture. A No. 2 braided thread of silk, boiled in 
 paraffin and armed with two curved needles, is gotten ready. 
 The eye is cocainized. The needles are passed down into the most 
 
 'Van Gils Beitrage, p. 90, Utrecht, 1870. 
 
 Described in a paper read before the Chicago Medical Society, and pub- 
 lished in the Medical Recorder for June, 1903. 
 
 FIG. 147 Snellen's suture for ectropion.
 
 ECTROPIOX AND BLEPHAROPLASTY. 
 
 279 
 
 prominent fold of the exposed conjunctiva, obliquely through the 
 tarso-orbital fascia, at its junction with the tarsus, on down and 
 forward to emerge from the skin opposite the rim of the orbit 
 (Fig. 147). They enter about one-half centimeter apart, and their 
 courses very slightly diverge. Two or, at most, three such sutures 
 are placed and each pair is tied over a cylinder of gauze or tubing. The 
 tension put upon them is just sufficient to cause a slight entropion. 
 They are left in for several weeks 
 or until suppuration appears around 
 them, the eye being meanwhile 
 bandaged, with daily renewal and 
 cleansing. Silver thread is pre- 
 ferred to that of silk by a number 
 of surgeons, the assumption being 
 that the metal is better tolerated. 
 I think, however, that if the silk is 
 thoroughly boiled in paraffin, so 
 that it will not act like an open 
 path for the entrance of bacteria, 
 that it will be found superior to any 
 other material. 
 
 Argyll-Robertson 1 devised a knot 
 which he used in conjunction with 
 a lead plate. The needles of a 
 double-armed suture were passed FIG. 148. Argyll-Robertson suture for 
 
 ectropion, 
 
 from in front, through the whole 
 
 thickness of the lid, each one about six or seven millimeters from 
 the middle line, and two millimeters from the border. Then 
 carried free over the conjunctiva and, entering at the bottom of the 
 cul-de-sac, were brought out on the cheek some thirty-two milli- 
 meters below the lid-margin. Before tying the ends over tubing a 
 lead plate (25 x 6 x i millimeters), with ends and corners smoothly 
 rounded, was slid beneath the threads lying on the conjunctiva. 
 The object of the plate was to straighten the out-curve of the tarsus 
 and the infold of the fascia resulting from the ectropion (Fig. 148). 
 Fukala 2 is the author of a combined suture and incision operation 
 
 Edinburgh Clinical and Pathological Journal, 1883. 
 2 Berliner klin .Woch., 1891, S. 287.
 
 280 
 
 ECTROPION. 
 
 that has met with approbation. Jaeger's lid spatula is put into the 
 lower fornix and an incision made through skin and muscle, down 
 to the tarso-orbital fascia, ten to twelve millimeters from the free 
 border, parallel with it, and somewhat longer than the palpebral 
 fissure. The upper flap, with its muscle, is undermined up to the 
 cilia and the fascia is exposed. Three sutures are introduced as 
 follows: the needle is passed through loosened skin and muscle 
 four millimeters or more from the border, thence carried upward, 
 between muscle and tarsus, and passed straight through to the 
 
 conjunctival surface, close up to the 
 cilia. It is taken back the same 
 route, only three millimeters away. 
 One thread is placed in the center 
 and one near either canthus and tied 
 over sections of tubing. In closing 
 the incision with interrupted sutures 
 they are made to dip in and out of 
 the tarso-orbital fascia, much after 
 the manner of those used in Hotz's 
 operation for entropion. The chief 
 feature is the doubling of the skin 
 flap upon itself (Fig. 149) . Angelucci 1 
 makes a similar operation in all save 
 that no sutures are used. Atonic 
 
 suture for ectropion of the lower lid. ectropionj whet her the result of actual 
 
 paralysis of the orbicularis or from a senile atrophy and relaxation 
 of the tissues of the lid, requires practically the same surgical 
 treatment, though the age of the subject, and the prospect of a cure, 
 as in the case of certain paralyses of the seventh nerve, would have 
 a tendency to qualify the means. 
 
 Three dominant principles underlying most of the operations 
 that have been undertaken for this variety of ectropion, are: (i) 
 shortening the free border by excision of a wedge therefrom, (2) the 
 pushing up and shortening by means of sliding flaps and excision of 
 a triangle of skin at the external canthus, and (3) the narrowing 
 of the palpebral fissure, or the holding up the drooping lid, by one 
 of the forms of tarsorrhaphy, or combinations of these. The fact 
 
 1 Rev. gen. d'Opht., 1898, No. 9. 
 
 FIG. 149. Fukala's incision and
 
 ECTROPIOX AXD BLEPHAROPLASTY. 
 
 28l 
 
 that the lid in this variety of ectropion does not so much incline to 
 inversion of the tarsus as to a festooning or sagging downward of 
 the free border, constitutes one of its most distinctive features. 
 In other words, in cases of long-standing senile ectropion, the 
 lower lid becomes so elongated that it is impossible for it to coapt 
 nicely with the globe, even if the original cause of the ectropion were 
 no longer active. This peculiarity was noticed by physicians 
 in the early days of modern medicine and the first operations con- 
 ceived for righting the defect were directed to this fullness. 
 
 FIG. 150. Adam's operation for ectropion. 
 
 Such was that of Sir William Adams 1 which is the forerunner of 
 all those that include excision of the tarsus. This surgeon was bold 
 enough to excise a gore 'from the very center of the lid (its size 
 regulated by the amount of surplus in the lid) that included the 
 whole thickness. To hold th& edges of the notch in apposition, he 
 put in, as near as practicable to the border, a surgical pin, on to 
 which was wound a figure-of-8 ligature. For the rest, fine inter- 
 rupted sutures (Fig. 150). 
 
 Von Ammon, 2 not satisfied with the cleft often, and the conspicu- 
 ous scar always, left in the middle of the lid, took the gore from 
 the outer canthus (Von Ammon- Adams operation) (Fig. 151), then 
 proceeded as did Adams; yet not, as has been stated in some text- 
 books, as did Walther,3 who included the outer extremities of both 
 
 1 Practical Obs. on Ectrop., 1812, p. 4. 
 
 2 Zeits. f. Aug., i, S. 529. 
 
 3 Syst. der Chir., vi, 1828.
 
 282 
 
 ECTROPION. 
 
 lids for the correction of double, i.e., upper and lower, ectropion 
 (Fig. 152). It has been urged against these operations, when made 
 at the outer canthus, that the site is situated too far from the point 
 most desirable to effect, viz., the vicinity of the punctum. Certainly, 
 
 those made in the center 
 have as many faults. 
 
 Of later years, Kuhnt 1 has 
 given still another modifica- 
 tion of the original Adams 
 operation. The accompany- 
 ing illustrations, taken from 
 Terrien's excellent work on 
 eye surgery, will describe 
 the method better than 
 words (Figs. 153 and 154). 
 
 FIG. 151. Von Amon's modification of Adam's It will be seen that the skin 
 operation for ectropion. . g ^ mduded w j th the trf _ 
 
 angle cut from the tarsus and conjunctiva. While there is no 
 doubt of the ability of the operation, in many instances, to relieve 
 the ectropion, there is the risk of the cutting through of the 
 marginal sutures, and the leaving of a permanent nick. Then, too, 
 the decided folding of the skin at the border is objectionable. 
 
 L. Miiller 2 sought to remedy these shortcomings and not 
 without a degree of success by altering Kuhnt's method, as 
 per the illustrations (Figs. 
 
 155 and 156), also taken from 
 Terrien. The sutures that 
 close the widest part of the 
 tarsal V are held on one side 
 by skin, and the slack of the 
 latter, instead of being taken 
 up in one pleat, is divided 
 among several. 
 
 Heembold,3 in order to 
 obviate the tuck of skin made at the center of the lid in the Kuhnt 
 operation, removes a triangle of skin corresponding to that of the 
 
 1 Beitrage z. operativ. Augenh., 1883, Jena. 
 * Kl. Mbl. f. Aug., Bd. xxxi, 1893, S. 113. 
 3 Klin. Mbl. 1897, P- 28 3- 
 
 FIG. 152. Walther.
 
 ECTROPION AND BLEPHAROPLASTY. 
 
 283 
 
 tarsus, but further out, splitting the lid between them. The two clefts 
 thus made are sutured separately. These procedures are equally 
 applicable to certain cases of cicatricial ectropion as, for example, 
 from a small scar that may be 
 included in the excised por- 
 tion. 
 
 A quite satisfactory way, 
 hit upon by the writer, of deal- 
 ing with the defect in ques- 
 tion, is to make canthotomy 
 and extend slightly the skin 
 cut, then loosen around, be- 
 low, remove a small triangle 
 of skin containing a few cilia, 
 force out skin as it were 
 the outer extremity of the 
 lower tarsus, grasp it with 
 fixation forceps, and while 
 skin and conjunctiva are retracted, pass a No. 2 silkworm, or 
 catgut, suture through, from without, at a distance from the cut 
 end proportioned to the length of the proposed shortening, after 
 
 which the superfluous bit of 
 the tarsus is abscised. Now, 
 a small triangle of integument 
 and muscle (base in) is cut 
 from the upper lip of the 
 canthotomy, exposing the ex- 
 ternal canthal ligament. 
 Through the latter is passed, 
 from within, the suture just 
 put into the tarsus, the ends 
 are knotted and cut off short, 
 while the skin opening is 
 united by fine black silk 
 sutures, and the conjunctival 
 
 FIG. 153. Kuhnt, No. i. 
 
 FIG. 154. Kuhnt, No. 2. 
 
 incision is left to itself. The buried suture is afterward absorbed 
 or encapsuled (Fig. 157). 
 
 The second category of operations for atonic ectropion have for
 
 284 
 
 ECTROPION. 
 
 their object the pushing, or pulling, the lid into place by the excis- 
 ion of a triangle of skin and muscle near the outer canthus, the 
 mobilizing the surrounding edges, and the closure of the gap. 
 
 FIG. 155. Muller, No. i. 
 
 The first of these was that of Dieffenbach. 1 This consisted in 
 making a horizontal, cutaneous incision, beginning at the outer 
 commissure, whose length was governed by the amount of lid slack 
 
 FIG. 156. Muller, No 2. 
 
 to be taken up. From the extremities of this incision two others were 
 made, jn a downward direction, so converging as to unite in forming 
 1 Zeis Handbook f. pi. Chir., 1838.
 
 ECTROPION AND BLEPHAROPLASTY. 
 
 FIG. 157. Beard's operation for elongated lower lid. 
 
 an equilateral triangle. The skin and muscle thus enclosed were 
 extirpated. The outer edge of the lower lid was pared off for a 
 distance coinciding with the length of one side of the triangle. The 
 skin at the inner side of 
 the angle and beneath 
 the outer half of the lid 
 was undermined, the 
 whole lower lid slid out- 
 ward, closing the angular 
 opening, and the coapt- 
 ing edges were s^utured. 
 Thus the pared, or raw, 
 part of the lid margin 
 becomes the lower lip 
 of the primary, or hori- 
 zontal, incision (Figs. 
 
 158, 159)- 
 
 Method of Szyma- 
 nowski. 1 With a view to the elimination of the downward 
 traction of the scar on the outer commissure and also to the 
 enhancement of the effect, this surgeon has changed the form 
 and axis of the Dieffenbach triangle (Fig. 160). That is, he 
 places its apex at the commissure, extends one short side up and 
 out, gives it a long, vertical base; then a third side, of intermediate 
 length, leading back to the canthus. In other respects the method 
 
 does not differ from Dieff en- 
 bach's. Thus, the upward slant 
 of the short side gives the pro- 
 cedure added capacity for lifting 
 up the lid, and the long, narrow 
 cicatrix, extending as it does 
 both up and down from the level 
 of the commissure, does not tend 
 to the latter's displacement. The 
 effect, moreover, is easier to dose than is that of the older operation. 
 The outer portion of the lid border AD is prepared by removing 
 its edge to a depth sufficient to include the hair follicles, and for a 
 1 Graefe-Saemisch Handb., Bd. iii, S. 466. 
 
 
 FIG. 158. Dieffenbach, No. i.
 
 286 
 
 ECTROPION. 
 
 distance commensurate with the surplus length of the margin. The 
 incision AB, made about at right angles to the tangent of the curve 
 of the upper border, should be somewhat longer than AD. BC is 
 nearly three times and CA twice as long as AB. In undermining, 
 
 to mobilize the skin and mus- 
 cle, only the side AC is loosened, 
 and to the extent indicated by 
 the dotted line, leaving the 
 other two fixed for supports. 
 In closing, the opening D is 
 sutured to B. A strong point 
 
 in this sort of operation is that 
 FIG. i 59 .-Dieffenbach, No. 2. the elongation of the tarsus is 
 
 definitely disposed of. 
 
 The third class of operations for this kind of ectropion is composed 
 of the several operations for tarsorrhaphy or blepharorrhaphy 
 already described (pp. 220-224) for occlusion of some portion of the 
 palpebral fissure. It may be the external tarsorrhaphy of Fuchs, 
 the internal (German median) of v. Arlt, or the median of Panas. 
 In the writer's opinion, only the latter has a place in modern ocular 
 surgery, and even it is seldom 
 indicated. He would rather 
 trust to one of the other pro- 
 cedures mentioned in connec- 
 tion with this subject or, in ex- 
 treme cases, to a combination of 
 more than one of them. For 
 example, a resection at the outer 
 commissure in conjunction with 
 a Snellen suture, where the ectro- 
 pion is a mixture of the atonic 
 and the mucous types or, if the 
 operation made at the canthus 
 failed to reinstate the punctum, 
 one could resort later to such a procedure as that of Wharton- 
 Jones (Figs. 164-5) placing the apex of the V directly beneath the 
 punctum, so that the maximum of pushing upward of the lid would 
 be where it would do the most good. In the event of an incurable 
 
 FIG. 1 60.
 
 ECTROPION AND BLEPHAROPLASTY. 287 
 
 paralysis of the orbicularis, with ectropion, the most satisfactory 
 single operation, taken all in all, is probably the median tarsorrhaphy. 
 It will more surely relieve the troubles from epiphora and from 
 exposure of the globe and prove more lasting as to its benefits. 
 
 Operations for Cicatricial Ectropion and Other Blepharo- 
 plasty. It is customary to make two subjects of the above terms 
 and to treat them separately. Technically, one means a turning 
 out of the lid from a cicatrix and the other, plastic surgery, for the 
 restoration of the lid Seeing that some part is destroyed in almost 
 all cases of the ectropion under discussion and must be restored, it is 
 a pretty difficult matter to disunite the two, even in theory, and as 
 to actual practice, they are one. In all that has been written on 
 "blepharoplasty" a vast majority of the cases cited have been 
 those of cicatricial ectropion. An operation for the restoration of 
 any part of the nose isrhinoplasty; for any part of the lip, chiloplasty 
 why go on trying to perpetuate "a distinction without a difference ?" 
 
 This is the most common, as well as the most serious form of 
 ectropion and the most difficult to handle. A glance at the more 
 frequent causes of partial or complete destruction of the eyelids 
 and the kinds of cicatrices they leave may not be amiss. First in 
 the list stand burns from fire or chemicals. These are apt to be 
 deeper, in the first instance, seeing that the victim often receives the 
 injury as a helpless babe, or invalid (epileptic), and the contact is 
 prolonged; while, in the second (those from strong caustics and 
 acids) they usually affect the skin only. Next in point of frequency 
 is epithelioma, or rodent ulcer, which, when situated in the region of 
 the tarsus, usually destroys the whole thickness of the lid within the 
 ulcerated area. The scars from syphilis and lupus, like those from 
 fire, although the disease is primarily from the skin, are liable to 
 penetrate beyond it. Another cause of cicatricial ectropion that 
 has come well to the front, particularly in the vicinity of Chicago, 
 is blastomycosis or blastomycetic dermatitis. The resulting scar 
 rarely reaches below the superficial fascia. 
 
 The gravest cases will sometimes tax the resources and per- 
 severence of the surgeon to the utmost and, unfortunately, exhaust 
 those of the patient completely. As before hinted, the nature of 
 the primary injury and its extent, considered together with its 
 date, will govern in the choice and compass of the surgical measure
 
 288 ECTROPION. 
 
 selected for the relief of the ectropion. Now and then one meets 
 with an eversion of the lid from a scar so slight that the mere 
 subcutaneous division of a restraining band or the excision of the 
 entire cicatricial mass, followed by the mobilization and righting 
 of the tarsus and closure of the opening, with perhaps consequent 
 massage and stretching of the affected skin, will lead to perfect 
 cure. As a rule, however, the indispensable element in the surgical 
 management of cicatricial ectropion as well as in blepharoplasly, in 
 general, is the replacing of lost substance, which refers mainly to the 
 skin. 
 
 There are four ways of obtaining the borrowed integument 
 and of bringing it to its new situation to fill the defect : 
 
 1. By fashioning and mobilizing flaps of the adjoining skin 
 and putting them in place by simple sliding or interchanging. 
 Autoplasty by the French method. 
 
 2. By cutting pedunculated flaps from the nearby skin, not 
 necessarily adjacent to the defect, and moving them into position 
 by turning or twisting of their pedicles. Autoplasty by the Indian 
 method. 
 
 3. By entirely detaching pieces of skin of various dimensions 
 from a distant locality and transplanting them in or about the lid. 
 Autoplasty (or heteroplasty) by cutaneous grafts. 
 
 4. By transporting a pedunculated flap, formed from a remote 
 part of the patient's body or from the body of another individual. 
 Autoplasty (or heteroplasty) by the Italian method. 
 
 The first two refer, of necessity, to autoplasty pure and simple, 
 and to that only. That is, the integument is taken from the same 
 individual, and from the immediate vicinity, or from one but 
 slightly removed. The third mode, while usually autoplastic, is 
 occasionally heteroplastic, in that the material is taken from another 
 person, or it has, in rare instances, been zooplastic got from 
 skin belonging to one of the lower animals. The fourth, although 
 not of necessity autoplastic, has, as far as it concerns blepharoplasty, 
 never been anything else. 
 
 It were vain to attempt an enumeration of the various operative 
 schemes of more or less merit that have been devised for cicatricial 
 ectropion, much less to think of describing them. Let it suffice, 
 therefore, to detail a few representative procedures, under the
 
 ECTROPION AND BLEPHAROPLASTY. 289 
 
 several headings, and to present certain other examples by means of 
 pictures that will speak for themselves. 
 
 i. The first (French) mode is best adapted to cases in which the 
 loss of lid tissue and that of the surrounding skin has been relatively 
 small. This is not to say that the method is applicable only to 
 partial or circumscribed ectropion. On the contrary, the latter 
 may be complete, and affect either one or both lids.' And part 
 of the available integument may be cicatricial, yet it must be not 
 deeply scared over any considerable 
 area, and must be capable of being 
 loosened from beneath, and made into 
 sliding flaps, excepting for such limited 
 portions as will admit of being excised 
 without being detrimental to the gen- 
 eral result. Tarsorrhaphy, provisional 
 or definitive, was a necessary adjunct 
 to most of these operations, but it may 
 
 often be omitted, and the ultimate 
 rr , , . , . . FIG 161. Von Ammon. 
 
 effect heightened by overlapping the 
 
 lids, and fixing the operated one by collodion or other means. 
 
 Given an ectropion from a deep circumscribed cicatrix with its 
 long axis vertical, and that cannot be readily excised, as when con- 
 tinuous with bone, one may have recourse to the process of Van 
 Ammon (Fig. 161). This consists in surrounding the cicatrix 
 by an elliptical incision, removing its top to a depth corresponding 
 with that of the contiguous skin, and leaving the rest to be buried. 
 Free dissection is made all about the opening, the lid is righted, 
 pushed up high onto the globe, and the wound closed by interrupted 
 sutures. 
 
 For ectropion of the lower lid, from a deep scar of moderate size, 
 if not too near a commissure, the old operation of Dieffenbach 
 is still practised. The adherent portion is encompassed by three 
 straight incisions that form a triangle with its base near and parallel 
 with the free border. The area thus enclosed is excised. From 
 either extremity of the incision forming the base of the triangle, 
 start a short incision, each about one-half the length of said base, 
 both lightly curving, the one down and out, the other down and in. 
 The upper lip of the whole incision is undermined up to the lid 
 19
 
 ECTROPION. 
 
 border, and the lid turned back into position. The lateral flaps are 
 dissected up and brought together, the resulting lines of union present- 
 ing the shape of a capital T. External tarsorrhaphy completes 
 the operation (Figs. 162 and 163). It is rather curious to note that 
 von Graefe, according to Baudry, 1 applied the same operation, 
 minus the tarsorrhaphy, to entropion of the lower lid. 
 
 
 FIG. 162. Dieffenbach. 
 
 FIG. 163. Dieffenbach. 
 
 A classic operation for cicatricial ectropion of either upper or 
 lower lid, is that of Wharton- Jones, slightly modified by Sanson 
 (Figs. 164 and 165). Two converging incisions, beginning near the 
 free border, .are made to include the scar and meet beyond it, like 
 the letter V, upright for the lower lid, inverted for- the upper. The 
 triangular flap is loosened from its apex to its base at the cilia, and 
 the surrounding skin is undermined. The lid is righted and the 
 approximating lips of the incision are joined by sutures, the lines 
 of juncture now resembling a Y instead of a V. Tarsorrhaphy may 
 be added, or the lid may be anchored by collodionized strips of 
 gauze to the cheek (if the upper) or to the forehead (if the lower). 
 Such an operation has a great advantage over those like that of 
 Dieffenbach in that it does not call for a further sacrifice of integu- 
 ment, and should have precedence whenever practicable. 
 
 Von Graefe conceived the idea of correcting extensive ectropion 
 of the lower lid by making a flap the whole width of the lid and 
 extending downward ten to twelve millimeters. He split the lid into 
 its two leaves, the anterior composed of skin and muscle, the 
 posterior of tarsus and conjunctiva, by an intermarginal incision 
 the entire length of the palpebral fissure. From the ends of this 
 
 1 Technique Operatoire, Paris, 1902, p. 700.
 
 ECTROPION AND BLEPHAROPLASTY. 
 
 291 
 
 43 
 
 ran two vertical cuts, extending as far as the lower rim of the 
 orbit. The flap thus outlined, was dissected up, the ectropion 
 corrected and the tarsus, together with the overlying flap, forcibly 
 drawn upward. The flap was 
 
 then joined to the adjacent 
 skin by interrupted sutures, 
 beginning below, for about 
 one-half the distance. The 
 top or elongated corners of 
 the flap were rabbeted (Fig. 
 1 66 ab-c}. The upper edge, 
 thus shortened, was put upon 
 the stretch and stitched to the 
 free border of the tarsus, the 
 ends of thread being left long 
 and fastened, in a pad of 
 
 collodionized COtton, to the FlG " ^--Wharton- Jones, No i. 
 
 forehead. A few shallow sutures were placed in the remaining 
 vertical skin openings and over all a compressive bandage. The 
 chief objection to this operation lies in the fact that new tissue is 
 not supplied to help the graft in supporting the lid. 
 
 F. Jaeger 1 devised a thoroughly rational and practical operation 
 for cicatricial ectropion of the upper lid, where the ciliary border 
 
 was so displaced as to lie close 
 to the supercilia. It may be 
 classed as a sliding-flap 
 method. He made cutaneous 
 incision as long as the palpe- 
 bral fissure, close to and 
 parallel with the margin, un- 
 dermined the tarsus and 
 turned the lid down into place. 
 If the border seemed much 
 elongated, he excised from the 
 FIG. 165. Wharton-jones, No. 2. center a wedge that included 
 
 the entire thickness and brought together the 'edges of the notch 
 by means of a surgical pin and figure-of-8 ligature. Figs. 167 
 1 Jaeger- Dryer, No vo blephar. methodus, 1831, p. 28.
 
 292 
 
 ECTROPION. 
 
 and 1 68). The upper edge of the open ellipse was dissected for 
 a considerable distance, that is, the skin of the entire brow 
 as far as the middle of the forehead and out to the temple was 
 loosened, and the whole drawn down to cover the opening, and the 
 wound closed by sutures. 
 
 In the light of modern methods, the triangular excision of the 
 free border alluded to in this operation would be made at the outer 
 
 FIG. 166. a, b and c, Graefe's operation for cicatricial ectropion. 
 
 canthus, a la Von Ammon-Adams, or after the Kuhnt-Miiller mode 
 (only in upper lid). The lid would be drawn away down, overlap- 
 ping its fellow, and fixed to the cheek by collodion, and the large raw 
 opening would be covered either by a pediceled flap or by a graft. 
 
 One of the earliest and best examples of a sliding-flap operation 
 for blepharoplasty is that devised by Dieffenbach, 1 while professor 
 
 * Casper's Woch., Bd. i, S. 8.
 
 ECTROPION AND BLEPHAROPLASTY. 
 
 293 
 
 of surgery in Berlin, about 1835. The process could be applied 
 to restoration of the outer leaf or of the whole thickness of the 
 lower lid, and was as follows: by removal of the offending tissue, 
 a triangular opening, with base upward, was made below the eye 
 
 FIG. 167. Jaeger's operation for ectro- 
 pion of the upper lid. Dotted line is line 
 of incison. 
 
 FIG. 168. Same lid turned down. 
 
 (Fig. 169), abc, taking care to conserve the conjunctiva. From 
 the outer canthus, extending horizontally outward for a distance 
 equal to the length of the palpebral fissure (or to the base of the 
 triangle) , another incision, b d, and from the extremity of this one, down 
 and in, and parallel with the outer side of the triangle, still another, 
 de. The trapezoid flap thus marked out, was loosened from summit 
 
 FIG. 169. FlG - 1 7- 
 
 FIGS. 169 and 170. Dieffenbach's blepharoplasty, e g., in the removal of a growth 
 
 to base, slid over, bringing b to a, then sutured internally to the skin 
 and superiorly to the conjunctiva. The secondary bared space, 
 bde,was left to heal by granulation (Fig 170). To-day this space 
 would be covered by a graft. Indeed, Angelucci and many others
 
 294 
 
 ECTROPION. 
 
 have so treated this space. Angelucci broadened the top of the 
 flap as shown by the dotted lines, and employed a pedunculated 
 flap from the temple for the secondary defect. 
 
 Szymanowsky, 1 with the view to a closer approximation of the 
 
 secondary defect, and in order to 
 obtain more tissue for replacing 
 loss in the lower lid, extended the 
 incisions according to the dotted 
 lines (Fig. 169). For the restora- 
 tion of ^the inner half of the lower 
 lid, Arlt modified the operation as 
 shown in Fig. 171. To avoid the 
 outward stretching of the new lid 
 and the displacement of the external 
 commissure that would result from 
 the Dieffenbach procedure, Harlan, 2 
 of Philadelphia, made the rather elaborate operation pictured in 
 Fig. 172. The broad space beneath the eye was narrowed as 
 much as practicable by undermining and bringing the lower edges 
 together before sliding the flap into place, and the same was done 
 with the second triangle on the temple. Thus, not only was the 
 secondary defect reduced in size, but so elevated as, by its healing, 
 
 FIG. 171. Arlt. 
 
 FIG. 172. Harlan. 
 
 not to exert an evil influence on the position of the lids. Another 
 advantage claimed was that, being stitched on either side to sound 
 skin, the nutrition of the new lid was better assured than if, on one 
 
 1 Graefe-Saemisch, iii, S. 476. 
 
 2 Norris and Oliver, p. 117-118, 1898.
 
 ECTROPIOX AND BLEPHAROPLASTY. 
 
 2 95 
 
 side, it were left to form the margin of an extensive granulating 
 surface. Marian's operation was for an epithelioma involving the 
 entire lower lid. Three years afterward, "the canthus was in 
 normal position and the deformity was slight." 
 
 A pure specimen of the sliding-flap operation is that devised 
 by Knapp, 1 and made for the repair of a lower lid whose inner 
 
 FIG. 173. Knapp. 
 
 two-thirds were sacrificed in the removal of a chancroid. Flaps 
 were constructed as per the lines in Fig. 173. After excision of the 
 section containing the ulcer, the two flaps, having been dissected 
 loose from free end to base, were butted together and sutured. 
 The result was excellent. 
 
 As a good illustration of a totally wrong principle in a sliding-flap 
 operation, I would cite the method of Burow. 2 Here the triangle 
 
 FIG. 174. Burow. 
 
 of skin, aed (Fig. 174), is excised and thrown away, in order that, in 
 the mobilized integument, d may slide to a and a to b and close the 
 openings. There is no chance of supplying suitable borrowed 
 tissue for the secondary defect. In other words, the loss of tissue 
 contiguous to the eye is exactly doubled. Much more rational is 
 
 1 Archiv. f. Oph. xiii, i, S. 183. 
 2 Berlin, 1856. '
 
 296 
 
 ECTROPION. 
 
 the Dieffenbach operation, wherein the resulting raw surface may 
 be covered by a pedunculated flap, cut from skin more remote 
 from the lids, or by a cutaneous graft. 
 
 2. The Indian Method. In the ancient days of India there was 
 endless strife between the black races, with their ugly flat noses, and 
 the lighter Aryan invaders, with their boasted nasal prominence and 
 beauty. Hence, the nasal feature soon became the target, not only 
 for ridicule and scorn, but for actual violence legal and otherwise. 
 Hence also the Hindu surgeons were early in devising means for 
 the' restoration of the mutilated organ. Among their methods was 
 that of building up the lost portions of the nose by transplanting 
 pedunculated flaps of skin from the adjoining cheek. When the 
 sanle was applied to the plastic surgery of the lids, it was referred to 
 as the Indian method. Blepharoplasty was not practiced to any ex- 
 tent, however, until the third decade of the nineteenth century, and 
 almost all the earlier attempts were after the Indian method that is, 
 
 FIG. 175. 
 
 by rotation of pedunculated flaps, taken from the nearby skin, with 
 more or less twisting of their pedicles. The first to claim having 
 successfully restored a lid in this way was Carl Ferdinand Graefe. 1 
 In 1818, this surgeon, after several years in trials of various means, 
 reported some of his experiences. Among them was the building 
 up of the lids by both this and the Italian methods. In the same 
 article (p. 19) it is stated that Dzondi had essayed the renewal of the 
 lower lid by a flap taken from the cheek, but had failed. 
 1 Journal of v. Graefe and Walther, ii, p. 18.
 
 ECTROPIOX AND BLEPHAROPLASTY. 
 
 297 
 
 The procedure was systematized and given its first real impetus 
 by Fricke. 1 His operations related mainly to the correction of ci- 
 catricial ectropion the tarsus, conjunctiva, and free border having 
 been intact. Fricke's perfected operation was as follows: given a 
 case of complete cicatricial ectropion of the upper lid, for example, 
 
 FIG. 176. 
 
 an incision was made between cilia and supercilia, parallel with the 
 rim of the orbit, the tarsus loosened from its attachments, and 
 turned down into place, thus leaving an oval raw surface (Fig. 175). 
 A flap, somewhat larger than the oval, was cut from the forehead 
 and temple, whose base, broader than the body of the flap not a 
 
 FIG. 177. 
 
 pedicle in the strict sense of the word was situated a little external 
 to the margin of the orbit and slightly above the operated lid. 
 Before turning the flap into its new position, the bridge of skin 
 between the two raw areas was excised sufficiently to receive the 
 
 1 Bildung neuer Augenlider nach Zerstorung und dadurch hervorge- 
 brachter Auswartswendung derselben. Hamburg, 1829.
 
 298 
 
 ECTROPION. 
 
 pedicle or base. It was found that this was more satisfactory than 
 to allow the pedicle to lie on top of an isthmus of skin, with the view 
 of cutting and trimming it later. The flap was held in place by 
 numerous sutures, and the gap from whence it came, or the sec- 
 ondary defect, was left to heal by granulation. 
 
 FIG. 178. Denonvilliers. 
 
 FIG. 179. Denonvilliers. 
 
 So far as it goes, this operation of Fricke is essentially the same 
 as performed by his successors and by many surgeons for the 
 same deformity to-day. The variations have been mainly as to the 
 region from which the flap was taken this has been covered but 
 
 FIG. 180. 
 
 in what manner is a matter that has been governed by the judgment 
 of the operator and by the peculiarities of the case. 
 
 Blasius, 1 for the restoration of the entire lower lid at one time, took 
 a flap, pedicle inward, from the side of the nose and the forehead. 
 (Fig. 176.) At another time, for replacing the lower lid, pedicle 
 
 1 Med. Zeit, Marz. 1842.
 
 ECTROPION AND BLEPHAROPLASTY. 
 
 2 99 
 
 outward, from the temple and forehead (Fig. 177). For an ex- 
 treme ectropion of the whole lower lid, Denonvilliers utilized an 
 enormous flap, cut from in front of the ear, with pedicle just 
 external to the outer canthus (Figs. 178 and 179). For the repa- 
 ration of an angular loss of substance external or internal the 
 
 \ 
 
 * 
 
 FIG. 181. Hasner. 
 
 bifurcate pedicle, as first employed by Hasner, serves admirably 
 (Figs. 180 and 181). For a yet more elaborate restitution of a 
 commissure, the process of Richer 1 is cited. The primary defect 
 was an inferoexternal ectropion, from an adherent scar of the 
 orbital rim, with fungus growth. . 
 
 After crescentic excision of the diseased portion a and righting 
 
 FIG. 182. Richet. 
 
 FlG. 183. Richtt. 
 
 of the lid (Fig. 182), a provisional tarsorrhaphy was made and 
 the threads were attached to the brow by collodion. Next, the 
 flaps b and c were fashioned (Fig. 183), which were interchanged 
 and sutured to cover the defect as shown in Fig. 184. 
 1 Recueil d'ophtalmologie, 1873.
 
 300 ECTROPION. 
 
 Some years ago, I 1 reported the restoration of the entire right 
 lower lid and the outer third of the upper by a mitten-shaped flap 
 formed from the cheek. The breadth of the mitten was so great at 
 its widest portion that it was impossible to approximate at this 
 point the edges of the secondary defect, and a cutaneous graft, 
 taken from the arm, was put in to fill the space; Fig. 185 shows 
 the result three years after the operation. The case was that of 
 an elderly woman, and the parts had been destroyed by a rodent 
 ulcer. 
 
 In place of borrowing skin to one side of a commissure, above 
 or below, as in the examples just given, the flap has been taken 
 from one lid to replace tissue lacking in 
 the other. Landolt 2 made from the upper 
 lid a bridge, or double pediceled flap, to 
 restore the lower lid that had been de- 
 stroyed by a carcinoma. An incision was 
 made through skin and muscle, two milli- 
 meters from and parallel with the upper 
 margin, and extending at either end some- 
 w r hat beyond the canthus'. This was re- 
 FIG. 184. peated seven or eight millimeters higher 
 
 .up, and the intervening strip of skin and 
 
 muscle was loosened throughout its length, except at the ends. 
 The conjunctiva was separated from the lower free border, from 
 canthus to canthus, sufficiently to receive the flap, which was 
 transposed to fill the gap and there stitched. The upper lip of 
 the superior opening was undermined, and the skin drawn down and 
 sutured to the lower lip. At the proper time the pedicles were cut 
 and trimmed to fit (Fig. 186). 
 
 Panass made a regular practice of taking from one lid and giving 
 to the other, though through a single pedicle left near the outer 
 canthus, and he usually subjoined provisional tarsorrhaphy. 
 This robbing of Peter to pay Paul would seem hardly justifiable 
 if suitable tissue for the flaps could be found outside the longitude 
 of the palpebral fissure, for the reason that it is inadvisable to 
 have the bulk of the secondary defect contiguous to the lid margins. 
 1 Am. Jour, of Ophthalmology, June, 1897. 
 3 Archiv. d'opht, 1885, P- 49 2 - 
 3 Clin. opht., 1899, p. 31.
 
 ECTROPION AND BLEPHAROPLASTY. 
 
 301 
 
 This brings us to a consideration of such questions as the prepara- 
 tion of the lid and the selection and outlining of the flap. Besides 
 the principle just stated, there are a number of others to be observed 
 in this connection. Before proceeding to mark out the skin that 
 is to be transplanted, its new site is opened up and carefully prepared, 
 so that its size and shape may be apparent, and all bleeding may 
 be stopped in due time. If, as is most often the case, the operation 
 
 FIG. 185. 
 
 is for the correction of ectropion, an incision is made through 
 the skin, three or four millimeters from the free border, whose 
 length somewhat exceeds that of the everted part. The lips of 
 this immediately retract, and the opening thus formed is deepened 
 till muscle or underlying fascia is reached. The free border is 
 seized by fixation forceps and pulled toward its normal position, 
 the dissection being meanwhile carried toward the convex bor- 
 der of the tarsus. The latter and the orbicularis are spared; 
 that is, the restraining cicatricial bands are divided without cutting
 
 302 ECTROPION. 
 
 the muscle and the tarsus, and the anchylosis between the tarsus 
 and underlying tissue is entirely freed. "The removal of all scar 
 tissue," once thought imperative, is no longer so rigidly insisted upon. 
 The harder masses are best gotten rid of, perhaps, but to attempt 
 the excision of all of it is not feasible. 
 
 The same allowance .is made for the subsequent contraction of 
 the oval bared space thus created, as for that of the skin that is 
 to cover it. Hence, this preliminary opening up is made extreme; 
 to such a degree, for example, that for complete ectropion of the 
 upper lid its free border would overlap the lower lid and lie upon 
 the cheek, opposite the inferior portion of the rim of the orbit or 
 even below it. The more recent the injury that caused the misplace- 
 
 FIG. 186. 
 
 ment, the greater must be this overeffect. If the operation is to 
 restore the lid after removal of a growth, or the excision of an ulcer 
 that involves the whole thickness, the conservation of the maximum 
 amount of the conjunctiva is important. 
 
 For the entire upper (or lower) lid or any part external to the 
 middle, the pedicle is best situated about on a level w r ith, and close 
 to, the outer canthus, and the long axis of the flap should be directed 
 upward (or downward). Some of the older surgeons have ad- 
 vised that a flap to replace the upper lid be taken from the malar 
 region, and one for the lower from the temple, for the reason that the 
 strain of cicatrization in the secondary defect will, in this arrange- 
 ment, tend to enhance the desired effect. As regards the body of 
 the second bared space, however, it signifies but little, yet, as con- 
 cerns the position of the pedicle, it does make a difference. On 
 account of its proximity to the original defect, to elevate it for the
 
 ECTROPION AND BLEPHAROPLASTY. 303 
 
 lower lid and to depress it for the upper, contributes to its success. 
 Moreover, in male subjects, it is difficult to fashion a flap from the 
 cheek without including the hair follicles of the beard, and the 
 presence of hairs in the flap no matter how few or small they may 
 be is objectionable. Yet we have seen patients exhibited with great 
 gusto who had been furnished with a new set of eyelashes borrowed 
 from the supercilia. For circumscribed defects situated more to- 
 ward the nasal side of the lids, the glabellar and nasomaxillary regions 
 offer the more fitting skin for pedunculated flaps; and whether or 
 not they are taken from the former for the lower lid and from the 
 latter for the upper, as advised by many surgeons, the pedicle at 
 least should be slightly higher than the canthus when the lesion is 
 of the lower lid, and vice versa. If only scar tissue is available for 
 the flap, it also may be utilized, provided it is superficial, movable, 
 and not too greatly contracted. 
 
 In the matter of choosing a flap, it is often not so much a question 
 as to what one would like to have, as what one can get. In cutting 
 the subsidiary integument, if it lies close to the inner canthus, the 
 lacrimal canal is to be respected, and if in the malar or infra- 
 zygomatic region, the duct of the parotid gland is to be avoided. 
 As has been intimated already, the pedicle should be situated as 
 near as practicable to the primary defect, and the body of the sec- 
 ondary defect more remote. If a desirable skin area can be reached 
 by moderate elongation of the pedicle, it may be so extended, but 
 a roadway or bed should be opened through the intervening bridge 
 of skin where to inlay this long neck, rather than have it lie on top. 
 It is hardly proper to refer to the pedicle as a neck, seeing that such 
 a term implies a considerable narrowing. It were better, perhaps, 
 to call it the base of the flap, since to be adequate for the nourishment 
 of the rest of the peninsula, this portion must be little, if any, nar- 
 rower. Slender pedicles and long-drawn-out points to flaps are 
 both serious faults, as they favor gangrene. For the pedicle to be 
 skimp, as to length, is equally grave. This means undue stretching 
 and constriction. It would far better be too long than too short, 
 especially as more or less swelling is to be expected after the opera- 
 tion. It is well to remember that the greater the degree of torsion of 
 the base required to put the flap in place, the greater the amount of 
 shortening, and allowance must be made accordingly. Indeed, it
 
 ECTROPION. 
 
 were prudent so to lay out the flap as to necessitate the minimum 
 torsion in rotation all things else being considered as this alone 
 tends to strangulation. 
 
 It pays to study carefully the original cicatrix, particularly with the 
 view to ascertaining the lines of greatest strain. Here is where the 
 overeffect must be most pronounced, which concerns both the prepa- 
 ration of the lid extensive opening up; and that of the flap- 
 surplus width at the points indicated. 
 
 FIG. 187. 
 
 Provisional tarsorrhaphy has been extensively practised as an 
 adjunct to blepharoplasty. In the correction of cicatricial ectro- 
 pion, however, where the repair is made with flaps or grafts, the 
 procedure so far from being of advantage, is a positive detriment, 
 in that it prevents the getting of that very pronounced primary 
 overeffect which is an indispensable element of success in these 
 operations. No doubt, the employment of it has had much to do 
 with the discouraging experiences so many surgeons have had in 
 such surgery.
 
 ECTROPIOX AND BLEPHAROPLASTY. 
 
 35 
 
 In order that the ultimate result of an operation for cicatricial 
 entropion, of the kind in question, may be sufficient, not only must 
 the aversion be rectified, but the opening up of the ellipse whereby 
 the correction is brought about, must be so extreme that the border 
 of the operated lid lies considerably beyond that of its fellow. If it 
 be the upper lid, the free border reaches the lower rim of the orbit; 
 if the lower, the lid margin reaches the upper corneal limbus. 
 Sutures are seldom required to maintain the lid in position if these 
 
 FIG. 188. 
 
 principles are observed; and when put in may do more harm than 
 good. Neither have I found a place for the excision of a gore from 
 the free border that is so often referred to. Whatever elongation 
 of the edge of the lid that may be present at the moment, will surely 
 disappear in the healing process. 
 
 Figs. 187, 188 and 189 refer to a case of total ectropion of the 
 lower lid corrected by the author. Here the Wolff graft when 
 taken from the arm measured three by four inches. The elliptical 
 bared space left after righting the lid measured one and one-fourth
 
 306 
 
 ECTROPION. 
 
 by two and one-half inches. On account of its great size and 
 weight, where the upper edge of the graft was stitched to the free 
 border of the lower lid, the suture ends were left long and fastened 
 to the forehead by collodionized gauze (Fig. 187). Fig. 188 shows 
 the result one month later. Fig. 189 shows the arm defect and 
 bracket incisions in which Thiersch grafts have been planted. 
 
 FIG. 189. 
 
 The Preparation of the Flap. Having opened up to the fullest 
 extent, and otherwise put in readiness the place that is to be repaired, 
 and covered it with a pad of cotton, wet with boric-acid solution, 
 an exact pattern of it, as to size and shape, is cut out of a piece of 
 sterilized gold beaters' skin, tin foil, or gutta-percha tissue. This 
 is laid on to the integument chosen to supply the subsidiary tissue 
 and the flap is outlined, except at its base, with the point of a scalpel. 
 To do this an incision is made, through the epidermis only, parallel
 
 ECTROPIOX AND BLEPHAROPLASTY. 307 
 
 with the edge of the pattern and at least one-half a centimeter 
 from it. 
 
 In order to allow for both the marked primary and the very 
 considerable secondary shrinkage, the flap is none too large if the 
 area marked out is at least twice that of the pattern. If the incision 
 is of the right depth, the flap will be denned by a tiny line of blood. 
 From the base the lines that form the pedicle are extended in the 
 direction 1 of the defect. The incision is then deepened, until it 
 reaches the superficial fascia, i.e., it includes the skin and the 
 subcutaneous fat, and the whole (adipose and all) is dissected up 
 by means of blunt-pointed scissors. The dissection is begun at 
 the apex, using. forceps to hold while cutting. As soon as the end 
 is sufficiently loosened, the fingers, clad either in cots or gloves 
 of thin rubber, are substituted for the forceps. In this way there 
 is less bruising of the flap, and one is enabled to use the scissors 
 with greater precision. The dissection is carried well to the base, 
 but the final fashioning of the pedicle, at its nearest point to the 
 defect, is left until the flap is turned into its new position, so that 
 the incisions may be so modified as to produce the most favorable 
 adjustment, the least stretching, etc. The parts are flooded, from 
 time to time, with quite warm boric or salt solution. Whatever 
 bridge of skin that separates the two defects is incised and retracted 
 to make a groove into which to countersink the pedicle (inlaying) . 
 
 After trying and insuring the fit of the flap and pedicle, these 
 and the beds in which they are to lie are given their last attention, 
 all bleeding is stopped, all clots removed, and they are put in the 
 best possible coaptation throughout. Especially must it be seen 
 to that there are no air spaces beneath the flap, and that its edges 
 are not left curled under, as they are strongly inclined to do. The 
 fewer the sutures inserted to fix the flap, the better. Their intro- 
 duction causes injury of the flap, through mangling and strangula- 
 tion; also bleeding of the skin to which it is stitched, and thus 
 the risks of failure are multiplied. One at the extremity may be 
 required, but good sitting flaps will often need none at all, the 
 dressing alone sufficing to hold them in place. Where the entire 
 substance is lacking, it is necessary, of course, to unite the edge 
 of the flap to the conjunctiva by a series of fine sutures. 
 
 It has been recommended by high surgical authorities that,
 
 308 ECTROPION. 
 
 before fixing the flap in place, the edges of the secondary defect 
 should be approximated, lest the stretching of the skin around the 
 primary defect, consequent upon the latter procedure, should call 
 for a different disposition of the flap. To the writer this seems 
 both inexpedient and inconsistent, for the reason that it is virtually 
 making a nice and propitious arrangement of the flap really 
 the essential part of the operation secondary to the closure of the 
 gap from which it was taken. Believing, therefore, that it is more 
 conducive to favorable results, I try to get the flap into position with 
 the least possible delay and to leave it undisturbed. To this end, I at 
 once cover it with the thin sheet of cotton wet with warm boric acid 
 solution and leave it thus while attending to the flayed space, where, 
 in bringing the edge of skin together, the undermining and traction 
 are so made as not to affect the operated lid. If absolute union of 
 the edges cannot be brought about without undue stretching, 
 a Thiersch or a Wolfe graft is put in to piece out, either at once or a 
 few days later. 
 
 The dressing consists in the usual thin sheet of cotton, wet 
 with hot saturated solution of boric acid, made large enough to 
 cover the whole field of operation. A large pad of dry cotton is 
 built upon this, over this is laid a piece of non-absorbent material 
 like gold beaters' skin or oiled silk to prevent dryness, and over 
 all, the regulation wet netting bandage (see chapter on Dressings) . 
 It is better to occlude both eyes for the first forty-eight hours, at 
 the end of which period the dressing is first removed. This is done 
 under free irrigation with warm boric acid solution. Any sutures 
 that may have been put in are then removed and the bandage reap- 
 plied. From this time the unoperated eye may be left free. The 
 other should be kept bandaged, with daily changing for purposes of 
 cleanliness and inspection, for about ten days or until a new layer of 
 epithelium has formed on the flap. Too early exposure to the air 
 leads to extra shrinkage and to dry gangrene. Even after the 
 bandage is discontinued, it is well to protect the graft for a time 
 by a film of sterile vaselin. 
 
 Ectropion from bone lesions of the orbit offers special diffi- 
 culties. Those cases occurring, for example, as a result of fracture 
 of the infero-temporal rim, with infection, the formation of sequestra, 
 caries, etc. It may be that both the outer tables of the bone the
 
 ECTROPJON AND BLEPHAROPLASTY. 309 
 
 one on the malar, the other in the orbit are destroyed, and be- 
 tween them is left a deep adherent cicatrix or cleft. To excise 
 the depressed integument avails nothing, for the excavation is 
 promptly repeated. 
 
 For this class of cases, Tripier 1 has given an ingenious surgical 
 procedure. The sunken, scarred, soft parts are excised. On 
 opposite sides of the opening, two ring flaps are fashioned, each 
 somewhat greater in area than half that of the cavity, bases toward it. 
 These are turned over, epithelial surfaces inward, i.e., looking 
 toward the cavity, and their edges brought together. From the 
 most available portion of the nearby skin is made a bridge flap, 
 large enough to cover the entire defect, which is slid on, and the 
 secondary defect closed by undermining and approximating the 
 borders. The latter consists, of course, of the raw surfaces of the 
 wing flaps plus those of the places from which they were taken. 
 By this method is sought not only the righting of the lid, but also 
 the filling up of the cleft. The only other alternative is to let the 
 scar alone, return the lid to its normal position in the usual way 
 by incision parallel with its free border and dissection and fill 
 the gap with a flap or with a graft. 
 
 Czermak advises that after operations necessitating a moderate 
 loss of bone in the orbital rim, the plastic operation be not resorted 
 to at once, as often such healing can be brought about as either to 
 avoid it altogether or to require only a slight surgical procedure, 
 such, for example, as the subcutaneous division of the adherent 
 scar, followed by massage. The same author remarks that after the 
 removal of an epithelioma or other malignant growth from the lids, 
 the opening be left uncovered for a time, so that a recurrence may 
 be early detected and promptly dealt with, arguing that, if hidden 
 by the borrowed integument, it could attain inconvenient dimensions 
 before being discovered. This might be well enough if the growth 
 were situated deep in the inner angle, where it could readily extend 
 into the lacrimal fossa or into the accessory sinuses of the nose. 
 As a rule, it is better to make the plastic operation at the same 
 sitting. 
 
 3. The Method by Cutaneous Grafts. As applied to plastic 
 surgery of the eyelids, this method is of recent date, yet, like that of 
 
 r Rec. d'opht., 1890, p. 129.
 
 310 ECTROPION. 
 
 pedunculated flaps, in its relation to certain other features, as 
 rhinoplasty, for example, it is of ancient origin. It, too, was 
 practised by the ancient Hindu surgeons. The grafts are referred 
 to as dermic or epidermic, according as they comprise the entire 
 thickness of the skin or only the epithelial layers. 
 
 Dermic Grafts were first used in blepharoplasty by Le Fort. 1 
 His earliest attempts were with pieces of skin cut from the arm, 
 that included the fat, and were large enough to cover the entire 
 defect. As they were mostly failures, he conceived the idea that 
 they were too thick. With this in view, in subsequent trials he 
 pared down the grafts at the back, removing the adipose and part 
 of the connective tissue, and had the satisfaction of seeing them 
 survive. 
 
 In Great Britain and America the process was popularized 
 through articles by Wolfe, 2 of Glasgow, in which he reported suc- 
 cessful blepharoplasties with the Le Fort method and gave original 
 details as to technic. The dermic graft is, therefore, referred to in 
 these countries as the Wolfe graft and on the continent of Europe, as 
 the Le Fort-Wolfe. It may be added that the method has never 
 ceased to find favor in the eyes of English-speaking ophthalmic 
 surgeons, having attained, in the United States, a specially strong 
 footing, where k is- employed with almost as much confidence as is 
 that with pediceled flaps. In truth, it is often chosen in preference 
 to the latter to obviate the extra scar on the face. Their thickness 
 or body, renders them peculiarly fit for replacing loss of substance 
 in the lids. In France and Germany, however, it is pretty gen- 
 erally decried, except as a last resort, a method of necessity and not 
 of choice, i.e., only employed when suitable material cannot be 
 obtained, in the form of flaps, from the neighboring integument. 
 
 Valude,3 for instance, speaks discouragingly of it, having operated 
 seventy-seven times, using Wolfe grafts for the loss of substance, 
 with but fifteen successes. Whatever may have been the chief 
 causes leading to the failures of our European colleagues, it is 
 certain that immensity of grafts and of perseverence did not figure 
 largely among them. 
 
 The habitual vice of the graft in question is shrinkage. Its 
 
 1 Bull, de la Soc. de Chir., .1872, p. 39. 
 
 ' Brit. Med. Jour., 1876, and Med. Times and Gaz., vol. vii, p. 608. 
 
 3 Archiv. d'opht., T. ix, p. 289, 1889.
 
 ECTROPION AND BLEPHAROPLASTY. 311 
 
 average capacity in that line is enormous, to offset which its original 
 size must be proportionately vast. This is the master key of the 
 situation. Yet knowledge of, and heed to, this property do not 
 always suffice, even when accompanied by the utmost precision in 
 all other respects. Here is where persistence comes to the rescue. 
 Some of the most gratifying results are obtained only after re- 
 peated operations, each one as extended and thorough as its pre- 
 decessor. 
 
 According to the observation of C. Garre, 1 the really useful part 
 of the graft is limited to the deeper layers of the epidermis, and to 
 transplant the corium, which is destined to undergo connective- 
 tissue degeneration, merely retards the union of the Malpighian 
 portion \vith the underlying vascular network and favors excessive 
 ultimate contraction. 
 
 As a further proof that the last word with regard to the dermic 
 grafts has not been said that there resides therein some subtle 
 beneficent quality that will one day be regularly utilized cases 
 can be cited wherein this bit of borrowed skin has neither shrunken 
 nor degenerated, but has regained its color, almost immediately 
 after being transplanted, and has not changed so much as to even 
 shed its epithelium. This has happened several times in my 
 practice. But with our present knowledge, the Wolfe graft is ex- 
 pected to shrink more than any of the other varieties, both primarily 
 and secondarily. As a rough 'estimate, one might state the total 
 contraction, from first to last, at something like 75%. Hence, in 
 outlining the graft, the area inclosed would be about four times 
 that of the defect to be covered. 
 
 Panas 2 states that one condition particularly favorable to success 
 of all autoplasty is the implantation of the flap or graft in the midst 
 of a plaque of scar tissue. Thanks to the retractile nature of the 
 cicatrix, an incision or opening made therein, instead of narrowing 
 or shrinking, actually expands, even to the extent of acquiring double 
 its first area. Nelaton, who first called attention to this important 
 fact, also observed that in order to give the opening this quality 
 the flap (or graft) should rest on normal tissue. Thus it comes about 
 that in palpebral autoplasty after burns, for example, a flap, appar- 
 
 1 Beitrage z. klin. Chir., iv. 
 
 2 Maladies des Yeux, 1894, t. ii, p. 174.
 
 fill ;' :',;.", 
 
 wily \ntu\wimte, may *erve Ittr the complete reparation, provided. 
 one fake* care to remove all *ear tissue from the place it is to occupy. 
 Tbl* I* not always feasible, especially when the cicatrix is very 
 d< ( 'p or wlherenl lo bone. In such eases some operators CWicher- 
 Itifwfcft among (hem; Divine secondary grafting, i,e,, not applying 
 flic iUppUmentary skin until the defect is well covered with granula- 
 llons, KwnovnJ of near tissue from the defect is more urgent 
 In gruff methods lhan in those with sliding "r pcduded flaps. 
 
 The size of the graft in limii<-d only \>y that of the bared space 
 ll In to occupy. In fact, a single pi<-< <, sufficiently large, is preferable 
 lo two or more smaller ones. l)c Wccker' with the idea of better 
 hmurlng the survival of the tr;m |-.ii<-d integument, tried cutting it 
 Itilo wjiiareH whoHt; nlden nn-fisiircd from me li;i.lf to one centimeter, 
 which were- placed on in iln form of a mosaic; but it was found that 
 I hd HUiiill fragmentldid not "l;ikc" IH-HI M.i-lily than larger ones, 
 and, moreover, shrinkage and scarring were greater. 
 
 Preparation of the Dermic Graft. -The lid defect is put in 
 rrmliwviM llic same as for a Ila|, save that in case of the graft 
 Ilir pi mi. M \ effecl inn I be yet more extreme. A certain area of the 
 delicate, hairless skin at Ihe inner side of the upper arm or of 
 the lef, or (high is \v;i:,hed \\illi !;reen so;ip ;ind boiled water and 
 thoroughly linsed with horic acid or salt solution. The skin over 
 the inner border of Ihe left biceps (of right handed patients) is 
 probably the most suitable, all things considered; yet in the case 
 of a feminine subject likely to take pride in b;ire arms, the thigh 
 would be a better local ion for the scar. The graft is outlined with 
 Ihe aid of the pattern as per the instructions for the flap, except 
 thai the ratio of its si/.e to that of the defect should be about four- 
 fold, instead of double, and, there being no pedicle, of course the 
 pattern is completely surrounded by the incision. The usual shape 
 of the section of skin is that of an ellipse, or oval, and as it is impor- 
 tant that the long axis of the graft coincide with that of the defect. 
 Orientation is facilitated by first dissecting up the extremities 
 of the oval and putting a tine suture through each from the epithelial 
 side. If this is not done the primary shrinkage is so great the moment 
 the piece is excised that it is then diilicult to place it properly. As 
 soon us one end is loosened enough, the coned or gloved ringers are 
 
 4 Aw\l vlWulist,, 1874, p. 6a.
 
 Fiona* A3fD KXTHAS-CI- 
 
 substitu' o hold the piece, and the entire dis- 
 
 section is comple the blunt scissors, exeirising care to avoid 
 
 injur 
 
 '.".-:- 
 
 knee, be chosen, which is probably the next mos 
 into the long saphenoos vein is to be guarded 
 
 ns can be seen through the skin, as they fie jnst beneath 
 
 - 
 
 Unlike 
 all ii 
 
 not as the judgment of the operator shall decide, laid on, according 
 
 to its dimensions, and carefnfly spread ooL The contained satnres 
 
 are inser corresponding ends of the defect and tied. 
 
 re put in only v facie they would seen to be 
 
 .utely necessary. If. as often luppcns, the graft adjaste 
 itsel: new location, these are best omitted. 
 
 -ing and after-treatment are identical with that described for 
 pedunculated fla 
 
 Until the lid operation is finished and the bandage is app- 
 a pad of cotton wet with sublimate solution, one to three thousand, 
 is kept on the wound in the arm. Since before Urban 1 signaled 
 their abandonment in this particular, the writer has never allowed 
 mercuric solutions to come in contact with th _ nor with 
 operated lid, because of their coagu. 
 
 they inflict upon the epidermis. The last attention having been 
 bestowed upon the eye. the edges of the opening in the arm are 
 widely undermined and approximated by interrupted 
 Should this require undue tension upon 
 
 where greatest, by bracks -rferably. 
 
 opposite edges of skin are approached only so nearly as practice 
 one to the other, and the gap afterward filled with a Thiersch 
 graft. If bracket incisions are made, the spaces between their 
 lips may be similarly covered. lodoform powder is dusted on. 
 iodoform gauze laid on. then a pad of cotton, and over all a muslin 
 or wet netting bandage. Even.* precaution should be taken t< 
 disturbance of both the eye and the arm < . A goo 
 
 to fix the bandages in place with flexible collodion, as described 
 1 Deutsche Zeit. f. Chir., i^ t
 
 314 ECTROPION. 
 
 under " Eye-dressings." It is well to fix the arm in a sling beneath 
 the clothing, the better to guard against exposure of its wound, 
 which is quite prone to infection. 
 
 The graft is at first blanched, but at the end of twenty-four 
 hours, if it has "taken," something like its normal tint is present. 
 A little later say on the second day it becomes of a rosy hue. 
 About the end of the third day begins the shedding of its epithelium, 
 when it again appears whiter. After this process is completed the 
 patch takes on a color that is, for a time, redder than that of the 
 surrounding skin, but its ultimate color is a shade whiter than that. 
 If the transplanted tissue or any part thereof perish, it may be 
 from one of several causes, chief among which are gangrene (white, 
 livid, or dry), secondary hemorrhage beneath, stitch-canal or super- 
 ficial infection, phlegmon, and erysipelas. These are all accidents 
 that either happen very early or not at all. A later sequel, coming 
 sometimes many days after the graft has become viable, is a progress- 
 ive ulceration. For sloughing, hemorrhage, and gangrene, little 
 can be done. Infections are to be treated by removal of sutures, 
 copious and frequent irrigations with mild antiseptic solutions used 
 quite warm, etc. An excellent remedy for the ulceration alluded 
 to is the painting of the raw surface with a 12% solution of silver 
 nitrate, followed by thorough washing with warm salt solution. 
 
 Epidermic and Dermo-epidermic Grafts. The epidermization 
 of parts denuded of skin was first conceived and accomplished by the 
 distinguished surgeon, Reverdin, 1 of Geneva. To assist and 
 hasten the healing of certain indolent varicose ulcers, Reverdin cut, 
 with a lancet, from the skin of a limb, epidermic flaps, \vhich he 
 subdivided into bits containing only a few square millimeters, and 
 deposited them on the granulating surface in the form of small 
 disseminated islands. It was demonstrated that the method stimu- 
 lated the cicatrization in raw surfaces of limited extent, but was 
 less efficacious for larger ones. 
 
 To better meet the latter condition, Oilier 2 made the grafts 
 of considerable size ten to fifteen millimeters long, by one to 
 three millimeters wide and purposely included a portion of the 
 corium (dermo-epidermic graft] . He carefully removed all cicatricial 
 
 * Bull, de la Soc. de Chir., 1869. 
 
 2 Comptes rendus de 1'Acad. des Sciences, 1872.
 
 ECTROPION AND BLEPHAROPLASTY. 315 
 
 tissue in the preparation of the defect to be repaired, and waited 
 for the surface to granulate before applying the graft. The latter 
 was held in place by strips of diachylon plaster. This species of 
 cutaneous graft was first employed in blepharoplasty by Lawson. 1 
 In preparing it, the skin may be separated from its original location, 
 as directed for the Wolfe graft, and then pared down very closely 
 with a razor, cutting well below the epidermis. Thiersch 2 adopted 
 the method of Oilier, but with certain modifications, the most 
 important among which was that he declined to implant the graft 
 upon a granulating surface (secondary grafting), placing it rather 
 upon a freshly prepared raw one (primary grafting}. If granula- 
 tions were already present, they were shaved off to conform to the 
 principle in view. This, according to the same author^ is that 
 granulations make an unfavorable base for the transplanted integu- 
 ment, for the reason that they of themselves produce a layer of 
 scar tissue. He also made the pieces thinner than did Oilier. 
 
 Eversbusch* advised that this form of graft be cut as thin as 
 possible translucent in fact the blade of the knife or razor show- 
 ing through during the section. This constitutes the true epidermic 
 graft, known in this country under the name of Thiersch and in 
 Europe under that of Thiersch-Eversbusch. While it is less effective, 
 owing to its lack of body, for the restoration of the lid than the 
 Wolfe graft, it has the advantage in most instances of shrinking 
 less. In point of ability to survive, the two varieties would seem 
 to be about on a par. 
 
 Whether concerned immediately^in the lid operation or not, the 
 transplanting of epidermis will often be found a valuable adjunct 
 thereto, as, for example, to make a patch when, after a few days, a 
 flap or dermic graft chances, through ulceration or other mishap, 
 to have its epithelium destroyed or when an unavoidable gap 
 remains in a secondary defect. 
 
 The Thiersch method is as follows: the primary defect having 
 been prepared as for the flap of the Wolfe operation (or if granula- 
 tions are present, they are removed), the inner side of the upper arm 
 or of the lower third of the thigh, is washed with soap and sterile 
 
 1 Lancet, Nov. 19, 1870. 
 
 2 Berlin, klin. Woch., 1874. 
 
 3 Arch. f. klin. Chir., Bd. xvii, 2, S. 318, ff. 
 
 4 Munch, med. Woch., 1887, Nr. i, u. 2.
 
 31 6 ECTROPION. 
 
 water, rinsed with boric acid solution and thoroughly dried with 
 gauze not with cotton, on account of the loose fibres that cling to 
 the parts. The thigh offers fewer difficulties to the cutting of 
 the graft because of its slight convexity, and might be preferable to 
 the patient as the site of the resulting scar. The chosen skin is 
 put moderately upon the stretch, while with a keen, long-bladed 
 razor, that has been thoroughly boiled, enough of the epidermis is 
 shaved off if possible, in one place to cover the entire defect. It 
 greatly facilitates the severing of the graft to have both the razor 
 and the skin perfectly dry. The blade is held flat and firm and 
 the cutting is accomplished by a long, slow, sawing motion. When 
 properly done, the blade of the razor can be seen through every part 
 of the graft, and the resulting raw surface is thickly speckled over 
 with tiny bleeding points that mark the spots where the tips of 
 the more prominent papillae have been cut off. To cause the skin 
 to present a flat surface to the razor I have profited by an ingenious 
 suggestion of M. L. Harris, of Chicago, whereby a straight-edged 
 object, such as the lid of a cigar-box, is dragged along in advance 
 of the razor. The graft is at once laid on where needed, without 
 previous dipping into boric or salt solution, and slid directly from 
 the razor on to the defect. Here it is nicely spread out, after which 
 any overlapping edges are trimmed with the scissors to fit. Few, 
 if any, sutures are put in. The usual dressings, comprising a thin 
 lamina of cotton, wet with hot, saturated solution of boric acid, 
 next to the skin, a thick pad of dry cotton so built on as to prevent 
 undue pressure on the graft, over this a generous piece of gold beater's 
 skin, tin foil, or gutta-percha tissue, and over all the wet netting 
 bandage, fastened on with flexible collodion. 
 
 For fear of carrying syphilitic, or other infection, grafts ought 
 never to be taken from another individual if they can be gotten 
 from the patient. 
 
 An effective method for the disposition and fixation of cutaneous 
 grafts in operations for cicatricial ectropion is that of Hotz. 1 In 
 order to prevent the shrinkage of the graft from acting with full 
 force upon the free border, he divides the wound area into two 
 sections, one representing the bared surface of the lid proper and the 
 other that beyond the lid, each of which he covers with a separate 
 
 1 Archives of Ophthalmology, vol. xxxii, No. 3, 1903.
 
 ECTROPIOX AND BLEPHAROPLASTY. 
 
 3 1 ? 
 
 Thiersch (or Wolfe) graft. The lid graft is anchored by sutures 
 to the strip of skin at the free border of the tarsus (upper lid) or to 
 the tarso-orbital fascia beneath the tarsus (lower lid). The second 
 division of the bared space is then covered by an unsutured graft. 
 Before implanting the grafts, two strong silk threads are put 
 through the edge of the reposited lid, it is made to widely overlap 
 its fellow, and the threads are fastened to the cheek (or brow) by 
 collodionized cotton or gauze. By thus fixing the edges of the lid 
 graft to firm supports, both its shrinkage upon itself and its traction 
 upon the free border are counteracted. Moreover, by this arrange- 
 ment, the contraction of the ultratarsal graft is not so directly 
 transmitted to the tarsal one. 
 
 FIG 190. Hotz. 
 
 FIG. 191. Hotz. 
 
 In some instances, Hotz, instead of transplanting a graft to 
 cover the tarsal portion, utilizes the cicatricial skin already overly- 
 ing it, which he dissects up in the form of a semilunar flap that is 
 left adherent along the lid margin. The bands of scar are divided, 
 the lid is turned into position, drawn over its fellow, and fixed 
 by ligatures and collodion as just described. If it be the upper 
 lid, the free border of the flap is stitched to the upper border of 
 the tarsus; if the lower, to the tarso-orbital fascia and the remain- 
 ing wound surface is covered by a Thiersch graft into which no
 
 318 ECTROPION. 
 
 sutures are put. If there is decided elongation of the free 
 border, a portion is resected at the outer canthus (see Figs. 190 
 and 191). 
 
 4. The Italian method, or autoplasty by means of a pediceled 
 flap taken from a distant part of the body. This, like blepharo- 
 plasty by cutaneous grafts, is applicable to cases where the destruc- 
 tion of the lids and the adjacent skin is such as to render the use 
 of the local integument impossible or undesirable. The method was 
 invented several centuries ago by a Sicilian surgeon of the name 
 Branca, and practiced by himself, and afterward by divers other 
 members of the same name and family for the restoration of 
 the nose. It has also been known as the Tagliacotian method, 
 in honor of Gaspard Tagliacozzi, who, in 1597, wrote a 
 treatise on it. 
 
 It consisted in preparing the part to be reconstructed and loosen- 
 ing a tongue of skin from some available portion of the arm or 
 hand. After granulation was well established in both defects, the 
 flap was brought into position by binding the member bearing it 
 securely to the head. Owing to the length of time required for the 
 granulations to appear, added to that for the healing process, and 
 to the great inconvenience occasioned the patient, the proceeding 
 was abandoned. In 1816, however, it was rescued from oblivion by 
 Carl Ferdinand Graefe, who employed it in a modified form for 
 blepharoplasty. Among other improvements, this surgeon hit upon 
 that of putting the flap into place at once without waiting for the 
 granulation of the surfaces to be united. The method has found 
 scant favor in the eyes of modern surgeons, still less in those of 
 their patients. In this country it has been resorted to with success 
 by R. H. Derby 1 to replace the lids lost in an extensive burn of 
 the face. 
 
 Still more recently it has been revived in France by Prof. Paul 
 Berger, 2 the Parisian surgeon. In this admirable report, among 
 much else of interest, Professor Berger details four cases in 
 which he applied the Italian method to blepharoplasty. In three of 
 them the reparation concerned the lower lid, and in the fourth both 
 the upper and the lower. In the last case, death occurred from 
 
 1 Trans, of the Am. Oph. Society, 1885, p. 141. 
 
 2 Cong. fran. de Chir. seance du 9 otobre, 1889, 4 session, p. 361.
 
 ECTROPION AND BLEPHAROPLASTY. 
 
 iodoform poisoning on the day previous to that which was set for 
 the severing of the pedicle. 
 
 Mode of Operation (Berger). An exact pattern of the lid defect 
 is cut out of oil silk or court plaster, the arm is approached to 
 the eye, and the point that makes the easiest and most natural con- 
 tact is marked in ink, as the site of the pedicle. The pattern is 
 then laid on in such a manner that the pedicle will be neither 
 twisted, stretched, nor compressed, and so outlined that the area of 
 the flap w r ill be one-fourth to one-third greater than that of the 
 model. The subcutaneous fat, as well as the superficial fascia, are 
 included with the skin. Near the 
 pedicle, the aponeurosis is slightly 
 raised in order that the nourishing 
 vessels may be free from pressure. 
 All the w r ounded vessels of any size 
 are tied. 
 
 After many trials Berger adopted, 
 as the fixing apparatus, a leather 
 corset provided w r ith a collar and 
 cap, all articulated by laces and 
 straps and strengthened by steel 
 braces. A laced leather gauntlet, ex- 
 tending, from the hand to a point 
 above the elbo\v, put on and strapped 
 to the cap, holds the arm firmly to the 
 head (Fig. 192). Nufnerous fine, 
 superficial, silk sutures are put in to 
 hold the flap while, near the pedicle, 
 a few, deep, strong ones are inserted 
 
 to aid in resisting traction. Salol, boric acid, or iodoform powder 
 (the last used guardedly) is dusted into the nooks and upon the 
 other parts. Over this, gauze or a thin layer of cotton, wet with 
 boric acid solution; on this, padding of cotton, and over all a bandage. 
 Liquid food and constant watching by an attendant. Quiet 
 in bed for four or five days, then propped up for a short time at 
 intervals. After a week, sitting in an easy-chair, and even walking 
 cautiously about the room. The pedicle is divided near the end of 
 the second week. 
 
 \ 
 
 FIG. 192.
 
 32O ECTROPION. 
 
 In order to accustom the patient to the constrained posture and 
 to the manner of performing such functions as sleep, alimentation, 
 evacuations, etc., as well as to test the immobility of the parts 
 concerned in the blepharoplasty, it is well to have him wear the 
 apparatus for a few days before the operation.
 
 CHAPTER VIII. 
 OPERATIONS UPON THE CONJUNCTIVA. 
 
 SYMBLEPHARON. 
 
 Literally, this term means an adhesion or a clinging together 
 of the eyelids In its true sense, however, it refers to a union 
 of the palpebral with the ocular conjunctiva, or to the severer con- 
 dition wherein the lid is firmly adherent to the globe. Among the 
 more frequent causes are burns from lime, molten metal, acids, etc. 
 Owing to gravitation and to the exposed situation of the lower part 
 of the conjunctival sac, it is more often affected than is the upper. 
 The extent of the adherence varies from that of a tiny isolated 
 bridge to that in which all traces of a cul-de-sac are lacking, and 
 the entire inner aspect of the lid is united to the ball. Symble- 
 pharon is designated as outward, inward, upward, and downward, 
 according to its location. For convenience in reference, the different 
 grades are classified as follows : 
 
 1. Symblepharon anterius, commonly spoken of as circum- 
 scribed, is the simplest form, and is so named because the junction 
 between the opposing portions of conjunctiva does not reach the 
 fornix. 
 
 2. Symblepharon Posterius, Partial Symblepharon. This 
 class comprises the intermediate grades, or those in which the attach- 
 ment extends to the fornix, but in which the cul-de-sac is not wholly 
 obliterated, nor is there marked cicatrization of the bulbar conjunctiva . 
 
 3. Symblepharon Totalis, Complete Symblepharon. Under 
 this heading are included all the more pronounced cases where the 
 attachment involves the whole of one or both lids, and the cul-de-sac 
 is utterly effaced. In the exaggerated instances there is often 
 ankyloblepharon also. Some authors (Fuchs among them) state 
 that blindness, or at most, quantitative perception of light, is a 
 necessary accompaniment of total Symblepharon. This is by no 
 means true of the commonest form, viz., that in which the entire 
 lower lid is grown to the globe, even when, as often happens, the 
 
 21 3 21
 
 322 OPERATIONS UPON THE CONJUNCTIVA. 
 
 conjunctival adhesion covers the greater portion of the cornea; nor 
 is it invariably true of that in which both lids are attached through- 
 out. Though in many instances sight has been restored only by 
 the additional operation of iridectomy. Surgical intervention is 
 a crying need in all cases, whether blindness exists or not. Among 
 the objects sought are greater motility of lids and globe, better 
 vision, relief from pain, improved appearance, and the making of a 
 socket for the wearing of a prothesis. 
 
 The same principles are concerned in operations for symblepharon 
 as in those for blepharoplasty, and the means are also similar, 
 viz., by: 
 
 A. Sliding flaps of conjunctiva. 
 
 B. Pediceled flaps of conjunctiva or skin. 
 
 C. Mucous or cutaneous grafts. 
 
 A and B refer to autoplasty only; C to autoplasty, heteroplasty, 
 and zooplasty. No intervention is admissible while contraction is 
 still active in the adhesions. 
 
 1. The surgical treatment of the first group (symblepharon 
 anterius) presents no special difficulties. It usually suffices, for 
 the narrow bridges, merely to cut them 'with blunt scissors, or 
 with a blunt bistoury and grooved director, and to watch for reat- 
 tachments which, occurring, are at once broken loose with a probe. 
 If the division of the symblepharon leaves a decided opening in the 
 ocular conjunctiva, fine silk sutures are put in to close it. If a 
 tag of the mucosa is left hanging to the lid, it is not severed until 
 after the healing of the bulbar wound. If the bridge is fast to the 
 cornea, the latter is first freed by careful dissection. In cases where 
 the defect is so large as to cause undue stretching of the conjunctiva, 
 in closing it Arlt advised the making of a bracket or relaxing incision 
 on either side. 
 
 2. The handling of the second class of cases, or partial symble- 
 pharon, is, in the main, attended with great satisfaction, though 
 they often call for much planning and perserverence. The easiest 
 to deal with and the most frequently encountered is what is known 
 as the columnar form, in which a thin, or relatively thin, bridle 
 uniting the lid and globe reaches into the fornix and many times 
 implicates the cornea. When it occupies the upper, lower, or outer
 
 SYMBLEPHARON. 
 
 323 
 
 cul-de-sac, the operation usually adopted is that of v. Arlt. 1 Manner 
 of doing it : If the conjunctiva is fast to the -cornea, the so-called 
 pterygoid symblepharon, the 
 
 apex of the adhesion is held with 
 delicate sharp-toothed forceps, 
 and the dissection made with the 
 bulge-edged scalpel. To aid in 
 this step, some surgeons first put 
 a suture through the apex to 
 hold by. If this is done, the 
 thread should be double-armed 
 and so inserted as to make the 
 loop lie crosswise, near the tip 
 of the apex, and upon the out- 
 side, so that the same suture 
 may be used at a later stage of 
 the operation. As this means 
 
 difficulty to avoid cutting the FlG " *93 Aril's operation. 
 
 thread, it is better to dispense with the procedure. 
 
 Having passed the limbus, the dissection is carried on with 
 
 small, blunt, curved scissors to the very bottom of the cul-de-sac 
 
 really farther, as a rule, than 
 to the limits of the fornix. An 
 incision is then made with 
 straight blunt scissors, on 
 either side of the bridle and 
 close to it, from apex to base, 
 if practicable, converging the 
 two near their ends. If the 
 double-armed suture has not 
 already been put into apex as 
 described, this is now done, 
 the pocket at the base of the 
 flap is pulled wide open, the 
 needles inserted at its bottom, 
 
 P'iG. 194. Arlt's operation. 
 
 brought out through the skin, 
 
 side by side, and tied over a cylinder of gauze. The edges of the 
 1 Graefe-Saemisch, Bd. iii, 1874, S. 439.
 
 3 2 4 
 
 OPERATIONS UPON THE CONJUNCTIVA. 
 
 bulbar opening are undermined and united by fine silk sutures, the 
 knots of which are not too tightly tied (Figs. 193 and 194). 
 
 When the loosening of the 
 lid from the eye leaves a de- 
 f ec t too broad to be covered 
 ^7 simple lateral mobilization 
 Q t j ie memDranej peduncu- 
 
 lated flaps are fashioned from 
 a part somewhat further 
 away and turned in to fill 
 the gap a method first 
 practised by Teale. 1 In de- 
 taching the symblepharon, if 
 only its point involved the 
 cornea, this surgeon made an 
 incision across the growth, at 
 the limbus, and left the 
 corneal portion which was 
 supposed to dwindle away 
 
 from . atrophy. The rest he separated in the usual way and (in 
 
 downward symblepharon) took a vertical flap from either side of 
 
 the cornea (Fig. 195); the two 
 
 were disposed one above the 
 
 other on the defect, to cover it, 
 
 stitched together, and, also, to 
 
 the cut edge of the pterygoid 
 
 above, and to the lid flap 
 
 below. The secondary de- 
 fects were closed by simply 
 
 drawing the conjunctiva to- 
 gether by sutures (Fig. 196). 
 
 Teale, 2 at a later period, made 
 
 an arched bridge flap from the 
 
 lateral and upper conjunctiva 
 
 which he slid down over the 
 
 COrnea, and Stitched into FI G. 196. Teale-Knapp operation. 
 
 FIG. 195 Teale-Knapp operation. 
 
 1 Ophthalmic Hospital Reports, Oct., 1861. 
 
 1 Report of Fourth Internat. Cong, of Oph., London, 1873, p. 143.
 
 SYMBLEPHAROX. 325 
 
 position, to fill the opening left by cutting away of a downward 
 symblepharon. 
 
 Knapp 1 combines the method of Teale with that of Arlt. In 
 downward attachment with corneal point, for example, he frees 
 the cornea and separates the lid to its base, turns the flap thus 
 formed down, and fixes it into the cul-de-sac by the double-armed, 
 externally-tied suture of Arlt. He also arranges the flaps as did 
 Teale and in order to keep them from riding up onto the corneal 
 defect, sutures the lower one to the submucous tissue of the fornix. 
 
 In a case where the removal of a very large pterygoid symble- 
 pharon caused the loss of considerable of the corneal substance, 
 Schrimer, to prevent a corresponding opacity, successfully grafted 
 on to the place small lamellae taken from the cornea of a rabbit. 
 
 Inward or outward symblepharon often affects both lids, and is 
 attended by ankyloblepharon. As an example of surgical correction 
 of inward symblepharon with ankylosis, the following method, after 
 Langier (1860) and Arlt (1870), is cited. Supposing, as is fre- 
 quently the case, there is obliteration of the internal fornices, and a 
 broad band of skin unites the inner thirds of the lids. A horizontal 
 incision is made, midway of the band, from its outer limit to the 
 inner commissure; the symblepharons are detached, a double-armed 
 suture is put into each of the resulting flaps, they are turned into 
 their respective cul-de-sacs, and fixed by tying the threads over 
 cylinders on the outer skin. 
 
 In the event of the primary injury having been deep in the fornix, 
 it is best to excise as much as is expedient of the scar, for it is the 
 inevitable pushing upward of this buried, inodular mass that is the 
 undoing of many an otherwise excellent result. To prevent these 
 relapses, Panas tried carrying the apex of the detached, downward 
 symblepharon out through a slit made through the base of the lower 
 lid, and suturing it to the cheek; but with poor success. 
 
 3. To attempt the relief of total symblepharon is always an 
 arduous undertaking, and often a hopeless one. Baudry says of it, 
 "/a cure de symblepharon reste-t-elleun des problemes les plus difficiles 
 de la chirurgieoculaire" and Knapp speaks even more discouragingly, 
 to wit, "The value of a symblepharon operation depends upon the 
 extent of conjunctival surface that is preserved." He intimates 
 
 1 Graefe's Arch, xiv, i, 1868, p. 270.
 
 326 OPERATIONS UPON THE CONJUNCTIVA. 
 
 that he believes with Arlt that cases of total atrophy (symblepharon) 
 are, for the surgeon, a. noli me tangere. And Fuchs flatly asserts 
 that "cases of extensive symblepharon posterius and, obviously, 
 those of symblepharon totalis, are incurable." It is a relief to know 
 that the gloomiest of these gloomy views are not altogether war- 
 ranted by the present status of the surgery in question and, as it has 
 now been some years since the two last-mentioned eminent men 
 expressed their opinions, it may be pretty safely assumed that they, 
 too, have come to regard the matter in a more favorable light. 
 That perfectly satisfactory results can be obtained in many of the 
 most unpromising cases of total symblepharon has been, during the 
 past ten years, positively and repeatedly demonstrated. It must 
 be borne in mind, however, that a single operation will seldom 
 suffice. The happiest issues have often come only after several 
 interventions. 
 
 'it were bootless to attempt the description of any considerable 
 number of the myriad surgical measures that have been devised for 
 the higher degrees of symblepharon, for the reason that the vast 
 majority of them have availed nothing. It will serve better to call 
 attention to a few that have proven more or less effective. The 
 separating of the lid from the globe is usually a simple affair to 
 keep them separate is the perplexing thing. Obviously, this can be 
 done only by interposing two leaves of tissue that will unite readily, 
 one with the inner surface of the lid and the other with the cor- 
 responding surface of the globe, yet remaining distinct as regards 
 their own opposing faces. To this end have been employed: (i) 
 mucous grafts taken from the mouth, from the fellow eye, or that 
 of another person, from the vagina, from the eyes of rabbits, hares, 
 and dogs; (2) flaps of skin turned in from adjacent parts of the face, 
 and (3) cutaneous grafts after the methods of Wolfe and Thiersch. 
 i. Mucous grafts undoubtedly afford the most suitable material 
 with which to replace the lost conjunctiva, especially when the 
 cornea is intact or, rather, when the eye is capable of useful vision. 
 Epidermis is always irritating to the cornea. It may be from its 
 harshness, from dryness, because of its oily surface, or from con- 
 tained hairs, etc., and although its character does change in time 
 so as to partake more of the nature of mucous membrane, it never 
 entirely ceases to be dermic, and requires to be frequently cleansed
 
 SYMBLEPHARON. 327 
 
 of dead epithelium. Moreover, mucous grafts are not only more 
 suitable from a physiologic standpoint, better tolerated by the eye, 
 etc., but they are more available since they may be furnished by 
 the lower animals. Unhappily, they are, perhaps, the least fitting 
 from a surgical standpoint. Not that they do not take promptly, 
 but, for one reason, because of their exceeding frailty and tender- 
 ness, which renders them incapable of holding the retaining sutures. 
 
 The originator of this species of grafting was Wolfe, 1 of Glasgow, 
 who in 1872 made use of the rabbit's conjunctiva. A little later 
 (1873) Stellwag, of Vienna, experimented with the same, also 
 with mucosa from the mouth and from the vagina. The rabbit's 
 conjunctiva has been tried by hundreds since then, generally 
 with some degree of immediate success, but the ultimate results have 
 been uniformly disappointing. Thinking to profit by its greater 
 toughness, Panas 2 essayed the effect of transplanting the conjunctiva 
 of the dog to no purpose. Just as with that of the rabbit and the 
 mucosae of man, there ensued a gradual pushing up, or shallowing 
 of the cul-de-sac till at the end of a few months nothing. After 
 a day or two the epithelium comes off, and two granulating surfaces 
 are found in contact, and neither the insertion of an artificial eye, 
 a plate of metal, nor any known force will stop the relentless prog- 
 ress of the obliteration. 
 
 It is not improbable that some one will ere long hit upon the 
 much-hoped-for method of permanently relieving symblepharon by 
 the transplantation of mucous membrane. When this is found, it 
 is likely that conjunctiva of some kind will be the mucosa selected, 
 on account of its appropriate texture, the other kinds being far too 
 meaty. 
 
 The method pursued has usually been, first, to detach the 
 symblepharon completely, to copiously irrigate the cavity with salt 
 or boric solution, stop all bleeding, and then cover the lids with a 
 pad wet with the same solution. If the rabbit's conjunctiva is 
 chosen, it is better to have ready two of them, in case of an accident 
 to the first one used. The animal is chloroformed, its eye cleansed 
 with the salt or boric solution, two or several sutures are put into 
 the conjuctiva through small cuts, by which the area to be excised 
 
 1 Annal. d'oct., t. 69, p. 121-126, 1873. 
 
 2 Mai. des Yeux, t. ii, p. 181.
 
 328 OPERATIONS UPON THE CONJUNCTIVA. 
 
 is marked off and by which also the piece is managed after de- 
 tachment. If this is not done, it is next to impossible then to tell 
 front from back. The lid to be repaired is pulled far away from 
 the globe, the latter is rotated strongly upward (the operation being 
 for a downward symblepharon) , the borrowed piece, with or with 
 out previous dipping in the warm solution, laid in right side out, 
 the contained sutures fastened to the surrounding tissue, and as 
 many others put in as are needed: 
 
 To finish, loop threads are put down through the middle of the 
 graft, brought out on the cheek and tied over cylinders of gauze to 
 form the cul-de-sac. Some operators wait for these to cut out. It 
 is a good plan to lay on a piece of sterile oil silk or similar stuff 
 before inserting the loop threads and pull it, folded, down with the 
 graft, as recommended by Thilliez. 1 Or one could employ the 
 paraffined lead plate, as detailed later. If a one-piece graft is not 
 large enough, two may be joined together and handled as one, or one 
 may be applied to the globe, the other to the lid and their lower 
 edges stitched to the tissue at the bottom of the newly-made pocket. 
 Where the rest of the bulbar conjunctiva is fairly normal, one may, 
 as advised by de Wecker, combine the transplanting of Teale or 
 Knapp (p. 324) with the mucous grafting. 
 
 2. Pedunculated skin flaps, under existing conditions, probably 
 offer a greater measure of success than do mucous grafts, for the 
 cure of total symblepharon, yet these, too, are far from reliable. 
 A pioneer in their use for this purpose was Taylor. 2 He took the 
 flap from the lower lid, in a case of downward symblepharon, with 
 its base toward the nose. After loosening it up, he cut a vertical 
 slit through muscle fascia and conjunctiva, near the pedicle of the 
 flap, pushed the latter through, twisted it 180 on its long axis and 
 stitched it to the inner side of the lid with its epidermis next to the 
 globe. The outer defect was then closed by sutures. Chisolms 
 made the same operation, except that the pedicle was left at the tem- 
 poral side. 
 
 Harlan* for a case of total lower symblepharon, formed a bridge 
 flap (with relatively narrow pedicle at either end) on the cheek 
 
 1 Jour, des Sc. med. de Lille, 1898, p. 143. 
 
 2 Med. Times and Gaz., i, July, 1876, p. 4. 
 
 3 Virginia Med. Monthly, 1877, p. 180. 
 
 4 Trans. Am. Oph. Society, 1890.
 
 SYMBLEPHARON. 329 
 
 below the lid, cut through into the bottom of the newly prepared 
 fornix along the upper edge of the flap, pushed the latter through 
 the opening, twisted the pedicles to bring what had been the lower 
 edge on a level with the free border, and stitched it in place with its 
 epithelium facing the eyeball. The result was only a partial success. 
 
 Panas 1 in a similar case cut a flap from the temple and one from 
 the cheek, carried them through a buttonhole in the outer orbito- 
 palpebral furrow, applying one to the lid and the other to the globe, 
 their cuticular surfaces in contact. After they had become firmly 
 adherent, their pedicles were cut and the buttonhole closed. For 
 total symblepharon of both lids, the same surgeon took a large flap, 
 the shape of a tennis racket, from the temple, pedicle near the orbit, 
 turned it in through the palpebral fissure, and put the raw side in 
 apposition with the two freshly dissected tarsi. At the end of three 
 months the flap was bisected horizontally, to reestablish the open- 
 ing between the lids. The operation was undertaken to enable the 
 patient to wear an artificial eye, the cornea having been destroyed 
 by sulphuric acid, but the object was not attained. 
 
 In a case of double total symblepharon, in which heteroplastic 
 and other autoplastic procedures had been tried in vain, Samelsohn 2 
 succeeded in the manner following: from the skin of one lid he 
 borrowed a quadrilateral flap, which was left attached along the 
 ciliary border, and turned it into the palpebral fissure to line the 
 posterior surface of the opposite lid. Union having been established, 
 the flap was severed at its base and the measure was repeated, 
 from the other side, for the fellow lid. The principal cause of 
 failure in most of these flap operations has doubtless been neglect 
 to construct a capacious artificial cul-de-sac and to provide means 
 for its preservation. Panas, with his two flaps for the restoration 
 of the lower fornix, fulfilled the first condition, but not the second. 
 To cover only one side of the raw pocket made by separating the lid 
 is clearly a lame procedure. 
 
 The most formidable foe to be combated in this surgery, is the 
 progressive ankylosis between lid and globe, which tends to efface 
 one's work. As a support for the transplanted tissue to keep it in 
 place in coaptation with the surface it is to unite with, and to 
 
 1 Mai. des Yeux, T. ii, p. 182. 
 
 2 Heidelberg Congress Report, 1892, p. 149.
 
 330 OPERATIONS UPON THE CONJUNCTIVA. 
 
 mold the cul-de-sacs glass or porcelain eye shells have long been 
 employed. The trustiest weapon for the purpose would seem to be 
 a properly fashioned plate of soft metal, as described, along with 
 other means to the same end, in the next section. 
 
 With a view to the prevention of a relapse, Scott 1 everted the 
 lid, put it on the stretch, and fixed its free border to the skin with 
 the aid of fine silver sutures, keeping the eye occluded until the 
 transplanted tissue took. 
 
 3. Cutaneous Grafts. The transplantation of skin by the 
 Le Fort-Wolfe method, to replace lost substance in the surgical treat- 
 ment of symblepharon has, like that with mucous grafts, proven of 
 little value. Their great thickness, and the excessive degeneration 
 and shrinkage which they usually undergo, having necessitated their 
 abandonment. Of late years their use has been confined mainly to 
 the restoration of the cul-de-sacs in cases where the globe was 
 absent. C. H. May, 2 of New York, has reported the successful 
 "transplantation of a large Wolff (Wolfe) graft, forming a new lining 
 for the orbit and permitting the wearing of an artificial eye." The 
 graft was wrapped around a porcelain support and the whole, 
 placed in the new-made socket, where a few fine sutures united the 
 edges of the piece with those of the conjunctiva. 
 
 Epidermic grafts, on the other hand, afford the best known 
 means of repair for the defect under consideration. They were used, 
 to a limited extent, in symblepharon operations by v. Arlt, in small 
 patches upon a granulating surface, after the manner of Reverdin. 
 Later, more extensively and in broader pieces, by Eversbuschs 
 and many others. 
 
 Czermak* gives an ingenious procedure for total symblepharon 
 of the lower lid, founded on a method of epidermization by Evers- 
 busch. The palpebral fissure is extended to the outer rim of the 
 orbit by a horizontal incision with the scalpel. From the outer 
 extremity of this another is made, down and in, along the orbito- 
 palpebral furrow, till it reaches a point one and one-half centimeters 
 below the inner canthus. The incision is deep enough to include 
 the whole thickness of the lower lid, which latter is dissected up in 
 
 1 Lancet, July 31, 1897. 
 
 2 Arch, of Oph., vol. xxx, No. 5, 1901. 
 
 3 Munch, med. Wochschr., 1887, Nr. i u. 2. 
 
 4 Aug. Operationen, 1893, p. 309.
 
 SYMBLEPHARON. 
 
 33 1 
 
 the form of a flap with its pedicle inward. The flap or lid is then 
 turned back over the nose, the bleeding is stopped, and the raw 
 surface of the globe and orbital contents covered over with a Thiersch 
 graft. The entire area is dusted over with iodoform powder and 
 covered with a piece of tin-foil, or gutta-percha tissue, well smeared 
 on both sides with vaselin. This covering must extend beyond the 
 outer and under borders of the wound and be pushed snugly into 
 the angle at the base of the flap. Above it must overlap the cornea. 
 If the latter is transparent, gutta-percha tissue is chosen instead 
 of foil. The graft is made to cover the lower half of the cornea also. 
 Now another epidermis graft, correspondingly large, is laid on 
 the tissue (or foil), epithelium downward, and the flap is turned 
 back into place. Both lids are now covered w r ith a piece of gutta 
 tissue greased with vaselin, and, over all, the regulation cotton 
 pad and roller bandage. The foil or tissue keeps the two grafts 
 apart while they heal. As soon as they have become firmly adherent, 
 with configuration like that of the flap, an incision is made along 
 the margin of the posterior defect, that must run exactly as did the 
 one by which the flap was originally outlined. In this way a cut is 
 made that, by the contraction of the surrounding tissue, is seen 
 slightly to gape. Then the whole convex edge of the flap and that 
 part of the upper edge near the point, made by the first or horizontal 
 cut, is freshened with the scissors and sutured to the surrounding 
 skin. Thus is formed a deep cul-de-sac. A linear scar remains, 
 of course, and the lower, lid looks puffy, "but faults like these," 
 says Czermak, " are not to be taken into account in such desperate 
 cases." He considers the operation of special utility in making a 
 new socket for holding a glass eye. 
 
 But it is in the United States that the employment of epidermic 
 grafts in this connection has been attended with the highest degree 
 of definite success. Hotz 1 advocated the use of Thiersch grafts to 
 replace the destruction of conjunctiva in extensive symblepharon. 
 Among the first signal triumphs in this country was one at the 
 hands of C. H. May 2 (in May, 1897) of New York. There was total 
 symblepharon of both lids. A number of large epidermic grafts 
 were used w r hich were kept in place by a porcelain shell resembling 
 
 1 Annals of Oph., April, 1893. 
 
 2 Reported in the Archives of Oph., April, 1899.
 
 332 OPERATIONS UPON THE CONJUNCTIVA. 
 
 an artificial eye. The result was perfect. Four years after the 
 operation it was still so. In April, 1899, the same surgeon, 1 after 
 vain attempts to relieve an extensive lower symblepharon by older 
 methods, detached it freely and placed a large Thiersch graft over 
 the defect thus made. This, too, was kept in place by means of 
 the porcelain shell. The cornea was transparent over two-thirds 
 of its area, yet the shell was well tolerated. In addition, the graft 
 was stitched to the margins of the raw surfaces by delicate sutures. 
 The graft adhered promptly and the symblepharon was cured. 
 Fifteen months afterward the effect of the operation had not dimin- 
 ished. In July and August, 1899, by two successive operations, 
 Hotz 2 relieved a nearly complete symblepharon of the upper lid, 
 covering the raw surfaces, after dissection, with broad Thiersch grafts. 
 Knowing of May's use of the porcelain shell to hold the graft in 
 place and having no such shells at his disposal, he "cut from a thin 
 sheet of lead an oval disk large enough that when slipped under the 
 lids it would fill the whole space from the retrotarsal sulcus of the 
 upper lid to that of the lower lid, and shaped and molded it so as to 
 fit accurately the curvature of the ball. A Thiersch graft, taken 
 from the arm, was spread out smoothly over the plate, epidermis 
 toward the lead, in such a manner that it covered the upper two T 
 thirds of both sides of the plate. Thus mounted, the plate was 
 inserted under the lids as we insert an artificial eye. The lid borders 
 were united by three sutures." The eye was dressed, and lid sutures 
 removed on the fourth day. Although the graft was adherent 
 throughout, the plate was worn four days longer. 
 
 The second operation was for the purpose of piecing out with a 
 Thiersch graft a small area that the first one failed to cover. The 
 eye was sightless and the operation was to make a prothesis practi- 
 cable. Dr. Hotz has just informed me that the patient is wearing 
 the glass eye with perfect comfort at the present time (March, 1906). 
 In November, 1901, Hotzs presented at a meeting of the Chicago 
 Medical Society a case wherein he had cured almost total lower 
 symblepharon in a similar manner. Instead of the large plate, 
 filling the entire conjunctival sac, as in the first case, he used one the 
 size and shape of the inner aspect of the lower lid, w r ith four small 
 
 1 Reported in Arch, of Oph., vol. xxx, No. 5, 1901. 
 
 2 Oph. Record, Nov., 1899. 
 
 3 Chicago Med. Recorder, Dec., 1901.
 
 SYMBLEPHARON. 333 
 
 holes through it near the upper edge. The plate was covered with 
 the graft, put into the new cul-de-sac and fastened along the free 
 border by silk sutures passed through the perforations and through 
 the lid. Two supplementary operations were required to complete 
 the cure in both of these; the lead plate also was used, but the sutur- 
 ing together of the lids was omitted. Fifteen months after the 
 first operation and three after the last the lid was free, easily 
 evertible, and there was perfect motility of the eyeball. In this case, 
 the greater part of the cornea was transparent had escaped in- 
 jury and the sight was preserved. 
 
 At a meeting of the Ophthalmic Section of the Philadelphia 
 Medical Society, April 17, 1900, Oliver reported a case of complete 
 restoration of the conjunctival sac by a single epidermic graft. 
 Indeed, since the publication of Hotz's and May's first articles on 
 the subject such operations have been made by ophthalmic surgeons 
 all over the land and, in numerous instances, with most gratifying 
 results. A notable series of six cases was reported and exhibited 
 by H. W. Woodruff 1 at the meeting of the Chicago Ophthalmologic 
 Society, February 10, 1903. Three had been relieved of high-grade 
 or total symblepharon and three, where the globe had been enu- 
 cleated and the cul-de-sacs had been effaced, were furnished with 
 new sockets. Woodruff thus describes his mode of procedure: 
 
 "The patient should be under a general anesthetic, preferably 
 chloroform. The eyebrow and skin about the eye, and the surface 
 from which the graft is to be taken should have been previously 
 thoroughly cleansed witri green soap and hot water, washed with 
 alcohol, and bandaged. Immediately before the operation is begun 
 the field is freely flushed with boric acid solution. If a pseudopteryg- 
 ium is present, it is first dissected from the cornea, and the lid is 
 thoroughly freed from its attachment to the eyeball, and the cul- 
 de-sac must be made large in all dimensions. Cicatricial bands 
 should be removed entirely. Bleeding is checked by hot water. 
 A plate is now cut from a sheet of block tin, which will snugly fit 
 into the new-formed cul-de-sac. The corners are rounded off and 
 the edges smoothed with the scissors or file. If the case be one of 
 symblepharon, and there is danger of the plates rubbing on the 
 cornea, it may be cut out in the center to the extent required. Four 
 
 i Annals of Oph., March, 1903.
 
 334 OPERATIONS UPON THE CONJUNCTIVA. 
 
 holes are made for the sutures, two at the outer and two at the 
 inner angle of the plate, to correspond to the lid margin. A razor 
 which is known to be in good condition is used for removing a thin 
 layer of skin, about one-third wider and more than three times as 
 long as the plate. In the method known as Thiersch's the trans- 
 planted flap includes only the epidermis and superficial layer of 
 the dermis. The graft is best taken from the inner surface of the 
 arm, which is put on the stretch by firm pressure with the hand, and 
 made flat by pressure w r ith the razor while cutting. The graft is 
 transferred at once to the plate, and folded over it with the raw 
 surfaces external. Plate and graft are then pushed into the cul-de- 
 sac, and sutured to the lid near its margin, tying them over small 
 rolls of gauze. The lids may be sewed together and dressed with 
 gauze, and bandaged in the usual way. Both eyes should be 
 bandaged as long as the plate is in place, and absolute quiet main- 
 tained. The plate is removed in four days, and more freedom 
 allowed the patient." 
 
 This is essentially the method as generally employed in America. 
 It will be observed that Woodruff speaks of having used plates of 
 block tin. This is probably a cleaner metal for the purpose than is 
 lead, less affected by the secretions of the eye and the fluids in the 
 raw tissues, though in other respects there is no choice between 
 them. Woodruff continues, "The particular advantages claimed 
 for the use of the plate over any other method of skin grafting are: 
 
 " i. It enables one to place the graft at once in the position wanted. 
 
 "2. It holds it down in the very bottom of the artificial cul-de-sac 
 until it has adhered, so that the raw surfaces of the lid and ball in 
 no part can again unite with each other in this angle, and, even 
 when the graft lives, gradually push it upward, as, in my experience, 
 it does, unless the plate is used. 
 
 "3. We secure, with the plate, accurate approximation over the 
 whole extent of the graft, and rest." 
 
 Weeks, of New York, at the Congress of Ophthalmology, Lucerne, 
 1904, gave a method for the restoration of the conjunctival cul-de- 
 sacs that he declared to have been highly successful in cases of 
 anophthalmos with obliteration of the socket. He believed that the 
 procedure 'owed its efficacy solely to the fact that a fixed point of 
 attachment was found for the graft in the periosteum at the rim
 
 SYMBLEPHAROX. 335 
 
 of the orbit. In addition, however, he had made use of a plate 
 for the support of the transplant. In this instance the plate is 
 gutta-percha, such as is employed by the dentists under the name 
 of "base-plate." A piece of this is cut to the desired outline, 
 molded to shape after immersion in hot water, and its form definitely 
 fixed by putting it in cold water. The first step of the method 
 is the making of a free canthotomy, in order to obtain room to 
 operate. Only one fornix is restored at a time. The lid is detached 
 almost to the margin of the orbit, and the cavity packed with cotton 
 wet with normal salt solution. A Wolfe graft is rapidly cut from 
 the arm, freed from subcutaneous tissue and dipped in the warm 
 salt water. It is then folded, epithelium inward, and three double- 
 armed sutures passed through at the bottom of the crease, leaving 
 loops, two millimeters long, on the cutaneous surface. The sutures 
 are next put through the periosteum of the orbital rim, from the 
 bottom of the newly formed cul-de-sacs, and out on the cheek. The 
 graft is helped into place while the sutures are all drawn down, 
 and threads are tied over rolls of iodoform gauze. Small interrupted 
 sutures fasten the graft to the conjunctiva of the lid and to that 
 of the ocular stump. Now the plate is inserted and, lastly, the 
 stitches put in to close the canthotomy. The deep sutures are left 
 in for ten to fourteen days, those in the conjunctiva are removed 
 in one week. The plate is left in situ until all shrinkage ceases 
 in the flap. 
 
 The writer, having found the gutta-percha plate unsatisfactory, 
 went back to the lead. -With it the periosteal sutures are a super- 
 fluous complication. A valuable expedient is that of Wilder, of 
 Chicago, whereby the leaden shell -is coated with paraffin. By 
 holding the plate with forceps by its middle, and dipping it several 
 times in liquid paraffin of high melting-point, the surface and edges 
 are made absolutely smooth and non-irritating. Another good 
 suggestion of Wilder's is that, instead of making a number of small 
 holes in the plate for the passage of the sutures, two large openings 
 are made, one on either side of the center. These serve just as well 
 for the threads, besides affording much-needed facilities for drainage 
 and cleansing. The tip of an eye-dropper can be inserted at one 
 opening and the injected fluid escape at the other. In conjunction 
 with a Thiersch graft suturing to the conjunctiva is unnecessary.
 
 336 OPERATIONS UPON THE CONJUNCTIVA. 
 
 Though it is wise to fix the graft to the plate by a few turns of 
 thread in order to prevent it from slipping while being put into the 
 socket. 
 
 Upper, outer, and lower cul-de-sacs can all be restored by a single 
 operation. Indeed, there is every good reason for doing whatever 
 is needed all at one sitting, and none against it. If need be, the 
 entire plate may be covered by the graft. In any case it is better 
 to have a superfluity than a lack of tissue on the metal. 
 
 Since writing most of the foregoing I have had the good fortune 
 to restore perfectly the cul-de-sacs in a few cases of total symble- 
 pharon where the eye was present, and to make artificial sockets 
 that are entirely practical and satisfactory for the wearing of a 
 prothesis in a number of others where enucleation had been per- 
 formed and there had been complete obliteration of the conjunctival 
 sac. In the first category the lead or block-tin plate, with and with- 
 out the paraffin coating, has been employed, and with and without 
 the opening for the cornea. In the second class, i.e., those in which 
 the bulbus had been removed, plates of the same materials have 
 been used with or without perforations for drainage and cleansing. 
 Of the two metals, lead or block-tin, for the plate I prefer the last 
 as being least affected by the fluids normally or artificially present 
 in the eye. The great advantages of such plates are that they can 
 be readily fashioned of any shape and size by means of the fingers 
 and strong scissors, and perforations of suitable dimensions are 
 easily made in them. Moreover, they can be bent by the fingers 
 into forms similar to that of an ordinary artificial eye. In order, 
 however, to make them evenly concavo-convex so that there will 
 be no signs of crimping or ruffling around the edges, a more elaborate 
 handling would be necessary. Fortunately, precision so great 
 is not required. When it is to be fitted over the eyeball the thick- 
 ness of the plate need not exceed one thrity-second of an inch, 
 especially if the paraffin coating is put on. But when the newly 
 formed cul-de-sac is intended for receiving and holding a prothesis, 
 particularly one of the Snellen kind, or ''reform eye," it should not 
 only be deep and long, but extra wide as well, so that, in the process 
 of cicatrization, it will still remain of fair capacity. Here, then, 
 a thickness nearer one-sixteenth of an inch were better. This, 
 heavily coated with paraffin, will make a plate that very closely
 
 SYMBLEPHAROX. 337 
 
 resembles a glass eye especially at and near the outer border. 
 In lieu of a sheet of metal of sufficient thickness I have fastened two 
 pieces together with collodion. At least one perforation in the plate 
 may be regarded as an absolute necessity. If the globe be intact, a 
 large opening corresponding in size to that of the cornea serves to 
 obviate undue pressure and friction upon this sensitive membrane. 
 It also permits of inspection, so that one may be informed as to the 
 health of the cornea and as to whether or not the posterior leaf 
 of the graft is "taking" within the limbus. Besides it gives oppor- 
 tunity for irrigation. Where the eye is absent there may be one 
 or two perforations. Should the graft required be large enough to 
 cover the entire plate, as is true in operations for restoration 
 of all four cul-de-sacs, there is only room for one opening 3/16 to 
 i 4 inch in diameter in the center; or for two, each about 1/8 inch, 
 placed close together on the horizontal axis of the plate. Either 
 will serve for cleansing the cavity or for manipulating the plate. 
 If the openings are larger they deprive the graft of the support 
 it needs. A squint-hook, put in through one of these perforations, 
 acts well as a handle by which the plate may be mobilized and 
 withdrawn when the proper time arrives. In coaling a one-hole 
 plate with paraffin a pair of fixation forceps may be thrust through 
 the opening, when the "spread" of the instrument will suffice to 
 hold the plate. If there are two holes one prong of the forceps 
 is passed through each. 
 
 Apropos of the paraffin coating, it would seem to be of unques- 
 tionable value. As Wilder has pointed out, the advantages of a 
 plate so. prepared over the naked metal are greater smoothne--. 
 less harshness, and the very desirable qualities, in addition, of 
 causing the epithelial surface of the graft to lie evenly spread out, 
 or clinging, and the facility with which it may be built up into 
 appropriate form and thickness. Wilder says that the melting- 
 point of the paraffin should not be lower than 130 F. I would 
 recommend that it be as high as it is possible to obtain it; for I 
 have observed that there is a tendency of the surface to become 
 hummocky and for a ridge to form along the palpebral fissure 
 after the plate has been in the eye for a few days. The harder the 
 substance, of course, the more uniform the coating would remain 
 under the influence of the animal heat and the movement of the
 
 338 OPERATIONS UPON THE CONJUNCTIVA. 
 
 tissues. That the new cul-de-sacs must be fashioned and main- 
 tained on a generous scale cannot be too strongly insisted upon. 
 Extra free division of the tissues at the outer canthus is the first 
 essential step. This is nicely sutured as soon as the plate is put 
 in place. The plate, if of adequate size, will be too large in some 
 instances to be removed without making a second canthotomy, 
 which also should be followed immediately by suturing. After 
 this a somewhat smaller plate may be substituted, or, if the original 
 one has again been inserted, it may be cut in two with strong scissors, 
 in situ, before removal. 
 
 It has for some time been a cherished intention on the part of 
 the writer to procure a number of ordinary shell eyes of varying 
 sizes, and to have made in them suitable openings. These are to 
 be coated with the paraffin and used instead of the lead plates. I 
 fancy they would possess distinct advantages over the metal plates 
 in all save the doubtful one of allowing themselves to be cut in two 
 while in position. 
 
 More recently we have taken the graft directly from the razor 
 and placed it on the plate, i.e., without dipping it in the salt solution; 
 nor have any sutures been employed in holding the graft to the 
 plate. 
 
 PTERYGIUM. 
 
 Pterygium, also called pterygion, is from the Greek, meaning, 
 literally, little wing, and in German it is Fliigelfell, or wing film. 
 The term is used in the various branches of zoology to denote 
 certain fins of fishes, feathers of birds, and coverplates of insects. 
 In pathological anatomy the word, besides its more common applica- 
 tion here under discussion, is also employed with reference to a 
 growth of skin over the nails. Indeed, ocular pterygium was, 
 by Celsus, called unguis. As applied to the eye, the word signifies 
 a growth of thickened or otherwise changed conjunctiva encroaching 
 more or less upon the cornea. Two varieties are recognized, viz., 
 the true and the false. 
 
 True pterygium is always situated in the horizontal meridian of 
 the eye and is usually the result of prolonged irritation of that 
 part of the conjunctiva exposed through the palpebral fissure, by
 
 PTERYGIUM. 339 
 
 wind, dust, etc., hence rarely occurring in females. It appears as- 
 a triangular band of more or less reddened conjunctiva with its 
 apex primarily at the limbus, and may be either stationary or 
 progressive. It is most often situated on the nasal side of the 
 cornea (internal pterygium), less often on the temporal (external 
 pterygium) and still less often on both sides at once (double pteryg- 
 ium) . Its rounded, whitish apex is usually referred to as the head, 
 the adjoining portion as the neck, and its wide, fan-like expansion 
 as the body. 
 
 Another classification is made of true pterygium into progressive 
 and stationary. The former being characterized by greater vascu- 
 larity, redness, and thickness (pterygium crassum), while the latter 
 is pale and thin (pterygium tenuis). Originally, of course, the 
 second form has been of the progressive kind which has become 
 retrogressive. 
 
 Progressive pterygia demand operative interference at the earliest 
 possible moment, in order to insure good and lasting results. In 
 proportion as they are allowed to occupy the pupillary area of the 
 cornea, the sight is prejudiced, both immediately and consecutively. 
 
 The stationary variety, especially when the cornea is but slightly 
 implicated, may be safely let alone. It is eminently justifiable, how- 
 ever, that they be removed, if only for cosmetic reasons. 
 
 The number of operative procedures that have been devised for 
 the cure of the growth in question is very large, but for convenience, 
 the methods may be reduced to three or, at most, four. 
 
 1. Ablation, or the complete taking away by excision, or by the 
 latter combined with scraping and cauterization, called also abscis- 
 sion. 
 
 2. Transplantation called by some deviation, and by others 
 burying. 
 
 3. Ligation. 
 
 4. Cauterization (though hardly admissible except as an ad 
 junct to one of the other measures). 
 
 i. Operations for pterygium were resorted to in very early times. 
 The growth was looked upon as a species of tumor, of a certain 
 malignance, and it was dealt with by ablation, partial or complete. 
 Celsus, 1 for example, seized the neck with a sharp hook and passed 
 
 * Rome, A. D. i.
 
 340 OPERATIONS UPON THE CONJUNCTIVA. 
 
 through it a thread, to which he held with one hand while, by means 
 of a small knife, he detached the neck and body, severed the base, 
 and allowed the wound to heal by granulation. If at the nasal 
 side, he was careful to spare the caruncle, as to remove this body, 
 he believed, would cause epiphora. 
 
 ;tius and Paulus, 1 of ^Egina, also made ablation of the pterygium, 
 but instead of using a knife, they detached it from base to apex, with 
 the aid of a horsehair passed beneath, which they worked like a saw. 
 According to Richter, 2 however, these surgeons left the head be- 
 hind, and Acrel was the first to dissect off this part. Richter 
 himself and Scarpa,3 extirpated the corneal portion only. The 
 idea of closing the defect left after ablation of the pterygium 
 first occurred to Coccius.* Previously, the diverging lines of 
 the pterygium were followed in the extirpation, a large trap- 
 ezoid scleral defect was left to heal as best it might, in con- 
 sequence of which, not only did there remain a large area of 
 cicatricial tissue, which interfered with the action of the underlying 
 rectus muscle, but was, moreover, unseemly in appearance, and 
 often leading, through overgrowth of granulation tissue, to what 
 was called "secondary pterygium." 
 
 To obviate this, v. Arlts in cases of large pterygia, instead of 
 following the borders of the scleral portion, made two converging 
 incisions which, meeting at or near the caruncle, left only a relatively 
 narrow, triangular, scleral wound opening. The piece excised, 
 or, if you will, the whole bared space, was manifestly of rhomboid 
 or diamond shape, its greatest measurement being horizontal. 
 Later, following Coccius, he undermined the edges and brought 
 them together by fine sutures. When the growth was of small 
 dimensions Arlt often contented himself by merely dissecting off 
 little more than the corneal part, leaving the scleral division, in 
 front of which he sutured together the conjunctiva, to disappear 
 spontaneously. 
 
 If the abandoned growth became swollen, or if it in any way 
 inconvenienced, it was excised by a simple snip of the scissors. A. 
 
 1 Greece, A. D. 7. 
 
 3 Treatise on Surgery, Gottingen, 1771, p. 92. 
 
 3 Trait, des malad. des yeux, 1802-1816. 
 
 4 Ruete, Lehrb. der Augenh., 1854, Bd. ii, S. 267. 
 
 5 Die Krankheiten des Auges, i, S. 164. Prag., 1850.
 
 PTERYGIUM. 341 
 
 Pagenstecher, of Wiesbaden, adopted this method. Arlt's method 
 of ablation, but slightly modified, still constitutes one of the favorite 
 and most effective pterygium operations, when the growth is of 
 moderate size and, as performed by the author, may be described 
 as follows: 
 
 The eye is cleansed and put under local anesthesia. The lids 
 are held apart by the blepharostat. The entire width of the growth, 
 about at the junction of the neck and body, is caught up by strong 
 mouse-tooth forceps, where an opening is made through beneath 
 it with knife or scissors. If it is loosely attached to the cornea, 
 one may now avail one's self of the admirable method of divulsion 
 invented by Prince, of Springfield, 111. This consists in passing a 
 Prince divulsor or a flat strabismus hook or other similar instru- 
 ment through the opening and forcing it toward the apex with a 
 series of short, prying motions, as a river of staves uses his frow. In 
 this way one often has the satisfaction of seeing the cornea stripped 
 absolutely clean. If the growth is too firmly adherent to yield 
 readily to this maneuver, a keen, narrow bistoury, or small scalpel, 
 is used. It is worked from the limbus of the cornea toward the 
 center, first loosening the lower edge, then the upper, then between 
 the two, always hugging the cornea. 
 
 It is well before loosening the apex to finish the incisions that out- 
 line the diamond to be excised, as they can then be placed with 
 greater precision. These, made only with small, straight, blunt 
 scissors, extend, divergent, for a short distance from the limbus, 
 governed by the size of the pterygium, then convergent to meet at 
 or near the caruncle or the neighboring canthus (Fig. 197). 
 
 We may now try to rive off the head or tip by prying. If this 
 fails, the knife is passed entirely beneath and this portion is severed 
 by a light sawing movement. To begin the dissection at the head, 
 except in the event of the pterygium being a cicatricial or an un- 
 usually meaty one, is unsurgical. Finally the excision of the 
 scleral part is finished with the scissors, taking care to avoid the 
 sheath and tendon of the rectus. Any corneal remains of the growth 
 are scraped away with a convex scalpel, or sharp curet, and the 
 episcleral tissue in the immediate vicinity of the limbus is like- 
 wise got rid of. To prevent overlapping the cornea, two vertical 
 incisions are now made in the conjunctiva, one upward and the
 
 342 
 
 OPERATIONS UPON THE CONJUNCTIVA. 
 
 other downward, for a few millimeters from the base of the denuded 
 space on the cornea, the edges of the scleral wound are undermined 
 for some distance by means of the blunt scissors and brought lightly 
 together by very fine silk sutures (Fig. 198). These have been re- 
 cently boiled in vaselin-paraffin. One should see to it that each 
 bite of the thread is deep enough to hold firmly. 
 
 A carefully applied four-yard wet netting roller is put on, the 
 patient is told to keep very quiet for forty-eight hours, and to re- 
 frain from use of the uncovered eye, also to keep it mostly closed. 
 
 FIG. 197. Arlt. 
 
 FIG. 198. 
 
 At the end of this time occurs the first inspection and redressing. 
 After this, daily for a few times. The sutures are taken out three 
 or four days from the date of operation. 
 
 2. Transplantation of pterygium, in order to divert its growth 
 from the cornea, was originally conceived by the elder Desmarres. 1 
 This surgeon dissected up the growth like a flap, from its base to its 
 apex, then from a convenient point on the lower edge of the con- 
 junctival opening he carried an incision, parallel with the corneal 
 margin, sufficiently far to accommodate the loosened pterygium. 
 Into this, after having been opened into a triangular bared space, 
 he turned the growth and secured it there by sutures (Figs. 199 
 and 200). The defect remaining about the limbus was left to heal 
 by granulation. When the apex of the pterygium is truncated the 
 
 1 Traite theorique et pratique des maladies des yeux, 2e edition, 1855, 
 Paris, t. ii, p. 1 68.
 
 PTERYGIUM. 
 
 343 
 
 younger Desmarres 1 advises dividing it into two equal portions by a 
 horizontal incision, and transplanting the two halves into two con- 
 junctival notches, one above and the other below. 
 
 Knapp, 2 in order to adapt the Desmarres double transplantation 
 
 TJ 
 
 FIG. 199. Desmarres, Xo. i. 
 
 method to the larger pterygia, modified the procedure in certain 
 important respects, the technic of which, as described by him in 
 Xorris and Oliver's System, p. 837, is essentially thus: 
 
 The body of the pterygium is seized with fixation forceps and 
 detached with a narrow cataract knife from near the limbus to and 
 
 FIG. 200. Desmarres, Xo. 2. 
 
 including apex, boldly cutting through the epicorneal tissue so as 
 to leave nothing of the growth behind. The scleral portion is in- 
 cised along its upper and lower borders and the cuts prolonged in 
 
 1 Lemons cliniques sur la chirurgie oculaire, Paris, 1874, page 302 
 
 2 Archiv. .iir Ophthalmologie, Bd. xiv, I Abtheil., 1868, S. 267.
 
 344 
 
 OPERATIONS UPON THE CONJUNCTIVA. 
 
 a curved direction into the upper and lower fornices. The whole 
 is then loosened from the eye in the form of a triangular flap which 
 is split horizontally into two equal portions. The part representing 
 the gray infiltrated head is cut off. The tip of each half is stitched 
 into the corresponding angle formed by the upward and down- 
 ward prolongations into the fornices. To cover the remaining 
 defect, two vertical incisions are made in the conjunctiva, beginning 
 at the limbus, extending up and down for several millimeters, 
 getting further from the cornea as they advance. Thus two squarish 
 
 FIG. 201. Desmarres, jr.-Knapp. FIG. 202. Desmarres, jr.-Knapp. 
 
 flaps are outlined which are undermined and joined together by two 
 sutures. The better to fix the various flaps and to keep them 
 from overriding the cornea, the suture furthest from the cornea is 
 made to include. the conjunctiva at the apex of the angle between the 
 two halves of the divided pterygium (Figs. 201 and 202). 
 
 Both eyes are bandaged for twenty-four hours afterward only 
 the operated eye though the patient is advised to use the uncovered 
 eye as little as possible the first week. The threads are removed 
 in five or six days. Both this and Desmarres' are true transplanta- 
 tion operations.
 
 PTERYGIUM. 
 
 345 
 
 McReynolds, 1 of Dallas, has, by a most ingenious and effective 
 modification of the original Desmarres operation, given new im- 
 petus to the transplantation method in this country. The present 
 writer is among the many who can testify, from experience with a 
 number of cases, to the excellence of the procedure. The different 
 steps of the operation, as described by its author, are as follows: 
 
 1. Grasp the neck with 
 strong narrow forceps. 
 
 2. Pass a Graefe knife 
 through the constriction and 
 as close as possible to the 
 globe; then, with the cutting 
 edge turned toward the cornea, 
 shave the growth smoothly 
 from that membrane. 
 
 3. With the fixation forceps 
 still hold the pterygium and 
 with slender straight scissors 
 divide the conjunctiva and 
 the subconjunctival tissue 
 along the lower margin of the 
 pterygium, commencing at the 
 neck and extending to the 
 canthus, a distance of 1/4 to 
 1/2 inch. 
 
 4. Still hold the pterygium 
 with the forceps and separate 
 the body of the growth from 
 the sclera with any small, 
 
 non-cutting instrument. (A flat Graefe strabismus hook serves 
 admirably.) 
 
 5. Now separate well from the sclera the conjunctiva lying be- 
 low the oblique incision made with the scissors. 
 
 6. Take black silk thread, armed at each end with smallest 
 curved needles and carry both of these needles through the apex of 
 the pterygium from within outward. Separate one from the other 
 by sufficient amount of the growth to secure a firm hold (Fig. 203). 
 
 1 Journal of the American Medical Association, Aug. 9, 1902. 
 
 FIG. 203. McReynold's modification of 
 Desmarres', Sr.
 
 346 
 
 OPERATIONS UPON THE CONJUNCTIVA. 
 
 7. Then carry these needles downward beneath the loosened 
 conjunctiva lying below the oblique incision made by the scissors. 
 The needles after passing in parallel directions beneath the loosened 
 lower segment of the conjunctiva, until they reach the region of 
 the lower fornix, should then emerge from beneath the conjunctiva 
 
 at a distance of about 1/8 to 1/4 
 inch from each other. 
 
 8. With the forceps lift up the 
 ~ loosened segment of conjunctiva 
 and gently exert traction upon 
 the free ends of thread, which 
 have emerged from below, and 
 the pterygium will glide beneath 
 the loosened lower segment of 
 conjunctiva, and the threads 
 may then be tightened and tied, 
 while the surplus portions of 
 thread are cut off, leaving enough 
 to facilitate the removal of the 
 threads after proper union has 
 occurred (Fig. 204). It is very 
 important that no incision be 
 made along the upper border of 
 the pterygium, because it would 
 gap and leave a denuded space 
 when downward traction is made 
 upon the pterygium. 
 
 If the head of the pterygium 
 is very large, it is cut off before 
 the pterygium is drawn down 
 beneath the loosened segment of 
 
 FIG. 204. McReynold's modification 
 of Desmarres, Sr. 
 
 conjunctiva. If any overlapping of the cornea occurs, McReynolds 
 simply trims away the offending portion of conjunctiva. This is 
 more a burying than a transplanting of the pterygium. 
 
 The writer would urge, as a precautionary act of no little impor- 
 tance, that before proceeding to draw the pterygium down into the 
 prepared pocket, the blepharostat (or retractor) be removed. 
 The effect of this instrument is, by its pushing the conjunctiva up
 
 PTERYGIUM. 
 
 347 
 
 into the fornix, to greatly limit the extent to which that membrane 
 can be drawn down. This is particularly necessary in cases of 
 elderly subjects and in those afflicted with chronic inflammations 
 of the conjunctiva, and whose cul-de-sacs are, in a measure, obliterated 
 from atrophy. It is also highly advisable, before actually putting 
 the growth in its new place beneath the conjunctiva, to take it by 
 its head with the forceps, pull it down and note and mark the place 
 where it fits best. 
 
 The younger Desmarres, 1 
 for large pterygia with trun- 
 cated apices, divided them in 
 two and transplanted similar 
 to Knapp, but, like Desmarres 
 the elder, he left the scleral 
 defect uncovered. / 
 
 Galezowski, 2 after mobiliz- / v 
 ing the pterygium, put a 
 double-armed suture through 
 the apex, tucked the growth 
 back beneath the semilunar 
 fold, or the caruncle, where he 
 brought the suture out and 
 tied it. 
 
 3. Ligation. In connec- 
 tion with the surgery of ptery- 
 gium, this measure, though 
 still occasionally resorted to, 
 may be considered obsolete. 
 Its origin is associated with 
 
 the name of Szokalski.s This operator passed two curved needles 
 beneath the pterygium, one near the apex, the other near the base, 
 both being attached to the same thread (Fig. 205). The thread 
 was then cut close to the needles. In this manner three ligatures 
 were made, two single and one (the middle) double. The single 
 ones were tightly knotted. The third, formed by the loop of thread, 
 served to detach and lift up the pterygium. At the last this thread 
 
 1 Legons cliniques sur la chirurgie oculaire, Paris, 1874, p. 302. 
 
 2 Maladies des yeux, 1888. 
 
 3 Roser u. Wunderlich Archiv., 1845, Xr. 2. 
 
 FIG. 205. Szokalski's ligature.
 
 348 OPERATIONS UPON THE CONJUNCTIVA. 
 
 was made into a slip-loop around the pterygium and the ends 
 fastened to the cheek by means of collodion. After a few days the 
 growth perished and was excised. 
 
 Von Arlt, 1 in a case of cicatricial pterygium, following blenor- 
 rheic conjunctivitis, cast two ligatures around it and allowed them 
 to cut through. The pterygium soon after disappeared. 
 
 4. The thermal cautery as a single measure for the removal of 
 pterygium, though it has been, to a limited extent, used in this 
 capacity, is not especially to be commended. Its only place, in 
 this connection, would seem to be in conjunction with other means 
 more strictly surgical. For example, Martin, 2 of Bordeaux, after 
 having practised ablation of the growth, made several successive 
 cauteries on the site of the corneal implantation, by means of a 
 strabismus hook heated to redness in the flame of a spirit lamp. 
 Panass did the same, only with an olive-tipped thermocautery. 
 Chibret* made a similar operation to that of Galezowski, just men- 
 tioned, but before rolling the pterygium upon itself, he applied the 
 galvano-cautery to its posterior, or raw, surface. This was supposed 
 to hasten the atrophy of the growth. Deschamps* affirmed that 
 cauterism of the corneal portion, when well done, especially if 
 combined with a good scraping, rendered any sort of conjunctival 
 autoplasty inutile, and that the cure was rapid and permanent. 
 Most all authorities agree that it is highly indiscreet to cauterize 
 the episcleral part of the wound opening. It should also be borne in 
 mind that the electric cautery is, in this respect, an instrument whose 
 employment should be confined to the most experienced and skillful 
 hands, as in any other than these, because of its tremendous energy, 
 its work is sure to be overdone and deep scars be the result. Unless 
 one is sure of himself, it were better to employ for the purpose the 
 iron made red-hot in the flame. The actual cautery is particularly 
 helpful in getting rid of the infiltrated head that sometimes thwarts 
 one's efforts at dissection and scraping, and whose complete 
 removal is of the utmost importance. 
 
 Starkey, 6 of Chicago, recommends the galvanic current for the 
 
 1 Operationslehre, S. 381. 
 
 2 Annal. d'oculist, 1881, p. 144. 
 
 3 Maladies des yeux, 1894, t. ii, p. 265. 
 4Archiv. d'opht., t. xi, p. 528, 1891. 
 
 s Bull, et mem. de la Soc. franc, d'opht., 1895, p. 510. 
 6 Journal of the Am. Med. Association, Sept. n, 1898.
 
 PTERYGIUM. 349 
 
 treatment of pterygium, but not to the extent of actually burning the 
 growth, but for its milder electrolytic effect. Among the other 
 procedures employed as adjuncts to pterygium operations may be 
 mentioned conjunctival autoplasty by means of mucous grafts 1 
 and of Thiersch skin grafts. 2 The last mentioned took from behind 
 the ear an epidermic graft somewhat smaller than the scleral defect, 
 and, in order to prevent overlapping of the corneal margin, fastened 
 it in with two fine sutures at a little distance trom the limbus. 
 Grafting is applicable to either ablation or transplantation, and the 
 method of Hotz is an excellent one. Thin epidermis furnishes more 
 suitable material for the purpose than does mucous membrane. 
 It is more easily kept in position, it does not become red and 
 meaty, it is less likely to perish, and its whiteness, lying as it does 
 upon the sclera, is a positive advantage. Such accessory measures 
 are, of course, reserved for the larger pterygia only. 
 
 False pterygium, also known under the names cicatricial 
 pterygium, pseudo-pterygium, and pterygoid, refers to an irregular 
 growth of conjunctiva taking place upon the cornea, as a result of 
 burns and other lesions, and its approach may be from any direction 
 or from several different points at the same time. Under this head- 
 ing may also be placed that unfortunate class of cases wherein there 
 have been recurrences of the pterygium after operations for its re- 
 moval, and there is a sclerotic degeneration of the cornea, or a condi- 
 tion resembling the so-called keloid cornea. Where these are present, 
 are not progressive, and the sight is not greatly diminished in conse- 
 quence, one would better abstain from further operative measures. 
 The exaggerated forms tend more or less to restrict the movements 
 of the globe and to produce strabismus, which constitute additional 
 indications for surgical intervention; and they are often associated 
 with symblepharon (symblepharo-pterygium). In its surgical treat- 
 ment, therefore, false pterygium involves many of the principles 
 which are concerned in operations for symblepharon as well as most 
 of those just described in connection with the true form. No sel 
 methods can be laid down for their operative handling, as they 
 present so great a variety that each case must be separately reckoned 
 with. 
 
 ' S. Klein, Allgem. Wiener med. Zeitung, 1876, Nos. 3 and 4. 
 
 2 F. C. Hotz, of Chicago, Klin. Monatsbl. f. Augenh., 1897, p. 6ic
 
 350 OPERATIONS UPON THE CONJUNCTIVA. 
 
 Great care should be exercised in the process of uncovering the 
 cornea where the destruction of that membrane has been deep, lest 
 the anterior chamber be opened. Optical iridectomy is occasionally 
 required in connection with cicatricial pterygium. 
 
 The tendency of pterygium to return after operations, seems to 
 depend upon the manner of its removal. Failure to cure does not 
 hang so much upon the specific method that is chosen, nor, as was 
 formerly supposed, upon any inherent proneness of these growths to 
 recidivate, as upon the neglect or the lack of certain essential condi- 
 tions. Among the causes of non-success stress is laid upon the 
 following : 
 
 (a) Failure to properly cover the scleral defect or so to fix the 
 covering as to keep it away from the cornea. 
 
 (b) Incomplete removal of the growth from the cornea, especially 
 the head. 
 
 (c) Want of care in placing the conjunctival sutures. Pulling 
 and tearing the delicate membrane, using needles and thread that are 
 too large, and taking with them bites that are insufficient. 
 
 (d) Leaving a thick growth of episcleral tissue at the cornea 1 
 margin. 
 
 (e) Operating when the whole .conjunctiva is hyperemic or 
 inflamed. 
 
 (/) Inadequate bandaging and allowing the patient too much 
 liberty during the first few days after the operation. 
 
 The causes (a) and (d) are those that are, perhaps, most often 
 operative. After having removed a pterygium, no matter by what 
 method, if the sclera adjacent to the cornea is left exposed over an 
 area, say of one-half a square centimeter, the defect were better 
 covered at once. A most satisfactory manner of doing this is by 
 means of a Thiersch graft, as first practised by the late Professor 
 Hotz, of Chicago. The graft is taken from the inner side of the 
 upper arm or from behind the ear, and is cut so that it bridges the 
 conjunctival gap in the vertical sense, but is narrower in the lateral 
 sense. It is placed in the middle of the scleral defect and held in 
 position by two sutures, one above and one below. Thus the graft 
 keeps clear of the cornea. Thiersch epidermic grafts are preferable 
 to those that are shaved from the mucous membrane of the mouth,
 
 PTERYGIUM. 351 
 
 because they remain white, while the mucous grafts never lose their 
 redness. Besides, the latter do not lie so smoothly, but become 
 bunchy from thickening, and from lateral contraction. It is of 
 the utmost importance that the patient be instructed to clean the 
 dead epithelium from the graft every day or two with warm boric 
 acid solution and a cotton swab. 
 
 The other cause of recurrence referred to under (<f) leaving a 
 thick growth of episcleral tissue about the corneal margin can 
 be rendered inoperative by scraping away this growth very thor- 
 oughly, leaving the sclera quite bare. 
 
 Gifford, 1 of Omaha, in an article on "Recurrent Pterygium," 
 cites Knapp's well-remembered warning, viz., "Pterygia that 
 have relapsed after one or several operations and have the aspect of 
 a keloid scar should not be meddled with." Gifford then says, 
 "The condition of this class of patients is so deplorable that it 
 would be unfortunate if this verdict of so high an authority should 
 be considered final. I have seen several of these cases, and my 
 experience has led me to an entirely different opinion." And, 
 further, "My experience indicates that all of these bad cases of 
 recurrent pterygium can be cured if a large enough Thiersch flap 
 or epithelial lip-flap is put on. In doing the operation it is impor- 
 tant, in dissecting back the conjunctiva, to clean the cornea and 
 sclera very thoroughly and to be sure that the flap is well attached 
 to the globe before the lids are allowed to close. The device which 
 I have adopted of fixing the globe in a position of abduction by 
 means of a guy-thread put through the tendon of the external 
 rectus and fastened to the skin outside the external canthus with 
 collodionized gauze to prevent displacement of the flap may be 
 necessary in some extreme cases. But if the flap is pressed down 
 firmly with an absorbent cotton toothpick swab, slightly moistened, 
 so as to bring its entire under-surface into close contact with the 
 globe, and the lids are held open for three to five minutes thereafter, 
 then both eyes kept closed with a rather firm bandage, with plenty 
 of cotton, for 48 hours, failures from displacement of the flap will 
 be rare. 
 
 In applying the latter it is sometimes necessary to tuck the edges 
 in under the loosened conjunctiva, and I have once or twice protected 
 
 1 Ophthalmic Record, Jan., 1900.
 
 352 OPERATIONS UPON THE CONJUNCTIVA. 
 
 he well-applied flap by temporarily drawing the conjunctiva partly 
 over it with a suture. The flap should be slid directly from the 
 razor to the globe. It should be cut large enough, and, after cover- 
 ing the defect on the globe, the excess on the temporal side is trimmed 
 off so as to leave bare the cornea and a strip of sclera about 1/16 
 inch wide between it and the flap." 
 
 What appears at a glance to be a recidivation is sometimes but 
 the vascularized and otherwise changed condition of the cornea 
 in the locality that had been occupied by the pterygium. This may 
 or may not wholly clear up. The immediate status of the vision 
 after the removal of pterygia that encroach even very slightly upon 
 the pupillary area is apt to be disappointing, owing to the fact that 
 there is usually some disturbance of the cornea which extends be- 
 yond the apparent limits of the growth. A little time is required 
 for this to disappear. 
 
 PERITOMY AND PERIDECTOMY. 
 
 According to the researches of Hirschberg the Arabian surgeons, early in 
 the Middle Ages, made circumcision of the cornea for the pannus of 
 trachoma. 
 
 In the year 1862, Fournari or Furnari, 1 of Paris, afterward of the 
 University of Palermo, published the description and the results 
 of his experience with an operative measure which he claimed 
 to have employed with success while previously, for twenty 
 years, a resident of Algeria. The author called it tonsure de la 
 conjonctive bulbaire. It consisted in the excision of a ring of the 
 conjunctiva immediately surrounding the cornea and the applica- 
 tion of nitrate of silver to the annular defect, together with the 
 scarification of the anomalous corneal blood-vessels. Afterward 
 the operation was named peridectomy, and still later syndectomy, 
 both of which words refer to the removal of the aforesaid ring of 
 conjunctiva, and, strictly speaking, should be so used in contradis- 
 tinction to peritomy. 
 
 This last is a term that was applied by Critchett, of London, to a 
 modification of Furnari's operation, which he devised. The chief 
 change suggested by Critchett was that the word implies, viz., the 
 
 'Gaz. med. de Paris, 1862, Nos. 4, 6, 8, 10, 12, 14 et Annal. d'oc., 1863, 
 t. xlix, p. 272.
 
 PERITOMY AND PERIDECTOMY. 353 
 
 substitution of a simple circum-corneal incision for the excision. 
 What Critchett really did, then, was to rehabilitate the old Arabian 
 measure. 
 
 The indications for peritomy and for peridectomy or syndectomy 
 are the same, to wit, a pertinacious vascularity of the superficial 
 portion of the cornea, whether consecutive to trachoma, interstitial 
 keratitis, leucoma, or aught else. The measure has also been 
 resorted to with marked success, especially in Great Britain, for 
 episcleritis, iritis, herpes ophthalmicus, purulent conjunctivitis, 
 and even for glaucomatous tension. 
 
 Peritomy was further modified by Agnew, of Xew York, and was 
 one of his favorite means of dealing with persistent pannus. Having 
 been the fortunate observer of much of Agnew's brilliant work, the 
 present writer was led to adopt the method, has employed it many 
 times, -and almost invariably with gratifying results. It may be 
 thus described: 
 
 Agnew's Method. The eye is carefully cleaned and put under 
 cocain anesthesia. The lids are held apart by the blepharostat. 
 The globe is fixed and the conjunctiva manipulated with delicate 
 mouse-tooth forceps. The conjunctiva is incised all the way around 
 with a pair of small curved scissors whose points are slightly 
 blunted, but whose cutting power, especially at the extremities of 
 the blades, is absolutely irreproachable. It is advisable that the 
 cut be as close to the limbus as possible, hence these qualities in 
 the scissors are insisted upon. Xow the mouse-tooth forceps are 
 exchanged for the broad-jawed fixation forceps. 
 
 While the eye is steadied with these, the severed conjunctiva 
 is pushed backward, all around, to a distance of about five milli- 
 meters, by means of a convex-edged scalpel. With this same 
 instrument the episcleral tissue is also scraped away till the sclera 
 is quite bare and, where practicable, the scrapings ace excised. 
 The larger trunks of the corneal vessels are gently scratched longi- 
 tudinally with the point of the knife, or, what is perhaps better, 
 each of them is touched where it crosses the limbus with a small, 
 red hot, bulbous electrode. Xo clots of blood nor shreds of fibrin 
 should be left about the field of operation. The eye is douched 
 copiously with hot boric or hot salt solution, and the regulation 
 monocular netting bandage is put on. The reaction is usually 
 2 3
 
 354 OPERATIONS UPON THE CONJUNCTIVA. 
 
 insignificant. Upon removing the bandage, if it is found that the 
 conjunctiva is creeping forward, it were best to loosen it up with 
 a blunt instrument, push it back, and smear with vaselin. 
 
 L. Webster Fox, 1 of Philadelphia, has recently made a plea for 
 the rehabilitation of peridectomy, and states that in 108 such 
 operations, performed by him within the past three years, the results 
 had been most gratifying. He further states, "The operation as 
 performed at present consists in excising a strip of bulbar conjunctiva 
 2 to 5 mm. wide surrounding the cornea. The vessels on the cornea 
 at the limbus are scarified by means of a Beer's knife, butnocauterant 
 is employed. The eye is anesthetized by the instillation of cocain 
 (5 per cent, solution) , and excessive hemorrhage may be controlled 
 by the application of adrenalin solution, i to 1000. This is the 
 operation referred to as peridectomy, and should always be combined 
 with treatment directed toward the underlying cause of the corneal 
 vascularity." 
 
 I believe with Fox that the operation, whether it be peritomy 
 or peridectomy, particularly the former, has been unjustly maligned. 
 Among those who speak disparagingly of it is no less a person than 
 Knapp, 2 who says, "I have performed it (in reality peridectomy) a 
 number of times. The result was too uncertain and the danger 
 of sloughing of the cornea was ever present. I think the operation 
 has been generally abandoned." The last two statements are 
 most surprising. Most surprising still, the distinguished author 
 falls into the popular error of confounding peritomy with peridectomy, 
 for he calls the operation by the first name and says that it "consists 
 in the removal of a strip, from 5 to 8 mm. in breadth, of conjunctiva 
 around the cornea." 
 
 In view of the fact that the vast majority of cases wherein such 
 surgery is indicated concerns eyes whose conjunctival sacs are 
 already shrunken, makes peritomy, in my opinion, by far the more 
 rational procedure of the two. Instead of sustaining a loss the 
 conjunctiva is made to gain, in that the pushing back of the bulbar 
 portion tends to deepen the previously contracted fornices. As to 
 the dangers, I have never seen any untoward consequences from the 
 operation. 
 
 1 Annals of Ophthalmology, Oct., 1903, p. 615. 
 3 Norris and Oliver's System, 1898, p. 853.
 
 PERITOMY AND PERIDECTOMY. 355 
 
 It is generally admitted, however, that these measures are only 
 to be resorted to when those of a less radical nature have failed to 
 restore to the cornea its transparency. According to Panas, 1 the 
 worst forms of pannus those known as crassus and sarcomatoid 
 are positive contraindications, for which, among other modes of 
 treatment, he suggests pericorneal cauterism, or igneous peritomy. 
 For large scattering vessels that have become a fixture in the cornea, 
 I have sometimes caused their disappearance by destroying a small 
 section of each trunk at or near the limbus by means of the galvano- 
 cautery. 
 
 1 Maladies des yeux, t. ii, p. 230
 
 CHAPTER IX. 
 
 THE SURGICAL TREATMENT OF TRACHOMA. 
 
 Measures more or less surgical have since the earliest times been 
 employed for the relief of this wretched malady. These measures 
 may be classed as: 
 
 1. Mechanical. 
 
 2. Chemical. 
 
 3. Operative. 
 
 Chief among the mechanical are: 
 
 (a) Scraping, or scratching. 
 
 (b) Expression, or squeezing. 
 
 The chemical are: 
 
 (c) Cauterism. 
 
 (d) Radiation. 
 
 And the operative : 
 
 (e) Curettage. 
 
 (f) Excision. 
 
 (g) Canthotomy (and canthoplasty). 
 (k) Peritomy (and peridectomy) . 
 
 It is worthy of remark that all of these measures, as used in this 
 connection, with the possible exception of electrolysis, radiation 
 and canthoplasty, are as old as history itself, or nearly so. 
 
 i. MECHANICAL TREATMENT. 
 
 (a) Scraping or Scratching. This is probably the most ancient 
 of any of the methods enumerated. Under the same heading one 
 may class massage. Primitive peoples afflicted with trachoma, 
 in seeking relief from the itching and other irritating effects of 
 the disease, early learned to evert the lids and rub the granulations. 
 For this purpose they usually sought some implement with a rough 
 
 356
 
 MECHANICAL TREATMENT. 357 
 
 surface or a sharpish edge fig-leaves, bits of broken pottery, 
 etc. Capt. Cook, on his first visit to one of the hitherto unknown 
 isles of the Pacific, saw a native mother holding in her lap a tra- 
 chomatous child whose everted lid she scraped with a chip of wood. 1 
 Hippocrates, to remove the granu ations, made use of a tightly 
 wound mop of raw wool. The name of the mop was Ophthal- 
 moxistron, and of the scrubbing ophthalmoxysis. Paulus, of 
 ^Egineta, employed a similar instrument which he called a Uepliaro- 
 \~ystr on, and the operation he named blepharoxysis. With these 
 crude things they rubbed until they exposed the tarsus, then applied 
 powdered drugs or the cautery to the denuded part. Severus 
 decried these rude procedures, preferring massage. This was 
 either simple, that is,' with the bare finger or other smooth object, 
 or medicamentous, that is, with the addition of unguents, etc. There 
 have been numerous revivals, within modern times, of the exact 
 principles involved in these ancient practices, and to the same end, 
 though, naturally, with improvement both as to the manner and 
 means. The first modern revival by Woolhouse, in England, at the 
 end of the i8th century, yet with an instrument little in advance 
 of the original ones, seeing that it was a brush made of barbs of 
 grain. The next was by Borelli, in 1859; then, later, by several 
 others; and still more recently (1891) by a number of French 
 oculists and a few in other countries. The French have called the 
 process variously as Brassage, radage, grattage, etc. It is not an 
 extremely bad measure, but it is far from being as good as some 
 others. That of massage, on the other hand, is a most excellent 
 one; particularly the medicamentous kind, recommended some 
 years ago by Below. 2 This consists in rubbing strong solutions of 
 sublimate, i-^oo up to i-ioo, into the infiltrated conjunctiva. 
 After an experience of ten years with like methods, I most heartily 
 commend it to my colleagues. Since the introduction of the organic 
 silver preparations I have found this form of massage particularly 
 effective. There is hardly a stage of the affection to which it is 
 
 1 To prove that such pristine practices have not wholly passed, the 
 writer, not long since, knew a young man who carried in his vest pocket 
 a fragment of window-pane with which he would, from time to time, 
 scratch the upper borders of his inverted tarsi. The trachoma bodies in 
 this instance were scarred veterans, and the noise that he made with his 
 "scratting" was anything but musical. 
 
 2 Jour, de med. russe, 1885.
 
 nu 
 
 f"-i fl||li( ttble, ilioiij/li it is ;{> iwlly valuable where other mean* 
 ftffc ronlrttlndi(Mfed. TIM- writer |>f.' follow*; "The lids 
 
 .ft< <-lwtfi*rd infernally with warm boric acid golutfon. They are 
 
 theft everted (Hid M single drop of adr< n.ilm ^olulion put onto the 
 conjunctive A small hard mop i* rr.ad<- by winding absorbent 
 cotton on I IIP lip of a carrier, Thlf if dipped mio,-. very hot solution 
 
 of sublimate, about I 250 In atMii'ih. ihe lid in again everted and 
 llw nlTw1t*d conjimclivu rubbed. The rubbing nhould be neither 
 loo dt*llcittp nor loo rough, and ni prolon/M-'l lu-yui'l a minute or 
 two, dipping lht' mop In the hot Miblim.iir n., ,,n-i tiicji, but never 
 lenvlllg Ut1 MM** of llqiiiil "n il, |o run 'l\vn over the ( onic;i ;irir| 
 hndlhy portions of the COnJtUU tlvt, Tlicn, without replacing the 
 lids, Ihe whole mueoiiH Ke is copiously mi-.iird for another minute 
 wllh 4 VI boric tvdd lOlutlon, 04 /'"/ CM "/ /" l>nn-. And, lastly, 
 It drop Of COCfclfl lOlutior i put m This is repealed with two day 
 Intervals, nnd, on the alternate days precisely the same is done 
 t'Mv|'lmi', lh. n i ,', .olulion 'l argyrol is substituted for the 
 sublhnulo, II propel l\ . arried out, there is no irritalion after either 
 t rent men I." 
 
 (b) ExprilSlion ol the Ivmphoid material from the trachoma 
 Collides, in order to hasten the cure, is by MO means a reecnt idea, 
 ll \\J\H fomUMh ICCOmplithed b\ me. ins ol ihe imj-,i-r nails, and was 
 called MH,CM </>'(>>/'(). \ number of attempted revivals of it had 
 occurred in the last ecnlurv. as. for example, by Kble i^iSjS). 
 ISU ^854)* and Tui^net U^7 V 0. It \vas not. however, until its 
 xtrwng nduH^u \ b\ Hot.-. 1 of Chicago, in u^So. that its day really 
 ;\mwd; rtd it looks as if it had come to stay. Hot/, first used his 
 thumb Urtils* but soon havl the jaws ot a pair of old angular forceps 
 made smooth tor this purpose. If I mistake not, this was the original 
 evpwssivW totwp'S, Then followed, in iSoi. Prince's ring forceps, 
 NvAiV trough jaxuxl torvcj^ and Knapp's roller forceps, all in 
 v(uick MKYttKuon ^ci v riatt VI), The next year the writer suggested 
 A tVg f\n\^|vs m^do ot x uvftoise-shcll *s an imprxnement over the 
 U in that U would nv>t admit of the same forceful application 
 The cornnwn fault of these instruments is the 
 txertevl xqx the membrane in stripping the
 
 jff;r:HAMCAL TREATMENT. 
 
 
 ;n that of Knapp, designed after the principle of a mangle, 
 does not objection. Could one invent a practical 
 
 roller for vhich an intrinsic force, other than the pull on the 
 
 handle, would impart the rotation to the tightly clamped rollers, it 
 would be ideal. Say a band, chain, gear, or screw. Lacking this, 
 the best and most available instrument is the expresser of Kuhnt. 
 the working part of which is composed of two coapting, perforated 
 metal plates . The perforations are so arranged that no two come 
 
 FIG. 206. 
 
 opposite, one to the other, and the expression is effected by simple 
 pression, i.e., without traction. In cases of advanced gelatinous 
 degeneration of the fornices, the mere inversion of the lids causes 
 laceration and bleeding. For these Kuhnt has had constructed 
 what, he terms a modified expresser, one plate being perforated and 
 the other solid. This he inserts beneath the uninverted lid, finds 
 the infiltrated tissue, and makes gentle pressure. The expressers 
 are made of varying shapes and sizes, in order that one may reach 
 any part of the conjunct! val sac (Figs. 206, 207, 208 and 209). 
 
 FIG. 207. 
 
 Expression is highly efficacious in selected cases. It shortens the 
 course of treatment, forestalls ulceration of the cornea, prevents 
 pannus, and reduces cicatricial contraction to the minimum. It is 
 almost painless under the topic application or the submucous 
 injection of cocain. It is simple of execution, and safe as to con- 
 sequences. Patients may be operated on and allowed to depart 
 at once for home, provided they live within calling distance, being 
 instructed to keep quiet meanwhile and to bathe the lids with very 
 hot water. For it must not be understood that they need no after-
 
 3 6 
 
 OPERATIONS UPON THE CONJUNCTIVA. 
 
 treatment. For one thing, it must be particularly seen to that ad- 
 hesions do not form between contiguous portions of the membrane 
 made raw by the operation. To this end, during the first days 
 thereafter, frequent examinations and, mayhap, the use of a probe, 
 are needed to prevent the formation of cavities and pockets. These 
 would only help to obliterate the already shallowed cul-de-sacs. 
 Repetitions of expression are required as long as any lurking 
 follicles can be discovered, always with a wholesome mistrust of the 
 
 FiG. 208. 
 
 fornices and the semilunar fold; and appropriate medical treatment 
 is to be continued until the cure is complete. 
 
 The technic of the process of necessity varies somewhat with 
 the kind of instrument employed, but is mainly such as common 
 sense and a thorough knowledge of the nature of the disease and of 
 the tissues involved would dictate. The principal things to be 
 avoided are undue traumatism of the conjunctiva and injury to the 
 corneal epithelium. The prolonged action of cocain, it must be 
 remembered, is bad for the cornea. Every infiltrated follicle must 
 
 FIG. 209. 
 
 be sought out and emptied at the one sitting. After finishing and 
 before replacing the lids, free irrigation of the entire conjunctival 
 surface with hot boric acid or normal salt solution is indispensable. 
 The time for expression is toward the end of the first, or at the 
 beginning of the second, stage of the disease, i.e., when the granules 
 have become soft or "ripe." This condition occurs when the in- 
 filtrated follicles take on a grayish or yellow-gray tint. Then the 
 affected folds and lobules of the fornices are plump but quiet. It is
 
 CHEMICAL TREATMENT. 361 
 
 then that the trachoma bodies assume the appearance so often re- 
 ferred to as that of "frog-spawn" and of "boiled sago." All 
 authorities agree in advising against expression in acute trachoma, 
 or during the first half of the chronic stage, or in a blennorrhagic 
 period, be it in the beginning or during an exacerbation. The most 
 violent outbreaks call for the mildest measures. This is one in- 
 stance where a desperate case does not demand a desperate remedy. 
 
 2. CHEMICAL TREATMENT. 
 
 (c) Cauterism. In its broadest sense this termrefers to the use of 
 both escharotic mineral substances or caustics and the actual or 
 thermic cautery. Caustics will not be considered. The ancient 
 Greeks and Romans and the physicians of the Middle Ages regularly 
 resorted to cauterization for affections of the conjunctiva, and often 
 in conjunction with scraping or scarifying. To judge from de- 
 scriptions in their writings, of the implements with which it was 
 done, and from relics of the same that have been preserved, they 
 seem to have taken great pride in these outfits. The first in 
 modern times to employ the cautery for trauchoma was Samel- 
 sohn, in 1857. He selected the more advanced cases for its applica- 
 tion, touching the separate follicles with a tiny tip of a galvano- 
 cautery (punctate cauterization). Reich (1888) and Burchart 
 (1889) were strong supporters of the galvano-cautery for trachoma, 
 but rightly limited its use to the recent cases. Indeed, it is ad- 
 missible at an earlier stage than any other surgical measure. For 
 the extensive infiltrations, to be properly applied, it is very tedious, 
 requiring many sittings. But for isolated granules and as an 
 auxiliary to other forms of treatment, it is most excellent. To 
 hasten matters, G. Lindsay- Johnson, of London, has resurrected 
 the ancient combination of scarification and cauterism, first in- 
 cising the conjunctiva horizontally with his triple knife and then 
 tracing the cuts with electrolysis. Neither thermic nor galvanic 
 cautery nor electrolysis have had many partisans of late. They 
 mostly add to the scarring. 
 
 (d) Radiation. Much is hoped for in the treatment of trachoma 
 or, rather, much has already been accomplished and much more is 
 hoped for from the comparatively new therapeutic agents- -X-rays
 
 362 OPERATIONS UPON THE CONJUNCTIVA. 
 
 and radium. Like caustics, they hardly have a place in this treatise, 
 and the reader is referred for details of their management to other 
 sources. Suffice it to state that none but those thoroughly con- 
 versant with the properties of these subtle things should attempt to 
 avail themselves of their virtues, for they are as potent for evil as for 
 good. 
 
 3. OPERATIVE MEASURES. 
 
 (e) Curettage. Along with this goes scarification, and both 
 are but phases of primitive methods, such as pricking, scratching, 
 and scraping. The Arabian surgeons Isaac Judeus and Rhazes, 
 a thousand years ago, recommended the sharp spoon for getting 
 rid of trachomatous follicles. Its use was again brought to the 
 front by Bardenheuer, of Cologne, in 1877. The best known and 
 most approved method of employing it is that of Sattler, of Leipsig. 
 After incising each individual follicle, this surgeon proceeded to 
 lade out its contents with a very small curet. Like cauterism, it is 
 not adapted to voluminous infiltrations because of its tediousness 
 and the increased cicatrization that it causes. Unlike it, however, 
 it is not suited to the earliest stages, but to the scattering granula- 
 tions that have escaped other kinds of treatment. 
 
 (/) Excision. The fornices, especially the upper, are the store 
 houses or reserve stations of the trachomatous infection. And, 
 as regards resistance to the attacks of any ordinary antagonist, the 
 deeper recesses of the upper fornix are veritable strongholds. They 
 often successfully resist all medical and mechanical treatment. 
 It is from these that start the relapses that have made the han- 
 dling of these cases so discouraging. Not only does the upper 
 fornix afford the best harbor for the poisonous germs, but the best 
 soil as well. So that, when cured cases are again exposed to a 
 trachomatous environment, the upper fornix has been oftenest the 
 site of a reinfection. Knowing these things doubtless, as well as the 
 fact that the cutting out of a fold of swollen or infiltrated conjunctiva 
 is often mentioned in the Hippocration and other old medical 
 writings, may have been the motive behind the active recourse to 
 surgery in fighting the tremendous epidemic of trachoma that in 
 Europe followed the Wars of the Empire. It is certain that these
 
 OPERATIVE MEASURES. 363 
 
 considerations actuated Bendedict, in 1822, to remove an occasional 
 fold from the cul-de-sac, and Galezowski, in 1874, to excise the three 
 upper retro-tarsal folds bodily. Galezowski's experiences with the 
 measure must have proven most satisfactory, for he has been in- 
 dustriously at it ever since. Who has not seen thp cavalier manner 
 in which he went about it! 
 
 Seeing that the tarsus was also often the seat of the trachomatous 
 affection and its complications, Heisrath, of Konigsberg, a pupil 
 of Jackson, in 1882, proposed, in fit cases, adding to the exsection 
 of the fornix that of the diseased portion of the adjoining tarsus. 
 Heisrath's idea was taken up and elaborated by Vossius and by 
 Kuhnt. The last-mentioned has been especially instrumental in 
 furnishing details as to the indications and in working out an ap- 
 proved technic. So closely identified is the School of Konigsberg, 
 i.e., now, Professor Kuhnt, with everything pertaining to trachoma 
 and its handling that it (or he) is rather looked to as the fountain- 
 head of such lore. It is to this source, therefore, that the author is 
 indebted for most of what follows on this subject. 
 
 In this connection there are three kinds of excision, to wit: 
 
 1. Simple. 
 
 2. Isolated. 
 
 3. Extirpation. 
 
 i. Simple excision means the removal of a strip of the infiltrated 
 conjunctiva, its dimensions being regulated by the requirements 
 present. Kuhnt restricts its application almost exclusively to the 
 lower fornix. Its indications are: 
 
 First. When the other methods have failed or when there are 
 recidivations. 
 
 Second. When the tarsus or the bulbar conjunctiva are be- 
 coming involved. 
 
 Third. When there are corneal complications. 
 
 Fourth. When the patient comes from a trachomatous district 
 and will go back to it. The operation is contraindicated when the 
 conjunctiva is at all scant. 
 
 Technic of Simple Excision of the Lower Lid. A few minims 
 of a 10% cocain solution are dropped into the conjunctival sac, and 
 a few drops of a 6% solution of the same are injected into the folds
 
 364 OPERATIONS UPON THE CONJUNCTIVA. 
 
 themselves. The upper lid is held back by an assistant with a 
 sublimated cotton sponge. The patient is made to look far up- 
 ward, the operator everts the low r er lid with his left hand, while with 
 his right he takes a pair of curved scissors, places them, convexity 
 downward, on the conjunctiva, and begins the incision from the 
 outer side. The plica semilunaris, if also affected, would better be 
 left for another sitting. If deemed necessary to excise it at once, 
 the resulting wound should not be continuous with that in the 
 fornix, else an ugly scar will ensue. Sutures are usually omitted. 
 After the instillation of atropin and dusting the opening with 
 airol, the eye is bandaged. The dressings are removed at the end 
 of 48 hours, and the conjunctiva is washed with sublimate solution, 
 1-5000. 
 
 2. Combined excision consists in cutting out the trachomatous 
 transition folds together with the affected part of the adjacent 
 tarsus, and its sphere is limited to the upper lid. The lower tarsus 
 never requires exsections. The indications for this muco-tarsal 
 excision are: 
 
 First. In all chronic forms of trachoma, with characteristic 
 follicles, associated with infiltration of the tarsus, w f hether the 
 cornea is involved or not. 
 
 Second. In extensive chronic trachoma of the fornices and palpe- 
 bral conjunctiva, independent of the condition of the tarsus, if 
 the cornea is involved or about to be. 
 
 Third. In gelatinous trachoma, even when mainly confined to 
 the fornices, if the convex edge of the tarsus shows typical thickening. 
 
 Fourth. In already cured trachoma of the fornices if the palpe- 
 bral conjunctiva and tarsus are gelatinous especially if, in addition, 
 there is secondary affection of the cornea. 
 
 The contraindications are: 
 
 First. Recent cases without corneal complications. 
 
 Second. The advent of the stage of scarring, and the granular 
 process has ceased or is in the act of ceasing. 
 
 Third. Marked tendency to shrinkage (Xerosis) of the con- 
 junctival sac. 
 
 Technic. The eye is prepared as for simple excision. The upper 
 lid is inverted and two pairs of special fixation forceps, with catches, 
 are made to grasp the tarsus near its extremities, in the horizontal
 
 OPERATIVE MEASURES. 365 
 
 sense, and are locked. An assistant, standing at the patient's 
 head, takes the forceps and rotates them so as to still further turn 
 the lid, the patient meanwhile being directed to look forcibly down- 
 ward, thus bringing the fornix into view. The first incision, through 
 conjunctiva only, is parallel with the convex border of the tarsus, 
 and far enough back to include the diseased folds. The purplish 
 muscle of Miiller is here to be avoided. Three sutures are now put 
 through the posterior lip of the wound from the epithelial side, and 
 it is undermined nearly to the globe, while making traction on the 
 threads. The two forceps are now removed, the operator seizes 
 the free border with a Blomer's forceps and the aid places a Jager 
 spatula behind the inverted lid as a support for the second or tarsal 
 incision. This begins at the inner and extends to the outer canthus, 
 uniting the extremities of the first incision, and includes both con- 
 junctiva and tarsus. It curves slightly toward the first incision so 
 as to leave greater width of tarsus at the center. The widest part 
 of the island thus surrounded should not be more than i 1/2 to 2 
 centimeters. The tarsal portion of the island is carefully dissected 
 out with blunt-pointed scissors, hugging the outer surface of the 
 tarsus, and avoiding the orbicularis and the muscle of Miiller. The 
 lid is closed, the sutures drawn down straight, the point where each 
 emerges from the free border is noted, the lid turned back, and the 
 needles put through the remaining strip of tarsus at the points indi- 
 cated, coming out on the conjunctival surface. The threads are 
 tied in single knots, the lid again turned down, and the patient 
 directed to open and close the eyes. If there be any puckering of 
 the lid, it may be best to evert and make further dissection of the 
 posterior flap before tying finally. Ends of thread an inch long are 
 left to facilitate removal. Before the bandage is applied scopolamin 
 is instilled and airol dusted on. The bandage is changed on the 
 third day, and on the sixth day the sutures are removed and the 
 bandage left off (Figs. 210 and 211). 
 
 The author has made a number of these combined excisions at 
 the Illinois Eye Infirmary during the past three or four years, and 
 would suggest certain modifications of the technic as just given. 
 First, with regard to the incision through the tarsus. Instead of 
 making it perpendicular to the plane of the tarsus, he would make 
 it slanting upward, as shown in Fig. 210, where the heavy black
 
 366 OPERATIONS UPON THE CONJUNCTIVA. 
 
 line indicates the parts excised. This conduces to less uneven- 
 ness in the resulting cicatrix. Second, as to the placing and tying 
 of the middle sutures. The usual way is to pass them first through 
 the flap, from the conjunctival surface, then through the remnant 
 of the tarsus to emerge and be tied on the conjunctiva. Now, to 
 avoid contact of the knots with the cornea, which is dangerous as 
 well as painful, he would advise the use of fine, double-armed 
 
 FIG. 210. Excision of tarsus. The heavy black line surrounds portion 
 excised in extreme cases. 
 
 sutures, introduced as follows: one needle passed through the flap of 
 conjunctiva from the epithelial side, then through the remnant of 
 tarsus, coming out at the free border almost in line with the cilia 
 (Fig. 21 1). The other needle is made to pass through the tarsus 
 in a similar manner, but slightly in front and to one side of the track 
 of the first needle. Both needles are not put through the flap of 
 conjunctiva. The two ends of thread are tied over a long slender 
 cylinder of gauze or absorbent cotton that will fold upon itself 
 without getting into the palpebral fissure. Two such double-armed 
 sutures are required. The two outer sutures are knotted in the
 
 OPERATIVE MEASURES. 
 
 367 
 
 usual way, i.e., on the conjunctival surface. Indeed, if the exsection 
 of tarsus reaches almost to the free border and, as is often the case, 
 the angle there, with the muscle of Riolani has been whetted away, 
 the second needle is not needed the end of thread being simply 
 brought around to be tied to its fellow. 
 
 Kuhnt considers the combined excision the best prophylactic 
 against pannus. 
 
 FIG. 211. Combined excision of the tarsus. Disposition of sutures. 
 
 3. Isolated Excision of the Tarsus. In this procedure all of 
 the upper tarsus but a narrow strip at the free border is excised; 
 but the overlying conjunctiva is spared. Kuhnt, its author, considers 
 it valuable in the cicatricial stage after the original disease has 
 disappeared, leaving a thick, infiltrated tarsus, exciting pannus, and 
 as a preventive of ptosis and slow atrophy. It is also deemed useful 
 in cases of shrunken and incurvated tarsi, as a relief from entropion, 
 whether or not pannus exists. 
 
 Technic. An assistant grasps the margin of the lid with the 
 Blomer forceps, everts it, and places beneath the now inverted tarsus 
 the Jager spatula. The operator makes an incision through, and
 
 368 OPERATIONS UPON THE CONJUNCTIVA. 
 
 the whole length of, the tarsus 21/2 mm. from the free border, 
 taking care not to wound the fascia underlying the orbicularis. The 
 conjunctiva is dissected from the tarsus, leaving the latter exposed. 
 The cartilage is then separated from the pretarsal connective tissue 
 up to the convex border by means of blunt-pointed scissors, and, 
 lastly, it is detached from the levator tendon. As a rule, sutures are 
 not required. The after-treatment is the same as for the combined 
 excision. 
 
 The operation just described is, I believe, comparatively seldom 
 resorted to. The combined excision, however, is in constant requisi- 
 tion in Konigsberg. Kuhnt alone has performed it more than 
 5,000 times. He sums up the results thus : 
 
 1. The course of the disease is shortened, the time required for a 
 case being, on an average, six weeks, including after-treatment. 
 He declares that expression cures only 10% of the cases, while 
 excision cures 50 to 60%. 
 
 2. Secondary corneal disease is prevented, or, when present is 
 more quickly cured. 
 
 3. The mechanical ptosis is corrected. 
 
 4. Recurrences are less frequent. 
 
 The objections to the measure that have been urged are too much 
 loss of conjunctiva, limitation of ocular movements, and serious 
 cicatricial contraction. To obviate the first, Kuhnt operates only 
 upon eyes with sufficient conjunctiva. As to the second objection, 
 he counsels the invariable conservation of the bulbar conjunctiva, 
 even when it is infiltrated, and treating it by medical and mechanical 
 methods. With respect to the third, it is declared that since only 
 portions of the conjunctiva and tarsus are excised and all the deeper 
 tissues are avoided, the resulting scars are superficial hence 
 harmless. 
 
 It is rather singular that so fe\v operations of either simple or 
 combined excision are made for trachoma in this country. We 
 have large areas in the State of Illinois where trachoma is endemic 
 and has been for fifty years or more. Vast numbers of the victims 
 are treated both in Chicago and in St. Louis, yet one rarely hears 
 of even simple excision; more rarely of combined. Two reasons 
 occur to me for this: First, the character of the people. They are 
 of a peculiar type shiftless and ignorant beyond belief and from
 
 OPERATIVE MEASURES. 369 
 
 some unexplained cause, the majority come for treatment in the 
 very last stages of the disease. Second, as regards the minority 
 who come in the early or middle stages, they are, for the most part, 
 so circumstanced, either from being cared for in a charitable institu- 
 tion, or from having nothing to call them home, that they are content 
 to worry along with conservative measures. When it comes to a 
 discussion of more radical steps the surgeon in charge, unlike our 
 European confreres, in like situations, has precious little to say in 
 the matter. The reason we do not make enucleation of the tarsus 
 (isolated) oftener in these old cicatricial cases is, I fancy, because 
 of the high state of efficiency to which the combination operations 
 for trachomatous entropion and trichiasis have been brought in 
 the United States. 
 
 A New Method of Operating in Pannus. Primrose, 1 William, 
 Glasgow. This writer describes a very simple operation which he 
 has found satisfactory; it consists in causing an extravasation of 
 blood into the subconjunctival tissue around the cornea, which by 
 mechanical pressure and irritation sets up localized inflammation 
 and thus causes obliteration of the vessels which vascularize the 
 cornea. The point of a small sharp-pointed knife is passed through 
 the conjunctiva 2 or 3 mm. from the cornea, made to puncture one 
 of the large blood-vessels, and then withdrawn. The conjunctival 
 wound should be as small as possible and oblique; in this way there 
 is no external hemorrhage; the subconjunctival bleeding is arrested 
 by pressure of the extravasajed blood upon the vessel walls, and thus 
 many of the smaller vessels are closed; this mechanical action is 
 increased by the information of a coagulum, the fibrinous part of 
 which shrinks. 
 
 " Extravasated blood acts as an irritant, probably chemical as well 
 as mechanical, so a non-infective inflammation is set up which re- 
 sults in the absorption of the blood-clot. This process acts as a 
 counterirritation to the inflammation of the corneal tissues and so 
 tends to remove the seat of inflammation and the supply of blood 
 from the diseased cornea to the clot, where the effects of the inflam- 
 mation are comparatively trivial. By the time the blood-clot has 
 disappeared the blood-vessels in the cornea affected by the operation 
 have shriveled up and the cornea has regained much of its trans- 
 
 'The Lancet, April 21, 1906. 
 24
 
 370 OPERATIONS UPON THE CONJUNCTIVA. 
 
 parency. The whole pannus may be treated in this way at one 
 time or the operation may be repeated from time to time, only 
 a part of the pannus being treated each time. The latter is always 
 advisable when the pannus is marked, as the inflammatory reaction 
 is sometimes very severe and accompanied by a good deal of pain. 
 Although the structures in the anterior part of the eyeball are all 
 more or less affected by the inflammation, this is easily controlled 
 and subsides in a few days with the application of suitable remedies." 
 In the classification of surgical measures for trachoma given at 
 the beginning of this chapter occur two other operative ones, viz.: 
 (g) canthotomy and (h) peritomy. The technic and the indications 
 for them have been given elsewhere in this volume, and they are 
 mentioned here only by way of completing the list.
 
 CHAPTER X. 
 OPERATIONS UPON THE GLOBE. 
 
 FOREIGN BODIES IN THE CORNEA. 
 
 About two-thirds of all the foreign bodies that enter the eye find 
 lodgment in the cornea. Fortunately, most of them are tiny 
 particles that strike with feeble momentum, such as bits of cinder, 
 iron, emery, etc., and do not penetrate beyond Bowman's membrane, 
 and, once located, their removal is simple. Whatever of difficulty 
 attends the operation is, usually, that of finding the offender and 
 keeping it in view. A particle so minute as to be invisible to the 
 unaided eye can be the source of great and prolonged irritation. 
 Such a foreign body is particularly hard to see when its color offers 
 no contrast to that of the iris or pupil and when it has but recently 
 entered the cornea. After resting in the same place a few days 
 a tiny zone of gray infiltration surrounds it, which serves better 
 to reveal its position. If the characteristic symptoms are present and 
 careful inspection in bright daylight and with the use of convex 
 lenses and focal illumination fails to show the foreign body, recourse 
 is had to artificial light and the binocular loop. The patient is 
 placed where a good artificial light is near on the side of the affected eye, 
 almost any kind of light will do, but if it be an unground incandescent 
 electric lamp, it were better to cover the bulb with a sheet of white 
 tissue-paper. Again, oblique focal illumination by means of a 2- or 
 3-inch biconvex lens, of large diameter, while the operator wears, 
 strapped to his head, a binocular loop. Search is made by directly 
 concentrating the rays upon the epithelium, i.e., keeping the image 
 of the lens as much out of the way as possible. If this fails, 
 a broad image of the lens is thrown on to the cornea, and in 
 the area of this reflection is sought a break that might indicate 
 the mote. Specks of transparent substances, like glass or sand, 
 will sometimes elude any form of seeking except the last. If the 
 quest prove specially trying, a drop of i % fluorescin solution put on
 
 372 OPERATIONS UPON THE GLOBE. 
 
 the cornea would aid by causing a tiny green stain at the site of the 
 foreign body. Throughout all the scrutiny the patient is told to 
 turn the eyes in various directions to favor the search. Having once 
 found the foreign body, it is easily seen afterward. If the eye has 
 not already been prepared, it is now. One should be as scrupulous 
 as to cleanliness of everything concerned as if for an extraction of 
 cataract. Warm boric acid solution is the best thing with which to 
 bathe and douche the eye. Cocain, or its analogue, is all that is 
 needed in the way of anesthesia. I have never yet had to resort to 
 narcosis, yet one can imagine how this might become necessary. 
 In cases of little children, they are put in the position described 
 under "Applications and Dressings." If there be much hyperemia, 
 a drop of adrenalin chlorid or similar solution is put in just before the 
 anesthetic to blanch the conjunctiva. 
 
 The best all-around form of instrument is the sharp, grooved 
 spud or gouge (Plate II, No. 42), thoroughly disinfected. A dis- 
 cission needle is also a good instrument, provided it is not too sharp. 
 The foreign body being of the kind that requires artificial light to 
 show it, the lens to illuminate the spot is held by an assistant. If 
 no one is by to help, the best substitute is one of the several forms 
 of lens-holder. This is a head-band with jointed ball-and-socket 
 bracket for carrying the lens, and is made fast to the patient's 
 head. If this is not available, the patient, if one of average intel- 
 ligence, can be made to focus the light, meanwhile supporting the 
 hand that holds the lens against the cheek. 
 
 Mode of Procedure (Fig. 212). The patient, with a towel cover- 
 ing the hair, is placed in an ordinary chair of suitable height, behind 
 which stands the operator. No lid speculum is used, as this would 
 necessitate fixation forceps also. The head is held firmly against 
 the surgeon's breast by pressure of the base of the left palm on the 
 forehead, while the eye is held open and the globe is steadied by 
 pressure of the first and second fingers, the first upon the upper lid 
 and the other upon the lower. The patient is made to look in the 
 direction that gives the best view of the foreign body, \vhich is lifted 
 out in such a way as to produce least disturbance of the corneal 
 epithelium. The practice of using very blunt instruments or of 
 wiping the foreign body off the cornea with a mop made by wrap- 
 ping cotton upon some small implement cannot be too strongly
 
 FOREIGN BODIES IX THE CORNEA. 
 
 373 
 
 discouraged. If it be a particle of iron or steel, a reddish stain will 
 be left behind; if a cinder or bit of emery that has entered the eye 
 while very hot, its bed will be a whitish eschar, and, if some days 
 have elapsed since the accident, it matters not what the nature of the 
 substance is, a layer of softened tissue will surround the foreign 
 
 FIG. 212. 
 
 body. In every case the little excavation should be scraped clean 
 by a sort of rotary handling of the gouge. If this is not done, the 
 condition of the eye may be worse than before. In the process of 
 loosening the foreign body and cleaning out its bed it is best that, in 
 a general way, the movements of the point of the instrument be
 
 374 OPERATIONS UPON THE GLOBE. 
 
 directed toward the center of the operative field and from every part 
 of the periphery. Thus one avoids leaving tags of epithelium and 
 flaps of Bowman's membrane around the place to harbor bacteria 
 and increase the dangers of infection. After the operation, another 
 copious douching of the cornea with warm boric acid solution and 
 instruction that the eye be bathed a time or two in very hot water, 
 and all is done that most cases require. A class of corneal injury 
 common in the United States is that from explosions of gunpowder, 
 and requires a management quite peculiar. The unburnt grains go 
 rather deeply into the cornea, but rarely perforate it. To dig at 
 them, particularly when the injury is recent, but results in further 
 traumatism without attaining the main object. Even when one 
 succeeds in removing a grain, it is broken, and a black stain remains 
 behind. It is best to wait from 48 to 60 hours, meanwhile watching 
 the eye and keeping it from infection by mild antiseptics, and 
 under other appropriate treatment, when it will be found that the 
 grains have become loosened. If the eye is then irrigated copiously 
 with boric acid solution, cocainized, the patient put in the recumbent 
 position and a few drops of H 2 O 2 instilled, the lids being held apart 
 to allow the liquid to overlie the cornea, most of the impacted 
 foreign material, be it powder or other debris, will come away. The 
 peroxid attacks the softened envelope, and the gas that is generated 
 forces the foreign body out. At the same time, the powder that is 
 in the lids and face is treated by rubbing the skin vigorously with 
 absorbent cotton wet with the peroxid. 
 
 Larger foreign bodies have often to be dealt with differently. 
 Jt may be that one has struck the cornea so obliquely and with such 
 force as to have plowed its way for some distance beneath the sur- 
 face. It were best here to slit up the track of the foreign body before- 
 attempting to dislodge it. Or, again, a particle may have stopped 
 just short of dropping into the anterior chamber and yet not be ac- 
 cessible by forceps, and so nearly through that it were unwise to use 
 the gouge. In this case one might have recourse to the method of DCS 
 marres, viz., that of passing a broad needle or .Beer's knife through 
 the base of the cornea into the anterior chamber immediately beneath 
 the foreign body. Upon the ensuing evacuation of the aqueous, 
 the blade of the instrument will tend to press the piece upward, and, 
 at the same time, form a solid foundation upon which to work. Jf
 
 ABRASION OF THE CORNEA. 375 
 
 the foreign body be of steel or iron, however, and so imbedded that 
 it cannot readily be got at with other instruments, it can surely be 
 removed by some form of magnet. If sufficiently loose, a horse-shoe 
 magnet or the Gruening pocket-magnet. If more tightly fast, 
 the Hirschberg electro-magnet or the giant electro-magnet of Haab, 
 or a moditicution of it. Traction should, of course, be from the 
 same direction as that in which the foreign body entered. More 
 explicit instructions for the use of the magnet are given in the 
 chapter on "Foreign Bodies within the Eye." Atropin and an 
 occlusion bandage, in addition to the mild antiseptic irrigation, 
 are the rule in the severe cases. 
 
 ABRASION OF THE CORNEA. 
 
 This consists in scraping, shaving, or excising from the cornea 
 varying amounts of its substance for the removal of opacities. It 
 is a very old procedure, having been practised long before Galen's 
 time. This surgeon employed it for certain forms of superficial 
 corneal opacity. Malgaigne, 1 having concluded from experiments 
 upon animals that half the thickness of the cornea could be re 
 moved without leaving an opacity, proposed giving the opera- 
 tion a much wider range of application. Notwithstanding, tin- 
 fact remains that, owing to their depth and the replacing of the 
 lost substance by opaque tissue again, very few of the many forms 
 of opacity will yield to such treatment. This is not to say, how- 
 ever, that the operation has not a wide sphere of usefulness. 
 This is particularly true of the scraping method. 
 
 Indications. It is most frequently indicated in deep slow 
 ulcers, such as those at or near the center that have been left from 
 phlyctenular keratitis, the removal of foreign bodies, etc. These, 
 being so removed from the vascular zone, often become tilled with 
 a mass of detritus and all efforts at repair cease. It has also been 
 extensively used in the more active, infectious ulcers of the cornea. 
 principally in the serpiginous. Meycrhofciv instituted a method for 
 the treatment of such ulcers that has been extensively followed, \i/., 
 curetment of the ulcer and its infiltrated border with a small 
 sharp spoon, filling the remaining cavity with iodoform powder 
 
 ' Annal. d'oculist., 1843-45. 
 * Kl. Mbl. F. A. S. 151, 1884.
 
 376 OPERATIONS UPON THE GLOBE. 
 
 and bandaging. The lost substance is thought by many to be 
 replaced much more quickly and with less opacity after abrasion 
 than after the cautery. In the days when collyria containing suba- 
 cetate of lead was such a universal remedy for "sore eyes," abra- 
 sion was frequently and successfully called into requisition for the 
 removal of the peculiar, opalescent metallic deposits they occasioned. 
 One rarely sees them nowadays. Other indications are the thick- 
 ened, opaque epithelium resulting from pannus, the so-called girdle- 
 shaped opacity, the black film caused by powder explosions, and 
 characteristic chalky deposit consequent upon certain chronic 
 diseases of the eye, especially those of the uveal tract. This 
 deposit, which has also been called " ribbon-shaped keratitis," is most 
 distinctive in appearance, resembling nothing so much as the 
 frothy, glistening white stuff one often sees overlaying portions of 
 the cornea in elderly people, and that has been expressed from the 
 Meibomian ducts. Leber has recently shown that it is calcific de- 
 generation of Bowman's membrane. It yields readily to abrasion. 
 The nebulous opacities, which result from superficial keratitis, have 
 sometimes been removed in this way. Indeed, as it is a relatively 
 harmless procedure when done under favorable conditions, it ought 
 oftener to be tried where there is any likelihood of the opacity 
 being shallow. 
 
 The operation is simple and easy. Local anesthesia is best 
 when practicable; when not, chlorid of ethyl or similar narcosis. 
 The lids are parted by the blepharostat and the eye steadied with 
 fixation forceps. The scraping instrument may be a small, very 
 sharp spoon or small convex-edged scalpel that is exceptionally 
 keen. In scraping it is best to work always from the periphery of 
 the spot toward its center so as not to leave the edge of the sur- 
 rounding layers loosened and lifted up. One has only to scrape 
 until clear or sound cornea is reached, irrigate thoroughly, and 
 bandage. A septic condition of the conjunctiva or of the lacrimal 
 canal are contraindications. 
 
 The shaving and excision processes are not so much to be recom- 
 mended. In the first, the opacity is pared away by means of a 
 knife or curved lancet. In the second, the edge of the area is out- 
 lined with the point of a knife and the flap dissected out with tiny 
 forceps and knife.
 
 CORNEAL CAUTERY. 377 
 
 CORNEAL CAUTERY. 
 
 Cauterization in some form or another for the treatment of 
 affections of the eye has so wide a range of employment and, as a 
 surgical measure, its application in most instances is so similar, that 
 opportunity will be here taken, once for all, to say a few words rel- 
 ative to its use in general as well as to that in connection with the 
 cornea. For the rest, it will be treated of under the different 
 headings wherever it finds a place. 
 
 One distinguishes three kinds of cautery, viz., i. the chemic; 
 2. the thermic, and 3. the electric. The first includes those sub- 
 stances which, brought in contact with the tissues, cause an eschar 
 by various forms of chemical action, such as nitrate of silver, for 
 example. Their modes of application are described in the chapter 
 on that subject. The other two refer to those where heat alone is 
 the agent which produces the decomposition and are identical in 
 their effect, the only difference being as to the manner in which the 
 heat is generated. The second kind is usually spoken of as the 
 actual cautery, and the third as the galvano-cautery. The thermic 
 cautery has been an adjunct to surgery since the earliest days of 
 medicine, and the instrument to receive and apply the heat has been 
 made of a variety of materials. Its best modern representative is a 
 platinum wire of suitable dimensions and shape of tip, supplied 
 with a handle of wood or other non-conductor of heat. In an 
 emergency one can easily improvise such a cautery from a bit of 
 wire or other small metal implement. The best means of heating 
 it are the flame of a spirit lamp or that of a Bunsen burner. 
 "Cherry-red" is the term used to denote the degree of heat which is 
 most serviceable. 
 
 The Paquelin appliance is also a handy form of actual cautery. 
 
 As concerns the electric cautery, since its introduction by Legroux 1 
 it has largely supplanted the other two in the hands of the ophthalmic 
 surgeon, partly because of the greater convenience. A small storage 
 battery weighing 6 or 8 pounds will supply an ample current for 
 many operations. Moreover, seeing that the home of the oculist is 
 in the city, he can always have access to the street currents, which 
 he converts to this use either by means of a transformer or of a 
 
 i Ann. d'oculist. t. 81, p. 181, 1879.
 
 378 
 
 OPERATIONS UPON THE GLOBE. 
 
 permanent battery and rheostat. Even the electrodes, handles 
 and platinum tips can be interchangeable between the portable and 
 the stationary apparatus. The handle and wires should be as light 
 as possible, and the button for making and breaking the current 
 should be easily manipulated by the tip of the forefinger (Fig. 213). 
 The form of the points is a matter of individual preference. Per- 
 haps the best adapted to all-around work is the simple, almost closed 
 loop of round or slightly flattened wire, though the olive tip is excel- 
 lent in many cases (Fig. 214). 
 
 FIG. 213. Electric cautery. The conductors go over operator's shoulder. 
 
 The electro-cautery has enjoyed a deserved degree of popularity 
 in the treatment of corneal ulcers, but the necessary accessory 
 equipment for its use is frequently not available when it is most 
 needed and it is always open to the objection of a clumsy handle 
 and difficult regulation of the current so as to produce the desired 
 amount of heat. The demand for a simple, effective, and ever-ready 
 instrument has produced Wordsworth's cautery (Fig. 215), consisting 
 of the regulation instrument handle and shank, on the end of which 
 is a copper bulb about five millimeters in diameter. The end of 
 the shank is bent at an obtuse angle so as to allow- a good view of
 
 CORXEAL CAUTERY. 
 
 379 
 
 the field of operation. One side of this copper bulb is drawn out 
 into a blunt protuberance for use in the cauterization of compara- 
 tively large surfaces, while at another point on the bulb is attached 
 a delicate, short platinum rod for use on small surfaces. The bulb 
 and point will remain sufficiently 
 hot to cauterize for several 
 minutes after being heated to a 
 cherry-red over a flame. 
 
 To Make the Cautery.. The 
 eye is prepared and anesthetized. 
 The speculum is put in and the 
 globe held by fixation forceps. 
 Having seen to it that the appa- 
 ratus is in working order, an 
 assistant supports the electrodes 
 while the surgeon applies the tip. 
 on and heat it in situ. Seeing, however, that the performance 
 should be a mere touch, it would seem that greater precision can be 
 attained by holding the wire close to the place to be burned, heating 
 it to the right color, then deftly making the contact. If the tip 
 is allowed to become white-hot (incandescent) its energy is too 
 great, and besides, the light startles the patient. The touch must 
 be particularly quick as regards the cornea, lest steam be generated 
 in the aqueous. It is much better to make several brief applica- 
 tions than attempt too much with one. 
 
 Since the year 1873, wnen Martinache, of San Francisco, first 
 called attention to its virtues in the treatment of ulcers of the cornea, 1 
 
 FIG. 214. 
 
 Some prefer to lay the cold tip 
 
 FIG. 215. Wordsworth-Todd cautery. 
 
 the cautery has come to be a standard remedy for all such infectious 
 diseases as serpent, fascicular, annular, dendritic and rodent ulcers, 
 ulcerated wounds, and the ulceration incident to purulent ophthalmia. 
 
 In addition to the rules governing the general method of ocular 
 cautery just given, there are a few points relating to corneal cautery 
 
 i Pacific Med. and Sur. Journal, Nov., 1873, p. 294.
 
 380 OPERATIONS UPON THE GLOBE. 
 
 in particular that it were well to mention. If, for instance, the 
 ulcer is filled with curdled pus or other debris, it had better be cleaned 
 out beforehand, as otherwise the operation would be cluttered. 
 Then, if a drop of a i % solution of fluorescin is put on at the cornea, 
 it will materially help one to distinguish the diseased tissue from the 
 sound, for the resulting green tint will not only show the lateral 
 dimensions of the ulcer and its zone of infiltration, but also their 
 depth. Czermak recommends touching first the infiltrated portion, 
 making a series of small burns close together, and, lastly, the center 
 or ulcer itself, the last either by the small points or by a somewhat 
 larger tip. 
 
 Descemet's membrane should be spared whenever possible. It 
 is the great safeguard of the anterior chamber. Not to wound it 
 when the ulcer is deep requires great delicacy in handling the tip. 
 To puncture it with the cautery also increases the risk of complica- 
 tions. If hypopyon, which ordinarily can be ignored, should be 
 present, it would obstruct the perforation and prevent healing. 
 The eye is bandaged after the operation and the patient kept quiet. 
 If necessary the cautery may be repeated. 
 
 Another form of corneal ulcer in which cautery gives most gratifying 
 results is the narrow, deep, round, central one, especially when this 
 is complicated by a tiny hernia of Descemet's membrane. When 
 these conditions are present there is, often apparently, no attempt 
 at spontaneous healing. I have seen such cases that remained 
 unaltered for months. It might be that the subject was young as they 
 mostly are in perfect health, and receiving every other appropriate 
 form of treatment for the eye, even to the pressure bandage. If 
 any change occurred, it was a slow one for the worse. This was 
 probably from pressure of the protruding membrane on the tissue 
 which surrounds it, for there is always a narrow ring of gray next 
 the hernia that, I take it, indicates a mild form of pressure necrosis. 
 One or, at most, two, applications of the galvano-cautery will effect 
 a speedy cure. Of course, in this instance, Descemet's membrane 
 is instantly perforated and the aqueous spurts, but, owing to the 
 absence of infection, and to the small size, and position of the 
 opening, no trouble with the iris ensues. 
 
 Incisions of the Cornea; Paracentesis. Function. The 
 number of indications for opening the anterior chamber that have,
 
 PARACENTESIS OF THE CORNEA. 381 
 
 first and last, been supposed to exist, is infinite. In truth it has, 
 perhaps, a broader field of alleged utility than any other opera- 
 tion that is made upon the eye. The following are some modern 
 applications: 
 
 1. In Acute Glaucoma, whether (a) idiopathic or (b) secondary. 
 
 a. Given, a case of acute glaucoma, with great pain, hyperemia, 
 chemosis, etc., and it is not practicable to give a general anesthetic 
 for iridectomy. It is well known that cocain has no effect in such 
 cases, yet it would be possible to make a simple incision at the base 
 of the cornea with far less additional suffering on the part of the 
 patient than to go ahead with the iridectomy. Having relieved the 
 tension, the iridectomy, if still necessary, could be made after a few 
 days under cocain. Moreover, the chances of loss of vitreous and of 
 choroidal hemorrhage would be lessened by the preliminary incision. 
 
 b. In acute secondary glaucoma, such as that from the swollen 
 lens after discission, and after accidental traumatism, paracentesis 
 is imperative. Under these conditions the procedure is usually 
 accompanied by the extraction of lens substance. I have had 
 occasion to make the operation in fulminating glaucoma due to 
 dislocation of the lens into the anterior chamber, not daring, for 
 the moment, to attempt extraction. 
 
 2. In certain cases of blood in the anterior chamber. Ordinarily 
 these are let alone, and the blood is promptly absorbed. If, on the 
 contrary, it remains for 5 to 7 days without appreciably lessening 
 in quantity, it would better be got rid of, as it may lead to the so- 
 called spongy iritis or organized clot and other dangers. When 
 present as the result of an injury, the blood could cause a foreign 
 body within the eye to be overlooked. Haab mentions the pos- 
 sibility of a hyphema occurring and obstructing the pupil in a case 
 where one is interested in ophthalmoscopic observations, as, for 
 instance, the development of a neoplasm. 
 
 3. In Iritis and Iridocyclitis. At the height of the inflam- 
 matory process there often comes a time when, because of the hyper- 
 emia, etc., the iris and the ciliary muscle cannot be made to respond 
 to the mydriatics and cycloplegics employed, nor do soothing reme- 
 dies serve to relieve the severe pain in and about the eye. As was 
 pointed out by Abadie, 1 free punction of the cornea makes the eye 
 
 i Gaz. des hopitaux, p. 219, 1874.
 
 382 OPERATIONS UPON THE GLOBE. 
 
 more responsive to treatment and the patient more comfortable. 
 Under these conditions the operation would need to be performed 
 under narcosis. There is another class of cases of uveitis, mostly 
 chronic, characterized by descemetitis, increased depth of anterior 
 chamber, cloudiness of vitreous, recurrent intraocular hemorrhages 
 (or not), and, rarely, notable disproportion between the amblyopia 
 and any apparent cause for it. These, too, are sometimes helped 
 by paracentesis ; and, as they are among the most tedious and trying 
 of all our charges, and the operation is, to say the least, harmless, 
 one is justified in trying it. 
 
 4. In ulceration of the cornea that threatens to perforate, 
 whether there is hypopyon or not. Apropos of the last, before 
 the time when the profession had learned to rely upon the efficacy 
 of antiseptic treatment for these infectious conditions, it was the 
 rule to make paracentesis in cases of hypopyon. Consequently, 
 eye after eye was lost. This was true even in the earlier period of 
 antiseptic medicine, when the case was having this treatment in 
 addition. At present, eye after eye is saved by disregarding the 
 hypopyon, using copious irrigation with mild antiseptics, atropin, 
 and, above all, the roller bandage. Paracentesis in any form, 
 according to the Saemisch or otherwise, has largely given way to the 
 non-operative treatment. 
 
 5. In Conical Cornea. (See section on Keratoconus.} 
 
 6. In Embolism and Thrombosis of the Retinal Vessels. 
 Paracentesis of the cornea has been suggested as an adjunct to 
 massage. One would hesitate before making the operation, how- 
 ever, in cases of advanced arteriosclerosis. It would seem from the 
 researches of Fuchs, 1 relative to the nature of panophthalmitis and 
 the course of the infection therein, that paracentesis may find an 
 extension of its sphere in helping to save from enucleation some 
 of the eyes thus afflicted. 
 
 Von Graefe, 2 proposed punction of the anterior chamber in glau- 
 coma simplex, as a sort of guide as to whether or not an iridectomy 
 would u prove beneficial. One is often put in a quandary when 
 dealing with this disease. For example, in spite of other means 
 of treatment the sight is fast going and the fields rapidly dimin- 
 
 1 Arch. f. Augenh., Iviii, 3,8. 391. 
 3 A. F. O., xv, 3, 211.
 
 PARACENTESIS OF THE CORNEA. 383 
 
 ishing, yet one shrinks from an iridectomy, and posterior sclerotomy 
 is out of the question. As a tentative measure, one may make para- 
 centesis. If the symptoms improve for a time, one is encouraged 
 to essay the excision of iris. 
 
 The Operation. Narcosis is required only for highly inflamed 
 and sensitive eyes, especially when the patient is shattered from 
 suffering, and for small children. Where there is much softening 
 of the cornea or tremendously high tension, conditions that would 
 make squeezing of the eye dangerous, the blepharostat would better 
 be omitted and the lids held apart by an aid with retractor or fingers. 
 The best form of keratome is a small iridectomy knife, except there 
 be extreme shallowness or obliteration of the anterior chamber, 
 w r hen a narrow Graefe cataract knife is preferable. The incision 
 should be sufficiently peripheral to lie within the vascular zone of 
 the cornea, but its position with regard to the circumference will be 
 determined by circumstances. When blood or pus is to be evacuated, 
 the proper point is downward. In other cases, as in glaucoma 
 from a swollen lens, when it is possible a portion of the iris will 
 have to be incised upward, and so on. 
 
 The globe is steadied by fixation forceps, the point of the keratome 
 is made to enter the anterior chamber just as in the incision for 
 iridectomy. When the blade has been pushed far enough, the 
 handle is tilted further backward to avoid wounding the lens during 
 the escape of aqueous, and then turned slowly to one side so that 
 the knife will pry open ,the cut and drain the anterior chamber. 
 Just here is when the patient is apt to feel the greatest pain, sup- 
 posedly from the contact of the sensitive iris with the cornea, and is 
 liable to squeeze or move the head. It is for this reason and also 
 to prevent prolapse of the iris, that the aqueous must not be allowed 
 to gush out suddenly. The knife is slowly withdrawn, if need be 
 extending the incision in its exit, as in iridectomy. If the Graefe 
 knife is chosen, the incision is made by puncture and counter- 
 puncture, as in extraction, though, of course, its extent is much less. 
 The section is finished slowly. After this the spatula may be used 
 to pry open the wound or, at least, to depress its posterior lip. If 
 blood or pus is to be evacuated, it may be coagulated and refuse to 
 come out with the aqueous. In this event an injection of i% warm 
 salt solution by means of one of the syringes for lavage of the anterior
 
 384 OPERATIONS UPON THE GLOBE. 
 
 chamber may be used to wash out the clot or curd. If the iris 
 escapes in spite of proper care in making the incision, it can usually 
 be replaced with the spatula. If not, the prolapse must be excised. 
 The eye is bandaged in the regulation way. 
 
 A distinctive method of paracentesis is the incision ofSaemisch* 
 and one that has been extensively employed in the different infectious 
 ulcers of the cornea. The original mode was to make the incision 
 as nearly as possible in the center of the ulcer. Alfred Graefe and 
 Meyhofer taught to make the cut as a tangent to the ulcer and thus 
 slit the infiltrated border, and that in the direction of its greatest 
 progress. Saemisch also came to make it somewhat similarly. 
 Since part of the object of the incision was to drain and relax the 
 infiltrated tissue, as in orbital phlegmon, this would seem rational. 
 A narrow Graefe knife is used; the blade is entered, edge forward, at 
 one extremity of the affected area, and brought out at the other 
 extremity, in its passage being made to open the anterior chamber; 
 i.e., by puncture and counter-puncture. The incision is reopened 
 daily by a small probe or probe-pointed lacrimal knife till the 
 ulcer is no longer a menace. The constant leakage of aqueous is 
 believed to prevent infection of the deeper parts of the eye. 
 Manifestly, the same precautions must be taken against squeezing 
 out of the crystalline, etc., as in other forms of paracentesis. The 
 operation is difficult with the Graefe knife in certain meridians 
 upon deeply set eyes, a difficulty that can be overcome by the use of 
 a small sickle-shaped blade. 
 
 Anterior synechia, leucoma adherens, and glaucoma, the natural 
 sequels of septic processes in the cornea, not to mention panoph- 
 thalmitis, are more frequent after paracentesis of any kind has been 
 resorted to in the treatment of kerato-hypopyon. 
 
 Paracentesis and Massage in Glaucoma. In cases of chronic 
 or intermittent or irritative glaucoma in short, in any but the 
 acute idiopathic variety- these are therapeutic measures that 
 cannot be too strongly recommended. They are harmless and cause 
 the patient little inconvenience, yet often effective in the highest 
 degree. The paracentesis should be thorough and very slowly 
 made. Within from 6 to 12 hours afterward the eye is washed 
 outwardly with warm sublimate solution, the contents of the 
 
 1 Ulcus Serpens Cornea und seine Behandlung, Bonn, 1870.
 
 MASSAGE AFTER PARACENTESIS. 385 
 
 Meibomian canals are greatly expressed, the eye and the entire 
 conjunctival sac are copiously irrigated with warm boric acid solu- 
 tion, and a systematic course of massage is begun. This may 
 be either direct, i.e., by a smooth instrument, such as a glass rod 
 with rounded end, applied immediately to the globe; or indirect, 
 i.e., by the fingers applied exterior to the lids, the mode accredited 
 to Pagenstecher. I prefer the last. The massage may also be 
 either plain or medicamentous. The use of myotics in conjunction 
 with the massage is most always indicated. These can be in the 
 form of solution or ointment simple or combined. The ointment 
 is usually preferable as it clings more tenaciously to the parts 
 chiefly concerned, and, besides, facilitates the massage as a lubricant. 
 Simple pilocarpin muriate or eserin or both together or, to what is 
 probably better, these two combined with cocain. The latter is 
 the pek so warmly commended by Wicherkiewicz, who, by the way, 
 has been one of the foremost advocates of this kind of massage. 
 The author has of late used with apparently good results a mixture 
 of eserin, cocain and dionin. 
 
 Modus Operand! of Massage. The same rules here given are 
 applicable to ocular massage in general. Hands and eyes are care- 
 fully prepared. The patient sits facing the operator. The work 
 is done with the thumb or with the first finger, which is clad in a 
 delicate rubber cot. Massage of any particular part of the globe, 
 except of the cornea, is made with the patient looking in the opposite 
 direction. Thus, for the upper equatorial region the eyes are 
 rotated far downward, etc. By noting the position of the other 
 eye one knows what part is being rubbed. The upper lid is utilized 
 for the upper half, or rather quadrant, of the bulbus, and the lower 
 for the rest. First, circular movements are made, say in the direction 
 of the hands of a clock. Second, this is reversed. Third, move- 
 ments in straight lines across, up and down, and diagonally. Fourth 
 and this is an important movement by backward strokes, 
 following the meridians of the globe. These are repeated, in regular 
 sequence, over and over. The degree of pressure exerted may vary 
 from very light to pretty firm, owing to the needs of the case, and 
 in accordance with the judgment of the masseur. The intervals 
 between sittings are from a few hours to an entire day, as the case 
 demands. The duration of the massage is from two to four minutes 
 for a single eye. By covering each thumb with a cot, both eyes 
 25
 
 386 OPERATIONS UPON THE GLOBE. 
 
 can be done simultaneously. Anointing of the lids or the thumbs 
 is inadvisable; though sterile vaselin or other ointment or i% salt 
 or 4% boric acid or other solution should be put into the conjunctival 
 sac. If ointment is employed, one application per sitting is sufficient; 
 if an aqueous solution, two or more instillations are made. Ocular 
 massage, intelligently practised, is a most valuable adjunct in the 
 treatment of most affections of the eye. It is peculiarly precious 
 in diseases dependent upon degenerative changes in the circulatory 
 apparatus, like glaucoma, the so-called albuminuric retinitis, 
 arterial and venous thrombosis of the retina, intraocular hemor- 
 rhage, and embolism. 1 
 
 Paracentesis by Galvano-puncture of the Anterior Chamber. 
 Haberkamp 2 has sought a measure which would be practicable 
 without preparation and which might be done in a consultation 
 room or at the home of the patient. While he claims no originality 
 in the procedure he proposes, he has been unable to find it mentioned 
 in the literature. The method is a paracentesis by galvano-puncture 
 of the anterior chamber the healing of the puncture being slow, 
 a prolonged effect is had, greater than would be the case from an 
 ordinary paracentesis. Haberkamp reports two cases treated by 
 this method. The first case was cured; in the second the patient 
 was blind from fulminating glaucoma, suffered agonizing pain, and 
 enucleation was at first deemed essential; galvano-puncture stopped 
 the pain and the necessity of removing the eye was done away with. 
 
 This, in the opinion -of the present writer, would be a delicate 
 undertaking at the hands of one not skilled in the use of the cautery ; 
 as overheating of the aqueous, with consequent injury to the iris 
 and the crystalline, could easily be brought about. 
 
 Conical Cornea; Keratoconus; Staphyloma Pellucidum. 
 The first two terms describe the abnormality better than does the 
 third, since it is the shape of the cornea that gives name to the defect 
 without any special reference to its transparency, for in many 
 instances considerable opacity exists. The apex of the cone 
 is seldom at the center, being for the most part situat ed below the 
 center. Many and varied are the surgical measures that have during 
 the last century been devised relative to this condition. The first 
 
 1 Bjerrum, of Copenhagen, very strongly recommends pression massage, 
 over the center of the cornea only after paracentesis and iridectomy for 
 chronic glaucoma. L'Oph. Pr ovine., March, 1909. 
 
 2 La Clinique Ophtalmologique, July 10, 1905.
 
 CONICAL CORNEA. 387 
 
 were directed more to improvement of the vision than to the reduc- 
 tion of the cone. Travers and Tyrrell, for instance, in the second 
 decade of the i8th century, made optical iridectomy, and later 
 Critchett and Bowman attempted to substitute the dangerous 
 operation of iridodesis. The first to institute a procedure for the 
 actual cure of the deformity was Fario, 1 in 1839. He removed a 
 wedge-shaped piece from the summit of the cone, dressed the eye, 
 and allowed the wound to heal without suturing, and declared 
 himself satisfied with the results. Sichel and von Graefe, near the 
 middle of the igth century, sliced off the tip of the cone, preserving 
 Descemet's membrane, then, after a day or so, touched the spot 
 with mitigated stick. The cautery was regularly applied until 
 healing occurred. After this the tip of the cone was punctured, 
 the aqueous drained, and attempts made to maintain the fistula 
 by subsequent punctures, with the object of still further flattening 
 the cornea. If necessary, an optical iridectomy completed the 
 surgical treatment. Bowman, in 1869, removed the whole thickness 
 of the apex with a trephine of his own invention. He later modified 
 the measure by leaving the posterior layer. Several days thereafter, 
 the floor of the excavation was perforated, and regularly reopened 
 for a period of two or three weeks. Such a procedure could not 
 be applicable where the usual amount of thinning exists at the 
 summit. De Wecker and Warlomont also had their trephines. 
 Bader 2 removed an oval flap from the apex, now stitching the open- 
 ing with fine silk or silver wire, again leaving it to close of itself. 
 All of these operative processes, while credited with a modicum of 
 success, were, on the whole, both unsatisfactory and hazardous 
 the last, mainly because of the great reaction, of infection, and 
 of iris complications. No better results followed the method of 
 excising a segment from the base of the cone, tried by Quadri, 
 Roosbroeck, and others. Gayet, 3 to avoid these dangers, practiced 
 cautery of the apex, to perforation. Abadie,-* to obviate central 
 opacity, moved the cautery from the apex to the more peripheral 
 portions of the zone, respecting the posterior layer. Since the 
 introduction of the thermic (or electric) cautery for this purpose, 
 
 1 Mem. della Med. contemp., 1839. 
 
 2 Lancet, 1872. 
 
 3 Lyon medicale, xxx, 1879. 
 
 4 These de Guiot, 1887.
 
 388 OPERATIONS UPON THE GLOBE. 
 
 cauterization of the apex has largely taken the place of excision. 
 The difference in the size of the resulting scar, after excision and 
 cautery, is very slight, particularly if the cautery is, as it should be, 
 limited to a small area. One beauty of the cautery is that it is its 
 own antiseptic. Since Tweedy's 1 report, the weight of opinion is 
 largely in favor of cautery with as against that without perforation. 
 Knapp 2 indorses perforation. This surgeon has had made a special 
 round tip for burning the cone. This he lays on cold and heats till it 
 perforates. He gives a timely caution as to overheating of the 
 aqueous, consequently of the lens and iris; even cites a case in which 
 he supposes he produced a cataract in this way. This would seem 
 to be another argument in favor of heating the tip before making 
 the contact. 
 
 Elschnig,3 of Munich, has for the past 15 years been an enthusiastic 
 advocate of the galvano-cautery for keratoconus. He believes that 
 one of the essentials of success is the prompt vascularization of 
 the cauterized area, which increases the density and lessens the 
 extent of the resulting cicatrix, and causes greater flattening of the 
 scar. In order to hasten this vascularization he connects the deep 
 eschar at the summit by a more superficial one, running in a broad 
 strip to the nearest portion of the corneal limbus. Because of the 
 eccentric position of the apex in most cases, neither the denser scar 
 nor its bridge-like extension interfere with vision through the 
 normal pupil. If it should so happen that the tip of the cone is 
 central, the profound burn is placed to one side so that the scar will 
 not encroach too mucti upon the pupil. He considers subsequent 
 iridectomy unneccessary or harmful, though he may afterward 
 tattoo the opacity in such a way as to prevent diffusion. He uses 
 the dull red heat. These measures, if not more potent for good than 
 the older ones, have at least been less productive of harm. 
 
 ^The author believes with Panas that, all things considered, 
 the more conservative measures are the best, except for the extreme 
 cases. These consist in the prolonged use of myotics and the 
 pressure bandage, as advocated by Weber,* and Mohr.s Continued 
 
 * Trans, of Oph. Scy. of the U. K .. Jan. 28, 1892. 
 
 2 Norris and Oliver, "Diseases of the Eye," p. 825, 1898. 
 
 3 Wiener klinische Rundschau, 1904, 20. 
 
 4 A. S. O., xxii, No. 4, p. 21 5, 1876. 
 
 s A. S. O., xxiii, No. 2, p. 180, 1877.
 
 ANTERIOR STAPHYLOMA. 389 
 
 pressure alone is probably the most efficacious of any single means. 
 The writer had occasion a short time since to cause removal of the 
 lenses in a case of high myopia and conicity of the cornea by a 
 series of discissions. The treatment consisted in incising the 
 capsule through puncture at the bass of the cornea done with a 
 Graefe knife, the use of atropin, and bandaging. The duration of 
 treatment for each eye was about six months. There were three 
 discissions in each, a good deal of reaction following the second and 
 third. The ultimate flattening of the corneas was truly remarkable. 
 The best vision with glasses before the operations, etc., was 20/70, 
 both eyes; the best after the year's treatment 20/30+ both. Here 
 the annulment of the myopia, which had been 26 and 24 diopters, 
 would account for most of the added sight, but I attributed much 
 of it to the reduction of the cones. Certainly, thorough trial of the 
 less radical measures should precede any operation that involves 
 special risk. These would be, prolonged wearing of compressive 
 bandage (best netting, put on wet), the cotton of the pad being 
 carefully built on, first filling in the depressions in the lids around 
 the globe, and the dressing renewed daily, when 2 drops of 2% 
 solution of the nitrate or muriate of pilocarpin are instilled. This 
 kept up as long as improvement continues. If no progress is made, 
 repeated paracentesis of the cornea is subjoined, to which might, 
 as an ulterior measure, be added the application of a small galvanic 
 tip, in three or four short meridional lines, near the base. If these 
 measures failed of material improvement, I should still advise 
 against more drastic surgical treatment save where the ectasia is 
 very great and the vision very poor, so poor, indeed, as hardly to be 
 called useful. True, much depends upon the condition of the 
 fellow eye. If this be possessed of fair sight, one may venture 
 further. 
 
 Staphyloma of the Cornea. Anterior Staphyloma. By this 
 term is understood those forms of ectasia of the cornea which de- 
 velop in consequence of disease, such as ophthalmia neonatorum, 
 accidental wounds, as from the blades of knives and scissors, and 
 surgical operations, such as iridectomy and extraction. The 
 Staphyloma is known as total or partial, according as the whole 
 cornea or only a portion of it is involved in the bulging. Blindness 
 is a necessary accomplishment of the total form, not of the partial.
 
 390 OPERATIONS UPON THE GLOBE. 
 
 The surgery of total staphyloma dates from ancient times. The 
 Greeks and Romans as early as the Alexandrian period practised 
 ligation for its removal. A needle and thread were run through the 
 center of the base. The thread, which was left double, after being 
 pulled well through, was cut near the needle. Of the two threads 
 thus formed, one was used to ligate each half of the staphyloma. 
 ^Etius, early in the Christian era, improved upon this method by 
 employing two needles put through the base at right angles one to the 
 other. Thus, when the double threads were pulled through and cut, 
 four ligatures were made, one for each quarter of the tumor. Am- 
 brose Pare, in the i6th century, in case of a staphyloma that pro- 
 truded beyond the lids, amputated it bodily. Beer, of Vienna, in 
 1805, gave a method that, under the name of abscission, became 
 classic. By means of his triangular cataract knife he made puncture 
 and counterpuncture in the horizontal meridian at the base of the 
 elongated cornea, directing the edge of the blade forward and 
 downward, cutting out within the base below, then, with the scis- 
 sors, he made a similar incision upward, completing the abscission. 
 Of course, the lens and part of the vitreous often escaped by the 
 enormous opening. George Critchett, 1 of London, to keep back the 
 contents of the globe after the Beer abscission, first inserted threaded 
 curved needles, convexity backward, from above downward through 
 the ciliary body, about 3 mm. apart, left them projecting from the 
 sclera at either end to serve as bars to the vitreous, etc., while the 
 staphyloma was removed. The needles were then passed on 
 through, leaving the sutures in their places, the last being tied to 
 close the wound. Not liking the idea of passing needles and 
 threads through the sclera, and especially through the ciliary region, 
 Knapp, 2 using fine curved needles, put them through the con- 
 junctiva and superficially into the sclera, as shown in Fig. 216. 
 Beginning just external to the vertical meridian, a little back of the 
 base of the cornea, one needle was put through the conjunctiva and 
 quilted for a distance of 4 or 5 mm. horizontally outward, brought 
 out, carried below the cornea, and passed in the same way, but from 
 without inward. The thread was not drawn down between the 
 two points, but left standing in a long loop. A second suture was 
 
 1 Royal L. O. H. Reports, vol. iv, p. i, 1863. 
 3 Archiv. S. Oph., Bd. xiv, i, S. 273, 1868.
 
 ANTERIOR STAPHYLOMA. 
 
 391 
 
 introduced in the same manner internally. The Beer abscission 
 was then made, the two loops drawn down across the extremities 
 of the wound, and the opposite ends of thread tied. Virtually, the 
 two threads play the role of four vertical sutures. De Wecker, 1 
 modified Knapp's procedure. He first incised the conjunctiva all 
 around the base of the incision, dissected it back somewhat, and put 
 into it a purse-string suture; abscised the corneal ectasis after Beer, 
 and tightened the thread drawing the conjunctiva tightly closed over 
 the opening in the globe. De 
 Wecker, about 1883, wisely con- 
 cluded to make complete exen- 
 teration of the globe before 
 closing the wound. 
 
 Ktichler, 2 of Darmstadt, sim- 
 ply incised the staphyloma hori- 
 zontally, straight through its 
 center, after the manner of his 
 Querschnitt for extraction, re- 
 moved the lens, and allowed the 
 wound to cicatrize. 
 
 Such is a brief history of the 
 development of the operation of 
 abscission, for total staphyloma of the cornea, a measure that is now, 
 happily, fast becoming obsolete. Ophthalmic surgeons are be- 
 ginning to realize the fplly of a procedure that only makes the 
 operated eye a greater menace to its fellow. That is to say, the 
 portion which is admitted to be the source of sympathetic inflam- 
 mation, viz., the uvea, was not only left behind, but left in condition 
 more potent for mischief; that the stump is unsightly without a 
 prothesis, yet that the latter is supported even better after exentera- 
 tion; that there are three objects for removing a total staphyloma 
 to correct a deformity, to prevent sympathetic inflammation, and 
 to make a suitable stump over which to wear an artificial eye. The 
 old method fulfilled only the minor indications. Of course, where 
 both eyes are blind it does not matter. When the eye is highly 
 glaucomatous or that of a subject well along in years, expulsive 
 
 FIG. 216. 
 
 i Ann. d'oculist t. xix, 51, 1873. 
 'Heidelb. med. Ann., vol. vii, 1841.
 
 392 OPERATIONS UPON THE GLOBE. 
 
 choroidal hemorrhage is apt to follow ablation. Gradually, there- 
 fore, the operation, without exenteration, has lost favor, and the 
 one with has found it. Notwithstanding the fact, that a number of 
 surgeons still resort to the first form, the writer believes that it has 
 had its day, and deserves no better fate. 
 
 Partial staphyloma of the cornea may be anything from (a) a 
 tiny bead no larger than a pin-head to a tumor the size of a pea, 
 centrally located, and composed only of Descemet's membrane, 
 translucent or whitish in color, and more or less thickened; or 
 (6) a globular mass of varying size, situated somewhat less centrally, 
 composed partly of changed iris tissue, and dark in color in pro- 
 portion to the amount of pigment or the thinness of the outer cover- 
 ing, and is in full communication w r ith the anterior chamber. Again 
 (c) it may occupy the extreme periphery, where it is made up in great 
 part of the iris, is of many sizes, and is connected with the aqueous 
 chamber only by a fistulous tunnel. This is know'n as cystoid scar. 
 The last two are prone to progressiveness, often reaching enormous 
 proportions the latter especially; eventually dragging in the 
 ciliary body and other parts of the globe. Hence, it is of the greatest 
 importance that surgical measures be instituted at the earliest 
 possible moment. 
 
 (a) A touch of the heated cautery tip or a simple incision, with 
 proper rest and bandaging afterward, is usually sufficient for the 
 first class. A very few will be found of sufficient size to oblige the 
 cutting out of an elliptical piece. This is done with cataract knife 
 and iris scissors. 
 
 (b) Glaucoma is a frequent attendant of the second variety. 
 If the tumor is of incipient size and quite recent, amounting to a 
 simple hernia of the iris, one may be able to mobilize the iris with 
 the spatula, then draw it out somewhat with iris forceps, and snip it 
 off, or to cause its disappearance by one or tw r o applications of the 
 cautery. If the tumor is larger, particularly if the intraocular 
 tension is high, an iridectomy will be required in connection with 
 cautery or incision or abscission, whichever of the three, in the 
 judgment of the operator, is called for. For these more trouble- 
 some cases with shallow anterior chambers, a very narrow Graefe 
 knife, one that has been reduced by many sharpenings, will be found 
 invaluable for making the incision to get at the iris; a pair of minia-
 
 CORNEAL GRAFTING. 393 
 
 ture forceps scissors will sometimes enable one to excise a portion 
 where, by reason of its union with the cornea, it could not be 
 drawn out by forceps in the usual way. How much benefit is de- 
 rived from the iridectomy and how much from the paracentesis 
 and bandaging, it were impossible to say. No fixed and precise 
 rules can be given for the manner of procedure in these cases 
 the conditions are too variable. 
 
 (c) If the cystoid scar has not reached proportions too consider- 
 able, it is best to adopt decisive measures while it is yet time. The 
 cyst-like tumor must be freely opened by an incision with a Graefe 
 knife, all of the included iris removed that seems practicable, and 
 what cannot be consistently taken away disconnected as thoroughly 
 as possible from that within the eye. Having cleaned the floor of 
 the cyst, the fistula is sought and touched with the cautery. Bandag- 
 ing and rest in bed for four or five days complete the cure. If the 
 ectasia has become so great and far-reaching as to make this form 
 of treatment inexpedient, iridectomy, light cautery of the most 
 prominent part of the tumor, the instillation of myotics, prolonged 
 bandaging, offer perhaps the best alternatives. The cautery may 
 be repeated as many times as it would seem to be necessary, and, if 
 done so lightly as not to cause evacuation of the aqueous, it were well 
 to add paracentesis for this purpose. The walls of the staphyloma 
 are commonly of extreme thinness. The effect of cautery is not 
 only to help the iridectomy, the paracentesis and the bandaging in 
 bringing about flattening, but it tends to cause thickening and 
 strengthening of the wall through the building up of connective 
 tissue. The support afforded by snug bandaging, if continued for 
 weeks or months, will of itself cause a deposit of connective tissue 
 that could not occur if the eye were left free. 
 
 CORNEAL GRAFTING. 
 
 KERATOPLASTY. 
 
 True corneal grafting, that is to say, the transplantation of corneal 
 tissue on or in corneal tissue, is of two kinds tectonic and optic. 
 The first relates to the building up or on of new corneal material to 
 replace that which is lost. For instance, a large pterygium is re- 
 moved or an area is laid bare in the operation for symblepharon,
 
 394 OPERATIONS UPON THE GLOBE. 
 
 and a true corneal graft is put on to prevent recidivation. This has 
 been mentioned in the chapter on Pterygium. The second, or 
 optic, keratoplasty, has reference to that form of grafting whereby 
 an attempt is made to substitute transparent tissue for opaque, and 
 principally concerns those cases where exists blindness from total 
 leucoma. 
 
 It is but natural that surgeons should strive, as did Pellier 1 more 
 than a hundred years ago, and as they have striven, at intervals, 
 ever since to put windows into these pitiable eyes. As yet their 
 striving has been mostly in vain in so far as accomplishing the main 
 object is concerned. Surely, though, it will be accomplished. One 
 cannot help being impressed with the probability of this when, 
 as has been the experience of many, one sees a patient with purulent 
 ophthalmia whose cornea has just been completely destroyed by 
 sloughing, yet enabled to count fingers or even to tell the time on 
 a watch, with the afflicted eye by means of a rising button of vitreous. 
 It may have been some such incident that turned Pellier's thoughts 
 toward the possibility of putting in an artificial cornea, and that 
 has actuated certain others since his time, as, for instance, Nussbaum, 2 
 who inserted a double button of glass in the center of the cornea; 
 and Dimmer,3 who made similar trial of a celluloid disk. These 
 foreign bodies, although they restored some vision for the moment, 
 either soon came out or were buried beneath the tissues. 
 
 Keratoplasty is called total when the piece to be replaced and the 
 graft each includes the entire thickness of the cornea, and partial 
 when each includes all but the posterior layer. 
 
 The first to make an actual attempt at optic corneal grafting was 
 Reisinger,^ who but acted, however, on the suggestion made to him 
 in 1813 by his friend and teacher, Himly.s Reisinger's experiments 
 were upon the eyes of rabbits and by total grafting. His success did 
 not encourage him to continue. Some years later, Muhlbauer, 6 
 proposed the method of partial keratoplasty, though he did not 
 
 1 Pellier, Manuel de Lefehure sur les ophtalmies, 1802. 
 
 2 Deutsche Klin. No. 34, 1853. 
 
 3 The Operative Treatment of Total Leucoma, etc., Trans. Heideb. 
 Oph. Scy., 1889, S. 147. 
 
 4 Baerische Ann. . . . aus dem Gebiete der Chirurg., etc., i Heft, 
 Sulzbach, 1824. 
 
 s Himly, Krank. und Misshildung. des Aug., S. 60, 1843. 
 6 Schmidt's Jahresb., xxxv. 1839.
 
 CORNEAL GRAFTING. 395 
 
 carry the notion into execution. Desmarres, 1 imbued with the 
 idea of Reisinger, made divers trials of it upon animals. He 
 demonstrated that the grafting of a cornea was possible, but he 
 found that the transplanted portion always lost its transparency, 
 so he abandoned the project. The next to take it up was Power, 2 
 but chiefly in a theoretic manner. The most determined and serious 
 efforts at optical keratoplasty within recent years were those of 
 von Hippel.3 Having, like Desmarres, become discouraged by 
 attempts at total keratoplasty, von Hippel finally adopted the method 
 proposed by Muhlbauer, just alluded to, viz., that of partial kerato- 
 plasty, and devised an ingenious trephine for cutting both the cornea 
 to be replaced and the graft. He found that while a total graft would 
 become opaque in 2 or 3 weeks, the partial would remain transparent 
 for a much longer time. Knapp* relates having seen a patient pre- 
 sented by von Hippel at the 1887 meeting of the Heidelberg Ophthal- 
 mologic Society, on whom he had made such a keratoplasty more 
 than a year previously. "The piece was still tolerably transparent, 
 and the patient had useful sight." The ultimate fate of the best 
 results so far obtained has been loss of the restored sight through 
 clouding of the graft. 
 
 It goes without saying that the operation is not to be thought of 
 in any case where vision can be restored by any other known means, 
 such as iridectomy. Seeing that the Descemet's membrane and 
 even the deepest portion of the corneal tissue proper must be 
 transparent, the cases to which the method is applicable are rare. 
 The graft may be made in any available part of the cornea. If the 
 iris should be in the way of vision it should be excised. 
 
 The operation of partial keratoplasty after von Hippel is briefly 
 as follows: Local anesthesia. First, one makes an estimate as to 
 the thickness of the leucoma. This is done by lightly pressing upon 
 it with a blunt stylet, and testing the degree of resistance. Usually 
 the trepan would be set to cut the depth of about 0.75 mm. The 
 diameter of the disk should not exceed 4.5 mm. The eye is steadied, 
 and the trephine, which works automatically by a spring, is made to 
 cut to the indicated depth. The instrument is removed, and, with 
 
 1 Ann. d'oculist, 1843. 
 
 2 Trans. London Congress, 1873, pp. 189-194- 
 
 3 A. S. A., xxiii, 2, S. 79, 1887; xxiv, 2, S. 335; xxiv, i, S. 108, 
 
 4 Norris and Oliver's System, 1898, p. 832.
 
 396 OPERATIONS UPON THE GLOBE. 
 
 delicate forceps and knife, the upper layers of the outlined portion 
 carefully dissected out, leaving a flat, transparent bottom to the 
 excavation. A young rabbit is chloroformed, the trephine is set for 
 1.5 to 2 mm. (for here the whole thickness is removed), the 
 graft is excised, and quickly transferred to its destined place. The 
 eye is closed and bandaged. No sutures are used. 
 
 Zirm modified this operation in 1905 by using a graft from a 
 human cornea instead of from that of a rabbit. The trephine is 
 used as in the von Hippel method. Eserin is instilled if the anterior 
 chamber is present. Zirm gives, as essentials for the successful 
 performance of the operation, deep anesthesia, strict asepsis, 
 the avoidance of antiseptics, and the protection of the graft between 
 two pieces of gauze, moistened with sterile physiologic salt solution, 
 and keeping it warm in steam until it can be placed in position. The 
 graft is held in position by two conjunctival sutures which pass 
 over it in such a way as to form a St. Andrew's cross at the center. 
 In the case reported the patient, a man 45 years old, had 5/50 
 vision; 5/20 with a convex lens, and J 13, seven months after the 
 operation. 
 
 TATTOOAGE OF THE CORNEA. 
 
 The staining of the cornea in cases of leucoma, partial or total, 
 is of ancient origin. Galen practiced cauterizing the surface with 
 a red-hot stylet and afterward rubbing into the raw area powdered 
 nut-galls mixed with iron or a mixture of powered pomegranate 
 bark and a salt of copper. The first to make use of tattooage 
 proper, i.e., with a needle and India ink, which is the most approved 
 substance, was Taylor, the noted English quack oculist, near the 
 middle of the i8th century. At first the ink was put into a cannula, 
 inside of which the needle \vas worked. It is, however, to De 
 Wecker 1 that we are mainly indebted for a distinctive method and 
 largely also for the technic of the modern operation. 
 
 The object of tattooage is either optic or cosmetic. The indica- 
 tions for optic tattooing would be found in such cases as aniridia, 
 albinism, coloboma of the iris, and in diffuse nebulosities of the 
 cornea the last in order to make the vision more net. In these 
 
 I Union med., mars, 1870, and Chirurg. oculaire, p. 181.
 
 TATTOOAGE OF THE CORNEA. 397 
 
 conditions, of course, the area of the cornea corresponding to the 
 pupil would be left clear, and the pigment made to occupy the per- 
 ipheral zone. In this way the photophobia would be lessened and 
 the visual acuity increased. The sphere of cosmetic tattooage is 
 limited to the hiding, or rendering less conspicuous, of opacities of the 
 cornea. Both kinds can be made to serve useful ends, for, even as 
 to the second, it is an indisputable fact that little blemishes of face 
 and figure constitute a decided handicap in the great bread-winning 
 race as regards both male and female. 
 
 The method of procedure is the same in both kinds of tattooage. 
 The instruments are blepharostat, fixation forceps with broad jaws 
 and no teeth, one instrument containing four needles in a compact 
 bundle for work in a circumscribed area, one with four needles in a 
 row for broader areas, and a tiny curved spatula for applying the 
 ink to the surface to be tattooed (Plate II, Nos. 24 and 25). The 
 needles must be quite sharp. The best grade of India or Chinese 
 ink, in cake, is appropriate for all cases, excepting where hazels 
 and brow r ns are to be simulated; for these admixtures of sepia of 
 vermilion and ultramarine are required. A piece is cut or broken 
 from the cake and sterilized by baking for half an hour at a tem- 
 perature of 150. It is then taken in sterile forceps or crayon- 
 holder, dipped in water or, what is probably better, a solution of 
 gum-arabic, and rubbed in the bottom of a paint saucer, dipping 
 occasionally for a fresh drop of the liquid, till a few drops of a thin 
 black paste are obtained. If done rightly, this process is tedious. 
 The finer the subdivision of the particles, the better. Of course, 
 the ink must be used as soon as prepared. The colored pigments 
 may be procured in fine powder, then washed, first in water, then in 
 alcohol, then in ether; evaporated in a sand-bath and, lastly steril- 
 ized as above, and mixed with aseptic gum-arabic solution. 
 
 Technic of the Operation. Local Anesthesia. After washing 
 the conjunctival sac with boric acid solution, the cornea is dried with 
 the tip of a small cotton sponge from which the moisture has been 
 well wrung. Some operators prefer to mark the pupillary area with 
 the edge of a sharp cylinder and to remove the epithelium within 
 the circle before applying the pigment, but this is unnecessary. 
 A drop of the ink the size of a pinhead is taken up with the spatula 
 and deposited exactly on the spot to be tattooed. If the area is small,
 
 398 OPERATIONS UPON THE GLOBE. 
 
 with the bunched needles one pricks the spot through the mass of 
 ink. The needles are jabbed in both perpendicularly and obliquely, 
 and until the color is sufficiently dense. The aim is to get the ink 
 deep in the corneal substance without perforating. If rather free 
 bleeding occurs, it may be stopped for a time by adrenalin solution- 
 else the operation should be postponed. Indeed, a single sitting 
 never suffices for an effective and lasting result; from three to five 
 or even more being required, with a week's interval between. It 
 has been estimated that from 100 to 120 pricks at a sitting are 
 necessary to obtain a good black pupil, and as many as 2,000 where 
 the leucoma is large and the peripheral portion is made to simulate 
 the iris. One should practise tattooage on fresh pigs' eyes, then 
 examine sections of the cornea microscopically, in order to get an 
 idea as to the proper force one should impart to the strokes of the 
 needle instrument. Considerable judgment and skill are needed 
 to do the thing right. If one is uncertain of his hand in the matter, 
 he should confine the maneuver to the slanting strokes. Every 
 little while the pricking must be stopped while the cornea is wiped 
 clean and warm boric or salt solution is gently poured over it, and 
 note made of the effects distribution of the pigment, etc. Through- 
 out, an assistant keeps the lower conjunctival fornix free from 
 fluid, but sponges the cornea only at the surgeon's bidding. Most 
 surgeons recommend using the needles on the bare cornea, that is, 
 before applying the ink, then rubbing the latter in with the finger. 
 While I have no exact data to prove the assertion, it but stands to 
 reason that a greater quantity of pigment can be driven into the 
 cornea by piercing it through the mass of finely divided ink than 
 could be rubbed in. There can be no harm in rubbing, however, 
 but let it be by the back of a tiny spoon or the like not in this 
 primitive and unsurgical manner with the finger. The ink and the 
 slightly fibrinous exudation from the cornea form a sort of pseudo- 
 membrane that rather resists one's efforts to wipe it off. I fancy 
 that this, by the entanglement of the pigment, tends to prevent the 
 needles from driving it in; hence, another reason for frequent 
 pauses and cleansing of the cornea. The eye is bandaged and the 
 patient cautioned to remain very quiet for forty-eight hours. The 
 reaction is usually slight. Armaignac, 1 of Bordeaux, employs 
 1 Receuil d'opht., Aug., 1903.
 
 TATTOOAGE OF THE CORNEA. 399 
 
 dome-shaped metal shields with various-sized circular openings at 
 the top as guides to tattooage those with the smaller perforations 
 are for doing the pupillary area, those with the larger for the iris 
 zone. The shield is held firmly on the globe while, with a four- 
 needle instrument, the exposed space is rapidly pricked. 
 
 The operation of tattooage has been decried by some because of a 
 supposed tendency to produce sympathetic ophthalmia. I cannot 
 see any reason for its being a dangerous procedure. It must be 
 remembered that eyes that are afflicted with leucoma of the cornea 
 are prone to inflammations and degenerative changes that some- 
 times lead to sympathetic trouble. It were well, then, for his own 
 peace of mind, if nothing more, that the surgeon exercise discretion 
 in selecting cases for tattooage. The eye should be absolutely 
 quiet, the globe in nowise atrophied, free from partial staphyloma, 
 any extensive adhesions between iris and cornea, and from septic 
 disease of the conjunctiva and lacrimal canal. 
 
 Anatomic investigation of tattooed cornea by Alt, 1 Browicz, 2 
 Hirschberg,3 and others have shown that the particles of carbon 
 which at first occupy the needle punctures almost immediately 
 begin a slow migration, which probably never entirely ceases. 
 After some months or a year, they are found sparsely among the 
 deepest layers of epithelial cells, but their chief abiding place is in 
 the anterior half of the stroma, being thickest in the layer immedi- 
 ately beneath Bowman's membrane. They accumulate in the 
 lymph spaces in the form of flakes and balls, while the smaller ones 
 are dispersed among the neighboring structures, some enclosed by 
 the corneal corpuscles and by the fixed and lymphoid cells. They 
 even find their way into the walls and endothelium of the blood 
 vessels. This dispersion, fortunately, is less rapid in proportion 
 as the leucoma is dense, i.e., as the cornea is degenerated. 
 
 Only pigments that are insoluble in water are suitable for tat- 
 tooage, the best being ultramarine, cinnabar, sepia, ochre, and 
 lampblack. Woinow,* Vocher,* and Hock 6 have written on multi- 
 color tattooage. 
 
 1 Am. Jour, of Ophy., i, p. 8, 1884. 
 
 2 A. S. ()., xxiii, 23, S. 212. 
 
 sA. S. O., xxviii.i, S. 269. ff, 1882. 
 
 4Trans. Russian Scy. of Physicians, Moscow, 1872, No. 13. 
 
 s Bull, et mem de la soc. franc, d'opht., 5 me annee, 1887, p. 248. 
 
 6 A. S. A. u. O., 1876, vol. i, S. 90-101.
 
 400 OPERATIONS UPON THE GLOBE. 
 
 The Influence of Tattooing of the Cornea on the Visual 
 Acuity. Dr. Nagoya, 1 Mageda, Japan, reports 30 cases out of 
 58 in which he had splendid optical results with tattooing of 
 semitransparent maculas of the cornea with India ink. On three 
 plates he demonstrates by his photographic method very instruc- 
 tively the impairment of vision by maculae of the cornea and the 
 improvement by tattooing them. With the Zeiss lens "unar" and 
 iris diaphragm of 15 mm. diameter he photographed a diploma. 
 If one-half or the center of the anterior surface of the photographic 
 lens was painted with paste, the photograph was indistinct; if the 
 painted surface was then blackened with India ink the distinctness 
 of the pictures remained uninfluenced. 
 
 OPERATIONS UPON THE SCLERA. 
 
 As Czermak quite rightly observes, with the exception of the 
 suturing of traumatisms and a few minor operations, such as curettage, 
 etc., all the operations upon the sclera are undertaken not because 
 of any disease or defect of this tunic itself, but for the relief of those 
 incident to one of the other coats or of the entire globe. They are, 
 sclerotomy, anterior and posterior; excision (trephination) ; 
 galvano-puncture, and suturing. 
 
 SCLEROTOMY. 
 
 Incision of the sclera, sclerotomia, is of two kinds -anterior 
 and posterior so named from the situation of the operation with 
 reference to the iris and ciliary body. 
 
 Anterior Sclerotomy. The idea that the efficacy of the opera- 
 tion of iridectomy for glaucoma was due, not so much to the excision 
 of iris as to the scleral incision, seems to have occurred first to De 
 Wecker. 2 About the same time, Stellwag v. Carion, who had formed 
 a similar opinion^ mentions that in a case of double glaucoma he made 
 iridectomy upon one eye and merely the incision upon the other, and 
 that the result was equally good in both. The first, ho\vever, to system- 
 atically practise anterior sclerotomy for glaucoma was Quaglino,-* who 
 
 1 Beitrage zur Augenheilkunde, 1905, Heft 64, p. 232. 
 
 2 Traite des maladies des yeux. 1867. 
 
 3 Der Intraoculare Druck, Wein, 1868. 
 
 4 Annali di Ottala., 1871, p. 200.
 
 SCLEROTOMY. 401 
 
 reported five cases of glaucoma in which he had made the operation, 
 giving favorable results. Quaglino made the incision with a large, 
 triangular keratome, much in the usual way for iridectomy, the 
 only differences being that he began the scleral incision 2 mm. 
 behind the sclero-corneal junction, pushing the blade very slantingly 
 through into the anterior chamber. Then, before withdrawing, 
 he tilted the handle back, and, slightly prying open the cut, allowed 
 the aqueous to run out very slowly, to avoid prolapse of the iris. 
 The same year that Quaglino made his report, De Wecker, 1 gave 
 an account of seven cases of glaucoma in which he made anterior 
 sclerotomy by a new method, which he called "incision double 
 avec pont sclero-conjunctival." This, which has been followed, 
 perhaps, oftener than any other mode of anterior sclerotomy, is as 
 follows: The pupil is, if possible, contracted by eserin, then the 
 eye is lightly cocainized. With a narrow Graefe knife, puncture 
 and counterpuncture are made above i mm. back of the limbus, 
 as if for linear extraction with flap 2 mm. high. The knife is 
 carried upward with slow sawing movement until the edge engages 
 well in the angle of the iris, when, instead of cutting out, it is twisted 
 a little on its axis to allow all the aqueous to escape, then withdrawn, 
 leaving undivided a bridge of sclera and conjunctiva, about 3 or 
 4 mm. wide or about one-third of the distance between the points 
 of the puncture and counterpuncture. The points claimed for the 
 procedure over the completed incision were freedom from iris 
 complications, staphylomatous scar, loss of vitreous, and relapses. 
 
 Wiegman 2 designed a dolible keratome for making the De Wecker 
 incision. 
 
 A Few of the Many Other Modifications. Panas* gave a 
 method of anterior sclerotomy which he called ouletomie, specially 
 destined, as its name implies, for incising the cicatrix in cases of 
 relapsing glaucoma after iridectomy, where adhesions and inclusions 
 of the iris had occurred. This consisted in making the usual punc- 
 tures with very narrow Graefe knife near the ends of the remaining 
 cicatrix, and so completing the section as to include the entangled 
 iris and scleral scar, but left intact a narrow bridge of conjunctiva. 
 
 1 Ann. d'oculist., 1871. 
 * KI. Mbl. F. A., 1897, p. 277. 
 3 Soc. franc, d'opht., 1883. 
 26
 
 402 OPERATIONS UPON THE GLOBE. 
 
 At times he also divided the latter. De Wecker 1 made a similar 
 operation which was named "cicatrisotomy." 
 
 Tailor, 2 under the name "internal sclerotomy," gave a measure, 
 and for the execution thereof Vicentiiss designated an instrument 
 consisting of a needle-like shaft, bearing at its extremity a tiny, 
 sharp, sickle-shaped, or slightly curved blade, with the cutting edge 
 on the convex side; blade and shaft being so designed that the latter 
 effectually stops the incision made by the former and prevents the 
 premature escape of aqueous. The blade is passed into the anterior 
 chamber on a level with the horizontal diameter of the cornea, and 
 15 mm. in front of the limbus, carried across to the other side, where 
 the convex edge is pushed into the angle of the iris; the handle is 
 given a sort of rotary motion, whereby the scleral border of the iris 
 is severed and the sclera itself cut to the depth of about i mm. 
 
 The Scleriritomy of Nicatij The very narrow Graefe knife 
 is passed through the anterior chamber at the bottom, with its edge 
 in the angle of the iris. When the point is fairly through the 
 conjunctiva on the opposite side, a quick, quarter turn is given the 
 blade, bringing its plane at a right angle to that of the iris, edge 
 backward. The aqueous here escapes, causing the knife to snip 
 into the iris. Now, with a rapid movement, the blade is withdrawn, 
 so manipulating the handle as to incise the root of the iris all the 
 way. Care is taken to pry open the wound with the spatula to 
 allow the blood to escape. The indications given are secondary 
 glaucoma from incarceration of iris, cystoid scar, occlusion of the 
 pupil, and primary senile glaucoma. 
 
 Kniess gave what he termed "irido-sclerotomy," made, under 
 myosis, by upward section with the Graefe knife, and in such a manner 
 as to divide the root of the iris from the sclera in cutting out as it 
 were a sort of iridodialysis. Sometimes a bridge of conjunctiva 
 is left intact. The indications cited are the same as those for 
 iridectomy and anterior sclerotomy in general. 
 
 De Wecker's 6 sclerotomie combinee has also as principal 
 object the making of artificial iridodialysis. Myosis is produced, 
 
 1 Ann. d'oculiste, xciii, p. 10, 1885. 
 
 2 Annali di Ottal., xx, 1891, p. 117. 
 
 3 Soc. It. d'opht., 14 session, Venise, 1895. 
 
 4 Bull, et mem. de la soc. franj. d'opht., 1892, p. 278. 
 
 5 Vers. der Ophth. Ges. zu Heidelberg, 1893, S. 118. 
 
 6 Annal d'oculist., t. cxii, 1894, p. 261.
 
 POSTERIOR SCLEROTOMY. 403 
 
 where possible, and i drop of cocain solution instilled. The 
 incision is made as for ordinary iridectomy, beginning i mm. 
 behind the limbus, but with that surgeon's own stop-knife. The 
 aqueous is evacuated slowly. A special forceps is introduced. 
 When the closed jaws are seen 2 mm. from the base of the cornea, 
 they are opened, the iris is caught near the periphery, and the forceps 
 pushed downward, hugging the posterior surface of the cornea, 
 till the iris is torn for a distance of 6 to 8 mm. from its fastening. 
 The forceps is now withdrawn, but in doing so one must not forget 
 that the jaws must be first opened. 
 
 Galezowski, 1 too, has furnished a measure crucial sclerotomy 
 and a special keratome with which to make it. The blade of the 
 instrument is lanceolate, measuring 3 mm. at its greatest width by 
 about 2 centimeters in length, and is slightly curved on the flat. It is 
 put through the anterior chamber twice, convexity toward the iris, so 
 as to incise the sclera at the four cardinal points. Thus is obtained 
 the maximum of severance (12 to 14 mm.), with the minimum of 
 risk. The second passage of the knife can hardly be an easy one. 
 
 The alleged indications for anterior sclerotomy are: 
 
 (a) Glaucoma simplex, especially as a tentative measure. 
 
 (b) As a preparatory step to iridectomy when T is high and 
 anterior chamber obliterated. 
 
 (c) Congenital glaucoma, or hydrophthalmus. 
 
 (d) For relief of pain in hemorrhagic and absolute glaucoma. 
 
 (e) For relapsing glaucoma after iridectomy. 
 
 As a matter of fact, wh'atever of benefit resulted was probably 
 due to the paracentesis rather than to the character of the incision, 
 and the measure in all its forms has practically been abandoned. 
 Yet there was a time, a few years after De Wecker, with character- 
 istic zeal, took the matter up, that it had a veritable boom, and 
 bade fair to supersede the operation of iridectomy as a cure for . 
 glaucoma. 
 
 POSTERIOR SCLEROTOMY. 
 
 SCLERAL FUNCTION. PARACENTESIS SCLER^E. 
 
 Incisions of the posterior segment of the sclera were made early 
 in the century, James Ware, of London, having practised it for 
 
 1 Congr. de chir., Paris, 1898, p. 175.
 
 404 OPERATIONS UPON THE GLOBE. 
 
 detachment of the retina. Later, Sichel, v. Arlt, and De Wecker 
 resorted to it in the same connection. Function of the sclera had 
 been done also for general staphyloma of the globe. The first, 
 however, to employ the operation for hydrophthalmus and glaucoma 
 was William MacKenzie, of Glasgow, about the year 1830. He 
 made the operation with a lance knife, choosing as the site about 
 the same part of the sclera in which the old scleronyxis was made 
 for couching. After piercing the vitreous, the knife was slightly 
 turned to pry open the wound. It fell into disuse for the diseases in 
 question, to be revived by de Luca, 1 who, it seems, was ignorant of 
 MacKenzie's use of it. De Luca made the incision, not only in 
 blind eyes, to relieve pain, but in those that still possessed vision. 
 
 The simplest method for posterior sclerotomy and the one com- 
 monly chosen is as follows: The eye is cocainized. The patient 
 is made to rotate the eye far up and in; the globe is steadied by 
 grasping with fixation forceps the conjunctiva near the infero- 
 temporal quadrant of the cornea. A point is sought between the 
 tendons of the external and inferior rectus muscles and at least 15 
 millimeters back of the corneal limbus, that is free from the larger 
 conjunctival and scleral vessels. Here a Graefe knife is inserted 
 to the depth of 5 or 6 mm., perpendicular to the center of the globe, 
 with its edge directed forward, and by a gentle sawing movement, 
 a meridional incision, some 5 or 6 mm. in length is made. Before 
 withdrawing the knife it is slightly turned on its axis to pry open the 
 cut. A bleb of conjunctiva arising tells of the escape of the contents 
 of the globe, and gives an idea as to the quantity. The knife is 
 removed and the eye washed and bandaged. 
 
 While the technic of the operation is simple, yet it is by no means 
 a measure to be slighted. Among the things to be avoided are 
 wounding of the larger blood-vessels of the conjunctiva, Tenon's 
 capsule and sclera (vasa vorticosa), carrying the incision too far 
 forward, i.e., into the ciliary body, pressure upon the globe after the 
 incision is made, either by the surgeon with fixation forceps or by the 
 patient with the orbicularis, and needless wounding of the vitreous. 
 To avoid squeezing, the lids would better be held apart by an as- 
 sistant with retractors. 
 
 Modifications. In order the more surely to obtain a filtration 
 
 1 Annali di Ottal., ii, 1872, p. 155.
 
 POSTERIOR SCLEROTOMY. 405 
 
 cicatrix and to protect the scleral wound, Baudry 1 recommends 
 drawing the conjunctiva to one side before making the incision, so 
 that the two wounds will not coincide. To prevent too rapid 
 healing of the incision, Parinaud, 2 after making the meridional 
 incision, before withdrawing, gives to the blade a quarter turn and 
 makes a V-shaped scleral wound. For the same reason, Terson,3 
 on completing the usual incision, withdraws the knife and makes an 
 equatorial incision, the whole wound thus taking the form of a T. 
 
 Others, again, either as a curative or a tentative measure in 
 glaucoma, have practised the sclerotomy without the retinotomy 
 and the choroidotomy. Masselon/ made a long, meridional incision 
 of the sclera alone, by using an extremely narrow Graefe knife, 
 passing it through by puncture and counterpuncture from before 
 backward. Later, he added a very small equatorial incision. 
 Simi,s and Galezowski, 6 made similar incisions, the latter using for 
 the purpose a knife of his own invention. 
 
 The writer, in cases of glaucoma where the eye still has useful 
 sight, and there is great tension, absence of anterior chamber, and, 
 especially, if there is likelihood of expulsive choroidal hemorrhage 
 from an iridectomy, would advise making the posterior sclerotomy 
 between the internal and inferior rectus muscles. In this way, any 
 resulting accident at the site of the puncture, within the globe, such 
 as hemorrhage, detachment of the retina, edema, etc., are further 
 removed from the macula. To favor greater precision, the over- 
 lying membranes are first incised. They are then retracted by two 
 Stevens squint hooks. After the sclerotomy, the membranes are 
 carefully arranged, but no suturing is done. 
 
 The indications for posterior sclerotomy are: 
 
 i. (a) In chronic (simple) glaucoma, with approaching blindness, 
 and other operative measures and forms of treatment have 
 availed nothing. 
 
 (b) In absolute glaucoma, for relief of pain, or for quieting the 
 eye in cases where enucleation is not practicable. 
 
 1 Technique Operatoire, 1902, p. 639. 
 
 2 Arch, d'opht., v, 1885, p. 180. 
 
 3 Midi, medical, du 8 oct., 1892. 
 
 * Ann. d'ocul., t. xcv, p. 231, 1886. 
 
 s Boll d'ocul., ix, 3, 1887. 
 
 6 Seventh Internat. Oph. Congress, Heidelberg, 1888.
 
 406 OPERATIONS UPON THE GLOBE. 
 
 (c) In irritative primary or secondary glaucoma, with absence 
 of anterior chamber, excessive tension, etc., either as a preliminary 
 to iridectomy or as a last or only surgical resort for relief. 
 
 2. In detachment of the retina. 
 
 3. In hemophthalmia, especially where the blood is in con- 
 siderable quantity and is causing high tension, or organization of 
 the clot is feared. 
 
 4. In abscess of the vitreous, as in panophthalmitis, when one 
 wishes to avoid enucleation or exenteration. 
 
 5. In cases of foreign bodies or cysticercus in the vitreous chamber, 
 to give access for their removal. 
 
 6. In total ectasia of the sclera, in lieu of a more radical measure. 
 
 Cyclodialysis. Heine, first assistant in the clinic of Professor 
 Uhthoff, of Breslau, 1 actuated by the idea conveyed in the observa- 
 tions of Fuchs and Axenfeld, relative to detachment of the choroid, 
 following incisions affecting the sinus of the anterior chamber, has 
 proposed a new operation for glaucoma. Fuchs had remarked 
 upon the relative frequency of such detachment after all operations 
 w r herein the outer limits of the chamber were incised; and Axenfeld 
 declared that it occurred in as many as 10% w r hen the interference 
 had been for glaucoma. In consequence, these clinicians were 
 led to believe it possible that both the detachment and the beneficial 
 results of the glaucoma operation were caused by the loosening of 
 the choroid from the sclera incident to the making of the incision. 
 Thereupon Heine imagined the surgical measure for glaucoma which 
 he calls cyclodialysis, and which consists in an attempt to establish a 
 lasting communication between the anterior chamber and the supra- 
 choroidal space. Heine proceeded to try the measure upon 20 
 glaucomatous eyes that were totally blind or nearly so. These 
 experiments demonstrated to his satisfaction that the effect of 
 the procedure was to permanently reduce the tension, even in cases 
 of absolute glaucoma. Briefly, the operation may be thus described: 
 A triangular flap of conjunctiva 8 or 9 mm. high is fashioned, 
 downward and outward, with its base left attached at the limbus. 
 A suture is put into the apex and the flap turned down over the 
 cornea. The episcleral tissue in the exposed triangle is scraped 
 
 1 Deutsche med. Woch., No. 21, p. 824.
 
 CYCLODIALYSIS. 407 
 
 away. With a small bent lance or a Graefe cataract knife a 2 or 3 
 mm. long incision is made in the sclera, 4 or 5 mm. from, and 
 parallel with, the limbus, directing the point of the knife, if it be 
 the lance, toward the chamber angle, but not entering it. Meller 1 
 advises making the cut not with the point of the lance, but with 
 one of its lateral edges, so that more nearly the same depth can be 
 maintained along the whole extent of the wound. A narrow 
 spatula, similar to that used in replacing the iris, only with five 
 transverse lines on its concave surface marking the 5 terminal 
 mm. of the blade, is introduced at the wound. About when the 
 fourth mark is entering, the resistance of the ligamentum pectinatum 
 is felt. After this is slowly pierced, the spatula is visible in the 
 anterior chamber. By lateral excursions this cyclodialysis is 
 enlarged 2 to 3 mm. No aqueous escapes if the instrument is 
 slowly extracted. If, however, an evacuation of some aqueous is 
 desired, the spatula may be pressed toward the globe or a little 
 twisted to pry open the wound. Finally, the suture is tied. Tension 
 is the same after the operation if no aqueous escaped and diminished 
 after two to three days. After escape of aqueous tension is at once 
 diminished. In certain cases it would certainly seem advisable to 
 let out a part of the aqueous and reduce the tension at once, and also 
 follow the operation by the use of miotics, so as to draw the root 
 of the iris away from the angle of the anterior chamber and thus 
 augment the effect of the operation. 
 
 Indications for Cyclodialysis : 
 
 1. In secondary glaucoma, especially with anterior synechia 
 due to wounds, ulcers or cataract extraction. 
 
 2. In glaucoma where the other eye has been lost by severe 
 hemorrhage following iridectomy. 
 
 3. In the aged or infirm where it is considered dangerous to keep 
 the patient in bed as in iridectomy. 
 
 4. As a preliminary operation where iridectomy is dangerous 
 on account of very high tension, no anterior chamber, atrophic 
 iris and wide pupil, as it lowers the tension, and there is no danger 
 of striking the lens during its performance. 
 
 :;. When the lens has been dislocated and fallen into the vitreous 
 
 i Ophthalmic Surgery, 1908, p. 201.
 
 408 OPERATIONS UPON THE GLOBE. 
 
 chamber. Iridectomy, for the secondary glaucoma of such cases, 
 is not feasible because of the certainty of losing vitreous. 
 
 Contraindications. 
 
 Seclusio pupillae, iris bombe, sarcoma of the choroid, or active 
 iritis. 
 
 Accidents and Complications. Immediate. 
 
 1. Failure to cut all of the scleral fibres. The spatula will then 
 go only about i mm. forward. 
 
 2. Hemorrhage from cyclon or scleral vessels or ciliary vein. 
 
 3. Running of spatula into a good scleral spur. 
 
 4. Detachment of Descemet's membrane from the corneal stroma, 
 indicated by corneal cloudiness. 
 
 5. Iridodialysis which is infrequent. 
 
 6. Hemorrhage from Schlem's canal, as its inner wall is formed 
 by the ligamentum pectinatum and the fibres of the ligament are 
 broken and split up. 
 
 Consecutive Accidents. While the operation is of too recent 
 origin to permit one to judge as to its remote effects, tumors, which 
 are apparently implantation cysts, have been observed to occur at 
 the seat of the operation as early as a few weeks after its performance. 
 Two such cases have been seen by the writer. 
 
 Results of Cyclodialysis. Lowering of tension immediate 
 if aqueous is permitted to escape, gradual if the aqueous is not 
 allowed to escape, so that the maximum effect is not produced 
 until from one to three days after the operation. These results 
 may be permanent or of only a few days' duration. In some 
 cases, especially in absolute glaucoma, there is no improvement 
 at any time. It is not known in just what way these results are 
 produced, whether by establishing an outflow through the peri- 
 choroidal space or through the canal of Schlem. It seems probable, 
 however, that the good results which occasionally follow this 
 procedure are due to freeing the angle of the anterior chamber, 
 and not to permanent choroidal detachment. 
 
 Excision and Trephination of the Sclera. Sclerectomy. 
 Removal of a portion of the sclera was first undertaken for cystoid 
 scars or staphyloma consequent upon penetrating wounds.
 
 SCLERECTOMY. 409 
 
 Coccius, 1 transfixed the center of the tumor with a fine Graefe knife, 
 cutting out parallel with the base, held the lips of the incision closed 
 with a tenaculum, and completed the excision with forceps and 
 scissors. More recently, in a smilar case, Fage 2 incised the over- 
 lying conjunctiva, put three catgut sutures through the base of the 
 ectasia, made the exsection, as did Coccius, and then tied the sutures. 
 The loss of vitreous was slight, and the result satisfactory. The 
 idea of first placing the sutures was taken from the Critchett opera- 
 tion for corneal staphyloma. Taylor, Argyll-Robertson and 
 De Wecker, tried trephining the sclera in absolute glaucoma, 
 but have had few imitators. In this connection, however, it may 
 be mentioned that Frohliclv of Berlin, reports that, in four out of 
 five eyes with absolute glaucoma, and that were as hard as stone, he 
 had succeeded, by trephination, in reducing the tension to normal 
 or subnormal, ridding them entirely of inflammation, and in per- 
 manently relieving them of pain. He proceeds thus: Cocain; 
 incision of conjunctiva along lower border of externus, and along 
 outer border of inferioris, extending nearly to cornea, where they 
 are joined. The flap is raised and turned back toward the 
 equator. Von Hippel's trephine, with 5 mm. crown, set for 
 the thickness of sclera only, is used for the excision. On 
 removal of the disk, if retina and choroid are not sufficiently 
 ruptured by vitreous, they may be punctured. The conjunctival 
 flap is put in place and sutured. The scleral wound takes care 
 of itself. 
 
 Of late years sclerectomy has been mainly employed in detach- 
 ment of the retina, the object being to shrink the walls of the globe 
 upon the already shrunken vitreous. Parinaud,* put a needle, 
 tangent, into the outer portion of the sclera over the center of the 
 detachment, and lifted up a cone. Through this, and parallel 
 with its base, he passed a Graefe knife so as to excise an ovoid piece 
 4 or 5 mm. in diameter. The choroid should not be injured. 
 The choroid could be punctured afterward, and, if need be, the 
 puncture repeated after 7 or 8 days. 
 
 A bold and extensive operation of sclerectomy for detachment 
 
 1 Heilanstalt fur arme Augenkranke zu Leipzig, 1870, S. 35-36. 
 
 2 Gaz. des hop. de Toulouse, 1894, 18 aoiit. 
 
 3 Kl. Mbl. f. A., Mai, 1904. 
 
 4 Bull, de la soc. franf., d'opht., 1884, p. .77.
 
 4IO OPERATIONS UPON THE GLOBE. 
 
 outward is that resorted to by L. Miiller. 1 The patient was 
 narcotized. Temporary resection of the outer wall of the orbit 
 by Kronlein's method. Excision of the orbital periosteum, exposure 
 of the external rectus, and the inferior oblique, and their severance 
 from the globe. Excision of a strip of sclera 10 mm. wide by 20 
 mm. long, extending from 2 mm. behind the attachment of the 
 externus to the posterior pole. Five silk sutures inserted, and 
 all without the slighest injury to the choroid. The choroid was 
 punctured and the threads tied. When the subretinal fluid ran out. 
 The retina immediately became reattached, the field of vision 
 became normal except for a small central scotoma, and the sight, 
 which had been reduced to counting fingers in lower field, rose to 
 fingers at 3 meters. 
 
 Galvano-puncture has been tried by De Wecker and others, both 
 for detachment of the retina and for circumscribed staphylomas of 
 the sclera, but the results have not been encouraging. 
 
 SUTURING SCLERAL WOUNDS. 
 
 Small wounds, and even pretty extensive ones that are meridional, 
 may often be left without sutures, simply cleansed, extruding vitreous 
 snipped off, and the conjunctiva stitched over them. But if the 
 scleral wound inclines to gape, it should be sutured. If the scleral 
 and the conjunctival wounds correspond, the same threads may 
 include both; if they do not, it is best to close the scleral opening 
 with absorbable sutures and the conjunctival with silk. Indeed, 
 it is usually deemed best to see to it that the two openings do not corre- 
 spond, even if a piece of the conjunctiva constituting one lip of the 
 wound must be excised to avoid coincidence. The wound is 
 not only freed from dirt and vitreous, but from shreds of choroid 
 and retina, should these be present. Double-armed, interrupted 
 sutures are preferable, so that the needle can be introduced from 
 within on both sides. The thread should, if possible, be made 
 to include only the outer layers of the sclera, and in no case should 
 the uvea and retina be included either in the wound or in the sutures. 
 The thread or gut should be very fine and the needles of exceptional 
 sharpness. 
 
 1 Wiener kl. Woch., Apr., 1903.
 
 EXENTERATIOX OF THE SCLERA. 
 
 411 
 
 Fage, 1 gives the following reasons for suturing scleral wounds: 
 
 1. The prevention of deep infection. 
 
 2. Holding back the contents of the globe. 
 
 3. The avoidance of fistula, cystoid scar, and staphyloma. 
 
 4. The resulting scar is more regular, less contracted, and conduces 
 less to detachment of the retina. 
 
 5. The healing process is shortened. 
 
 Czermak 2 makes a rule of suturing all scleral wounds that exceed 
 5 mm. in length. Even the subconjunctival ruptures are sought out, 
 trimmed up, and sutured. If the 
 lens has escaped beneath the con- 
 junctiva, of course it is let out. 
 
 Ntiels has contrived a most in- 
 genious and effective arrangement 
 of the thread for closing corneo- 
 scleral ruptures, as well as for the 
 wound left after the removal of a 
 cystoid scar in that locality. The 
 suture is double-armed. One needle 
 is quilted into the sub-conjunctival 
 tissue for a distance of 2 centimeters at, and parallel with, the 
 equator, i.e., for a distance of i centimeter on either side of the 
 meridian of the wound. The threads are then crossed over 
 the center of the wound, and each needle carried beneath the 
 conjunctiva, in the episclera, close to, and half-way around the 
 cornea, where they are brought out together and tied (Fig. 217). 
 
 EXENTERATION OF THE SCLERA. 
 (EVISERATIO BULBI.) 
 
 Seeing that this operation consists in making an opening in the 
 front wall of the globe and the removal of its entire contents, the 
 author has taken the liberty of classing it among the operations upon 
 the sclera. In this way it can better be kept distinct from the 
 operation of simple incision of all the tunics of the globe; that has 
 
 1 Ann. d'ocul., cxii, p. 262, 1894. 
 
 2 Augenarztlichen Operationen, p. 690. 
 
 3 Ann. d'ocul., xcix, 1888, p. 270. 
 
 FIG. 217.
 
 412 OPERATIONS UPON THE GLOBE. 
 
 been commonly called evisceration. Indeed, it would be better 
 if the term evisceration were dropped from the medical dictionaries 
 altogether, since it has precisely the same etymologic significance as 
 exenteration, and is the preferable word in common parlance, where 
 exenteration is rare. 
 
 About a century ago, Wardrop, of Edinburgh, as a cure for the 
 sympathetic ophthalmia of horses, advised incision of the cornea of 
 the exciting eye, and the removal of the lens and vitreous, suggesting 
 at the same time that a similar procedure might be applied to the 
 human eye. The first to put the suggestion into effect was Barton, 1 
 who employed it for the removal of fragments of copper from the eye. 
 As has already been stated on page 391, De Wecker, about 1883, 
 added exenteration to his tobacco-pouch modification of Critchett's 
 ablation. Frohlich, 2 in 1881, "removed the front section of the 
 globe and scooped out the contents of the scleral capsule," with 
 the hope of escaping the grave consequences that sometimes follow 
 enucleation. Alfred Graefes adopted exenteration for most cases 
 for which formerly enucleation had been practiced. He excepted 
 those in which there was, or threatened soon to be, sympathetic 
 ophthalmia. This surgeon was the first to plan for the operation a 
 definite technic, the main points of which are as follows: The 
 upper lid is held up by an assistant with a Desmarres retractor. 
 Supposing it to be the right eye, the operator grasps the conjunctiva 
 at the external corneal limbus with fixation forceps, while the as- 
 sistant does the same only 5 mm. further back in the horizontal 
 meridian. The intervening tissue is put upon the stretch, but 
 without pressure upon the globe, and with a convex scalpel a 
 small vertical incision is made, close up to the forward forceps, 
 carefully carried in until the blackness of the ciliary body shows. 
 Now, with delicate, blunt-pointed scissors, the incision is extended 
 between the sclera and the cornea till the two meet at the corre- 
 sponding point on the opposite side. Here Bunge's exenteration 
 curet is inserted between sclera and uvea, convex side out, and the 
 two tunics separated, cutting in succession the vorticose veins, the 
 ciliary arteries and nerves, and finally the neck of the optic nerve- 
 head. Having seen that only the bare sclera remains, the cavity is 
 
 1 Crampton Med. Gaz., London, 1837. 
 
 * Klin. Mbl. F. S. f 1881, S. 30. 
 
 3 Tagb. der 57. Vers. Deutsch. Naturf. u. Aerzte, Magdeburg, 1884.
 
 EXENTERATION OF THE SCLERA. 413 
 
 washed and the opening closed by from 3 to 5 vertical sutures that 
 include both conjunctiva and sclera. 
 
 The reaction after this operation is usually considerable, the 
 chief features being chemosis, particularly of the lower half of the 
 conjunctiva, and swelling of the upper lid. The chemotic mem- 
 brane often projects beyond the palpebral fissure, and is very slow 
 to disappear. There is, moreover, needless sacrifice of the outer 
 wall of the sclera. To obviate this, Gifford, of Omaha, quite 
 properly, omitted excision of the cornea, making the exenteration 
 through a simple horizontal incision, thus causing less reaction, and 
 securing a more ample stump. 
 
 The writer, who had previously made only the De Wecker opera- 
 tion (described in chapter on Anterior Staphyloma), seeing the 
 advantages of Gifford's method, adopted it. He had noticed, 
 however, that the stump, after all methods where the long axis of 
 the wound lay in the horizontal meridian, was always characterized 
 by a deep cleft, lying in the same direction and reaching far back 
 into the sclera on both sides really a folding of the globe upon 
 itself, causing it to resemble a grain of barley. This determined 
 him to make the opening vertical, though still, like Gifford, without 
 the excision of cornea, except in cases of anterior staphyloma, when 
 just enough is removed to cause adequate flattening. A long, 
 narrow, vertical, pointed ellipse is ample for even a pronounced 
 staphyloma. In either case, the ends of the incision or the points 
 of the ellipse are extended sufficiently far into the ciliary region to 
 give ingress for instruments and small spindle-shaped cotton 
 sponges. The operator grasps the center of the wound on one 
 side with fixation forceps (without catch); an assistant does the 
 same on the other, and in such a way that, by rotating the instru- 
 ments, the cornea and sclera can be rolled back like the turning up of 
 a sleeve (Fig. 218). A knife of special design, first described in the 
 Ophthalmic Record, July, 1905, is used to dissect the choroid from 
 the sclera (Plate II, No. 39). The blade, which is not oversharp, 
 is double-edged, curved on the flat so as to fit into the scleral 
 cavity, and has a rounded extremity. This serves to sever the roots 
 of the iris, the ciliary body, the veins, arteries, and nerves, but for 
 fear of perforating with the knife when it comes to the optic nerve 
 the assistant takes both forceps, the surgeon holds choroid and retina
 
 414 
 
 OPERATIONS UPON THE GLOBE. 
 
 with broad-jawed forceps, and cuts the tissues at the limina cribrosa 
 with small, curved, blunt-pointed scissors, which completes the 
 exenteration. Copious irrigation of the cavity with hot sublimate 
 
 FIG. 218. 
 
 solution, 1-2000, is now used, for the double purpose of checking 
 the hemorrhage, so that one may see that every vestige of the con- 
 tents has been removed, and of antisepsis. Any relics of the uvea
 
 EXENTERATION OF THE SCLERA. 415 
 
 are scraped away with the knife or sharp curet. A small flattish 
 curet w r ith finely serrated edge is best. Having been assured that 
 nothing is left behind, the opening is immediately closed by several 
 horizontal silk sutures, allowing the oozing blood to fill the scleral 
 capsule if it will. No attempt is made to stop the moderate oozing 
 of blood, but rather it is encouraged, by mild curetment if necessary, 
 so as to insure a clot of sufficient size to fill the scleral capsule, with 
 the view to its becoming organized, thus adding to the efficiency of 
 the stump. The eye is bandaged in the usual way. For some 
 reason there seems to be even less chemosis following the vertical 
 incision than the horizontal, and the cleft, just alluded to, does not 
 ensue. In case after case the parts involved have remained abso- 
 lutely quiet. The sutures are removed after 3 or 4 days. Union is 
 usually by first intention. If it is not, a small round hole may 
 appear, which slowly closes. I have never seen any harm come of it. 
 
 There is pretty free bleeding while the separation of the choroid 
 is going on, but it does not materially interfere. Of course, the lens 
 and the vitreous escape as soon as the globe is well open. 
 
 Exenteration is indicated in all instances where it has been the 
 custom to make enucleation, save where exists sympathetic ophthal- 
 mia, a neoplasm of the globe, or phthistis so advanced that only a 
 tiny, shapeless button remains. I would not even except those in 
 which sympathetic trouble is impending, nor would I those in which 
 it is already present but for the popular prejudice of the profession. 
 Yet more, I would, and do, add all the cases of total staphyloma of 
 the cornea. For, as before stated, ablation of the staphyloma ful- 
 fills none of the indications, or, if any, does it poorly, while exentera- 
 tion meets them all and meets them well. For all but the cases 
 mentioned as exceptions, it is not only a much better pro- 
 cedure than enucleation, in view of the objects desired, but all the 
 evidence points to its being a safer one. All those parts that have 
 been deemed a menace to the fellow eye are as effectually gotten rid 
 of as by enucleation. As to the growth of new nerve structures 
 within the exenterated sclera, discovered by Forget, 1 and mentioned 
 as a possible source of discomfort, if not of danger, it would seem 
 quite as easy for this to occur within the capsular envelope which 
 remains after enucleation. As to the conditions for the wearing of 
 
 1 Arch, d'opht., t. xii, 1892, p. 693.
 
 4l6 OPERATIONS UPON THE GLOBE. 
 
 a prothesis, they are vastly more favorable where the walls of the 
 globe are left intact than where they have been taken away entirely. 
 Made according to the principles just given, there being no inflam- 
 matory reaction, not only is an extra large stump afforded for 
 filling out the orbit and giving to the artificial shell something like 
 suitable prominence, but the muscles are all left with their original 
 attachments, and in their normal relations, so that its movements are 
 reasonably extensive and natural. 
 
 The Substitution of an Artificial Vitreous Body. In spite of 
 the greatest care in, and of only a minimum of reaction after, the 
 operation of exenteration, the shrinkage of the stump becomes, in 
 time, considerable, and, in consequence, its motility becomes much 
 restricted. With the view to supplying a larger and more movable 
 permanent stump, Mules, 1 of Glasgow, conceived the idea of placing 
 in the exenterated sclera a hollow glass ball. Encouraged by the 
 immediate results of the procedure, ophthalmic surgeons every- 
 where followed Mules' example, and a few became enthusiastic over 
 it. After a few years, however, even those who had in the begin- 
 ning been most captivated grew less ardent. Too often the ball 
 refused to remain imprisoned. The measure was mostly abandoned. 
 Some, who had been won by the really great plausibility of the 
 method, began to cast about for spheres of different substances 
 and of different construction. Kuhnt, for example, tried silver; 
 Keal, gold; Bryant (of Omaha), fenestrated aluminum, etc. The 
 material that seems, at the present time, to promise most in this 
 connection, is paraffin. Living tissue will bear incorporation with 
 this substance more tolerantly than with any other thus far in- 
 troduced. There are two ways of filling the sclera with paraffin: 
 i. By closing the opening in the globe and overlying membranes by 
 a common purse-string suture, or by suturing them separately; 
 then injecting into the scleral cavity the melted paraffin. This is 
 the method of Brockaert, also that very successfully followed by 
 Ramsay, of Glasgow. 2. By fashioning the sphere of hard paraffin 
 beforehand, and inserting it in the cavity after the same manner in 
 which Mules employed the original ball of glass. This is the mode 
 recommended by Oatman, of New York, and is probably the more 
 desirable as to precision. Balls of paraffin having a high melting- 
 
 1 Trans. Ophthalmolog. Society, 1885, vol. v, p. 200.
 
 AMPUTATION OF THE SCLERA. 417 
 
 point 140 degrees and over are prepared by fusing, filtering, 
 and sterilizing, then rolling, while yet warm and plastic, with the 
 protection of rubber gloves. In size, they should vary from a 
 diameter of 12 mm. to that of 18 mm., according to the capacity 
 of the sclera they are to occupy. They are kept ready for use in a 
 glass jar filled with a 5% solution of formaldehyd. Before being 
 placed within the sclera, the ball is rinsed with a solution of bichlorid, 
 1-2000. If the opening in the sclera is sufficiently large, the ball 
 may be put in place with ordinary dressing forceps. Usually, 
 however, it will be found more convenient to introduce it with the 
 aid of the Mules inserter (Plate VIII, No. 89). All bleeding is 
 previously stopped by means of hot bichlorid irrigation. The 
 scleral opening is closed over the sphere in the vertical sense, i.e., 
 by silk sutures, placed horizontally. If the conjunctiva has been 
 first incised around the cornea, chromicized catgut is used to close 
 the sclera in the manner just stated. The conjunctival opening is 
 then drawn together in the horizontal sense or, by interrupted silk 
 sutures placed vertically. Purse-string or tobacco-pouch sutures 
 are not admissible. The eye is dressed in the usual way and left 
 for 48 hours before redressing. Not only is the most rigid asepsis 
 necessary, but it is indispensable that the character of the coapted 
 lips of the scleral opening is such as to insure primary union, else 
 the ball will surely be extruded. Whereas, after exenteration with- 
 out substitution of the artificial vitreous, it matters but little 
 whether the adhesion be prompt or delayed. 
 
 Amputation of the Anterior Segment of the Globe. Guerin, 
 Saint-Ives, and Heister, in the i8th century, advised, when practi- 
 cable, to remove the front half of the eyeball, instead of making a 
 complete excision of the globe in order to facilitate the wearing of a 
 prothesis. The procedure was considered applicable to cases of 
 malignant tumors confined to the section to be discarded and to 
 total staphyloma of he cornea. The operation consisted in the 
 ablation of the cornea, the iris, and the ciliary zone, leaving intact the 
 insertions of the straight muscles with their capsular coverings. 
 The scleral incision should be started with a cataract knife, and 
 finished with blunt-pointed scissors. The remainder of the uveal 
 tract, with the retina, is then to be curetted out, and the cavity kept 
 packed with antiseptic gauze until healing occurs. If the operation 
 27
 
 41 8 OPERATIONS UPON THE GLOBE. 
 
 were done to-day, the scleral opening would doubtless be closed, 
 at least partially, by suturing. 
 
 Amputation of the Posterior Segment of the Globe. Nicati, 1 
 performs this operation as follows: A horizontal (or vertical) in- 
 cision is made into the conjunctiva on the inner side of the globe. 
 The internus is seized, divided through its tendon, and guarded by a 
 catgut suture, which is passed through the tendon and the con- 
 junctiva. The capsule is separated above and below and the optic 
 nerve is sectioned in the ordinary manner. The posterior pole of 
 the eyeball is caught by a tenaculum and drawn forward. The 
 obliques are detached from it and it is drawn through the con- 
 junctival opening, after which the posterior portion of the globe is 
 exsected up to the insertions of the rectus muscles. The tendon of 
 the adductor is secured to its stump, and the conjunctival opening is 
 closed. An accumulation of blood behind forces the cornea forward, 
 but this is removed by compression and absorption. Nicati claims 
 that the convalescence is more rapid than after enucleation, and the 
 results are an excellent stump with the conjunctiva and cornea 
 entire. He asserts, also, that sympathetic ophthalmia is avoided, 
 but th s must be open to question, seeing that there is no provision 
 for the removal of the anterior portion of the uvea. Moreover, the 
 operation is difficult, and involves dangers of deep infection not in- 
 curred in those previously described. 
 
 None of these operations possess that virtue, dear to the heart of 
 the pathologist, of preserving a perfect specimen for the laboratory 
 as does enucleation. 
 
 OPERATIONS ON THE IRIS. 
 
 IRIDOTOMY IRITOMY. 
 
 This has for its object the making of an opening or pupil in an 
 otherwise imperforate iris by means of a simple incision, and of the 
 several operations made upon this membrane it is the oldest. The 
 idea originated with Thomas Woolhouse, 2 of London, who pro- 
 posed, in case of loss of sight from posterior synechia, to tear the 
 iris asunder from behind, with a needle entered through the sclera as 
 
 1 Archives d'ophthalmologie, June, 1903. 
 
 2 Exper. de dirf erentes oper. aux yeux, Paris, 1711.
 
 IRIDOTOMY. 419 
 
 if for couching (scleronyxis) . Whether or not he made the opera- 
 tion, is not known. It is known, however, that 17 years later, 
 another English surgeon, and a pupil of Woolhouse, William 
 Cheselden, 1 put the idea of Woolhouse into practice for closure of 
 the pupil in eyes where cataract had been depressed. Heuerman, a 
 of Copenhagen, changed the point of entrance to the cornea. 
 Guerhv and Janhv observing that the needle of Cheselden tore, 
 rather than cut, the iris, first made a corneal incision, then made 
 the iridotomy with small curved scissors, one blade of which was 
 pointed and the other blunt. Guerin made a crucial incision in the 
 iris, Janin, a bow-shaped. Maunior,s in cases of atresia of the pupil, 
 with atrophy of the iris, thrust the pointed blade of the scissors 
 behind the iris in two places, making a V-shaped incision, base 
 peripheral. The inclosed piece was not excised, but merely al- 
 lowed to retract. Bowman, 6 of London, who was, from first to 
 last, an advocate of iridotomy, invented scissors whose points 
 served as a keratome, whereby the operation could be accomplished 
 with a single instrument. The operation of iridectomy having, in 
 the meantime, become popularized, it for a time largely superseded 
 that of iridotomy. The latter was again brought forward by von 
 Graefe, in 1869, as an efficient measure for those forlorn cases of 
 closure of the pupil, atrophy of the iris, and flattening of the an- 
 terior segment of the globe from iridocystitis following a cataract 
 extraction. Von Graefe at first employed the method of Heuer- 
 mann. The matter was taken up with a will by ophthalmic sur- 
 geons, having been specially pushed by Bowman and De Wecker. 
 The last-mentioned brought to bear all his wonted ingenuity, skill, 
 and industry, refining and elaborating the procedure until he not 
 only evolved for it a system of technic that has remained standard, 
 but devised also kindred measures and the rules governing them 
 for cases not adapted to iridotomy. Conspicuous among these were 
 his irito-ectomy and irito-dialysis. His labors in this line included 
 the invention of several instruments, the most valuable of which is 
 his forceps-scissors, which embodies the principle of the Liebreich 
 
 1 Philosoph. Transactions, 1728. 
 
 * Abhandlungen v. d. Chir. Operationen, Kopenhagen, 1756. 
 
 3 Traite sur les mal. des yeux, Lyon, 1769. 
 
 4 Mem. et observations sur 1'oeil, Lyon, 1772. 
 s Mem. sur Toper, de la pupille artif., 1812. 
 
 6 Med. Times and Gazette, 1852, p. 35.
 
 420 
 
 OPERATIONS UPON THE GLOBE. 
 
 iris forceps, and which, in some form, is still the favorite instru- 
 ment for all sections of the iris. The corneal incision he made with 
 a stop-lance, similar to the paracentesis knife of Desmarres. The 
 advantage of this instrument over the ordinary keratome is that there 
 is no danger of penetrating too deep, or even, as could happen, to the 
 extent of having the entire blade enter the anterior chamber. 
 
 De Wecker's Methods of Iridotomy. In cases of occlusion of 
 the pupil, with presence of the crystalline, he made a corneal in- 
 cision opposite that part of the iris zone where the pupillary border 
 was least adherent. Through this he inserted, closed, the blades 
 of a pair of his scissors, both points of which were blunted. When 
 approaching the pupil, the blades were slightly opened, one of them 
 
 FIG. 219. Incisions. 
 
 FIG. 220. Result. 
 
 passed behind the iris, taking care not to wound the lens capsule, the 
 blades still wider opened and pushed further in, a cut made, the in- 
 strument slightly rotated and another cut made, thus loosening a 
 pointed flap, apex inward, like that of Maunior (Figs. 219 and 220). 
 For complete atresia of the iris in aphacic eyes either the point of 
 the keratome, while engaged in the corneal incision, was made to 
 pierce the iris at a suitable spot for inserting the scissors, or else the 
 operator used a pair of scissors, one blade of which was sharp- 
 pointed, and with this the membrane was transfixed. The cut 
 could be single or double. 
 
 De Wecker's irito-ectomy and irito-dialysis are applicable 
 only to cases of closure of the pupil where the lens is absent. Irito- 
 ectomy is a combination of iridotomy and iridectomy, or, in other 
 words, intraocular iridectomy. In this operation the corneal 
 incision and the primary incision of the iris are made simultaneously
 
 IRITO-DIALYSIS. 421 
 
 and with the same knife. Where a relatively small opening in the 
 iris is desired, an iridectomy knife is entered at the limbus toward 
 which the iris is drawn, and a corneal incision made as if for iridec- 
 tomy, except that the blade is directed backward at such an angle 
 as to make a corresponding cut in the iris close to its periphery. 
 The blunt-pointed forceps-scissors are then put in at one extremity 
 of the wound, one blade passing behind the iris, and a snip is made 
 toward the normal pupil center. The scissors are withdrawn, put 
 in at the other extremity of the corneal wound, and a similar snip 
 made, the two cuts meeting, whereby is completed the excision of 
 a triangle of iris. If a larger iridectomy is wanted, a large, linear, 
 corneal incision, which includes the iris, is made with a Graefe 
 knife near the limbus opposite the point toward which the pupil is 
 drawn, and the triangular piece cut, as just described. Here, how- 
 ever, before making the final snip to complete the section, iris forceps 
 is introduced at the other end of the corneal incision for the double 
 purpose of holding the piece for the cut and removing it from the 
 anterior chamber when severed. 
 
 In order to facilitate the making of the iris incision when it is 
 made one step with that of the corneal, as soon as the point of the 
 knife is well within the eye it is tilted so as to pry open the cut and 
 evacuate the anterior chamber, which causes the iris to advance 
 close to the cornea. 
 
 The advantage of such (scissors) operations is that they insure a 
 minimum of traction on the root of the iris and upon the ciliary 
 body, hence it suffers less traumatism and remains more quiet 
 afterward. This is not true of those iridotomies made with needle 
 or knife alone except in instances where the instrument can be 
 made to cut. Usually, after the point of the knife or knife-needle 
 has passed through the iris, all cutting ceases it is merely tearing. 
 The chief objections to the scissors, or knife and scissors methods, 
 are the too free incisions in the globe, often lying wholly in the clear 
 cornea, entailing undue loss of aqueous and vitreous, thus causing 
 other dangers, and that they are, on the whole, complicated and 
 
 difficult. 
 
 Irito-dialysis. DeWecker considered a measure of last resort 
 in those troublesome cases where, in addition to closure of the pupil, 
 there existed adhesions between cornea and iris, and especially in
 
 422 OPERATIONS UPON THE GLOBE. 
 
 such of these as had not been benefited by other means. It consisted 
 in making the primary combined incision with keratome or stop- 
 knife near the center of the cornea, and facing that segment of 
 the periphery where the iris was most nearly normal. The intro- 
 duction of the blunt-pointed scissors, one blade behind the iris, 
 and making two diverging cuts, one from each end of the first iris 
 incision, and reaching to the outer border of the iris. The interven- 
 ing segment of iris was then forcibly torn from its fastening and 
 extracted by means of strong straight forceps. This procedure 
 was naturally often productive of very unpleasant reaction. 
 
 Modifications. A few of the many modes of performing the 
 foregoing operations will be here mentioned. 
 
 Iridotomy. Milles 1 and Nacati, 2 instead of making the corneal 
 incision at right angles to the course of the iris fibres, recommend 
 making it parallel therewith in order the better to direct the cut 
 of the scissors across said fibres. Sicheb and Scherk* reverted 
 to the Heuermann-Graefe method, but each with a knife, or rather 
 a knife-needle, of his own invention. Sichel's instrument was 
 something like his discission needle, only the tiny blade, instead 
 of being curved, was straight, and resembled in form the Zehender 
 cataract knife. The Knapp knife-needle does not differ ma- 
 terially from the iridotome of Sichel. Scherk's was compli- 
 cated, having on the handle an attachment whereby the little 
 lance-like blade could be given a sawing motion. 
 
 Of all forms of simple iridotomy I prefer that of Gayet.s This 
 is essentially the same as that given in the chapter on " Discission 
 of Secondary Cataract" as the method of Pagenstecher. Gayet 
 used an ordinary Graefe knife, punctured the anterior chamber at 
 the base of the cornea, the flat of the blade parallel with the plane 
 of the iris; the handle was then slightly raised, the iris pierced and 
 incised, without enlarging the corneal wound, by making the blade 
 describe a small arc. Now, it is next to impossible to make a 
 clean cut of the iris or of a membranous cataract (and discission is 
 but a phase of iridotomy) by mere pressure of the edge of the knife, 
 
 1 Royal Oph. Hosp. Rep., x, 3, 1882, p. 403. 
 
 2 Ann. d'opht., iii, 1883, p. 403. 
 
 3 Klin. Mbl. F. S., xv, 1877, S. 273. 
 
 4 Klin. Mbl. F. S., xxi, 1883, S. 315. 
 s Prog, med., No. 35, 1880.
 
 IRITO-ECTOMY. 423 
 
 no matter how keen it may be. The membrane will only be pushed 
 along and torn. But a little sawing motion imparted to the blade, 
 however slight, will cause it to cut. In sawing with a sharp knife, 
 it is difficult to prevent harmful wounding or extension at the 
 point where it engages the cornea. To avoid this, I have the edges 
 of the Graefe knives, which are used both for discission and iridotomy , 
 made dull and smooth, for the first two-thirds of the distance and 
 sharp and w r iry for the last, or end, third. The operation can be 
 done in this way without any loss of aqueous, which cannot be 
 said of the knife-needle method. This form of knife, particularly 
 if the blade be somewhat smaller in every way than that of the 
 regulation cataract knife, is one of the most manageable of instru- 
 ments. The old and worn-down Graefe knives can be thus utilized. 
 The corneal wound is insignificant and, being in the vascular zone, 
 heals at once. If one is careful to make the iris incision at right 
 angles to the direction of greatest strain of the fibres, and no inflamma- 
 tion of the membrane follows, a permanent round or elliptical pupil 
 will result. Should the iris tissue be such as not to retract, or should 
 the new pupil close from iritis, there is still time to resort to 
 irito-ectomy. 
 
 Modifications of Irito-ectomy. TyrelPs blunt-hook method. 
 The primary corneal incision is made with a lance-keratome, 
 the blade of which is made to traverse the anterior chamber to a 
 point just beyond the limits of the proposed pupil. Here it is 
 passed through the iris, when, by a sort of rocking motion, the cut 
 is enlarged. The knife is withdrawn, the blunt iris hook is inserted, 
 flatwise, at the corneal wound, pushed across to the iris wound, 
 given a quarter turn so as to catch the hither edge of the cut, the 
 membrane drawn a little way outside of the corneal incision, and 
 a small piece cut off with scissors. This measure is less complex and 
 difficult than the intraocular scissors methods, and done with less 
 dragging upon the iris than is the operation of irito-dialysis. It is 
 the same as the procedure described by Knapp 1 as " irido-cystec- 
 tomy." The writer was led to adopt it for many cases of membranous 
 cataract and closure of the pupil after extraction by the splendid 
 results he had seen obtained for the procedure at the hands of the 
 late Cornelius R. Agnew, of New York. 
 
 * Norris and Oliver's System, p. 792.
 
 424 
 
 OPERATIONS UPON THE GLOBE. 
 
 To obviate traction upon the iris, Abadie 1 devised an ingenious 
 mode for irito-ectomy, by which he obtained a quadrilateral pupil. 
 Two parallel incisions of the cornea, 5 or 6 mm. apart, made with 
 the lance-keratome, the first one smaller, the second larger and 
 made to pierce and incise the iris to form one side of the opening. 
 
 FIG. 221. Incisions. 
 
 FIG. 222. Result. 
 
 Introduction of tiny forceps-scissors at the larger, and extending 
 the iris cut in this form (Fig. 221). Withdrawing the flap with iris 
 forceps or hook at the smaller corneal incision, and cutting it 
 off its base (Fig. 222). 
 
 OPERATIONS FOR SYNECHIA. 
 
 SYNECHIOTOMY. 
 
 These operations have for their object: 
 
 1. The cure of the defect itself, i.e., the severance of the iris from 
 its attachment. 
 
 2. The affording of relief from the effects of the synechia. 
 
 The first constitutes true synechiotomy. In the second instance, 
 the breaking up of the adhesions is apt to be but partial and incidental. 
 
 As the synechia is said to be pos erior or anterior, according as 
 it concerns union of the iris with the crystalline lens or with the 
 cornea, so is the synechiotomy posterior or anterior. 
 
 Corelysis is the term that distinguishes posterior synechiotomy. 
 Wenzel, of Paris and London, in the latter part of the i8th century, 
 was the first to practise posterior corelysis. He broke the adhesions 
 with a needle introduced by way of the anterior chamber, and the 
 
 1 Ann. d'ocul., 1888, p. 261.
 
 OPERATIONS FOR SYXECHIA. 425 
 
 measure was resorted to only when the lens- was cataractous. A 
 little later, Beer did the same by means of a tiny sharp hook. The 
 first to make the operation in cases where the lens retained its 
 transparency was Streatfeild, 1 of London, at whose hands the 
 procedure attained a degree of popularity. He first made an 
 incision with the keratome, then attacked the synechia with an 
 instrument that he called a spatula, but that was, in reality, a tiny 
 knife bearing at the extremity of the blade a blunt hook. Weber, 2 
 of Darmstadt, also devised a method and a synechitome, the latter 
 being a knife-hook with blunted point. The operation is not with- 
 out danger to the lens; besides, the adhesions often refused to yield, 
 or yielded only to recur. Moreover, iridectomy, it has been demon- 
 strated, is a better remedy for the irititis, etc., that sometimes result 
 from pronounced synechia posterior. A few slight, isolated attach- 
 ments are usually harmless. For these reasons the operation has 
 fallen into disuse. 
 
 Anterior Synechia. Here the involvement of the iris is not so 
 much an adhesion to the cornea as it is an incarceration, the extent 
 of which varies greatly from a few fibres caught up by a linear 
 or punctate scar, to the inclusion of the greater portion of the mem- 
 brane in a leucoma (leucoma adherens). The surgical treatment 
 applies more to the second category just mentioned, as, aside from 
 a few special measures and instruments relative to the synechia 
 itself, most of the operations are but phases of those already described 
 in connection with the iris. When the synechia involves only the 
 pupillary border, the freeing of the iris from the cornea is called 
 sphincerolysis; when a more extensive area, iridolysis. Here 
 follow a few of the methods of dealing with small synechias. 
 
 Von Arlt,3 in cases of small, anterior synechia, advised passing 
 a lance-keratome into the anterior chamber, advancing the point 
 to the adhesion and trying to cut it by a rocking motion of the blade 
 from side to side. Bowman first made a small incision through the 
 cornea, then introduced a probe-pointed lacrimal knife to divide 
 the synechia. Meyer* essayed to sever the attachment with a small, 
 blunt-pointed sickle, passed into the chamber through an incision, 
 
 1 Oph. Hosp. Rep., 1857-1860. 
 
 2 A. f. O., 1860-1861. 
 
 3 Operationslehre, S. 341. 
 
 4 Handb. der Augenb., Berlin, 1883, S. 108.
 
 426 OPERATIONS UPON THE GLOBE. 
 
 and advised cutting from the periphery toward the pupil. Of 
 course, it was necessary that a space existed in the meridian of the 
 synechia between cornea and iris. Lang 1 used two knife-needles, 
 one blunted at the point. With the sharp one he punctured the 
 cornea obliquely near the site of the adhesion, then substituted the 
 blunt one, with which, in the withdrawing, he freed the iris. 
 
 For the more extensive adhesions between cornea and iris, a number 
 of simple and combined measures have been employed a few 
 of them effective, many ingenious. Naturally, the phase of irido- 
 corneal adhesion that has specially concerned the surgeon is that 
 where exists blindness from incarceration of the entire sphincter. 
 I have seen Dr. Agnew obtain the object sought in such a case 
 by inserting his angular lance as if for an ordinary optic iridectomy, 
 then piercing the iris just short of where it entered the cicatrix, and 
 pushing the point into the posterior chamber, thus freeing the iris 
 sufficiently to admit of a small iridectomy, which he at once proceeded 
 to make. Again, where the limited space between cornea and iris 
 would not permit the handling of the lance-knife, the same surgeon 
 would accomplish the end thus : A very narrow Graefe knife is passed 
 into the anterior chamber close down to the limbus, the iris is 
 partly severed from the scar with the point of the knife, counter- 
 puncture made, the section completed, the loosened segment of iris 
 pulled out with forceps and cut off. 
 
 For elaborations of this branch of ocular surgery the reader is 
 referred to Czermak's " Augenarztlichen Operationen," p. 716, 
 where are given descriptions of the very original methods of the 
 Hungarian ophthalmic surgeon Schulek. 
 
 IRIDECTOMY. 
 
 This is a surgical measure w r hereby a portion of the iris is excised. 
 The first iridectomies on record were probably those made by 
 Daviel 2 to facilitate the removal of cataract. It was Reichenbaclv 
 however, who first proposed partia' excision of the iris as a separate 
 and independent procedure; and for making the coloboma he de- 
 
 1 Oph. Hosp. Rep., vol. xii, 1889, p. 356. 
 
 2 De Wecker, "Reminiscences historiques, etc.," Arch, d'opht., t. xiii, 
 1893. 
 
 3 Dissertation, Tubingen, 1767.
 
 IRIDECTOMY. 427 
 
 signed a sort of punch or trephine. Janin about 1772, cut off a 
 prolapse of the iris that had occurred in an attempt to make an 
 iridotomy, and remarked how little was the tendency of the resulting 
 pupil to close, as compared with that produced by the older opera- 
 tion of iridotomy. The elder deWenzel 2 made numerous iridec- 
 tomies in conjunction with his cataract cases, either at the time of 
 the extraction or afterward, to create an artificial pupil in atresia of 
 the iritic membrane. These operations were mostly of the sub- 
 corneal variety, i.e., the sections of the iris were made within the 
 anterior chamber, in contradistinction to the pre-corneal kind, as 
 usually practised, wherein the portion to be removed is withdrawn 
 with a traction instrument before being severed. The great 
 Viennese ophthalmic surgeon, George Joseph Beer, was the pioneer 
 of the latter mode, which he first conceived in 1806. Not only this, 
 but he greatly enlarged the sphere of the measure by applying it to 
 cases other than those wherein the lens was opaque or was absent, 
 as in staphyloma and opacities of the cornea, for artificial pupil. He 
 also gave a correct method of technic and fitting instruments for the 
 making of the operation. His broad, triangular cataract knife was 
 used for the corneal incision, which he made as close as possible 
 to the sclera. If there was no posterior synechia, the sphincter was 
 caught by a small sharp hook, pulled out, and the section made 
 with small Daviel scissors. If adhesions with the anterior capsule or 
 cornea existed, the withdrawal was by means of tiny toothed forceps. 
 The operation underwent slight modifications at the hands of 
 Beer's immediate disciples, as Walther, Langenbeck, Rosas, Chelius, 
 Flarer, and the two Jaegers, Karl and Friederich; in England, at 
 those of Gibson and Tyrrell, and, in France, at those of Sichel and 
 Desmarres. 2 The last mentioned added iridorrhexis, or tearing of 
 the iris from its periphery, to increase the breadth of the coloboma. 
 But it is to the most distinguished pupil of both Beer and Desmarres, 
 viz., the immortal Albrecht von Graefe, that the world is indebted 
 for the inestimable value of iridectomy as a curative agent, espe- 
 cially in recurrent iritis and irido-cyclitis,' and in glaucoma. * Did 
 the fame of this versatile and subtle genius in ophthalmology rest 
 
 1 Traitc de la Cataract, Neuremberg, 1788, p. 188. 
 
 2 Traite des maladies des yeux, 1855, T. ii, p. 542. 
 
 3 Arch. f. Ophth., ii, 1856, S. 202. 
 
 4 Arch. f. Ophth., iii, 2, S. 456, 1857.
 
 428 OPERATIONS UPON THE GLOBE. 
 
 only upon this last-named discovery, it were enough, and more, 
 for all time, and the beneficient results thereof were an all-sufficient 
 monument. 
 
 As may be inferred from perusal of the foregoing historic sketch, 
 where the chief offices of iridectomy are touched upon, the forms 
 and uses of the operation are varied. The principal kinds and their 
 indications may be thus tabulated: 
 
 KINDS OF IRIDECTOMY AND THEIR INDICATIONS. 
 
 1. Preparatory iridectomy, or that which is employed in con- 
 junction with the extraction of cataract. 
 
 2. Optic iridectomy, or the making of an artificial pupil for 
 visual purposes. 
 
 3. Therapeutic iridectomy, that which is undertaken for the cure 
 or for the prevention of morbid processes in the eye. 
 
 i. Preparatory iridectomy is, as has been stated, the oldest 
 form of the operation. It is, moreover, the purest form of iridec- 
 tomy. It is made either immediately preceding the extraction, 
 thus constituting the combined operation, or some weeks or months 
 previously, when it is called preliminary iridectomy. Combined 
 iridectomy was the original kind, having been that of Daviel and of 
 ophthalmic surgeons in general, for more than 100 years following 
 the introduction of the operation of extraction. It was first in- 
 tended merely as an aid to the delivery of the cataract, as in cases 
 of rigidity of the pupil; luxation of the lens, etc. Later, the pro- 
 cedure was resorted to in order to prevent iris entanglements 
 (Schifferli, 1776), and, still later, with the view of warding off iritis 
 and suppuration of the wound (Graefe, 1850). The late Prof. 
 Mooren, of Berlin, in 1862, was the author of preliminary iridectomy, 
 which he practised with the idea of lessening the dangers of sup- 
 puration after operations for cataract. The chief objects of pre- 
 paratory iridectomy, as practised to-day, are to facilitate extraction 
 particularly as regards removal of cortical remains and to forestall 
 iris complications as sequelae of extraction. Some eye surgeons 
 make preparatory iridectomy only as occasion demands, as in com- 
 plicated cataract, the others never omit it. In this connection the 
 operation is treated of under " Extraction of Cataract."
 
 KINDS OF IRIDECTOMY AND THEIR INDICATIONS. 429 
 
 2. Optic iridectomy, or coremorphosis, as we have just seen, 
 is next, in point of age, to the preparatory variety. It is indicated 
 in atresia iridis, or where the normal pupil is obscured by opacities 
 of the cornea, as partial leucoma; or of the lens, as large pyramidal 
 and zonular cataract; in occlusion of the pupil, in subluxation of the 
 crystalline with great reduction of visual acuity in short, when- 
 ever it is possible by the excision of a portion of the iris to restore 
 or to greatly improve the sight. The resulting coloboma should 
 be small, to insure a clean image, and, when practicable, should not 
 extend to the periphery, because of the imperfect refraction and 
 senile changes that characterize this region. As to the position of 
 the artificial pupil, when one has the option, it is customary to place 
 it downward and inward. Really, provided it does not lie beneath 
 the lid and is not too eccentric, the situation of the opening is, 
 dioptrically considered, of little or no consequence. Indeed, as 
 regards the lens, this is a matter to be decided solely by the site of the 
 opacity, and, as concerns the cornea, by data obtained from careful 
 study of the available parts of that membrane. To this end, it is 
 of the utmost importance that not only the degree of transparency 
 of the different areas be ascertained, by means of strong focal 
 illumination and magnifying glasses, but that one takes into con- 
 sideration their curvature, as revealed by such implements as 
 Placido's disks, the ophthalmometer and the ophthalmoscope. 
 Especial care should be given the opthalmoscopic examination, 
 since transmitted light and a strong plus lens will reveal corneal 
 areas practically opaque on account of diffraction, which could not 
 be seen by other methods of examination. That portion of the 
 cornea which is freest from opacities and irregular astigmatism 
 should be chosen as the sight of the coloboma. These investigations 
 are to be made, whenever possible, with full mydriasis, before 
 subjecting the patient to the operation. In zonular cataract and in 
 subluxation of the lens, one must be fairly sure that increased vision 
 will ensue, for the best made optic iridectomy is apt to prove disap- 
 pointing in these defects. A piece of card-board or other dia- 
 phragm, stenopaically perforate, used in such a way as to cause a 
 narrow pencil of light to pass through the different parts of the dilated 
 pupil will, occasionally, solve the problem in question. In many 
 instances, however, the area of clear cornea is so limited that the
 
 430 OPERATIONS UPON THE GLOBE. 
 
 location of the coloboma becomes, not a matter of choice, but of 
 necessity. If one be obliged, by the exigencies present, to make 
 the iridectomy in an unfavorable position, other artificial means 
 may often be evoked for heightening the visual results. If, for 
 example, it be extremely peripheral, cylindrical lenses can, in many 
 cases, be fitted with benefit. If diffusion is caused by the light that 
 passes through thin opacities in the immediate vicinity of the clear 
 spot selected, the image can be sharpened by tattooage (see 
 page 397). The same may be done to advantage in the event of 
 too large a coloboma, by way of "stopping down," as it were. 
 
 Now and then it happens that one is confronted with a patient 
 whose only hope of obtaining a modicum of sight is through the 
 making of an opening in the iris beneath a tiny area of cornea 
 situated at the extreme periphery. If the incision encroaches upon 
 this area, the ensuing scar will cloud the new pupil. One has, then, 
 the choice between entering the angle of the iris through a long 
 wound-canal by way of the adjacent sclera, or of making a com- 
 bination of irido-dialysis and iridectomy, as resorted to by Panas. 
 This surgeon would make the corneal incision on the side opposite 
 reach across the pupil with the forceps, seize the iris beneath the 
 spot of clear cornea, tear it from the periphery, withdraw, and 
 excise. Both methods are difficult. 
 
 A drawback to the artificial pupil is its fixidity, no withstanding 
 the varying intensities of illumination. It was to obviate this that 
 Adams, in 1812, and Himly, in 1843, proposed displacing the 
 natural pupil in the desired direction by drawing the iris into the 
 corneal wound and there leaving it to be incarcerated iridendeisis. 
 It was to the same end that Critchett, in 1857, devised his operation 
 of ligature of the iris iridesis, or iridodesis. This consisted in 
 making a small incision with a broad needle or lance-knife as near 
 as possible to the base of the cornea, withdrawing with cannula- 
 forceps the nearest portion of the sphincter, throwing a delicate 
 silk ligature around the part brought out, leaving it thus for two days 
 in order that the iris might become firmly adherent in the wound, 
 then cutting off the extrusion or allowing it to slough. These 
 measures proved excellent in so far as their optic effects were con- 
 cerned, seeing that they gave a narrow, movable pupil, but disastrous 
 as regarded their physical consequences among the last having
 
 KINDS OF IRIDECTOMY AND THEIR INDICATIONS. 431 
 
 been iridocyclitis, glaucoma, and sympathetic ophthalmia. Hence, 
 their respective vogues were short-lived. As a safe substitute for 
 them, in the year 1871, Pope, 1 brought forward his method of 
 making an optic iridectomy without dividing the sphincter of the 
 pupil. With a very narrow keratome he entered the extreme 
 periphery of the anterior chamber by way of an almost scleral 
 wound, allowed the aqueous to drain slowly to avoid a prolapse, 
 seized with fine, slightly curved forceps, the iris in the center of the 
 exact spot to be excised, and withdraw, taking care that the pupil- 
 lary border came not into the incision. Then, with small curved 
 scissors, just as much was cut off as was held by the forceps. If 
 a round coloboma was wanted, the scissors blades were held at right 
 angle to the direction of the corneal wound; if an oval section was 
 preferred, the blades were held parallel with the wound. The 
 remaining portion of the pulled-out iris was gently replaced. 
 
 Such an artificial pupil has certain advantages among them 
 being its small size, its slight disfigurement, and the little tendency 
 it has to widen or to be drawn toward the root of the iris. Singular, 
 that the procedure has so few advocates. One reason is, doubtless, 
 the popular belief that double vision polyopia and a double 
 pupil polycoria go together. Such, however, is not likely to be 
 the case even when the normal pupil is unobstructed, much less 
 so when it is obscured, as is precisely the condition for which an 
 optic iridectomy is made. Another reason for the relative rarity 
 of the measure is the difficulties that attend its proper execution. 
 These, however, should not stand in the way. If, for instance, 
 the sphincter should be inadvertently embraced in the section, 
 the result amounts only to an ordinary iridectomy. If merely 
 a thread-like bridge at the very border of the pupil be left behind, 
 it amounts to the same, since it will most probably atrophy and 
 disappear. The really substantial difficulty lies in the making 
 of the ideal, perfectly peripheral, primary incision, which will be 
 described under the "Technic of Iridectomy." I have several 
 times of late, had recourse to this form of iridectomy when a highly 
 eccentric pupil was demanded, and commend it most heartily. 
 The common practice of introducing a blunt hook or other instru- 
 ment to get rid of a pupillary bridge accidentally left in the operation 
 
 f Arch. f. A. u. O., ii, i, S. 192-197.
 
 432 OPERATIONS UPON THE GLOBE. 
 
 of optic iridectomy or any, save in preparatory iridectomy is to 
 be deprecated. 
 
 Sphincterectomy. The most eligible method of optic irid- 
 ectomy, where existing conditions permit the more centrally placed 
 coloboma, as in central leucoma of the cornea, is what is called 
 Sphincterectomy, and is that with which Critchett replaced his un- 
 fortunate iridesis. Briefly described, the manner of performing 
 it is as follows: Incision 3 or 4 mm. in extent with a narrow 
 keratome, beginning in the opaque zone at the sclero-corneal junc- 
 tion. If deftly made, the knife may be quickly withdrawn without 
 loss of the aqueous and without causing the iris to follow the 
 blade into the wound. These two things are desirable for two 
 reasons, viz., a certain depth of the anterior chamber favors the 
 manipulation of the iris forceps, and having the iris spread out 
 in its normal relations is conductive to the accurate dosage of 
 the excision. With fine, moderately curved, back-toothed forceps 
 (or median-toothed), the iris is seized near the pupil, drawn out 
 sufficiently to expose the pupillary border, and a small triangle of 
 the uveal lining, and, with a single snip of the curved iris scissors, 
 or the De Wecker forceps scissors, the blades crosswise to the 
 primary incision, a small piece, comprising a little more than the 
 sphincter itself, is excised. The unsevered portion is gently replaced 
 with the spatula, the eye washed with a mild antiseptic solution, 
 and the dressings applied. 
 
 3. Therapeutic Iridectomy. This variety of iridectomy is 
 either prophylactic or curative or both. In the first capacity its 
 chief indication is in 
 
 a. Recurrent Iritis or Irido-cyclitis. In the second capacity 
 therapeutic iridectomy finds its main office in 
 
 b. Glaucoma. It is both remedy and preventive in certain 
 instances of 
 
 c. Foreign bodies in, tumors, parasites, and prolapse of, the iris, 
 a. Iridectomy has proven of great value in cases of partial 
 
 posterior synechia, characterized by relapses of iritis, provided 
 the operation is made in an interval when the eye is absolutely quiet. 
 This is especially true of cases where exists exclusion of the pupil 
 more or less complete. For these, the excised portion of iris need 
 be only of small dimensions, and no necessarily peripheral, except
 
 KINDS OF IRIDECTOMY AND THEIR INDICATIONS. 433 
 
 there be a tendency to glaucoma. In complete exclusion of the 
 pupil, unless there be occlusion besides, the coloboma is made to 
 reestablish communication between the anterior and posterior 
 chambers, and is best made upward, so as to lie beneath the upper 
 lid; if the exclusion is incomplete, however, the position of the 
 coloboma will be determined by that of the free section of the 
 pupillary border. This is ascertained by -noting the effect of a 
 mydriatic upon the contour of the pupil. Associated with these 
 conditions the iris is apt to present the symptomatic appearance 
 known as "crater-shape," and iris bombe, due to a bulging forward 
 of the free middle zone by pressure of the aqueous in the posterior 
 chamber. It must not be supposed that this peculiar configuration 
 of the surface of the iris always indicates that the middle zone is 
 not adherent to the lens capsule. The apparent bellying forward 
 may be but the swelling caused by the infiltration or the thickening 
 to which this region of the iris is more prone, and there may be 
 total posterior synechia. Under such conditions, iridectomy under- 
 taken for either therapeutic or optic purposes, is almost sure to be 
 a disappointment; for, aside from the difficulty of making an ade- 
 quate incision, it is usually impossible to excise any but the stroma 
 of the iris, leaving the uvea still adherent to the capsule. True, 
 most gratifying results can, exceptionally, be obtained even where 
 the plight is most unpromising, as note the case of Mrs. K., cited 
 under "Specially Complicated Extractions." In these extreme 
 cases, however, where there is total posterior synechia, especially 
 where exists, in addition, occlusion of the pupil, obliteration of 
 the anterior chamber, and, above all, glaucomatous tension, iridec- 
 tomy and extraction combined, after the manner of deWenzel 
 (see page 540), is oftenest the more fitting measure. If, on the 
 other hand, the intraocular tension is markedly low, its association 
 with the other features just enumerated constitutes a positive 
 contraindication as regards iridectomy and extraction. Neither 
 could a few isolated points of adhesion between iris and lens be 
 construed as a cause for iridectomy unless, perchance, all other 
 forms of treatment have failed to stop the repeated attacks of iritis. 
 
 b. Iridectomy for Glaucoma. It is herein that the operation 
 performs its highest function. This is particularly true of it in con- 
 nection with acute idiopathic glaucoma, in which relation it has been 
 28
 
 434 OPERATIONS UPON THE GLOBE. 
 
 termed antiphlogistic iridectomy. Whatever the variety or the 
 grade of the glaucoma whether acute (fulminant), subacute 
 (intermittent], chronic (simple], secondary (symptomatic], absolute 
 (degenerative], or congenital (hydrophthalmus] , the same surgical 
 principles are applicable, though the technic and the instruments by 
 which the several steps are accomplished vary with the demands of 
 the case and are treated of in detail later. 
 
 Iridectomy, as regards its indications in glaucoma, has many 
 limitations. In simple or chronic glaucoma it is admissible only 
 when there is unmistakable overtension, either constant or inter- 
 mittent or as a last resort. In absolute glaucoma it may, perhaps, 
 be tried when there is also glaucoma of the other eye. In mono- 
 lateral absolute glaucoma, except the progress of the affection is 
 sufficiently well known to exclude the possibility of an intraocular 
 tumor, such as melanosarcoma, the eye must be enucleated at once. 
 In acute hemorrhagic glaucoma it is allowable. In acute idiopathic 
 and acute secondary glaucoma following operations and injuries, 
 the indications are positive, imperative, and immediate. The steps 
 themselves are notably specialized, and are, in most respects, the 
 direct antithesis of those in optic iridectomy, that is to say, the in- 
 cision must be as nearly scleral as practicable; its extent must 
 exceed that which is required merely for getting at the iris, being 
 usually equal to about one-fifth that of the corneal limbus; the 
 coloboma must be broad and reach to the very root of the iris; the 
 location of the coloboma is a fixed one, i.e., in the upper segment 
 of the iris. 
 
 c. Therapeutic iridectomy of the third class is, as stated, both 
 prophylactic and curative; moreover, in order to fulfill the first three 
 indications mentioned under this heading, viz., foreign bodies, 
 tumors, and parasites in the iris, the methods to be employed par- 
 take of those appropriate to both optic iridectomy and that for 
 glaucoma. To remove a clean foreign body which has but recently 
 become entangled in the iris, for example, the length of the primary 
 incision shall not be greater than is ample for proper manipulation 
 of the forceps, nor placed back of the limbus, except \vhen the 
 situation demands it, nor the piece of iris excised be much larger or 
 more peripheral than is sufficient to include the offending sub- 
 stance. Given, a sarcoma of the iris, however, while the same
 
 GENERAL CONSIDERATIONS OF IRIDECTOMY. 435 
 
 holds good as regards the incision, the segment excised must not 
 only be larger, all around, than the apparent size of the tumor, but 
 must, in every instance, extend to the outer limits of the anterior 
 chamber, no matter how diminutive nor how centrally placed the 
 neoplasm. The same might be said concerning foreign bodies of a 
 poisonous nature, such as copper, or those around which appear 
 fungoid growths or pus. The primary incision will, on occasion, 
 need to be extensive and sclerally placed. 
 
 The fourth indication in this series prolapse of the iris necessi- 
 tates iridectomy when the protruding membrane cannot be re- 
 placed in its normal position, be it the result of disease, of trauma, 
 or of an operation. The modes of dealing with this condition are 
 elsewhere described. 
 
 GENERAL CONSIDERATIONS RELATIVE TO THE 
 DIFFERENT KINDS OF IRIDECTOMY. 
 
 Models and management of the iridectomy instruments are 
 treated of in special chapters as is also preparation of the eye. 
 
 Mydriatics and Myotics. As a rule, neither a mydriatic nor a 
 myotic is greatly wanted in fitting the eye for an iridectomy, though 
 there are exceptions. Some surgeons advise against mydriasis in 
 every instance. It is certainly not admissible in cases characterized 
 by increased intraocular tension and pre-existing mydriasis. Yet 
 a dilated pupil is desirable,in certain optic iridectomies; for example, 
 where the border of the normal pupil is hidden by opacity of the 
 cornea, for to have the sphincter in view aids precision and lessens 
 risk as to the lens and in the handling of the iris forceps. It also 
 has its advantages when the pupil is narrow, particularly if rigidity 
 of the sphincter is suspected, to promote relaxation, if for nothing 
 else. The less traction required to withdraw the iris, the less pain 
 and movement on the patient's part. Any untoward dilation will 
 always disappear with evacuation of the aqueous. To have an 
 extremely wide-open pupil while making the corneal incision 
 would be objectionable, for the following reasons: the bunched up 
 iris would be more apt to get in the way of the point of the keratome, 
 would be predisposed to follow the knife into the wound, and more 
 difficult to properly seize with the forceps. Fortunately, this does
 
 436 OPERATIONS UPON THE GLOBE. 
 
 not occur except there be glaucoma. Whenever, therefore, it is 
 possible in this disease, to reduce a considerable or an ad maximum 
 dilation by the use of a myotic, the same should be done. Thus 
 the iris becomes better spread out and more accessible. 
 
 Anesthesia. Narcosis is indispensable with children, irre- 
 sponsible and timorous adults, and with all eyes that are hyperemic 
 and inflamed. There is no operation in the whole domain of 
 surgery more exacting upon the care and skill of the operator than 
 is that of iridectomy, and all the circumstances attendant upon 
 the measure should be as favorable as can be made. To have one's 
 patient asleep not only renders him (or her) incapable of doing harm, 
 but gives greater confidence to the operator. Modern methods of 
 general anesthesia and the substances employed, such as chlorid of 
 ethyl and nitrous oxid in conjunction with ether, have eliminated 
 danger to such a degree as to make them applicable to most any 
 subject. Hence, if one has any misgivings as to the patient's be- 
 havior, or as to the difficulties of the operation, he would better in- 
 voke their aid. The anesthesia of chlorid of ethyl alone is sufficient 
 for the simpler and more quickly executed iridectomies. It is im- 
 portant that the narcosis be maintained until after the toilet of the 
 wound is finished, for much depends upon the thoroughness of this 
 feature. 
 
 Local anesthesia, too, has its advantages, for by its use the 
 patient is not subjected to the added risks and inconveniences, as 
 from vomiting, etc., consequent upon narcosis, and it is a satisfaction 
 to operate upon an eye that is thoroughly under the control of its 
 possessor. Aside, however, from their other drawbacks in this con- 
 nection, just alluded to, they have others. For instance, as to 
 cocain, if one waits to begin the operation till the iris is anesthetized, 
 there is likely to be mydriasis, injury to the corneal epithelium, and 
 secondary dilatation of the blood-vessels, ergo, hemorrhage. These 
 hindrances might be done away with by the choice of some other 
 local anesthetic than cocain, yet still would there remain a large 
 proportion of cases suitable only for narcosis. Adrenalin, or its 
 like, I have found to cause unpleasant after effects, and by their 
 secondary action they are also conductive of bleeding. 
 
 Technic of Iridectomy. The operation must be described in 
 general terms, leaving specific methods and modifications to be dealt
 
 GENERAL CONSIDERATIONS OF IRIDECTOMY. 437 
 
 with later. The patient lies on a table. For all upward iridectomies 
 the operator is usually stationed at the head, though a few prefer, 
 for these, to stand at the side nearer the eye, which, of course, 
 necessitates an inverse handling of the instruments, i.e., pulling 
 the keratome instead of shoving it, and pushing out the iris in lieu 
 of drawing it out. For invard iridectomy the favorite place for 
 the surgeon using the bent keratome is on the side opposite that 
 of the eye concerned, while in downward and external iridectomies, 
 it is on the side adjacent. The assistant takes position facing the 
 operator. The blepharostat is used, excepting in cases where 
 loss of vitreous is to be apprehended, in which event the assistant 
 holds the upper lid with a Desmarres reactor and the lower with his 
 fingers. The globe is steadied by grasping the conjunctiva and 
 episcleral tissue close up to the cornea, just across from the site of 
 the incision, with strong fixation forceps having no catch. The hold 
 of the forceps must be deep and broad. The point of the keratome 
 is placed at, or slightly back of, the sclero-corneal junction, with its 
 blade almost perpendicular to the globe, cautiously shoved in till 
 the thickness of the corneal base has been perforated or till, by the 
 feel, it is known that it has barely entered the anterior chamber. 
 The handle of the knife is then depressed, to bring the blade parallel 
 with the plane of the iris, just above which membrane it is pushed 
 along, taking care that the point engages nothing more, and that 
 neither edge encroaches upon either clear cornea or upon the ciliary 
 body until it is deemed wise to stop (Fig. 223). Thereupon, the 
 handle is further depressed to avoid wounding the advancing lens, 
 the globe is held firmly, without pressing down or lifting up on the 
 forceps, the blade is gently withdrawn a little way, and most of the 
 aqueous allowed slowly to escape, when the knife is wholly withdrawn. 
 Should one wish to extend the cut in the withdrawal of the knife, the 
 point is swung around in the direction of the proposed extension, 
 but holding the blade pressed close up to avoid premature running 
 out of aqueous, the handle depressed, and the incision lengthened 
 by a steady movement which consists in shoving the whole knife 
 to that side and at the same time withdrawing. "Where an extra 
 long incision is wanted, as in glaucoma, one makes the incision with 
 the view to such enlargement. To this end the incision is begun, 
 say, to the left of what will be its middle, so that in extending
 
 438 OPERATIONS UPON THE GLOBE. 
 
 toward the right, the location of the wound will be where originally 
 planned. 
 
 The fixation forceps is here removed, provided the eye is under 
 a local anesthetic and the patient tractable. If not, the instrument 
 is given to the assistant. To do this is a delicate matter. The aid 
 lays his hand, palm up, on the patient's face, slides it deftly beneath 
 
 FIG. 223. 
 
 that of the operator, and grasps the blades firmly close under the 
 surgeon's fingers. If there be any doubt as to the outcome of the 
 maneuver, the surgeon would better release the forceps from the 
 eye, give them to the aid, and let the latter catch his own hold. 
 Having done so, he watches his forceps, and not the progress of the 
 operation, save that he may know when to let go.
 
 GENERAL CONSIDERATIONS OF IRIDECTOMY. 
 
 439 
 
 The operator picks up the iris forceps in one hand, the scissors 
 in the other, the one with jaws tightly closed, the other with blades 
 moderately open. The eye is turned so as to look somewhat 
 downward. The tip of the forceps is placed immediately behind 
 the incision, the scissors brought in close proximity, and both 
 instruments held in the most stable manner. The posterior lip 
 
 FIG. 224. 
 
 of the wound is depressed by the forceps, the closed blades are 
 advanced with a slight motion from side to side beneath the anterior 
 lip. They are made to hug the under lip until their extremities 
 are within the anterior chamber, when they are made rather to 
 follow the posterior surface of the cornea, not to disturb the iris, 
 till the point is reached for seizing that membrane. The blades are 
 now allowed to separate just enough to get the necessary hold
 
 440 OPERATIONS UPON THE GLOBE. 
 
 usually about 2 mm. The patient, if conscious, is told to keep 
 quiet even though a slight twinge of pain ensues, the iris is firmly, 
 but not roughly, caught and withdrawn, all the time keeping in touch 
 with the patient's mood and acts. As the points of the forceps emerge 
 from the anterior chamber, the open scissors blades are slid astride 
 them, with the radii of the cornea if a small excision is wanted, 
 athwart them if a large one. When the pupillary border, together 
 with a triangle of the uveal lining of the iris, appear outside the 
 wound, the forceps are lifted sufficiently to allow the scissors blades 
 plenty of room to close beneath, and, holding the scissors snug 
 down upon the eye, the cut is made with one steady snip (Fig. 224). 
 The eye is douched with warm boric or salt solution, the fixation for- 
 ceps, if employed, is removed, and the lids closed to wait for a slight 
 accumulation of aqueous. Or one may proceed at once, after 
 the douching, to the 
 
 Toilet of the Wound and Eye. If it had been deemed best 
 to use the fixation forceps for the operation proper, that instrument 
 is retained for the toilet. The same may be said as to the blepharo- 
 stat or retractor. However, if the patient is well behaved and the 
 orbicularis lax, both blepharostat and fixation forceps may be 
 dispensed with the operator holding back the upper lid and the 
 patient being made to look downward the while. If no portion of 
 the iris is seen caught in the wound, the latter is patted with the 
 flat of the wet spatula to cause the coloboma to appear opened out 
 full within the anterior chamber; such spontaneous return of the 
 iris to position having occurred, it only remains to free the incision 
 from shreds of clotted blood and bits of pigment, to see that its 
 lips are nicely in apposition, again douche the eye, and apply the 
 dressing. Should the coloboma not appear at all or but one pillar 
 thereof, the tip of the spatula is inserted at the extremities (or 
 extremity, as the case may be) just far enough to poke the entangled 
 portion from between the lips not deep down into the anterior 
 chamber (Fig. 225). This having been done, the wound is patted 
 with the wet spatula to straighten out the pillars of the coloboma. 
 If actual extrusion of a part of the iris is manifest, it can be put in 
 place by a gentle slicing movement with the edge of the spatula,
 
 GENERAL CONSIDERATIONS OF IRIDECTOMY. 
 
 441 
 
 while, at the same time, bearing upon the lower lip of the wound 
 (Fig. 226). A prolapse, however, that will not readily yield to such 
 efforts at reduction, would better be pulled up with the iris forceps 
 and cut off with the scissors. Loose ends of outlying fragments of 
 iris must be cut off at once. Every precaution must be taken to 
 prevent injury to the lens by a sudden turning upward of the globe 
 during the manipulation of the spatula. The hand must be quick 
 to draw back the instrument if need be. 
 
 FIG. 225. Freeing the pillars of the coloboma Pen-holder fashion 
 
 After the simpler forms of iridectomy the healing is usually prompt 
 and safe, so that the patient may be granted the liberty consistent 
 with ordinary quietude and limited use of the unoperated eye. 
 Binocular occlusion and greater restriction are reserved for the more 
 complicated cases.
 
 OPERATIONS UPON THE GLOBE. 
 
 Modifications. The instruments employed in iridectomy arc 
 various, and the methods subject to numerous changes, in accord- 
 ance with the demands of the case and the notions of the operator. 
 
 They have reference mainly to: 
 
 (.4) The making of the keratotomy. 
 
 (B) The grasping and withdrawing of the iris. 
 
 (C) The size and shape of the coloboma. 
 
 (4) Choice of a Knife for, and the Manner of Making, the 
 Primary Incision. In general, the bent keratome or English 
 
 FIG. 226. Slicing movement Left hand. 
 
 lance-knife is the most suitable instrument, and the method such as 
 has just been described. The healing qualities of its wound are 
 exceptional, for the reasons mentioned in the chapter on Cataract 
 Extraction. The size of the blade will vary with the extent of the 
 incision wanted. It is best, however, that the angle between blade 
 and handle be uniform for all sizes, as insisted upon by Knapp,
 
 CHOICE OF KNIFE FOR IRIDECTOMY. 
 
 443 
 
 since habitual use of this particular bend insures greater precision 
 on the part of the operator. In cases of very deeply set eyes, es- 
 pecially if, in addition, there are short palpebral slits, and shallow 
 conjunctival cul-de-sacs, it is sometimes very difficult to make the 
 incision in the ordinary way. Here a free canthotomy, as the first 
 
 FIG. 227. 
 
 step of the operation, will often prove a great help. In a few such 
 instances a small Graefe knife will be found superior to the lance. 
 To overcome the difficulties in question, Bader 1 gave to the Graefe 
 knife a shank of bayonet shape. Others, notably Scherk, have 
 
 i Lancet, ii, p. 760, 1874.
 
 444 OPERATIONS UPON THE GLOBE. 
 
 devised both lance and Graefe knives with shanks of similar form for 
 like emergencies. 
 
 For the extra peripheral iridectomy in glaucoma, with very 
 shallow anterior chamber, it will be necessary, in the use of the lance, 
 to begin the incision 1/2 to 2 mm. back of the apparent sclero- 
 corneal junction and push the blade straight forward with just 
 sufficient backward inclination to cause the point to enter the ex- 
 treme outer limit of the anterior chamber, keeping the wound 
 parallel with the corneal base aiming, as it were, for the iridic 
 angle having pierced which, the handle is depressed to clear the 
 iris, but not so as to engage the posterior surface of the cornea, and 
 thus pushed forward, only altering the plane of the blade in the 
 event of infringing too much upon either iris or cornea, always 
 bearing in mind that it is safer that the point should hug cornea than 
 iris (Fig. 227). Should there be no visible space between cornea 
 and iris, one can hardly hope to make an adequate incision with the 
 bent keratome but must resort to either the unsatisfactory proced- 
 ure of extending the cut by another instrument or to a totally 
 different means for opening the anterior chamber. The instru- 
 ment most often chosen for such cases is 
 
 The Narrow Cataract Knife. Ever since its introduction by 
 von Graefe, thus instrument has been used by ophthalmic surgeons 
 for iridectomy as well as for extraction, either habitually or in 
 selected cases. It becomes almost a necessity where there is practi- 
 cally obliteration of the anterior chamber. The blade should be 
 exceedingly narrow. The incision cannot be started as far back of 
 the apparent limbus as with the lance knife, for the reason that the 
 plane of the iris is the same as that of the cornea, and puncture and 
 counterpuncture would lie too close together. The point is made 
 to enter the anterior chamber by a short wound canal, the handle 
 then depressed, the blade insinuated a little way, not pushing it 
 straight across, as in extraction, but rather working along nearer the 
 periphery of the iris, even pushing back the more bulging portion of 
 the membrane, as the blade is advanced, using the puncture as a 
 fulcrum, until the point is reached for making the counterpuncture, 
 or from 6 to 8 mm. from the point of insertion. Being now assured 
 that the blade lies flat upon the iris, the point is pushed out and close 
 down to the limbus; then the incision is completed by a steady saw-
 
 CHOICE OF KNIFE FOR IRIDECTOMY. 445 
 
 ing motion. One may make a conjunctiva! flap at the finish, just 
 as in the operation of extraction. 
 
 Adversely, it may be truthfully urged that the use of the Graefe 
 knife leads to gaping of the wound and inability to control the escape 
 of aqueous. Hence, seeing that the instrument is resorted to mostly 
 in glaucomatous eyes, dislocation of the lens, jamming of that body 
 into the incision, or even its escape, prolapse of the iris, and post- 
 choroidal hemorrhage are all invited. The usual method is by 
 puncture and counterpuncture, though not always. Streatfeild, 
 for instance, would employ a rather broad Graefe or Sichel cataract 
 knife, force it as far as practicable into the anterior chamber, then 
 extend the wound to the requisite length by cutting in the icit/nlraical. 
 Such a maneuver necessitates not only much skill, but an exception- 
 ally docile patient. Somewhat less daring is a mode practised by 
 Dehenne, which is quite practicable where the anterior chamber 
 is shallow and but a small incision is desired. This consists in 
 entering the outer limit of the anterior chamber with a narrow 
 Graefe knife from a point 1.5 mm. back of the limbus, and, as soon 
 as the point appears in front of the iris, extending the cut for four 
 or five mm., parallel with the corneal border, by a steady motion 
 which is a compound of pushing and sawing. To prevent torsion 
 of the globe the grasp of the fixation forceps must be close up to the 
 place where the incision begins. 
 
 To obtain an incision of sufficient length in an eye whose anterior 
 chamber is lacking, has taxed the ingenuity of the ocular surgeon 
 severely, and has given rise to a number of expediments that are, for 
 the most part, no less perplexing than the original problem itself. 
 To cite a few: 
 
 Brundenell Carter 1 advised making a small puncture at each of 
 the spots marking the extremities of the incision and joining them 
 by means of the blunt bent keratome of Desmarres. introduced 
 first at one puncture, then at the other. 
 
 The late Prof. Gayet, 1 of Lyons, has supplied what is probably 
 the most practicable method. The globe is firmly fixed, close to 
 the site of the proposed incision, by the double fixation forceps of 
 Monoyer. The cut is made with the Desmarres scarificator. The 
 
 1 Lancet, vol. ii, p. 561, 1875. 
 
 2 Bull. et. mem., soc. franf. d'opht., 1884, p. 41.
 
 446 OPERATIONS UPON THE GLOBE. 
 
 convex edge is placed at the sclero-corneal junction, with the blade 
 set at about the angle which is given to that of the lance-knife in an 
 ordinary iridectomy, and the penetration is achieved by slowly 
 sawing, meanwhile maintaining the same inclination and keeping 
 parallel with the limbus. As soon as a drop of aqueous appears at 
 any part of the cut, the scarificator is put aside and the incision is 
 finished by means of small blunt-pointed scissors. Dianoux, 1 
 proposed a modification of this method which consisted in substi- 
 tuting a Beer's cataract knife for the scarificator and a Weber probe- 
 pointed lacrimal knife for the scissors. A better instrument than 
 either of the last two one less likely to wound the iris would 
 seem to be a small model of the Desmarres keratome. 
 
 Burnett, 2 of Washington, in cases of acute glaucoma, when the 
 
 FIG. 228. 
 
 anterior chamber is abolished, and the iris is reduced to a narrow 
 rim or is lost sight of beneath the scleral border of the cornea, 
 proceeds as follows: By means of a rather short stout Graefe knife, 
 held at right angles to the surface of the globe, the incision is ac- 
 complished, from without, by successive strokes of the point. 
 The curve of the cornea is followed for a distance commensurate 
 with the extent of the opening desired, and as far back as is needful 
 to insure the most peripheral position of the wound. The bottom 
 of the cut thus carefully made finally gives way, at some point, 
 evinced by a gush of aqueous, and, usually, a prolapse of iris. At this 
 point is introduced a bulbous pointed, triangular knife (Fig. 228), 
 and section of the already thinned tissue is completed. Burnett aptly 
 observes that bleeding, which in this location would otherwise prove 
 embarrassing, is prevented by the instillation of adrenal solution. 
 (#) Grasping and Withdrawing the Iris. These acts are 
 executed by some form either of forceps or hook. For uncompli- 
 cated iridectomies, the forceps is usually preferred. The general 
 model conforms to the original instrument of F. Jaeger, of Vienna, 
 
 1 Ibid., p. 44. 
 
 3 Am. Journal of Ophthalmology, April, 1902,
 
 IRIS HOOKS. 447 
 
 being of delicate make and with extremities of limbs more or less 
 curved. As few surgeons now employ any but toothed iris forceps, 
 the special feature of its construction has reference mainly to the 
 arrangement of the teeth, which is a matter of choice on the part of 
 the operator. This appears to be about evenly divided between 
 those with the teeth placed mesially of the jaws and those situated 
 posteriorly, called, respectively, middle-toothed and back-toothed. 
 In both instances the teeth are even with the tip of the blades, and, 
 in case of the back-toothed variety, they are also flush with the 
 nether edge of the tip. It is only in those instruments peculiarly 
 designed for grasping the adherent and the funnel-shaped iris, and 
 in the capsule forceps, that the teeth project beyond or below the 
 edge. These are not safe instruments for simple iridectomy, on ac- 
 count of the risk to the lens, though invaluable in their proper sphere. 
 The rotary forceps of Liebreich and Mathieu, after which was 
 patterned the forceps-scissors of De Wecker, are excellent for use with 
 incisions of limited extent, since they admit of wide opening of the 
 jaws without separation of the blades. The first have their teeth 
 in the middle, the second at the back. They are, moreover, the 
 safest forceps with which to go after a second bit of iris when the 
 first piece excised is deemed inadequate. Many operators seem 
 undetermined as to the breadth to which the iris should be seized, 
 to regulate which Kuhnt 1 invented a forceps with adjustable stop, 
 which can be set for a broader or a narrower grasp especially 
 useful, as in optic iridectomy, when a narrow or small coloboma 
 is wanted. The writer's preference is for the back-toothed kind, 
 and for correct model of the instrument the reader is referred to 
 the chapter on Instruments and their Manipulation. By it the iris 
 is readily laid hold of with a minimum of bearing down and tilting 
 forward. 
 
 Iris hooks are of two kinds sharp and blunt. The first is for 
 engaging the tissue of the membrane itself for withdrawal, the 
 second to catch its pupillary border. The sharp hook (of Beer) 
 has been abandoned because of its danger to the lens and its faculty 
 for becoming entangled within the anterior chamber. The blunt 
 hook, the invention of Himly, though commonly attributed to Tyrell, is 
 still used to some extent. It is particularly useful for iridectomy 
 
 * Centralbl. f. A., 1879, S. 138.
 
 448 OPERATIONS UPON THE GLOBE. 
 
 in the aphakial eye. In one respect it has the advantage over the 
 forceps, in that its grasp is practically painless, while that of the for- 
 ceps is decidedly the reverse. One of its greatest disadvantages lies 
 in the fact that it cannot be made to let go promptly in an emergency. 
 Singularly enough, this fault is due to a virtue in its construction, 
 seeing that to be effective, the bend must be sharp and of fair depth. 
 The blunt hook has the further advantages of easy manipulation 
 through a very small incision and of holding the iris by a tiny 
 area, which is favorable in dosing the extent of the excision. 
 
 (C) Size and Shape of the Coloboma. The manner of grasp- 
 ing the iris with the forceps, that is, the precise location of the part 
 seized, and its dimensions, must depend largely upon the object 
 of the iridectomy. In the vast majority of the uncomplicated 
 iridectomies the lesser circle, or corona, is the most eligible objective 
 point. The somewhat greater elevation and thickness of this 
 portion of the iris, together with the looseness of its tissue, afford 
 a safe and ready hold. For a sphincterectomy and for iridectomy 
 in exclusion of the pupil, when one would avoid leaving a bridge, 
 the bite of the forceps must be as near as practicable to the pupillary 
 border. It is possible in making sphincterectomy to grasp the 
 iris at the outer limits of the lesser circle, withdraw till the free 
 border appears without, then cut in front of the tip of the forceps, 
 but this mode is uncertain and not to be recommended. In iridec- 
 tomy for glaucoma, the point of seizure is usually about midway 
 of the membrane, or, to be more technical, toward the inner limit 
 of the ciliary zone, in order that the ligamen-tatum pectinatum 
 may the better be put upon the stretch to insure the most peripheral 
 coloboma. The ciliary zone is also the portion selected for the tiny 
 forceps-bite in the optic iridectomy of Pope and in the drain iridec- 
 tomy of Chandler the last being described under "Extraction." 
 In all instances in which the excision of the iris is made with a 
 single snip of the scissors, the section removed embraces the part 
 held in the jaws of the forceps, and, in addition, a strip of varying 
 width, in proportion as much or little of the iris is drawn out at the 
 wound, and as the blades of the scissors approach the cornea. The 
 size of the coloboma, therefore, in the one-snip iridectomy, with a 
 given corneal incision, will depend upon the breadth of the bite 
 given to the forceps, the extent to which the iris is withdrawn,
 
 VARIETIES OF COLOBOHA IN IRIDECTOMY. 449 
 
 and the manner of manipulating the scissors in making the cut. 
 Accurate dosage of the excision is not possible without close atten- 
 tion to each of these three features. For a narrow coloboma with 
 converging pillars the said bite is small, little more than the sphincter 
 is withdrawn, and the cut is made with scissors blades at right angles 
 to the lips of the wound and without hugging the cornea very closely. 
 For a broader, more peripheral iridectomy, the bite is wider, the 
 withdrawal is more pronounced, and the snip is made while holding 
 the scissors blades parallel with the lips of the wound, even, if need 
 be, pressing them down at the moment of closing upon the iris, 
 in order to make a yet larger section. A convenient form of colo- 
 boma for preparatory iridectomy and the kind most suitable 
 in the ordinary therapeutic iridectomy in acute glaucoma is the 
 "key-hole coloboma" of Sir William Bowman. This is made by 
 three snips of the scissors, and in this manner : As the iris is withdrawn 
 it is pulled to one extremity of the corneal incision, the pillar of that 
 side is formed by a snip with the points of the scissors, the latter 
 directed toward the root of the iris; the membrane is then more 
 strongly withdrawn, the base of the coloboma is formed by a snip 
 parallel with the lips of the corneal wound, the iris is then pulled 
 to the other extremity of the incision, and the second pillar of the 
 coloboma is formed by the third and final snip which, like the first, 
 is directed at right angles to the course of the corneal incision. This 
 snip, however, is not made with the points of the blades only, 
 but, to the end that the severance of the iris may be complete, the 
 blades are placed well astride the protruding iris. In each cut 
 the scissors are held close down to the surface of the globe, but 
 not in such a manner as to cut the conjunctiva. For the extra 
 broad and peripheral coloboma in glaucoma, Bowman 1 recommended 
 tearing the base of the coloboma, instead of cutting it, cutting only 
 the pillars, a procedure that has been attributed also to De Wecker 
 and to Cuignet under the name of arrachcment of the iris. This 
 tearing away of the iris in iridectomy for glaucoma has several 
 advantages. It admits of an absolutely peripheral coloboma with 
 a long wound canal, whether said length is the result either of 
 beginning of the primary incision well back of the sclero-corneal 
 junction, or of making too slanting a wound in attempting to 
 i Trans. London Congress, 1873, p 203. 
 
 2Q
 
 450 OPERATIONS UPON THE GLOBE. 
 
 clear the iris with the keratome (Fig. 229). The anatomic 
 arrangement of the tissues at the base of the iris is such as to cause 
 the rent naturally to occur in the most favorable, i.e., the most 
 peripheral situation, viz., in the cribriform portion of the ciliary 
 zone of the iris. Indeed, it is. not difficult by this method to make 
 a coloboma whose lateral dimensions exceed the length of the primary 
 incision, and, on occasion, one whose base is more peripheral than 
 are the inner lips of the incision. With a good bite of the forceps, 
 near the mid-zone of the iris, it is easy to tear the entire membrane 
 from its attachment to the annular ligament. It is well to bear in 
 mind the frailty of this fastening. Another condition that adds 
 
 FIG. 229. Not possible to make peripheral coloboma with either 
 incision without tearing the base. 
 
 to the efficiency of tearing the base of the coloboma is that there is 
 usually less bleeding than from cutting. In case of an overhanging 
 inner lip or partial splitting of the cornea, it is best, as soon as the 
 forceps has secured the necessary substantial hold upon the iris, 
 to start the tear by pushing the instrument toward the center of 
 the cornea, as it will then yield more readily than by drawing the 
 iris at once into the wound. 
 
 Accidents During the Operation of Iridectomy. Something 
 untoward can occur at any step, from the beginning of the incision 
 to the completion of the toilet. Taken in their order, those most 
 likely to happen are: 
 
 i. Faulty Incision. This has reference to the placing, the 
 direction, and the extent. If the wound lies decidedly within the 
 clear cornea, it is objectionable in nearly every form of iridectomy. 
 In the optical form the scar might encroach too much upon an 
 important transparent area. In glaucoma the drawbacks of 
 such a wound are obvious, for, as has been seen, both incision and 
 coloboma must here be peripheral. Then, too, the further removed
 
 ACCIDENTS IX IRIDKCTOM V. 451 
 
 the incision from the sclcra, the more liable it is to gape. On 
 the other hand, in no instance outfit the wound to be further back 
 than is sufficient to admit of its inner lips occupying the extreme 
 outer limit of the anterior chamber. That such should be the case, 
 however, especially when there is considerable lack of said chamber, 
 the outer lips of the incision will be anywhere from i to ^ mm. 
 behind the apparent sclero-corneal junction. Faulty direction 
 may be due to a movement on the part of the patient, as, for example, 
 turning backward of one edge of the keratome into the ciliary 
 body or forward into the cornea. This is particularly liable to 
 happen while endeavoring to extend the incision in withdrawal 
 of the knife. Hence, a timely word of caution to the patient, firm 
 fixation of the globe, and a steady, deliberate manipulation of the 
 knife are the best preventives. The defect in direction, however, 
 that is most frequent is the interlamellar incision also referred to 
 as split cornea and pocket incision. This is usually consequent upon 
 the mistaken judgment of the operator. In his anxiety lest he 
 engage the iris, and possibly the lens, the knife either utterly fails 
 to enter the anterior chamber or does so through a cut so slanting 
 that the inner wound opening is far .from the periphery and the 
 proper grasping of the iris is difficult or impossible. If one is 
 confronted with the first dilema, of course the aqueous does not 
 escape, and he has but to withdraw the knife and begin over, this 
 time with more discernment. Hut if the chamber is opened and 
 the iris safe from seizure beneath the shelving nether lip of the wound, 
 the iridectomy must be postponed for a time. An insufficient hold 
 of the globe by the fixation forceps may lead to splitting. At the 
 moment one attempts to make the puncture, mayhap with a knife 
 none too keen, the considerable force required causes the grip of 
 the forceps to yield, and the eye to rotate away from the knife, 
 thus changing the original plane of the incision to one of a grade 
 less sleep. The making of a pocket in the cornea is usually evinced 
 by a peculiar opacity which surrounds the advancing point of the 
 knife. The obstacles offered by loo small an incision mainly concern 
 the opening of the iris forceps, and may be sometimes overcome 
 bv substituting the rotary forceps or the blunt hook. If neither 
 serves, the incision nuisl be extended by blunt pointed scissors 
 (Stevens' strabolomy scissors), or by some such instrument as
 
 452 OPERATIONS UPON THE GLOBE. 
 
 Desmarres' blunt-pointed keratome. Given a lance-knife with a 
 blade at once relatively broad and short, a cornea relatively thick, 
 and a wound canal not of the shortest, and it is easy to obtain an 
 insignificant inner wound opening with a fairly long external one. 
 Should one suspect such a state of affairs, a slight rocking of the 
 knife from side to side just before its withdrawal will result in 
 enlargement of the inner opening. 
 
 2. Engaging the Iris with the Knife. This comes (a) of 
 failure to alter the plane of the blade to one parallel with that of the 
 iris the moment the point has entered the anterior chamber, or (b) 
 from piercing the sclera so far back and so squarely that the knife 
 encounters the iris before entering the anterior chamber; or (c] 
 because of hugging the front surface of the iris rather than the 
 back surface of the cornea in pushing forward the blade. The 
 prevention in each instance is obvious. If a occurs and is detected 
 immediately, the knife may be very slightly pulled back and faintly 
 wiggled to disengage. If the involvement is more pronounced 
 and withdrawal necessitates emptying of the anterior chamber, 
 the operation would better be deferred. If b happens, the iris 
 begins to tear from its attachment the moment the point enters it, 
 and if the operator is not led to suspect the accident by the non- 
 appearance of the point at the expected time and place, iridodialysis, 
 or grave injury to the lens, or both, may ensue. At best, it means 
 postponement of the operation. In the event of being confronted 
 by c, if one is closely observant of the progress of the knife and 
 the patient is quiet, the point may be promptly freed as soon as it 
 catches, as suggested for a, its direction changed to a safer plane and 
 the section completed. If for any reason the entanglement is 
 such as to necessitate escape of the aqueous in trying to free it, 
 and so peripheral as to make certain an extensive iridodialysis by 
 forging ahead, it were best the operation be put off. It is only in 
 case of picking up the iris at the lesser circle with the extreme tip 
 of the blade that one might risk tilting back the handle to avoid 
 the lens and pushing forward a short distance, even at the expense 
 of a small rent of the iris, with the view to enlarging the incision 
 afterward. These points have reference to the use of the lance- 
 knife. Those relative to that of the Graefe knife are given under 
 " Accidents During Extraction."
 
 ACCIDENTS IN IRIDECTOMY. 453 
 
 A rare accident that can happen to a novice using a small keen 
 keratome, and one apt to prove most disastrous, is the shoving of 
 the blade bodily into the anterior chamber. I have seen it occur 
 only in student operations upon pigs' eyes. 
 
 3. Too Sudden Evacuation of the Aqueous. This is an 
 occurrence of much graver import than is commonly admitted. 
 The usual result of the rush of the fluid is that the iris is carried 
 with it into the wound, which, of itself, is bad enough; but, worse 
 yet, the abrupt lowering of the intraocular pressure, even when not 
 previously high, may give rise to choroidal hemorrhage and to 
 rupture of the zonule and hyaloid, with presentation of vitreous or 
 subluxation of the lens. So slightly, however, has the accident been 
 regarded that many operators, following the example of Bowman, 
 have, in certain simple iridectomies, regularly practised quickly 
 jerking out the knife with the express purpose of causing a prolapse 
 of the iris, in order to be spared the necessity of drawing out the 
 iris with a traction instrument. The custom is much to be deprecated, 
 for, aside from the danger just mentioned, what one gains in readily 
 seizing the protruding membrane is more than counterbalanced 
 by the unavoidable lack of precision in properly fashioning the 
 coloboma under such conditions in giving it due symmetry, 
 and in dosing the excision. For these reasons Czermak strongly 
 advises replacing the prolapse before preceding, so that the seizure 
 and withdrawal may be accomplished in the regulation way. He 
 makes exceptions, however, as follows: 
 
 1. When the conjunctiva is so inflamed as to entail danger of 
 infection. 
 
 2. When the tension is high. 
 
 3. When the lens is dislocated or abnormally small, as in hydroph- 
 thalmos, or when the vitreous is presenting. 
 
 4. In cases of nervous persons and children, operated under local 
 anesthesia. 
 
 True enough, a prolapse can be brought about by other means 
 than by carelessness in removing the knife, such as pressure upon 
 the globe by fixation forceps, movement or squeezing upon the part 
 of the patient, etc. Having occurred, whether or not an attempt 
 should be made to replace it before making the excision must be
 
 454 OPERATIONS UPON THE GLOBE. 
 
 left to the discretion of the surgeon. In spite of the utmost pre- 
 caution on the surgeon's part and the most praiseworthy conduct on 
 that of the patient, a prolapse will sometimes follow the knife. 
 This is particularly true of iridectomy in eyes whose tension is 
 raised. 
 
 4. Iridodialysis, other than that produced by engaging the iris 
 with the keratome, may happen because of an unexpected move- 
 ment of the patient while the iris is in the grasp of the forceps, and 
 as a result of a too peripheral seizure of the membrane. It is im- 
 portant, therefore, that one try to prevent the one by gentle words 
 of encouragement to the patient and by anticipating his motions, 
 and to avoid the other by a suitable hold upon the iris. 
 
 5. Leaving behind a pupillary bridge is not always intentional 
 or desirable. It ensues most often through failure to draw the 
 sphincter well out before cutting off the iris. Again, where exists 
 posterior synechia, it may come of grasping the iris too far from the 
 free border, or it may be inevitable on account of the firmness of the 
 adhesion. A bridge that is free can best be dealt with by means of 
 the blunt hook. The blepharostat is removed, a pad of cotton, wet 
 with boric solution is laid on the closed lids for a few r minutes while 
 the anterior chamber is partially reestablished. This facilitates 
 the manipulation of the hook. The eye is opened. The blepharo- 
 stat is replaced, the globe fixed, the hook inserted, flatwise, at the 
 incision, the bridge deftly caught, so as not to wound the lens, the 
 hook again turned flat, brought out, and the strip of iris severed. 
 A tightly adherent bridge would better be left unmolested. 
 
 6. Leaving the uveal lining of the excised portion adherent to 
 the anterior capsule is an unavoidable accident in complete posterior 
 synechia. Whether the object of the iridectomy is optic or thera- 
 peutic, the only alternatives, in this connection, are to leave the eye 
 to its fate or to extract the lens. If the eye be glaucomatous, the 
 extraction would better be made at once, first enlarging the corneal 
 incision, then making free capsulotomy in the area occupied by the 
 pupil and the pigmented coloboma. Should the tension be normal, 
 further operating would better be postponed-. For self-protection, 
 in no case will the surgeon fail to obtain beforehand the patient's con- 
 sent or its equivalent to an extension of the measure originally 
 proposed.
 
 ACCIDENTS IN IRIDECTOMY. 455 
 
 7. Wounding of the anterior capsule is a grave casualty when 
 the lens is transparent and in elderly individuals with opaque lenses 
 and glaucoma, since it leads in many cases to cataract or to forced 
 extraction to prevent loss of the eye. It is serious in any case. It 
 is due to some fault, preventable or otherwise, in the management 
 of the knife, the forceps, or the spatula. It is the extremity of each 
 of these instruments that it behooves one to watch. The use of 
 forceps with sharp teeth projecting beyond the posterior edge of the 
 jaw r s is most hazardous. The spatula should be well curved and of 
 nicely rounded end. 
 
 8. Rupture of the Zonule. Aside from the too sudden evacua- 
 tion of the aqueous, which has already (third) been mentioned as a 
 cause of the accident, it may also result from too great pressure 
 upon the forceps in grasping the iris, from sudden movement of the 
 eye while handling either forceps or spatula, and from external 
 pressure by patient or operator. It is highly unfortunate, whatever 
 the kind of iridectomy. In the preparatory it complicates the ex- 
 traction and often induces loss of vitreous; in the optic and the 
 therapeutic it may give rise to escape of vitreous, to cataract, to 
 secondary glaucoma, or to a worse form of glaucoma on top of one 
 already bad enough. In other words, malignant glaucoma may 
 follow an iridectomy for a milder form of the disease if, through sub- 
 luxation of the crystalline, the periphery of that body becomes 
 jammed in between the ciliary processes and the canal of Schlemm. 
 Methods have been devised whereby to replace lenses thus dis- 
 located, as, for example, that of De Wecker, 1 which consists in 
 making, after firm union of the corneal wound, his anterior sclerot- 
 omy on the side opposite that of the coloboma, then, while the cor- 
 nea is still transfixed by the knife, essaying, by means of pressure 
 of the thumb through the intervening lid, to force the lens back into 
 position. Such procedures are mostly unsatisfactory. It were 
 better one trusted to immediate or subsequent extraction did the 
 exigencies of the case seem to demand it. Should the lens become 
 actually engaged in the corneal wound, be it cataractous or not, 
 it should be extracted at once. 
 
 9. Bursting of the hyaloid usually attends any considerable 
 rupture of the zone of Zinn and from the same causes. When it 
 
 i LaChirurgie oculaire, p. 155.
 
 456 OPERATIONS UPON THE GLOBE. 
 
 occurs before the excision of the iris, the latter is likely to be rendered 
 difficult. The only indication of the break, perhaps, is the sudden 
 deepening of the anterior chamber, more marked on the side where 
 the incision is situated, provided the iris has not followed the knife 
 into the wound. The backward slant of the iris, suspended in 
 vitreous, makes the use of the forceps for its withdrawal impracti- 
 cable, so, unless a spontaneous prolapse has taken place, the blunt 
 or sharp hook must be substituted. Should the vitreous present 
 at, or escape from, the wound before the withdrawal of the iris, it 
 would be well to postpone the operation save in the event of most 
 pressing need of an iridectomy. As soon as it is evident that the 
 hyaloid has given way, all extraneous pressure upon the globe is 
 quickly reduced to the minimum, and the eye is closed. Blepharo- 
 stat, fixation forceps, etc.. are discarded. If it is decided to go 
 ahead with the excision, an assistant retracts the lids with instru- 
 ments or with his fingers. If the pupillary border of the iris is 
 visible, it is grasped with the blunt hook, if not, one may, when sure 
 of his hand, attempt to seize the membrane with the sharp hook, 
 catching in the stroma just where it is folded backward. It is worse 
 than useless, however, to try to get the iris out when it is completely 
 introverted. In cases where the luxation of the lens is discovered 
 prior to the operation or where loss of vitreous is feared, the writer 
 would recommend theAngelucci fixation, i.e., grasping the tendon- 
 ous portion of the superior rectus, as described under "Extraction." 
 A trained assistant is necessary. As the surgeon completes the 
 primary section, the helper takes from him the knife and gives the 
 traction instrument forceps or hook. Then, as the surgeon pulls 
 out the iris, the assistant is ready with the scissors to cut it off, which, 
 having been accomplished, the hold on the tendon is released and 
 the lids closed. Of course, the fixation forceps has no catch. This 
 is one of the few instances where the keratome with bayonet shank 
 may be found serviceable. 
 
 10. Blood in the Anterior Chamber. This comes from the 
 cut or torn iris or from the incised conjunctiva. Bleeding is 
 always more profuse when the eye is under the secondary effect 
 of either cocain or adrenal solution. Blood in the anterior chamber 
 is chiefly objectionable when it accumulates to considerable degree 
 directly the incision is finished, in that it conduces to faulty technic
 
 EXUCLEATIOX. 457 
 
 in the remaining steps. It can often be got out and ought to be, 
 when possible, before proceeding, by the methods described under 
 "Immediate Accidents in Extraction." A thin layer of blood lying 
 between cornea and iris after the operation is concluded is of no 
 consequence, for it will soon be absorbed, but if a greater quantity 
 be present, it should not be ignored lest the resulting clot might 
 serve as the starting-point of a new growth within the anterior 
 chamber. 
 
 With regard to the consecutive accidents in connection with 
 iridectomy, they are, in the main, such as are treated of under 
 "Extraction," and need no repetition here. Given a fairly healthy 
 eye and a normal iridectomy, with keratome or bent-lance incision, 
 done under the conditions demanded by modern ideas, and few 
 operations in eye surgery are attended with less risk in the after- 
 treatment. The corneal wound closes in most instances by primary 
 union, and great restriction of the patient's liberty is not needful. 
 After iridectomy for glaucoma, on the other hand, a binocular 
 bandage and the utmost quiet that is consistent with safety to the 
 circulatory system are indispensable. These things are all the 
 more to be insisted upon if the wound does not close promptly. 
 Tardy closure of the incision after iridectomy for glaucoma par- 
 ticularly the subacute or intermittent variety is something to 
 be dreaded; more so than after the ordinary extraction, for all the 
 good that might otherwise accrue to the eye can be thereby nullified. 
 The pillars of what had been an ideal coloboma are swallowed 
 up, and the anterior chamber is definitively abolished. The much- 
 lauded "filtration scar" that is. one that is truly effective in keep- 
 ing the intraocular tension within bounds is no more apt to 
 follow delayed than immediate closure of the incision. In short, 
 the more quickly the anterior chamber is reestablished, the better. 
 
 A second iridectomy is occasionally required in a glaucomatous 
 eye. It is the practice of most surgeons to make the new coloboma 
 but a continuation of the old an extension, as it were. 
 
 ENUCLEATION. 
 
 Enucleatio bulbi ; excision of the globe; shelling out the 
 eyeball are terms in good usage for a surgical procedure whereby
 
 458 OPERATIONS UPON THE GLOBE. 
 
 the naked bulbus is severed from its attachments and removed 
 from the orbit. The first recorded attempt at such an operation 
 was that of Lange, 1 but the precise method is not given. George 
 Bartisch, of Konigsbriick, Saxony, a contemporary and survivor 
 of Lange, 2 soon after removed an eye that was in a state of procidence 
 and, still later, described the mode of operating. He used a small 
 razor-shaped knife; with this he cut and scraped, following the 
 sclera, and loosening it from all connection with surrounding tissues. 
 In a case of cancerous growth affecting the bulbous and neighboring 
 structures, Bartisch made exenteration of the orbit, having recourse 
 to a sort of spoon, with sharp edges, taking great care to preserve 
 the eyelids. Fabrice de Hildens instead of the razor knife, em- 
 ployed in a similar way a straight, double-edged, bulbous-pointed 
 knife, which he introduced through the opening caused by a previous 
 circumcorneal dissection of the conjunctiva. Louis substituted 
 for the knife blunt scissors, curved on the flat, the instrument that 
 has since been used. Notwithstanding the value of the operation 
 of enucleation it fell into oblivion, from which it was not resurrected 
 till near the middle of the ipth century. The classic method of 
 ablation of the globe, on which are based all of those practised to- 
 day, is that proposed and described by Bonnet, * of Lyons, as a 
 result of his studies of Tenon's capsule. This procedure was 
 first put into practice by Stoeber, of Strassburg, in 1842, and its 
 technic was largely refined by White Cooper, of London, in 1856. 
 Panas says: "The principal merit of Bonnet's operation is the 
 conservation of Tenon's capsule, which admits of the extirpation 
 of the globe without injury to the soft parts of the orbit." Briefly 
 described, it is as follows : 
 
 The eye having been properly prepared and the blepharostat put 
 in place, the conjunctiva all around the cornea is detached by 
 means of scissors and freed from its episcleral attachments. The 
 four rectus tendons are laid bare, lifted in succession upon a blunt 
 strabismus hook, and divided with curved scissors, even with the 
 sclera. This done, the globe is dislocated forward, the scissors 
 passed behind it, and the optic nerve is severed slightly back of its 
 
 1 Thema. Chir. Figuri, 1555, p. 313. 
 
 2 Augendienst Dresden, 1583. 
 
 3 Observation. Chirurg., Frankfort, 1646. 
 
 4 Annal. d'oculist, T. v, 1841, p. 27.
 
 EXUCLEATIOX. 459 
 
 junction with the sclera. The globe is now held well forward, 
 with the fingers, while the tendons of the obliques and the few 
 remaining attachments are cut. 
 
 Slight modifications of this operation or a much altered form of 
 it devised by Yon Arlt, 1 of Vienna, constitute the methods now 
 practised, and they are referred to as the Bonnet and as the Vienna 
 methods. In the Von Arlt enucleation the hook is dispensed with. 
 An assistant usually holds the lids apart with the Desmarres' 
 retractors. We will suppose the right eye is to be removed. The 
 operator stands at the patient's right side. With the forceps a 
 fold of conjunctiva is picked up in the horizontal meridian, close 
 to the nasal limbus of the cornea, and snipped. The blunt point of 
 a pair of small curved scissors is put through the opening, the 
 conjunctiva is incised all around, save for a small bridge at the 
 temporal side, then dissected from the sclera and shoved well back. 
 The tendon of the internus is seized with the forceps, and thus held 
 throughout the rest of the operation. The blunted scissors blade 
 is slid beneath the tendon, and the latter is cut back of the forceps. 
 The globe is rotated downward, the scissors inserted beneath the 
 superior tendon, which is divided flush with the sclera. The eye 
 is rotated upward, and, in similar manner, the inferior tendon 
 is severed. The globe is now rotated somewhat outward, while 
 the closed scissors are passed behind it at the nasal side to locate 
 the optic nerve, then opened to cut it. The bulbus is lifted out of 
 its socket, the obliques are detached, and, lastly, the externus, the 
 bridge of conjunctiva, and all remaining connections are cut away. 
 
 Agnew's Method. The mode of enucleating that has always 
 commended itself most strongly to the author is a phase of the 
 Bonnet operation adopted by the late C. R. Agnew, of New York. 
 I have never seen a published description of this procedure, but my 
 conception of it and mode of making it, from having seen Dr. 
 Agnew perform it a number of times, is here given. The instru- 
 ments required are blepharostat (or, better, provided an efficient 
 aid is available, Desmarres, retractors), fixation forceps, without 
 catch, mouse-tooth forceps, Stevens' strabismus scissors, a pair of 
 stronger blunt scissors, curved on the flat, and two medium-size 
 
 'Zeitsch. der Wiener Aerzte, 1859, and Handb. von Graefe und 
 Saemish, 1874.
 
 OPERATIONS UPON THE GLOBE. 
 
 Graefe squint hooks, neatly flattened and rounded. The operator 
 stands facing the top of the patient's head, as in extraction, and it 
 does not comport with elegance to change one's position from start 
 to finish if one's training will warrant it. On causing the lids to be 
 held apart, if a general anesthetic be employed, as is usually the 
 case, the globe will be found strongly rotated upward. The object 
 
 FIG. 230. First step in Agnew's enuclealion. 
 
 of having the fixation forceps at hand is to rotate the eye in the 
 opposite direction while, with the other forceps, a substantial 
 meridional fold of conjunctiva and episcleral tissue is picked up 
 near the upper corneal border (Fig. 230). This is snipped with the 
 Stevens scissors between forceps and cornea, and from the opening 
 thus made the conjunctiva is incised so as to completely encircle the 
 cornea, the forceps all the while maintaining the first hold. By
 
 ENUCLEATION. 
 
 461 
 
 first sliding a blade of the scissors beneath the conjunctiva as close 
 as practicable to the cornea then working it toward the limbus with 
 a sort of riving motion, the incision can be made very close to the 
 base of the cornea. Still holding the bite of the forceps the con- 
 junctiva is undermined for a few mm. all round, and the anterior 
 prolongation of Tenon's capsule is likewise incised. Still keeping 
 the grasp of the forceps, the scissors are exchanged for a hook which 
 is inserted beneath the tendon of the superior rectus, and, thereafter, 
 one hook or the other serves' to fix the globe. The forceps is laid 
 
 FIG. 231. Severing tendon of externus in enucleation. 
 
 aside, the hook shifted to the left hand, the scissors again taken, the 
 conjunctiva and capsule pushed back to expose the caught-up 
 tendon, and the latter severed by cutting from heel toward point of 
 hook. Before freeing the point, however, and allowing the eye to 
 roll upward again, and without dropping the scissors, the second 
 hook is inserted. In this way the hooks and scissors are carried 
 around the spiral, and continuous line of insertion of all the recti 
 muscles, never letting go with one hook till the other is in place. 
 It is the aim to always leave enough tissue engaged by the tip of
 
 462 
 
 OPERATIONS UPON THE GLOBE. 
 
 the hook to serve for fixation while the second hook is being inserted; 
 but should the instrument be cut entirely free, it is easy enough to 
 reinsert it without first fixing the globe. The operator can work 
 from right to left, as move the hands of a clock, or in the opposite di- 
 rection, or in both directions. When it comes to division of the tendon 
 
 FIG. 232. Severing the' opticus 
 
 of the externus it should be cut at least one-eighth inch from the sclera 
 so that the stump will later serve as a handle (Fig. 231). In 
 most cases the tendons of the two obliques can now be caught and 
 detached previous to the neurectomy, or they can be left alone until 
 after the nerve is divided. A hook is then swept around to search 
 for stray fibres. The strong scissors here replace the other instru-
 
 ENUCLEATION. 463 
 
 ments, the globe is dislocated slightly forward by pressing the lids 
 backward, and steadied by the fingers; the closed blades are 
 carefully insinuated between capsule and sclera, at the temporal 
 side, and worked back to feel for the optic nerve. Having found 
 what seems to be the object sought, one slides the scissors above it 
 and presses down, then below, and presses up. If it be the nerve, 
 the globe will turn up, then down, in obedience to the pressure. 
 It only remains to draw back slightly, open the scissors moderately, 
 and then advance so as to include the opticus between the blades. 
 Before cutting, it is well to again press down and up to be sure, by 
 the movements of the eye, that the blades are really astride. A 
 single firm snip, and the globe jumps forward followed by an extra 
 gush of blood (Fig. 232). It is best now to terminate the operation 
 quickly. The globe is grasped firmly in the fingers of the left hand 
 or the stump of the externus is seized with the fixation forceps, and 
 one proceeds to divide whatever else is still adherent. If the bleeding 
 is not excessive, the socket is copiously irrigated with hot sublimate 
 solution, when the flow is promptly checked. The opening in the 
 conjunctiva is neatly drawn shut not sutured and any extruding 
 shreds from the tissues beyond are cut off. 
 
 Other Modifications. There is another French method worthy 
 of mention. It is that of Tillaux, and is called enudeation from 
 behind forward. After dissection of the conjunctiva the tendon of 
 the externus is severed at a little distance from its insertion. The 
 stump of tendon is seized with fixation forceps, the globe strongly 
 rotated inward, and, with the curved blunt scissors, the opticus is 
 divided. Still held by the forceps, the globe is drawn out through 
 the conjunctival opening, when it is easy to detach, flush with the 
 sclera, the five remaining tendons. Cunier made the operation in 
 reverse manner, i.e., starting with the internus. 
 
 E. Meyer 1 carefully abstains from cutting or loosening the sub- 
 conjunctival tissue in the region of the insertions of the recti. To 
 make a passage for the hook, he incises the mucosa alongside each 
 muscle, that is, in the interval of each one of the insertions. More- 
 over, in order to preserve the union between the muscle and their 
 capsular envelops, he lifts the tendon and shaves it from the surface 
 of the sclera. Lastly, to augment the lateral movements of the 
 'Bull, et mem. de la soc. franf. d'opht., 1898, p. 185.
 
 464 OPERATIONS UPON THE GLOBE. 
 
 prothesis, he closes the opening in conjunctiva and capsule by several 
 sutures placed vertically. 
 
 With the idea of increasing the movement of the stump left after 
 enucleation, De Wecker, some twenty-five years ago, after the 
 pericorneal incision, put in a tobacco-pouch suture that included 
 conjunctiva, capsule, and tendons of the recti. He then proceeded 
 to excise the globe by the Bonnet method, and finished by drawing 
 up and tying the suture. This bringing together of the tendons 
 with their aponeuroses intact would seem to be an improvement, 
 with respect to control of the prothesis, over the earlier and simpler 
 operations. The arrangement of the threads ^ has been subjected 
 to various alterations. One of the latest and best is that of Hansell 
 and Sweet. 1 "After dissecting the conjunctiva from the limbus, 
 each straight muscle, together with the overlying conjunctiva and 
 capsule of Tenon, is firmly grasped by the fixation forceps and 
 separately sutured by single threads, before dividing the tendons 
 from the sclera. After enucleation of the ball and the checking of 
 the hemorrhage, the cut edges of the conjunctiva, w y ith the muscles 
 and capsule are brought together over the muscle bed by two or 
 three sutures." The sense in which the sutures are directed is 
 not specified, but as lateral movement is more to be sought in the 
 artificial eye than is vertical, and as this movement depends, in a 
 measure, upon the conservation of the conjunctival cul-de-sacs, to 
 place the sutures vertically, thus closing the opening into a hori- 
 zontal line, will act to deepen the lateral cul-de-sacs at the expense 
 of those above and below. 
 
 In a series of five papers published in the Ophthalmic Record for 
 November, 1908, it appears that there have come to light 18 cases of 
 sympathetic ophthalmia following Mules' operation; i.e., the insertion 
 of some sort of ball within the sclera. These include the original 
 13 collected by Cross, and 5 since reported, namely, one each by 
 Sherman, Emerson, Gifford, Oliver, and Brobst. 
 
 The same source furnishes 4 cases of sympathetic ophthalmia 
 following Frost's operation, i.e., implantation of a ball of some 
 material in Tenon's capsule, one each by Cant, Lang, Sattler, and 
 Davis. 
 
 Also nine cases of the disease after evisceration without artificial 
 
 1 Diseases of the Eye, Phila., 1903, p. 283.
 
 ENUCLEATION. 465 
 
 vitreous, namely, one each by Dransart, Waldispiihl, Van Duyse, 
 Forget, Hotz, Nieden, and De Wecker, and two by Schmidt-Rimpler. 
 
 Forget's r case can hardly be included as it was one of "optic 
 neuritis occurring 19 months after evisceration," nor can Hotz's, 2 
 for it was one of " mild optic neuritis 3 w r eeks after evisceration, and 
 recovered without removal of the stump." 
 
 Since the operation of evisceration came into vogue there have 
 been reported 36 cases of sympathetic ophthalmia coming after 
 enucleation. 
 
 In view of the fact that all ophthalmic surgeons and some who 
 are not make enucleations, and that the vast majority of them 
 make exenterations (of some kind), the few unfortunate results 
 just quoted in connection with these two measures are of little 
 consequence. Especially is this true of evisceration, when one 
 considers that many of the so-called eviscerations have not resulted 
 in the thorough cleaning out of the scleral cavity, and many others, 
 in which although this cleaning out may have been thorough, have 
 finished by the tying of a purse-string suture or of some other kind 
 that caused strangulation of the circulation of the conjunctiva and 
 that of Tenon's capsule, thus producing intense inflammatory 
 reaction. 
 
 On the other hand, in view of the relatively small number of 
 surgeons who have made the Mules' and Frost's operation, the 
 showing is bad indeed for those procedures. 
 
 Intracapsular, or Intratenonian Prothesis. In 1887 
 Frost and Lang, 3 simultaneously conceived and carried out the 
 idea of implanting the glass ball of Mules in the fibrous capsule of 
 the globe, after enucleation. Since that, glass having shown a 
 decidedly effective propensity for extricating itself, other sub- 
 stances have been employed. Although the relatively few advocates 
 of the measure out of the many who have tried it have expressed 
 themselves as eminently satisfied with their results, a glance at a 
 partial list of the different materials with which it has been attempted 
 to replace the living bulbus is not calculated to strengthen their 
 position in the matter: 
 
 * Arch, d'oph., p. 693. 
 
 2 Trans. Oph. Sec. Am. Med. Assoc., 1893, p. 93. 
 
 3 Brit. Med. Jour., vol. i, pp. 1043 and 1153. 
 
 3
 
 466 OPERATIONS UPON THE GLOBE. 
 
 Glass ................ Frost. Rubber ............. Pick. 
 
 Celluloid ............ Lang. Wire ............... Laudman. 
 
 Sponge. Silk ....... Bourgeois. 
 
 Peat ................. Bourgeois. Catgut J 
 
 D =. / Living \ T Fat from gluteal 
 Bone n 
 
 Decalcified / region. ............ Barraquier. 
 
 Agar-agar ........... Suker. Skin and adipose from 
 
 Vaselin ............. Rohmer. gluteal region ....... Rollet. 
 
 ld ..... PrinCe ' Rabbit's eye ..... { 
 
 Paraffin ............ Brockaert. 
 
 Paraffin is the latest aspirant for honors in this line. In an in- 
 teresting article in Knapp's Archives for March, 1905, Spratt, of 
 Minneapolis, reports 23 cases in which spheres of this kind were 
 used, with only one known failure from extrusion. The idea is 
 conveyed, however, that from first to last these cases had been 
 under observation for a period of only seven months. The paraffin 
 was of the melting-point of .60 degrees C. (140 degrees F.), made into 
 balls about 17 mm. in diameter. The operation is as follows: 
 After the pericorneal incision and dissection each of the rectus 
 tendons is caught fast by a Halsted "mosquito" hemostat. One 
 then proceeds to divide the tendons and enucleate in the usual way. 
 The paraffin ball is placed in Tenon's capsule with common forceps. 
 The tendons of the opposing muscles are stitched together over 
 the paraffin by mattress sutures of chromicized catgut, Tenon's 
 capsule and the conjunctiva are closed by purse-string sutures; the 
 first of ordinary catgut and the second of silk. The writer of the 
 article warns against spheres too large, and against undue tension 
 upon the sutures. The advantages claimed for paraffin are: 
 
 1. It is non-irritating, hence least likely to be extruded. 
 
 2. The spheres can be made easily and are inexpensive. 
 
 3. No danger of being broken. 
 
 4. The paraffin adapts itself to the shape of the cavity, is soon 
 surrounded by a fibrous capsule, and is firmly held in place by 
 connective tissue down-growths. 
 
 Abundant experience has demonstrated that the inorganic sub- 
 stances, such as glass and metal, introduced in the cavity of Tenon 
 are generally, sooner or later, eliminated, while those of organic 
 or living tissue, thus separated from their natural environment, 
 although grafting well in this location, unfortunately, in time, 
 undergo so great a retraction that there remains of them but an
 
 ENUCLEATION. 467 
 
 insignificant trace. Paraffin is treacherous in that it is prone to 
 change its location even when not expelled. Dr. Chibret, of 
 Clermont-Ferrand, conceived the original idea of replacing the 
 enucleated eye by that of the pig "Idee Audacieuse." But it 
 succeeded, in a measure. Then Prof. Rohmer, of Nancy, after 
 having made several implantations of the eyes of animals in the 
 peritoneal cavity, with positive results, grafted in man, in case of 
 a blind subject, whose eye was lost from iridocyclitis and enucleated, 
 an eye of the rabbit in Tenon's capsule. But after 2 weeks the 
 implant was eliminated, and Rohmer, discouraged, gave up the 
 experiment. Then Prof. Lagrange, without knowledge of Rohmer's 1 
 experience, undertook the same researches, published in 1901, 
 with encouraging results. In his first article and in another, 
 published in La Clinique Ophtalmologique, 1901, he declared that 
 the result depends solely upon the choice of method that is made 
 for the operation. Some years afterward, in 1905, Lagrange 
 made to the French Society of Ophthalmology at Paris a new 
 communication upon the subject. Wicherkiewicz, of Krakow, 
 was present and saw the patients operated upon by Lagrange, 
 and listened to the discussion which occurred. It was Rohmer who 
 then declared that, in time, all these transplanted eyes undergo 
 complete absorption. He contended that Lagrange would soon 
 be disillusioned, and would return to the transplantation of balls 
 of paraffin. 
 
 Operation of Lagrange. He used silk threads to unite the 
 severed tendons. After enucleating the eye he employed iced 
 compresses to arrest the hemorrhage. He then introduced the 
 eye of a rabbit, of appropriate size, the cornea backward. Over this 
 the recti tendons were united, in opposing pairs, and, lastly, the 
 conjunctival opening was closed by sutures. The predecessors 
 of Lagrange Chibret, Rohmer, Terrien and Bradfort gave to 
 the transplanted eye its normal orientation, i.e., cornea forward, 
 which sometimes led to disaster, such as ulceration, perforation, and 
 loss of vitreous. 
 
 The divergence of opinion of his eminent confreres caused 
 Wicherkiewicz, 2 to undertake to satisfy himself personally as to 
 
 1 Annales d'Oculistique, iii. 
 
 2 L'Ophthalmologie Provinciate, March, 1909.
 
 468 OPERATIONS UPON THE GLOBE. 
 
 the value of this form of transplantation. In consequence, Wicher- 
 kiewicz and his assistants made 35 implantations, with a technic 
 somewhat modified from that of Lagrange. He, like Lagrange, 
 placed the eye in the inverse position, which is better for the nutrition 
 of the cornea. He used catgut to unite the recti tendons. The 
 Tenonian cavity was first irrigated with cold, sterile, physiologic 
 salt solution. Fifteen were children. In 32 instances chloroform 
 narcosis was employed, and in 3 local (Schleich's), with novocain 
 and adrenalin. These last reacted much more severely than did 
 the chloroform cases. In 24 cases there was no marked reaction. 
 In a few instances the threads cut out of the tendons, necessitating 
 their renewal. Once there was copious hemorrhage beneath the 
 conjunctiva. In two pronounced exophthalmos occurred, the 
 result of deeper hemorrhage. In eleven there was considerable 
 edema of the conjunctiva. Wicherkiewicz's operations demon- 
 strated that the eye of the rabbit "takes" readily in its new soil. 
 As an illustration of the intimacy of its union with its surround- 
 ings, in one of Wicherkiewicz's cases the original eye had been 
 removed because of a malignant tumor, the growth recurred and 
 penetrated to the interior of the new eye. It was also demon- 
 strated that the. grafted eye progressively lost volume in all cases, 
 and that this atrophic process was most marked in the older 
 subjects, in whom it did not cease until the graft disappeared 
 completely; while, as regarded the children, it remained of fair 
 size, even at the end of two years. For these reasons Wicher- 
 kiewicz now limits the operation to children and to those adults 
 who are in urgent need of an enucleation, but will only consent to 
 undergo it by being promised that another eye will be put in to 
 replace that which is sacrificed. In children, who are too young 
 to wear an artificial eye, the grafted eye, according to Wicherkiewicz, 
 serves to fill the socket, prevents falling in of the free borders of the 
 lids, obviating irritation from the lashes, favors development of 
 that side of the face, and prevents the ugly sinking backward of the 
 upper lid and the formation of the deep orbito-palpebral furrow. 
 
 Enucleation. General Considerations as to Technic. If 
 one is blest with a trained assistant, the operation of enucleation is 
 greatly facilitated by entrusting to him the opening of the lids by 
 means of a pair of Desmarres' tractors. He knows just how to
 
 ENUCLEATION. 469 
 
 follow the course of the operator with the points of widest separa- 
 tion of the lids, now widening the palpebral fissure most exter- 
 nally, now internally; now lifting high the upper lid while easing 
 up on the lower, and vice versa, always guarding the free borders 
 from a snip of the scissors. In the absence of such help, the Mel- 
 linger blepharostat serves, by reason of the parallel opening of its 
 lid-holders, as the best substitute. 
 
 Detaching the Recti. It is in respect to this feature that the 
 Arlt method departs farthest from that of Bonnet. For the few 
 uncomplicated cases where the relations of the parts are normal, 
 the Vienna mode, without squint hooks, offers to the skilled surgeon 
 an opportunity for exceedingly brilliant work an excision of the 
 globe in a little more than one minute, and with the use of but two 
 instruments. But for less experienced operators, and for the more 
 difficult cases, such as shrunken or flabby globes and those charac- 
 terized by inflammatory processes, with adhesions to the surround- 
 ing tissues, no matter how clever the surgeon, it is not to be recom- 
 mended. The tendons cannot be picked up so easily and divided 
 so precisely with the scissors alone as with both hook and scissors, 
 and there is greater liability of wounding the fibrous capsule of the 
 globe which, in view of possible infection of the cellular tissue of 
 the orbit, is by all means to be avoided. The Bonnet method, 
 as modified by Agnew, admits of nearly or quite as rapid an excision 
 in the simpler cases, and both simplifies and hastens matters as 
 regards the complex ones. When the tendons can be readily caught 
 upon the hook, no other fixation of the globe is necessary, but 
 where extensive adhesions exist, one may either leave a bit of tendon 
 attached as a hold for ordinary fixation forceps or, what answers 
 better, have recourse to the tenaculum forceps, the grip of whose 
 talon-like extremities may be varied at will. 
 
 Dividing the Opticus. Most writers have taught that, for this 
 purpose, the scissors should be inserted at the nasal side, arguing 
 that this affords the shortest route to the nerve. It would seem, 
 however, that those who favor the external route have decidedly 
 the advantage. The manipulating of instruments at the temporal 
 side in operations upon the globe is always handier than at the 
 nasal side. Then, the diverging outer wall of the orbit makes the 
 opticus more accessible from that side. Moreover, as the larger
 
 47 
 
 OPERATIONS UPON THE GLOBE. 
 
 blood-vessels lie more to the nasal side there is less risk of excessfve 
 hemorrhage by choosing this way. It is not advisable to rotate 
 the globe strongly to bring the nerve nearer to the scissors in severing 
 it, as this is apt to result in mangling the bottom of the eye-socket, 
 in oblique section of the nerve, and in greater wounding of blood- 
 vessels, with unnecessary bleeding. I have never felt the need of 
 any instrument other than the medium-sized curved blunt scissors 
 for this step in the operation. The bifid spoon of the elder Terson 
 (Plate VIII) and the hemostatic clamp attachment for the scissors 
 of Warlomont (Fig. 233) sometimes employed in this connection 
 having always struck me as a useless augmentation of an already 
 adequate apparatus; therefore, subversive of the wholesome rule 
 
 FIG. 233. Warlomont's hemostatic scissors. 
 
 that the fewer the instruments the better always provided the 
 results are in no way prejudiced by too scant an equipment. If 
 there be a tumor of the posterior hemisphere or one that fills the 
 vitreous chamber, it is best to remove as much of the opticus as is 
 practicable. The same is true of cases wherein signs of impending 
 sympathetic ophthalmia are present in the fellow eye. Knapp is 
 the author of a convenient and efficient mode of making this re- 
 section. Before cutting the nerve he passes behind the globe the 
 closed blades of a delicate pair of hemostatic forceps, curved on the 
 flat, feels for and seizes the nerve a few mm. behind the eye, and 
 locks the ; handles. He then introduces the scissors and severs 
 between the point of fixation and the optic entrance. After the 
 bleeding has ceased, the nerve is drawn forward by the still adhe-
 
 ENUCLEATION IMMEDIATE ACCIDENTS. 471 
 
 rent forceps, and as much cut off as is deemed sufficient. Indeed, 
 when the enucleation is made because of a small tumor, and in- 
 spection of the section of the opticus shows that it is normal, the 
 forceps may be released without making the resection. 
 
 Suturing the conjunctival opening accomplishes no special good. 
 Healing is as safe and prompt and smooth without it. Granulation 
 buttons seem to occur about as often with as without. On the 
 contrary, it prolongs the operation, increases the number of instru- 
 ments, becomes foul with the discharges, acts like a seton in the 
 tissues, and in the end necessitates an operation for its removal. 
 
 IMMEDIATE ACCIDENTS. 
 
 i Perforating the Sclera. This is most likely to occur in 
 eyes of normal, subnormal, or increased tension by pulling up too 
 strongly on a tendon while detaching it from its insertion, especially 
 when the scissors are rather pointed or are made to hug the sclera 
 too closely; and in eyes of reduced tension by attempting to sever 
 the opticus flush with its entrance while making undue forward 
 traction upon the globe. The most serious objections to this mishap 
 are that it embarrasses the subsequent steps of the operation and 
 that, in the event of the contents of the eye being septic, there is 
 danger of infection of the tissues of the orbit. 
 
 2. Hemorrhage. While in most instances there is no trouble 
 from this source in excising the bulbus, bleeding is sometimes 
 copious from the very beginning and throughout the operation. 
 That from the conjunctiva and Tenon's capsule can usually be 
 controlled by the instillation of adrenal solution or by flooding the 
 eye with hot sterile or sublimated water, though to apply the adrenal 
 solution too long beforehand only tends to favor the flow of blood. 
 It is, however, upon section of the optic nerve and surrounding 
 vessels that the worst hemorrhages are to be apprehended. This is 
 particularly true of subjects in whom there has been marked de- 
 generation of the vascular system. One should, therefore, exercise 
 great discrimination in making this section. First, take care not to 
 pop the eye too much before cutting, thus putting the posterior 
 ciliary arteries too greatly upon the stretch, so that after their 
 division, their distal cut ends will retract behind the fibrous capsule
 
 472 OPERATIONS UPON THE GLOBE. 
 
 of the globe and convert the whole orbit into an enormous hematoma. 
 So tense can the tissues become from this cause as to result in 
 necrosis of the lids. Secondly, guard against shoving the blades of 
 the scissors too far astride the nerve, thus including the nasofrontal 
 artery; and also against opening the blades too wide and making the 
 section to comprehend large branches of the ophthalmic vein that 
 might be otherwise avoided. Inexperienced operators are too 
 prone to grow flustered at this stage of an enucleation and to poke 
 and haggle aimlessly, deep in the orbit, provoking needless hemor- 
 rhage. If the outward escape of blood from the empty eye-cup is 
 excessive or prolonged, it is best to tampon the cavity with wet 
 (sublimate) absorbent cotton, and over all put a compressive 
 bandage. This, be it observed, is but temporary, i.e., to be kept in 
 place only until the bleeding ceases, when it is to be removed, the 
 tampon taken out, the cavity washed, the conjunctival opening 
 neatly arranged, the lids closed and the dressing applied in the 
 regulation way. No foreign substance, such as cotton or sponge, 
 must ever be left in the open wound long enough to become ad- 
 herent. This can occur in a comparatively few hours and can prove 
 extremely vexatious. It is rarely, indeed, that more strenuous 
 measures are called for, such as the application of sesqui-chlorid 
 of iron, ligation, or the Paquelin cautery, in dealing with the 
 hemorrhage. 
 
 3. Leaving Part of an Ocular Tumor in the Orbit. If, upon 
 the removal of an eye for an intraocular tumor, it is discovered that 
 the growth has become extraocular, and there is evidence that any 
 portion remains behind, it must be sought at once and scrupulously 
 excised. The same also as regards any infiltration of the optic 
 nerve by a neoplasm. 
 
 4. If the Globe be too large to Pass Through the Palpebral 
 Fissure. The remedy lies in a free external canthotomy. As 
 soon as the enucleation is completed, the divided conjunctiva and 
 the skin are to be separately sutured so as to restore them to their 
 normal condition. 
 
 5. Operating Upon the Wrong Eye. That this most deplorable 
 accident is not beyond the realm of the possible has been abundantly 
 proven, and that by more than a single instance. Although one of 
 the victims thereof may be terribly culpable, they are both deserving
 
 KNUCLEATION CONSECUTIVE ACCIDENTS. 473 
 
 of our sincerest commiseration. Let every ophthalmic surgeon see 
 to it, henceforth, that this calamity does not happen through fault of 
 his or through that of anyone else connected with the case. Never 
 trust in the matter to those who prepare the patient for the opera- 
 tion. Examine the eye immediately beforehand. If the one to be 
 removed has no conspicuously distinguishing external feature as 
 in intraocular tumor shave the brow upon that side, or, better 
 still, place a mark upon the forehead adjacent. 
 
 CONSECUTIVE ACCIDENTS. 
 
 1. Secondary Hemorrhage. This is a contingency against 
 which we have been repeatedly warned, yet one that seldom arises. 
 The writer has never encountered it. Unlikely though it be, one 
 must be prepared to meet it. For this reason it is best to have the 
 case under strict surveillance for at least 24 hours after the operation. 
 A mere sanguinary staining of the dressings signifies nothing. 
 Should it be discovered that blood actually trickles from beneath the 
 coverings of the eye, the bandage must be taken off and measures 
 instituted tending to stop the flow iced compresses to the lids, hot 
 sublimate irrigation, and tamponment of the open socket, with re- 
 application of the compressive bandage; or, if need be, recourse to 
 the more extreme ways and means mentioned under "Immediate 
 Accidents." 
 
 2. Infection. Cellulitis of the orbit, ascending meningitis, and 
 thrombophlebitis of the ophthalmic vein and its adnexes are the 
 truly grave sequels that enucleation can engender. But with due 
 regard to the laws of modern surgical prophylaxis and to the in- 
 tegrity of the protecting fascia of the orbital tissues, their advent 
 is scarcely to be apprehended. There are three main factors for the 
 prevention of the accident in question that one should strive to 
 eliminate, viz.: unclean implements, needless wounding or opening 
 of Tenon's capsule and contamination from the tissues involved. 
 The first is accomplished in great measure by thorough boiling of 
 the instruments and cleansing of the hands; the second, by carefully 
 dissecting up the anterior prolongation of the capsule, picking up 
 and dividing the tendons of the ocular muscles close to the sclera 
 with the least disturbance of the aponeurotic wrappings, and the
 
 474 OPERATIONS UPON THE GLOBE. 
 
 absolute conservation of the fibrous capsule that envelops the 
 posterior half of the globe; the third, by the free use of antiseptic 
 irrigation and the preservation of the walls of the globe (when its 
 contents are septic). Here it may be again remarked that exentera- 
 tion may be often substituted with greater safety for enucleation. 
 
 INDICATIONS FOR ENUCLEATION. 
 
 These may be arranged in three groups: i. absolute and impera- 
 tive; 2. elective, and 3. optional. 
 
 Absolute indications are those that leave no choice of other 
 means of treatment. Among them are the cases for which enuclea- 
 tion affords either the only chance or hope of preserving the integrity 
 of the fellow eye or of saving the life of the patient. To this 
 group belong the following classes: 
 
 (a) Eyes, be they sightless or not, that are causing sympathetic 
 irritation or the actual beginning of sympathetic inflammation. 
 
 (b) All blind eyes and in this connection blind means hopelessly 
 so that are exciting or have excited sympathetic inflammation, 
 no matter what the stage of said inflammation. 
 
 (c) All eyes, whether sightless or not, in which positive diagnosis 
 of an intraocular malignant tumor has been made. 
 
 (d) All blind eyes within whose walls there is any reason to suspect 
 the presence of a malignant growth. 
 
 (e) All eyes, sightless or not, where exists an epibulbar malignant 
 growth that it is not practicable otherwise wholly to remove. 
 
 (/) All blind eyes with epibulbar malignant growths, regardless 
 of the degree of involvement. 
 
 (g) Persistent pain referred to the eye after exenteration or optico- 
 ciliary neurectomy. 
 
 (h) Extreme atrophy of the globe. 
 
 (i) Grave phlegmon of the orbit when sight is utterly destroyed 
 and the operation may aid in curing the disease. 
 
 Remarks on Group i. Class a. Ophthalmic surgeons are 
 almost a unit in affirming that immediate excision of the globe, 
 together with a pretty generous section of the optic nerve, constitute 
 the only remedy. There are, however, a number of men whose 
 word is authoritative, who would place these cases in Group 2,
 
 INDICATIONS FOR ENUCLEATION. 475 
 
 as admitting of a choice between enucleation and exenteration as 
 the means of dealing with them. The inflammation having become 
 thoroughly established in the sympathizing eye, while useful vision 
 is still possessed by the exciting eye, then the question as to the 
 removal of the latter becomes a problem the solution of which 
 must be left to those who have the case in charge, as it opens a field 
 of discussion too wide to have a place here. With regard to Class c,. 
 if the tumor is manifestly of insignificant proportions, expecially 
 if its exact nature is not known beyond peradventure, it is true that 
 the excision is not at once obligatory, and further developments, 
 might be awaited and observed indeed, in that event it would 
 not really belong to this class. Prominent in Class d are those 
 eyes that are in a state of absolute glaucoma. It would be good 
 practice to enucleate every one of these as soon as possible, lest 
 hidden therein should be a dangerous sarcoma. This is particularly 
 true when the other eye is free from signs of glaucoma and the 
 subject is of middle age or older. To make iridectomy or any 
 form of sclerotomy for the relief of the tension or pain, and with 
 the view of "saving the eyeball," is worse than folly in these cases.. 
 Aside from the hazard of a lurking tumor, such eyes are, as a rule,, 
 better out than in. 
 
 Group 2. Elective Indications. These have reference to 
 eyes that may be regarded in the light of a menace, more or less, 
 imminent, to the well-being of their fellow, yet can be rendered 
 impotent for harm by some other procedure, as, for example, the 
 operation of exenteration, as well as by that of enucleation. They 
 may be classified thus: 
 
 (a) Recent fresh, extensive injuries seriously involving the 
 ciliary region. 
 
 (b) Eyes blind from chronic inflammations of the uveal tract. 
 
 (c) Phthisis bulbi, not extreme, with or without calcific or osseo- 
 calcific degeneration of the choroid. 
 
 (d) Total extensive staphyloma of the cornea or of the globe. 
 
 (e) Blind eyes containing inextricable foreign bodies. 
 (/) Acute suppurative panophthalmitis. 
 
 Remarks. Class a. It is remarkable to what an extent the tunics, 
 of the globe may be wounded, even when the ciliary body is included
 
 476 OPERATIONS UPON THE GLOBE. 
 
 in the trauma, yet recover promptly. Provided there has been no 
 infection, and reparation has been rapid and complete, so long as 
 the eye remains absolutely quiescent, plump, and of normal tension, 
 it is not only safe to leave.it in place, but it were wrong to enucleate 
 or exenterate irrespective of questions of sight or the location of 
 the original wound. Should a lingering iridocyclitis or choroiditis 
 result with, perhaps, disturbances of tension, and sight is gone, 
 excision of the globe or exenteration should be done without 
 further delay. Given these conditions, together with useful vision 
 and a wound of the ciliary zone, nothing short of "eternal vigilance" 
 on the part of one capable of properly observing, could be an 
 excuse for not resorting to one of the operations named the moment 
 it was found that other modes of treatment were of no avail. In the 
 writer's opinion, exenteration is better suited to every class cited 
 in Group 2 than is enucleation. 
 
 Group 3. Optional Indications. This group is relatively 
 small, containing only two classes, viz.: 
 
 (a) Quiet eyes, apparently normal in every way save that they 
 are blind from total leucoma of the cornea. 
 
 (b) All instances of bilateral blindness in which the removal 
 of an eye or the eyes would decidedly improve the personal 
 appearance. 
 
 Remarks. This group is so named because it embraces those 
 cases concerning which it is purely a matter of choice on the part 
 of the patient whether or not he parts with an ugly useless member. 
 Class b is peculiar in that, of all the classes under the three groups, 
 it is the only one that does not assume some degree of usefulness on 
 the part of the other eye. Like Group 2, there can hardly be a doubt 
 but that exenteration is the preferable procedure whenever practicable 
 for this division also. It may be mentioned in passing that 
 Class a of this group includes just the cases that are appropriate 
 for tattooage of the cornea. 
 
 Concluding Observations. Age of Patient. Neither extreme 
 that of youth nor that of age are considered bars to an urgently 
 needed enucleation. 
 
 Anesthesia. Narcosis is, of course, the rule, and, all things else 
 being equal, is most suitable. Excision of the globe has frequently
 
 INDICATIONS FOR ENUCLEATION. 477 
 
 been accomplished under local anesthesia, but it is far from being a 
 pleasant undertaking. Seeing that the really painful part of the 
 operation is the section of the optic and ciliary nerves, it is quite 
 possible to perform this step under chlorid of ethyl or even nitrous 
 oxid, having executed all those preceding under cocain. For 
 subjects who are unfit for ether or chloroform this method is highly 
 to be recommended. Indeed, as regards the youngest class of sub- 
 jects, it is practicable to make the entire operation under the ethyl 
 chlorid. Highly inflamed and sensitive eyes do not admit of using 
 local anesthesia at any stage of the procedure.
 
 CHAPTER XL 
 EXTRACTION OF CATARACT. 
 
 GENERAL CONSIDERATIONS. 
 
 Condition of Patient's General Health. All that is requisite in 
 this particular is that the patient be in his usual health and that this 
 should be such as to give a reasonable expectation of life. While 
 it is well, as a routine practice, to make careful physical examination, 
 there are really very few pathological conditions existing in cataract 
 subjects, as we find them, that are actual contraindications as regards 
 the operation of extraction. Although it is almost the universal 
 custom (with the writer among the rest) to ascertain the exact 
 condition of the urine; neither diabetes nor nephritis are actual bars 
 to the operation so long as dissolution is not imminent. The same 
 may be said of cardiac disease, aortic insufficiency, etc. General 
 arteriosclerosis, while it makes one fear expulsive hemorrhage 
 from the choroid, should not cause rejection, but should lead to 
 extreme caution and to the institution of appropriate preparatory 
 measures as regards diet and other regimen; also the exhibition of 
 remedies whose effects are supposed to counteract the evils of this 
 disease. 
 
 Age of the Subject. Extreme old age of itself should not stand 
 in the way. The writer's eldest subject was ninety-two, and the 
 result was all that could be desired. On the other hand, given an 
 unusually youthful subject for senile cataract, the question merely 
 hinges upon the kind of cataract and the manner of operating to be 
 undertaken. 
 
 Condition of the Eye and its Appendages. There should be 
 no thought of operating for cataract upon an eye so long as there is 
 any active inflammatory condition of either the globe or its ap- 
 pendages, such as conjunctivitis, acute catarrhal disease of the 
 lacrimal canal, and, above all, dacryo-cystoblennorrhea. These, 
 when present, even in the opposite eye, should first be got rid of. 
 
 478
 
 GENERAL CONSIDERATIONS. 479 
 
 It is not to be expected that there should actually be a normal 
 lacrimal passage even mucocele does not deter some good men. 
 Old, burnt out stages of trachoma, provided there is not entropion, 
 with trichiasis, etc., may be ignored. Bacteriologic investigation 
 of the apparently healthy conjunctiva preliminary to extraction 
 might seem to be unnecessary, yet it is really important as it oc- 
 casionally reveals an incipient infection that would positively pro- 
 hibit the operation for the time. 
 
 Suppuration of the lacrymal canal, when very slight, is best 
 dealt with by ligation of the canal with a single thread, just at the 
 union of the two canaliculi, immediately preceding the extraction; 
 i.e., when the patient is on the table for the latter. With the more 
 profuse and chronic forms, however, it is best not to temporize, but 
 at once to extirpate the sac and as much as its practicable of the 
 canaliculi. (See "Operations upon the Lacrimal Apparatus." 
 Pterygium, progressive or encroaching upon the pupil should first 
 be removed. The skin of the lids should be fairly free from disease. 
 
 Condition of the Globe. First and foremost, there must be 
 tolerable light perception, if not projection. One must judge of the 
 individual case. Black cataracts and those with very thick or 
 calcine anterior capsules may very greatly interfere with these 
 functions, even though the deeper structures be normal. On the 
 other hand, many eyes characterized by chronic or very old choroidal 
 and retinal lesions and affections may give most gratifying results 
 after extraction. 
 
 The Cornea. Opacity of this membrane, so long as it alone does 
 not preclude the possibility of useful sight, should not prohibit 
 extraction. Arcus senilis presents no special obstacles to the heal- 
 ing process, though it is likely to cause "grooving" of the wound 
 made for extraction. 
 
 The Iris and Pupil. Only some active pathological process of 
 the iris would be cause for non-interference. It is highly desirable to 
 have a normal iris and a pupil that reacts well to light, yet if dealt 
 with as the exigencies of the case demand, one need not hesitate to 
 operate even when there is a very great departure from the normal. 
 One of the author's most satisfying cases is that of a woman, blind 
 in both eyes from anterior uveitis, exclusion and occlusion of pupils, 
 opacity of the lenses, and even opacity of the lower halves of the
 
 480 EXTRACTION OF CATARACT. 
 
 corneas the result of punctate keratitis which afterward extended 
 to the whole thickness. Ten years ago I made in this case upward 
 iridectomies, then extractions ,and, lastly, discissions, and the patient 
 has good vision in both eyes to-day even reads and sews without 
 difficulty. 
 
 Condition of the Lens Itself. It is highly to be recommended 
 that, as nearly as possible, the exact character of the cataract be 
 ascertained, for on this often depends the surgical methods we are 
 to pursue in dealing with it. If there is much clear, soft cortex 
 an iridectomy is indicated, or if the anterior chamber be very 
 shallow and the opacity be an even gray not white throughout, 
 we may suspect a large sclerosed cataract which will necessitate a 
 large corneal section. As to this point we are usually put in the 
 position where we have but little to choose; as, aside from the fact 
 that a certain number of cases on first presentation are those of 
 incipient cataract, the great majority, particularly in hospital 
 practice, have already reached or passed the requisite stage of 
 ripeness. The circumstances under which the patient comes to us 
 make it often the choice of two evils to operate on an unripe 
 cataract or to send him many miles to his home. Again, the very 
 form of cataract that we prefer to let alone till mature, viz., the 
 so-called nuclear, with transparent cortex, is precisely the kind that 
 causes greatest blindness when in this unready state. Preliminary 
 iridectomy is almost a necessity before the extraction of all highly 
 immature cataracts. 
 
 In a large charitable institution like the Illinois Eye and Ear 
 Infirmary, for example, where indigent cataract patients are sent to 
 us, at the public expense, from remote parts of the State, we operate 
 on many a cataract that in private practice, or belonging to anyone 
 residing at convenient distance, would be allowed to grow more 
 opaque. Yet, on the whole, considering the class of patients we 
 have to deal with, I think the results we obtain in this hospital will 
 compare favorably with any. 
 
 It is not wise, on general principles, to extract the lens from 
 an eye possessed of vision, for example, exceeding one-fortieth of 
 the normal, yet with double cataract and no better vision in either 
 eye, even such a restriction seems too great, in view of the probable 
 results under modern methods. The mere fact that a senile lens
 
 GENERAL CONSIDERATIONS. 481 
 
 is even fairly transparent does not of necessity indicate that it 
 is not entirely operable, i.e., capable of being extracted intact. This 
 is the case with the large sclerosed lenses. Indeed, it is not so much 
 the so-called immature cataracts that expose to the graver dangers, 
 but the complicated, anomalous, and degenerated ones. When 
 the patient's only hope of continued sight is centered in one eye, 
 then I should say do not operate so long as there is useful vision. 
 If the fellow eye be sound, especially if its lens also is cataractous, 
 greater liberty is allowable. Moreover, it is perfectly justifiable, 
 nay, advisable, to remove a cataract from an eye whose fellow is 
 normal, provided the stage of opacity is fit and the conditions in 
 general are favorable. It is the duty of every individual to obtain 
 what sight is possible in both eyes in order to have a wholesome 
 reserve in the event of an emergency. True, the immediate result 
 is not so gratifying, either to the patient or to the operator, be the 
 operation ever so successful, as the former cannot appreciate the 
 added vision, especially when, as it sometimes happens, an annoying 
 diplopia ensues. Later this will disappear, whereas, if left alone 
 the cataract would reach a stage not so favorable for extraction. 
 It is also an error to assume that binocular single vision is impossible 
 in such cases. 
 
 To operate for cataract upon both eyes at one sitting would, 
 according to most surgeons, the writer included, be the height of 
 folly unless the circumstances were peculiar. If some unknown 
 or unforeseen danger threatened, it would likely be common to both 
 eyes. Then, too, through the experience gained by operation 
 upon one eye as to the patient's behavior and as to any unpleasant 
 physical happenings during and after the extraction one would 
 be in better position would know his ground, so to speak when 
 it came to dealing with the other eye. True, there are some strong 
 arguments advanced in favor of greater boldness in this regard. 
 As, for example, through timidity the patient might refuse extraction 
 on the second eye and thus be deprived of the benefits of bilateral 
 vision. Again, a double extraction means practically one operation, 
 and one course of after-treatment, which has great weight in our 
 consideration for the comfort and convenience of these elderly 
 and feeble subjects, particularly when they live some distance away. 
 A recent paper by Howard Hansell, of Philadelphia, in favor of 
 3*
 
 482 EXTRACTION OF CATARACT. 
 
 double extraction of senile cataract, and the discussion thereon was 
 published in the January (1904) number of the Ophthalmic Record, 
 Chicago. 
 
 The Preparation of the Patient. Let it be understood the 
 following precautions hold good for most of the eye operations that 
 are practiced, whether on lids or globe. 
 
 Whenever possible, the operation should be made in a well- 
 regulated hospital. The conditions for success are neither pro- 
 pitious nor convenient even in the best appointed homes. The 
 patient should be admitted to the institution at least twenty-four 
 to forty-eight hours previously in order to give time for preliminaries. 
 A bath is usually in order, though as regards a certain proportion 
 of these elderly individuals, we should hesitate before actually 
 putting them into the tub. Ordinarily cleanliness from head to 
 foot, however, must be insisted upon. 
 
 It is necessary, too, that the bowels and the urinary organs be 
 in a normal state; indeed, a good routine practice is to administer 
 a cathartic, with calomel, the first evening at the hospital, followed 
 by a saline draught the next morning. The diet should be as 
 light as is consistent with health throughout the treatment. It 
 goes without saying that at this time a careful examination should 
 be made of the eyes and the results fully recorded. Examine for 
 signs of arteriosclerosis and, if present, institute the regimen that 
 is calculated to put such a subject in favorable condition for the 
 operation. Light diet, an abundance of pure water, aperients, and, 
 possibly, the exhibition of such medicaments as are supposed to 
 reduce blood pressure. The surgeon in charge should be apprized 
 of the findings so that he may be on his guard. (See chapter on 
 Para-operative Technic.) 
 
 Incidentally, a little beforehand training of the patient in the 
 different acts he is expected to perform during the operation would 
 be well-timed, as it tends to confidence both on his and the surgeon's 
 part. Placing him in a chair, instilling boric acid solution into the 
 eye, manipulating the lids, having him rotate the eyes in different 
 directions, opening and shutting them, etc., and all without telling 
 him why these things are done. It is the practice of some surgeons 
 to apply a test bandage to the eye that is to be operated, leaving it 
 over night, with the view to ascertaining whether any undue secre-
 
 PREPARATION OF THE EYE. 
 
 tion from the conjunctiva occurs. This procedure I consider not 
 only unnecessary, but positively injudicious, since the mere 
 occlusion of the eye actually tends to an abnormal secretion 
 through retention and consequent proliferation of bacteria normally 
 present. 
 
 At the time appointed for the extraction, the patient is washed, 
 combed, clad in a nightdress, over which is worn a heavier garment 
 (sterilized), such as a bathrobe, and the feet are encased in warm, 
 sterilized hospital slippers. 
 
 Preparation of the Eye. As stated elsewhere, it is the writer's 
 custom to instill a drop of atropin solution into the eye about one 
 hour previous to the operation. After one hour the relaxation of 
 the iris is pronounced enough, in the average case, to bring about 
 the desired results. The indiscriminate or prolonged use of mydri- 
 atics in the eyes of elderly individuals is not without its risks, chief 
 among which is hypertension of the globe, with its train of troubles. 
 Then the general toxic effect is thought to increase the liability of 
 postoperative delirium. Having applied the one drop to the eye, 
 no more is instilled unless something in the after-treatment calls 
 for it. The mydriasis, which disappears with the escape of 
 the aqueous, reasserts itself, but in a feeble manner, after the 
 healing of the incision. It matters not whether the simple or the 
 combined method of extraction is contemplated, the mydriasis 
 favors either expulsion of the lens, or the withdrawing of the iris for 
 iridectomy. 
 
 For the first examination of the eye, we often wish to use a mydri- 
 atic to satisfy ourselves a^ to how far the pupil is dilatable and as to 
 the appearance of the peripheral portions of the cataract, for which 
 purposes cocain. perhaps, is the best, as its effect is transient, and 
 it lias not the tendency to excite overtension possessed by most 
 other mydriatics. It has been argued that mydriasis leads to ex- 
 trusion and entanglement of the iris at the incision. I take the 
 ground that there is no such involvement excepting when the 
 anterior chamber is empty or in the act of emptying, at which 
 times the mydriasis cannot be a factor, as it is then practically 
 absent. 
 
 Immediately before putting the patient on the table the eye is 
 <nven its final clean-ing, which consists of
 
 484 EXTRACTION OF CATARACT. 
 
 1. The requisite manipulation and massage of the lids for the 
 expression of the contents of the Meibomian ducts. 
 
 2. The washing or scrubbing of the entire face, up to the hair 
 and down to the neck, giving special attention to the cilia and lids, 
 with sterile green soap and hot sterilized water. If the supercilia 
 are long and thick, they are shaved; if not, merely lathered and 
 scrubbed. It would seem an act of supererogation to make a rule 
 of shaving the eyebrows when the lashes, be they ever so numerous 
 and lengthy, are left intact. But to trim off the cilia, save those of 
 the upper lid near the outer canthus, were a grave mistake, as the 
 stubs of hairs would be a source of considerable irritation. To 
 wash, or rather to thoroughly dampen the cilia with benzin is a 
 most excellent preparatory measure, as the residue left on the hairs 
 after the evaporation of the liquid makes an effective coating in 
 which the bacteria are imprisoned. 
 
 3. The patient is put into a half-reclining position and the eye 
 copiously irrigated with lukewarm boric acid solution, the lids being 
 everted during a part of the time. Throughout all of these prep- 
 arations, great care should be exercised to avoid undue violence. 
 A jab of the thumb, knuckle, or scrub-brush could, in the eye of 
 these senile subjects, lead to very unpleasant results; and in the use 
 of the cotton sponges, or other implements, one must never touch 
 the cornea, as the consequent removal of a patch of epithelium 
 leaves a spot especially vulnerable to bacteria. 
 
 4. A thin sheet of absorbent cotton, wet with boric acid solution, 
 is spread upon the closed lids on which is laid a pad of dry cotton. 
 Dry cotton is never put next the eye in a dressing nor used to wipe 
 the lids, because of the loose fibres entering the conjunctival 
 sac. Over all, tied obliquely around the head, is applied a two 
 and one-half inch wide strip of sterilized muslin, or netting, and 
 in this dress the eye awaits the moment when the operation is to 
 begin. 
 
 When the patient is brought to the operating-table (and it is better 
 that he be led, rather than carried or wheeled) a strong box or 
 step is placed for him by which to mount. He is told to first sit 
 upon the table at its middle, then to lie down, when the top of the 
 head is placed even with the head of the table-top, lying on a thin, 
 firm pillow.
 
 ANESTHESIA. 485 
 
 While instructing the patient during this performance of placing 
 him upon the table, as indeed on all occasions, it should be done in 
 the gentlest, quietest, and most adroit manner, so as not to fluster 
 him. We have too often seen these unfortunates victimized by 
 brutal or thoughtless attendants, yea, by the surgeon himself, and 
 as often observed the demoralizing effect. Storming, gesticulating, 
 yanking, thumping, and even swearing at the patient seem to have 
 their uses among our confreres of certain nationalities, judging 
 from the frequency of their use; but I much doubt their wisdom in 
 any country, most of all in our own, especially with our own people. 
 They serve merely, in most instances, to rob the patient of whatever 
 coolness he is possessed withal, and to lead to disagreeable com- 
 plications, if not to disastrous consequences. 
 
 The entire body, up to the head, is covered with a sterile sheet. 
 Sterile towels are placed around the neck, over pillows and (a light 
 one) over the mouth and nose. A linen cap, with drawstring, or a 
 rubber cap, is put upon the head, covering all the hair, and the 
 string securely tied. 
 
 The Anesthesia. I shall ever guard the pleasant remembrance 
 of the wonder and gratitude excited in the medical world by Roller's 
 report upon the local action of cocain in the autumn of 1883. I 
 was then a student of ophthalmology in New York, and it was, of 
 course, particularly the impression made upon the minds of the 
 votaries of this branch of medicine to whom local anesthesia has 
 proven the greatest bo9n that I refer. Notwithstanding the 
 many other drugs similar in their action that have been brought 
 forward, several of which T have tried, cocain is to-day, in my 
 opinion, the most efficient and desirable. 
 
 Cocainization. Three or, at most, four drops of properly and 
 freshly prepared 4% solution of cocain hydrobromate, instilled with 
 two-minute intervals, should be sufficient for the thorough anesthesia 
 of the eye. It will be borne in mind that too much cocain or the 
 too prolonged use of it tends to hypotonicity of the globe, to corneal 
 collapse, to hemorrhage, and to exfoliation of the corneal epithelium. 
 Between drops, and throughout the entire operation, when nothing 
 is being done to the eye, it should be kept closed, and the lids 
 covered with a pad of cotton wet with warm boric-acid solution.
 
 486 EXTRACTION OF CATARACT. 
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION. 
 
 DESCRIPTION OF THE OPERATION OF EXTRACTION AS PRACTICED 
 
 BY THE AUTHOR. 
 
 The surgeon, the patient, and the requisite apparatus having 
 been duly prepared (see chapter on "Preparation of Patient"), the 
 operator takes his place at the head of the table, his assistant, who 
 has charge of the instruments and other needed articles, being at 
 his left, and the assistant operator at his right. 
 
 If the operator is ambidextrous, he stands at the head of the 
 table, of course, for either the right or the left eye. Should he be 
 at all in doubt, however, as to his ability to make a satisfactory 
 section with his left hand, he should have no hesitancy in standing 
 with his left side to the table, for the left eye, so as to make the 
 section with his right hand. There is nothing derogatory in thus 
 acknowledging his slight limitation. 
 
 A few words of reassurance and instruction are spoken to the 
 patient, such, for instance, as, "I shall not hurt you, be quiet and 
 do not squeeze the lids, ' ' and the blepharostat is introduced. We will 
 suppose it is the right eye which is in question, and the table 
 has been set diagonally to the window as stated. The Beard 
 modification of Mellinger's speculum is employed. To put this 
 instrument in place the handles are grasped by the thumb and two 
 fingers of the right hand and pressed as near together as they will 
 go, w r hile, with the thumb and middle finger of the left hand, the 
 lids are pushed widely apart, the patient meanwhile looking straight 
 ahead, and the lid-holders are gently and deftly slid into place- 
 first the upper, then the lower and allowed to separate by pressure 
 of the spring alone. If the lids do not open sufficiently, ask the 
 patient to relax the lids and, at the same time, slowly press upon the 
 ends of the slides, thus forcing the lids apart. Cut off the lashes 
 of the upper lid exterior to the lid-holder if in the way. This is 
 best done with small straight scissors, meanwhile holding a thin pad 
 of wet cotton so as to protect the eye from the falling hairs. From 
 an eye-dropper or other suitable implement a quantity of warm 
 boric solution is poured on to the cornea and neighboring con- 
 junctiva (the operator will find it of advantage to warn the patient
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION. 487 
 
 when about to pour or drop liquid into or upon the eye, as to do so 
 unexpectedly is apt to cause a start or a wince), after which that 
 portion of the liquid caught behind the lower lid is imbibed by a 
 cotton sponge. 
 
 The assistant operator places his left hand on the patient's brow 
 and supports it with his shumb pressed firmly on the upper rim 
 of the orbit, dropping his wrist and forearm well down so as to get 
 them out of the way of the operator. This grip on the brow dis- 
 courages a spasm of the orbicularis, aside from forcibly preventing it. 
 
 Fixation of the Globe. The surgeon takes the knife in his right 
 hand (for the right eye), the forceps in his left. The best point at 
 which to take hold with the fixation forceps in upward extraction is 
 a matter of no mean importance. The point in question is at or 
 near the center of the inferonasal fourth of the corneal limbus; in 
 other words, just beneath the inner extremity of the horizontal 
 diameter of the cornea. To grasp the tissues here affords a much 
 more satisfactory means of controlling the eyeball than does the 
 more generally chosen one of seizing them in the vertical meridian 
 below the cornea. It is especially effective in preventing torsion of 
 the globe during the keratotomy. The jaws of the forceps are 
 placed against the eye dosed, then allowed to open. Thus the loose 
 structures are smoothed out or put lightly on the stretch, the object 
 being to obviate picking up too much of the conjunctiva, thereby 
 causing it to overlap the cornea along the site of the proposed in- 
 cision. The instrument is then pressed more firmly, and a good 
 big bite is taken, and as deep a one as can be obtained. The fold 
 composing this bite should stand perpendicular to the tangent of 
 the limbus. If the conjunctiva proves too friable to insure a 
 sufficient hold, try lower down or even beneath the cornea. The 
 forceps referred to here are without a catch or lock and have broad 
 jaws. If, while the knife is engaged in the section, the fixation 
 becomes insecure because of a purely conjunctival bite, twisting 
 of the forceps on its long axis will tighten the hold. The second 
 finger rests upon the patient's nose, the third and fourth upon the 
 opposite cheek, and the hold is steadily maintained, meanwhile 
 scrupulously avoiding either to press or to pull upon the eyeball. 
 Now, a look is given at the knife to see that its edge is directed upward, 
 and the incision is begun.
 
 4 88 
 
 EXTRACTION OF CATARACT. 
 
 Puncture. The point is placed exactly at the apparent sclero- 
 corneal junction, just on a level with the union of the middle and 
 upper thirds of the vertical diameter of the corneal base. Puncture 
 and counterpuncture may be a trifle lower, of course, but it is hardly 
 wise to begin higher. Rest the little finger on the patient's cheek, 
 and have him look down not a bad idea to direct him also to hold 
 the mouth and the other eye wide open. The handle of the knife 
 is elevated to about 45 to a tangent of the corneal curve, and 
 
 FIG. 234. Puncture and counter-puncture. 
 
 pushed until, just as it is entering the anterior chamber, the handle 
 is depressed, in one sense, till the blade is brought parallel with the 
 plane of the corneal base, and elevated, in another sense, so as to 
 point toward the center of the pupil, advancing all the while; then 
 again depressed (toward the patient's feet) and made to emerge 
 fpom the anterior chamber precisely opposite to the point of entrance 
 (counterpuncture} (Fig. 234). Now, onward, vigorously, without 
 hesitation, first pushing up the blade to make the cut on the inner 
 side of the cornea, then pulling it up to cut the outer side, holding it 
 flat on the iris, and following the apparent sclerocorneal junction
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION. 
 
 489 
 
 rather rocking than sawing till, when the edge has just reached the 
 upper angle of the iris, it is given about one-eighth of a turn back- 
 ward, and made to emerge beneath the conjunctiva, so as to make a 
 small conjunctival flap (Fig. 235). The length of this flap should 
 be about three or four millimeters, and the width four or five milli- 
 meters. When sufficient of the conjunctiva has been lifted up, the 
 edge of the knife is suddenly turned directly forward and the flap 
 cut off. The fixation forceps is now removed and the operator, 
 himself, may support the brow. Before going further the con- 
 
 FlG. 235. Finishing the 
 
 al section and fashioning the conjunctival flap. 
 
 junctival flap is turned down over the cornea, else it may give 
 trouble later by getting into the incision. This is best done with 
 the back of the ready-to-be-discarded knife and not with any 
 instrument that has yet to enter the globe. 
 
 In completing the corneal section, it is best to slow up somewhat 
 so as to cut out without a sudden jerk, as this might have the effect 
 of producing a prolapse of the iris or of causing an involuntary 
 movement on the part of the patient, such as a spasm of the orbic- 
 ularis. Indeed, the only period in the making of the section that 
 should be as brief as possible is that between the instant of counter- 
 puncture and the moment when the edge of the knife has just passed
 
 4QO 
 
 EXTRACTION OF CATARACT. 
 
 beyond the upper border of the pupil. A certain rapidity of exe- 
 cution here insures against catching the iris upon the knife. Take 
 care not to prick the lid or the nose with the point of the knife, as 
 it causes the patient to start and squeeze and also soils the knife. In 
 addition to supporting the brow, particularly with nervous or 
 agitated patients, a useful precaution is to have a trained assistant 
 
 FIG. 236. The cystotomy. The shank of the cystotome should be straight in 
 order to turn without wabbling. 
 
 elevate the lid holders of the blepharostat so that they will not lie 
 on the globe. 
 
 Every now and then a word of encouragement spoken to the 
 patient, as "all is going well," "soon over now," and never failing 
 to express commendation of good behavior, are things well to 
 remember. 
 
 The Cystotomy or Capsulotomy. The cystotome is held pre-
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION. 
 
 491 
 
 cisely as in the accompanying illustration and in a perfectly horizontal 
 position (Fig. 236). The heel of the instrument is slid gently 
 beneath the conjunctival flap, thence down over the iris until it is 
 just within the upper portion of the pupil; then pushed behind the 
 iris at the nasal side, holding the blade flat and the point or edge 
 
 FIG. 237. The application of the spoons for expression of the lens. 
 
 upward all the while. Now the handle is given a one-quarter turn 
 toward the operator, so as to bring the point squarely in contact 
 with the capsule and, pressing lightly and slightly elevating the 
 handle, an incision is made, in a light curve, almost parallel with 
 the equator of the lens. This is carried as far to the outer side 
 as was its beginning to the nasal, when again the quarter turn is
 
 49 2 
 
 EXTRACTION OF CATARACT. 
 
 again made toward the operator, to bring the heel upward, and the 
 instrument is slid out at the incision, heel foremost. 
 
 Delivery of the Cataract. The back of the Graefe spoon is 
 placed against the globe, well down in the lower fornix, and the back 
 of the flat spoon is laid on just behind the incision above; the 
 patient is told to look constantly downward (Fig. 237). (Some 
 operators have a light held low down for the subject to fix his eyes 
 upon.) The lower spoon is pressed firmly and steadily, but not too 
 forcibly, toward the center of the globe, while with the upper one the 
 
 FIG. 238. Moment in the delivery of a cataract when the cortex should 
 be driven up. 
 
 posterior lip of the incision is depressed, keeping both still, i.e., not 
 rubbing them back and forth nor up and down. It is a curious fact 
 that the eye, when profoundly cocainized often loses its sense of 
 orientation, so that the patient cannot with certainty give it the 
 desired direction, hence the advantage of giving him a bright object 
 on which to gaze. 
 
 The first effect of the impact of the spoons is to cause a slight 
 parting of the lips of the incision. Mayhap the advancing lens is 
 covered by the iris; if so, only blackness is seen in the opening.
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION. 493 
 
 This must be differentiated from another sort of blackness, viz., 
 presentation of vitreous. Pretty soon there is a separation of the 
 black from the anterior lip of the cut, and the edge of the cataract 
 rises between. Its appearance is quite characteristic looking gray, 
 of irregular surface, and may be likened to a bit of dirty ice that has 
 been slightly thawed. It should be borne in mind that a too rapid 
 delivery of the lens is harmful. 
 
 The cataract having presented its edge in the incision, it gradually 
 advances, spoons being held still and the same pressure kept up 
 until, when the widest part of the lens is just passing out of the 
 incision, the lower one is slid upw r ard, the patient is warned not to 
 squeeze w r hen a bright light enters the eye, and the lens is so delivered 
 as to cause as much as possible of any following cortex to come 
 out w T ith it (Fig. 238). This is accomplished by pausing just when 
 the greatest diameter of the lens is engaged in the incision, and 
 driving the cortex upward, collecting it in a mass about the lens, by 
 gently stroking the cornea with the back of the spoon; then, with 
 one final sweep, delivering nucleus and cortex together. Wilder, of 
 Chicago, is the author of this valuable maneuver. When it is 
 clear out, if there is thought to be any cortical remains left behind, 
 they may be removed as follows: 
 
 Removal of Cortex. As this is a description of the simple 
 extraction, it is assumed that the cataract is of a kind favorable 
 to the operation. Hence, those portions that are stripped off in 
 the delivery are supposed to be mainly opaque -visible. Moreover, 
 the appearance of the cataract that has been removed, gives an idea 
 as to about how much of it may have been left behind. The more 
 complete it is in form, the less the residue. The consideration of 
 transparent lens remains is found elsewhere (see page 535). 
 
 The blepharostat may be taken away, the lids closed, and a pad 
 of cotton, wet with boric acid solution, laid on them for a few 
 minutes, while a certain amount of aqueous accumulates. This is 
 supposed to favor the " milking " out of the lens remains. However, 
 this necessitates either replacing the speculum, which is not always 
 a safe procedure at this stage of the operation, or using the retractor 
 or fingers to hold back the upper lid, exposing the instruments and 
 incision to the cilia and to the contents of the Meibomian canals. 
 Besides, the pupil would, in many instances, become much narrowed
 
 494 EXTRACTION OF CATARACT. 
 
 during the wait, shutting the cortex securely in the posterior cham- 
 ber, thus making, it impossible of extraction. For these reasons the 
 writer prefers to go ahead at once without removing the blepharostat. 
 
 If the patient is of the irresponsible kind, the assistant, if he be 
 clever, might steady the eye with the fixation forceps during this 
 process, but I have for a long time proceeded alone in all cases, 
 trusting to the special design of the blepharostat and to the holding 
 up of the brow to prevent loss of vitreous. 
 
 The site of the incision should be kept bathed with boric acid 
 solution and the spatula and spoon wet with the same. If the 
 iris has been displaced during the delivery of the cataract, it is left 
 so until after the cortex is disposed of. A prolapsed iris rather 
 favors the expulsion of lens remains, whereas, should there be a 
 pause just prior to this step, the iris is apt to go back spontaneously 
 and complicate matters by shutting off the cortex from the anterior 
 chamber. The brow being still supported either by the assistant 
 or by the third finger of the surgeon's left hand, the patient looking 
 down, the assistant still holding up the speculum, the spatula (in 
 the left hand) is entered, vertically, for the double purpose of holding 
 back the iris and affording a chute, or inverted shoehorn office; 
 meanwhile, from without, the Graefe spoon, held in the right hand, 
 is used to follow up the particles by a very gentle patting or rubbing 
 process upon the cornea, until all of them seem to have been removed. 
 The globe must be closely watched during this procedure so that 
 should it, as it often does, turn suddenly upward, the spatula may 
 be as quickly withdrawn, else there is danger of its puncturing the 
 posterior capsule or rupturing the hyaloid and letting out the 
 vitreous. While it is important that we should do our utmost to 
 that end, it is not always possible, even under favorable conditions, 
 to remove all the opacity from the pupil, as a portion of the posterior 
 cortex may adhere closely to its capsule, or there may be a visible 
 thickening of either capsule, and it is not wise to fuss too long with 
 that which shows no disposition to come out. This will often 
 successfully resist efforts at removal even by lavage. 
 
 A few surgeons still employ intraocular irrigation, or lavage 
 of the anterior chamber with a neutral liquid or a mild antiseptic 
 solution, but it is not favored by the great majority except in selected 
 cases. When I was a student in Paris, I became favorably im-
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION. 
 
 pressed with De Wecker's method of lavage, and bought one of the 
 syringes he devised for the purpose, but have never employed it but 
 once. De Wecker afterward abandoned the procedure. At the 
 same time, Panas, after all his extractions at the hospital Hotel 
 Dieu, was performing a species of lavage, not for the washing out of 
 cortical remains, but as a means of preventing sepsis. There have 
 been a number of irrigators and syringes devised for washing out the 
 
 FIG. 239. Intraocular lavage. Lippincott's instrument 
 
 anterior chamber, among the best of which are Lippincott's (Fig. 
 239) and McKeown's. Lippincott has been the foremost and most 
 constant advocate in this country of intraocular lavage. 
 
 Some operators counsel entering the cannula into the anterior 
 chamber, some into the capsule itself, while others are content with 
 merely depressing the posterior lip with it, and not pushing it 
 beyond the inner wound opening. The reader is referred to a paper
 
 496 EXTRACTION OF CATARACT. 
 
 by Lippincott, of Pittsburgh, in the American Journal of Ophthal- 
 mology, for July, 1904, for the description of his latest irrigator, 
 together with a discussion of the technic and indications for lavage. 
 It may be added that the advocates of the measure advise against 
 prolonged and forcible irrigation and against the use of any but the 
 blandest liquids and the mildest antiseptic solutions, such as sterile 
 water, normal salt solution, etc. Eserin is never employed after 
 the extraction because its effect favors posterior synechias and 
 iritis. 
 
 DON'TS. 
 
 Rather than overburden the description of the operation with 
 details, the latter are here subjointed as don'ts. 
 
 Don't get shaky. Pick up the knife, make a few finger move- 
 ments with it and, if the hand is turning craven, just call a slight 
 halt, resort to a little inward discipline, and one can usually regain 
 his composure. A colleague once told me that when he found 
 himself becoming demoralized on the eve of an operation, he walked 
 to the window and, while apparently taking in the view, proceeded 
 to give himself, mentally, a sound castigation, with the invariable 
 effect of restoring his calm. 
 
 Don't drop cold or hot liquid into the eye during or after the 
 operation have it lukewarm. Don't let it fall from a height onto 
 the eye and lids, as all tends to produce wincing. Don't squirt nor 
 fire solutions at the eye, but pour them gently over it, and always 
 warn the patient of your intention. Don't permit sponges to touch 
 the cornea and disturb the epithelium. 
 
 Don't begin the instillation of the cocain solution until it is known 
 that the operation can follow in not more than ten minutes. Don't 
 let the speculum fly out of the fingers like a Jack-in-the-box while 
 in the act of putting it in position. Get a good, firm grip on it. 
 
 Don't pry the lids too far apart, for it induces spasm of the 
 orbicularis and increases intraocular tension. Don't allow the 
 speculum to rest heavily upon the globe. Don't fail to lift it away 
 from the eye, and \vith a firm grasp, in removal. 
 
 Don't use fixation forceps that have a catch, and don't forget 
 the hand that holds the forceps while fixing the eye. Don't rotate 
 the eye with the forceps as if it rested with its posterior surface
 
 SIMPLE PERIPHERAL CORXEAL FLAP EXTRACTIOX. 497 
 
 on a transverse vertical plane, but as it is, like a ball that turns on a 
 universal central pivot. 
 
 Don't seize merely a fold of conjunctiva by which to steady the 
 eye, but in addition, as much as possible of the subjacent tissues 
 and as near as practicable to the cornea. Don't employ fixation 
 after the bulbus is opened unless the need is urgent. 
 
 Don't neglect to test point and edge of both knife and cystotome 
 before they are disinfected, to see that they are sharp. Don't 
 use a knife with long needle-like point the tip might break. Don't 
 hold the knife so tightly as to cramp the fingers, nor yet so loosely 
 as to cause wavering. Don't attempt either corneal or capsule 
 incision free hand. No matter how steady the latter, always 
 rest the little finger on the patient's face not only for support, but 
 in order to move n'ith him should he stir. 
 
 Don't haggle, fuss, nor hesitate in making the section, yet, while 
 forging steadily ahead, do so with a certain deliberateness. Faulty 
 sections, premature escape of aqueous, etc., come not so often of 
 slowness as of vacillation. 
 
 Don't lose sight of the patient's demeanor. If this be favorable 
 throughout the corneal section, it is apt to be so for the entire opera- 
 tion. If he begins to squeeze, pause, even though in the midst of 
 the incision, and remonstrate with him in a kindly tone, and have 
 the assistant guard closely the brow and speculum. 
 
 Don't take the eyes off^the site of the operation for an instant. 
 Have the assistants so trained that it will not be necessary for the 
 operator to seek instruments and implements, nor to lay them down. 
 Be in the closest touch with the subject, allowing not a single break 
 in that subtle, intuitive current whereby we anticipate a move on 
 his part. 
 
 Don't scrawl all over the capsule and zonule with the cystotome. 
 Take pains to place the point properly on the cataract just where 
 the opening should begin not hastily; elevate the handle until 
 the point is sure to have engaged the capsule, then draw it very 
 lightly along, making a definite cut, and note that the lens respon<i> 
 to the liberation by springing forward. If not, it is better to go 
 over it a second time, there and then, trying to improve upon the 
 first effort, than to be obliged to again enter the instrument. 
 
 Don't triturate the cornea too much with the spoon in delivering
 
 498 EXTRACTION OF CATARACT. 
 
 the cataract, nor rub it about in an aimless sort of way to get out 
 the cortex. Be sure that the back and not the edge of the instrument 
 is applied. Don't stop to pick up the extracted lens unless it is 
 caught deftly upon the upper spoon merely brush it aside until 
 the operation is terminated. 
 
 Don't have the instruments dripping wet, as the liquid, streaming 
 downward, carries bacteria from the fingers to the eye. Don't hold 
 instruments in the mouth to disembarrass the hands. Give them 
 to an assistant or lay them down. 
 
 Don't talk any more than necessary, and never with explosive 
 aspiration, to emit showers of germs, even though mouth and nose 
 be covered by a mask. 
 
 It is the better part of wisdom to close and bandage the eye as 
 soon as practicable after the extraction of the cataract, and to 
 discourage all unnecessary movement or turning of it. With this in 
 view, little exhibitions like having the patient count the operator's 
 fingers or to tell the time on a watch, through a convex lens, it 
 is deemed prudent to omit. Such things were formerly supposed 
 to be a test as to whether any portions of the cataract were left 
 behind, but as such the performance is a delusion. 
 
 The Toilet of the Eye. Having seen to it that no part of the 
 iris is caught in the wound nor in any manner disarranged, and that 
 the lips of the cut are nicely in apposition, gently sponge away all 
 the loose debris, cortical matter, etc., carefully remove any shreads 
 of fibrinated blood from about the incision with the toilet forceps, 
 and arrange the conjunctival flap. Flow a dropperful or two of 
 warm boric acid solution over the eye and close the lids. Instead 
 of ordering the patient to do this last, the operator will often do 
 well to perform the act himself, usually by taking hold of the lashes, 
 lifting the lid slightly and shutting it. Docile patients, however, 
 may be trusted to do it unaided, but must be warned against forcible 
 closure. 
 
 Dressing of the Eye. A lamina of absorbent cotton, almost as 
 thin as a veil and about two inches square, is made sopping wet 
 with warm boric-acid solution and laid on the lids rather high up 
 (see chapter on "Dressings"), then pulled down into place. In 
 this manner the lashes are smoothed out not crumpled up in the 
 dressing. Although this may seem a trivial item, it is really an
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION. 499 
 
 important one, both for the patient's comfort and for the good of 
 the eye. This first layer of cotton is so thin that when the air is 
 squeegeed out by the fingers, which causes it to adhere evenly, 
 the skin and lashes can be plainly seen through it. The direction 
 of the cotton fibres should be vertical. The boric acid solution 
 with which it is moistened is made from the impalpable powder 
 and should be more than saturated; in other words, there should 
 be an extra quantity of the powder in suspension so that the meshes 
 of the cotton, upon drying, will be filled with it. Gauze or any 
 woven material is not put next to the lids because the twisted threads 
 are more or less hard and press into the delicate skin. Neither 
 is sublimate solution used for moistening the cotton for the reason 
 that it would be found irritating to the lids of many patients. Over 
 the wet cotton, a thick, soft pad of dry cotton is carefully built up 
 so as to give an equal pressure under the bandage at every point. 
 The bandage of netting, wet with boric acid or sublimate solution, 
 is then applied as per the method described elsewhere and fastened 
 with ordinary pins. 
 
 Thanks to an idea lately hit upon by Dr. Fullenwider, 1 one of 
 our internes at the Illinois Charitable Eye and Ear Infirmary, never 
 is there any more slipping or displacement of the dressing nor even 
 a chance for the patient to finger the eye beneath the cotton pad. 
 As soon as the bandage is applied, a quantity of flexible collodion 
 is painted on where the folds cross the forehead and cheek and a 
 strip of gauze is laid on the nose and cheek, extending up onto the 
 dressing and similarly smeared, to bar any meddling with the eye 
 on the part of the patient's fingers. The collodion sets immediately, 
 even on the wet netting, and holds beautifully. One of the stiff 
 shields or masks may be tied on, such as Ring's, or the aluminum 
 mould. The latter can be more conveniently and effectively . sterilized. 
 As the writer bandages only the one eye, save in exceptional cases, 
 if the shield is for both eyes, a large hole is made in that part over 
 the unoperated eye for the patient to see through. He is told to 
 keep both eyes shut most of the time, only opening the free eye 
 when it is absolutely necessary. With a few the emergency will 
 often arise, but with the majority not at all. In case after case 
 
 'I have since learned that collodion was used in a similar way by De 
 Wecker, of Paris, some years ago.
 
 500 EXTRACTION OF CATARACT. 
 
 when it comes to the first dressing, the unbandaged eye will be 
 found to have its lids firmly glued together by old, dried secretions. 
 
 After-treatment. While yet on the operating-table, it is well 
 to give the patient a few parting instructions. He is told that he 
 must keep very quiet in bed for a short time, that it will not be 
 long before he will be allowed to sit up. That he must remember all 
 the while that he is in the hands of his friends, that night and day 
 there is someone within easy call, etc., all of which has the effect 
 of reassuring him, particularly if he can be truthfully informed of 
 the success of the operation. He is warned against stooping or 
 straining, and told that he may turn about, quietly, to assume 
 different positions of lying on back, side of unoperated eye, and 
 even a little to the side of the operated one, so long as he doesn't 
 press the dressing upon the pillow. 
 
 On the journey from the operating-room to the bed, I prefer to 
 have the patient walk to having him lifted often by untrained 
 assistants to and from a stretcher or cart. He is helped to a sitting 
 posture on the table, with his feet hanging, then an attendant 
 stands on either side, each with one hand beneath the patient's arm- 
 pit and the other holding his wrist or hand, when he slides down 
 until he is standing on the floor and is led to his room. There he 
 is told to sit on the edge of the bed while' shoes, stockings, and 
 outer dress are taken off by an attendant, being prevented from 
 attempting to help in the disrobing. Having been duly put to bed, 
 he is again assured that there are always near him those whose duty 
 and pleasure it is to answer his calls and attend to his wants. 
 
 A moderate amount of light is admitted to the room, and a shaded 
 lamp is allowed at night. To have the privilege granted him of 
 changing his position from time to time as he lies there is a great 
 boon, especially to the elderly subjects, and prevents many complica- 
 tions (one being hypostatic pneumonia) while it causes none. But 
 to be enjoined from moving told even that he must lie very still- 
 is terrible for the average individual. He gets a notion that the 
 slightest move would be disastrous, and the restraint is torture. All 
 manner of aches and other physical disturbances, including flatulence 
 of the bowels, accumulation of gases in the stomach, etc., are inevi- 
 table. Another occasional effect of the operation is to cause reten- 
 tion of urine, and the function of the bladder must be looked after.
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION. 50! 
 
 If there be retention, a few catheterizations are sufficient to 
 reestablish the function. The subsequent after-treatment is 
 pretty well laid down in the chapter on Consecutive Accidents and 
 Complications. 
 
 The First Dressing. If all goes well, the bandage is left in 
 place for forty-eight hours. This will have given time for normal 
 primary closure or healing of the wound. At the end of this 
 period, no matter how favorable the progress, the eye is inspected. 
 The undressing of an eye requires as much care as the dressing. 
 According to the statement which has already been made (see 
 chapter on Consecutive Accidents and Complications), extrusion 
 or entanglement of the iris is not an infrequent occurrence at the 
 first dressing, and the explanation is as follows : 
 
 When one raises the upper lid to open an eye that has been 
 bandaged and the light strikes in, if great caution is not exercised, 
 there is a sudden spasm both of the superior rectus and of the 
 orbicularis, the wound is opened, there is a rush of aqueous, the 
 iris is -washed out, and when the cut is examined, a prolapse is 
 found. This fact furnishes an argument, therefore, for letting the 
 eye alone if all seems to be going well until time enough has elapsed 
 to insure permanent closure of the incision. This, on the other 
 hand, may be effectively answered by the counter proposition 
 that the mere fact that the patient is uncomplaining, is not conclusive 
 evidence that all is going well. While house surgeon at the Man- 
 hattan Eye and Ear Hospital, \vhich was in the days when it was 
 the custom of most operators not to remove the first dressing for 
 six or seven days, I saw complete breaking down of the cornea 
 of a stolid male cataract patient from infection. The poor fellow 
 had been as contented as could be ever since the operation, and 
 although he had been repeatedly asked how the eye felt, his replies 
 were uniformly favorable. 
 
 Preventives. The strongest argument, therefore, would be that 
 we should use the utmost prudence in the handling of these cases, 
 as to the nursing, the dressing, and the examining of them. The 
 patient is made ready for the dressing by a few assurances that the 
 eye is only to be looked at, "no hurting, etc.," and by instruction 
 not to open the eyes until told to do so, never to squeeze, etc. As 
 to the kind of light employed, it may be either soft, diffuse daylight
 
 502 EXTRACTION OF CATARACT. 
 
 or focal illumination from moderate lamp flame or gas jet held to 
 the side. 
 
 Where practicable, the first dressing should be with the patient 
 in his bed. With strong scissors made for the purpose, the bandage 
 is cut on the side opposite to that of the operated eye. It is then 
 lifted just enough to allow of the fingers being placed upon the 
 edges of the cotton pad which lies upon the lids. This is to hold 
 the pad in place while the bandage is stripped off. After this, if 
 there is the least tendency of the cotton to stick, a little warm boric 
 acid solution is dropped in behind it. The cotton removed, the 
 lids of both eyes are gently wiped with a cotton sponge from which 
 the boric acid solution has been so squeezed that the sponge takes or 
 drinks rather than gives. In this way the soiled solution is drawn 
 away from the palpebral fissure and not driven inward through it. 
 At this point, if the patient is nervous, a drop of cocain solution 
 should be instilled, as it will greatly facilitate the inspection. After 
 waiting for he anesthesia the patient is quietly asked to open the 
 eyes, and the thumb is placed on the brow to elevate the upper lid 
 having as a base the rim of the orbit of the operated eye. Now, with 
 the light full on the eye, the patient is told to look down or at an 
 object held for the purpose. 
 
 One should not be content with a cursory inspection, but w r ould 
 better look closely, even with the aid of a strong convex lens or the. 
 stereoscopic loup, to make sure, as otherwise faint signs of impend- 
 ing trouble might be overlooked. So long as nothing untoward 
 appears no collyria are employed. The eye is dressed precisely 
 as before, and every day thereafter the same examination and re- 
 dressing are repeated so long as bandaging is necessary, which, in 
 favorable cases, is about one week. 
 
 For a day or two after the first dressing, the patient is permitted to 
 sit part of the time in a chair and, at the end of three or four days, to 
 walk about the room. If he has made normal progress and lives 
 near by, he is discharged from the hospital in about ten days, but is 
 kept under observation until the eye is perfectly quiet or free from 
 any redness. When the bandage is left off, a shade is substituted 
 or medium smoke coquilles. The spherical lens that gives the best 
 visual result is fitted in two weeks to a month from the time of the 
 extraction.
 
 IMMEDIATE ACCIDENTS, ETC. 503 
 
 ACCIDENTS AND COMPLICATIONS. 
 
 The accidents and complications that may occur in connection 
 with extraction are divided into immediate and consecutive, the 
 former having reference to those that are incident to the operation 
 itself, and the latter to those that may involve the after-treatment. 
 In either instance, when they arise, their origin may be due to one 
 of a number of causes. Lack of skill, care, or experience on the 
 part of the surgeon must stand first in the list of causes. Next in 
 prominence, perhaps, comes want of control and ignorance on the 
 part of the patient. Third, incompetency and neglect on the part of 
 assistants, and, lastly, a whole group of causes for which no one may 
 be held responsible. In this chapter, therefore, an attempt will be 
 made to enumerate the various undesirable happenings and, in so 
 far as possible, to suggest appropriate preventives and remedies; 
 for they all incline to embarrass the operator and to jeopardize his 
 ultimate success. 
 
 Reviewed in the order of occurrence they are : 
 
 IMMEDIATE. 
 
 1. Accident. Over or prolonged cocainization, causing drying 
 and exfoliation of corneal epithelium, bleeding from conjunctival 
 flap, hypotonicity of the globe, collapse of the cornea, and delayed 
 union of the lips of the wound. 
 
 Preventive. Use only two to four drops of a 4% solution. 
 Keep the lids closed and covered with wet cotton between whiles, so 
 as to prevent drying of cornea, and make the operation under the 
 primary effect of the drug. 
 
 Remedy. Defer the operation until another day or the next day. 
 
 2. Accident. Touching the eye with the fingers. 
 Preventive. Obvious. 
 
 Remedy. Douche the eye copiously with warm boric acid solu- 
 tion. 
 
 3. Accident. Allowing the knife or any instrument to touch cilia, 
 skin or any object other than that desired. 
 
 Preventive. Obvious.
 
 504 EXTRACTION OF CATARACT. 
 
 Remedy. Immediately either take a fresh instrument or cause 
 that one to be again disinfected. Or, if the accident happens while 
 using, as knife, for instance, try to keep the portion contaminated 
 from entering the eye. 
 
 4. Accident. The serio-comic dilemma of finding that the knife- 
 blade has been inserted upside down. 
 
 Preventive. Obvious. 
 
 Remedy. Knapp 1 advises that, without withdrawing, the knife 
 be simply turned 180 on its long axis, thus reversing the position and 
 continuing the section. He states that the accident has happened 
 to him four times and that there has never been any reaction seen 
 from it. He doesn't say that he resorted to this redress in each 
 instance, but such is the inference. Now, every man is not a Knapp, 
 and the writer would, in view of this accident, counsel postponement 
 of the operation for at least twenty-four to forty-eight hours. Given 
 a deft hand and a very narrow knife, this feat of turning the blade 
 might be attempted but, having accomplished it, if the anterior 
 chamber is found empty, it were better to desist for the moment 
 from pushing the operation further. 
 
 5. Accident. Engaging the point of the knife in the iris just 
 after making the puncture. 
 
 Preventive. Depress the handle immediately the point enters 
 the anterior chamber, so as to clear the iris. 
 
 Remedy. Withdraw the knife, without changing its direction, 
 just enough t o release the point, and continue. 
 
 6. Accident. Starting the counter puncture too far back or too far 
 forward. 
 
 Preventive. Better light, and bearing in mind that owing to the 
 refractive media through which we see the blade, it seems to be 
 nearer to us, or higher, than it really is. 
 
 Remedy. Same as for No. 5. 
 
 7. Accident. Pressing tlie jaws of the fixation forceps into the 
 globe during the making of the cut, forcing out the aqueous and 
 causing premature emptying of the anterior chamber. 
 
 Preventive. Rest the little finger of the hand that holds the 
 forceps firmly on the patient's nose or cheek and do not altogether 
 lose sight of what that hand is doing, else not only is this accident 
 
 1 Norris and Oliver System, p. 800.
 
 IMMEDIATE ACCIDENTS, ETC. 505 
 
 more probable, but one's grip of the forceps is apt unconsciously to 
 relax and leave the globe free to turn. To insure firmness, the bite 
 of the forceps should include the episcleral tissue. 
 
 8. Accident. Rising o] the iris in front oj the edge of the knife. 
 Preventive. Attention to fixation forceps. Avoidance of all 
 
 unnecessary alterations in the cutting plane which pry open the 
 incision and spill the aqueous. See to it at the time of making 
 puncture and counterpuncture that the blade \\esflat upon the iris, 
 as to turn the edge backward, risks to engage that membrane. 
 
 Remedy. Seeing that the iris is overlapping the knife, some- 
 times a slight turning forward of the edge or lightly lifting the entire 
 instrument will free it, albeit the first maneuver causes the incision 
 to end somewhat further within the limbus than was intended. 
 If these fail, nothing is left but to cut boldly ahead as if nothing 
 were n the way. The result may be a buttonhole, a clean coloboma, 
 or some irregular form of iridectomy. In any case make sure that 
 there remains neither pupillary bridge nor dangling fragment, before 
 proceeding with the operation. 
 
 It is not humiliating for a surgeon to confess that he does not 
 always accomplish just what he plans or desires in this operation, 
 whatever his skill and experience. In this connection, for example, 
 an exceedingly shallow anterior chamber may thwart the making of a 
 classic incision. Again, an unruly or restive patient may baffle 
 the most practised hand. 
 
 9. Accident. Splitting, of the cornea. The best form of cor- 
 neal incision has already, to a certain extent, been dwelt upon. 
 Suffice it here to reiterate that the best apposition is obtained and 
 the kindliest healing assured where the outer and inner wound 
 opening are not widely separated and where the summit of the 
 incision is neither very far within the limbus nor decidedly back of it. 
 Those who have not the good fortune to operate frequently for 
 cataract are prone to magnify the snares and pitfalls, hence, in 
 making the puncture, dreading to become entangled in the iris, 
 they depress the handle of the knife too soon and, in pushing the 
 point further, they observe a dimple appear in the cornea over the 
 blade and then realize that they are splitting that membrane. 
 
 Remedy. Since the anterior chamber has not been entered, 
 withdraw the knife completely and begin over.
 
 506 EXTRACTION OF CATARACT. 
 
 Then, in making the counterpuncture, they have painfully in 
 mind that illusive refraction of the cornea and aqueous, and make 
 it too high up. Continuing, so very solicitous are they lest the 
 iris " falls in front of the knife," that they steer far above it and 
 again split the cornea on emerging. Thus is made a long "wound- 
 canal" which greatly involves matters. To begin with, its inner 
 opening is likely to be too narrow for the ready passage of the lens, 
 while the long projecting nether lip forms a shelf which interferes 
 with the work of attending to iris and cortex. These attenuated 
 lips, moreover, impair the healing quality of the wound because they 
 are, of necessity, poorly nourished leading to gray infiltration, 
 necrosis, "grooving," nests for bacteria, and, ultimately, broad and 
 contracted cicatrices. 
 
 10. Accident. Including with the section rather large, lateral, 
 conjunctival flap. 
 
 Preventive. Observe the rules already given for the fixation 
 of the globe, though if it should occur pay no attention to it so long 
 as the incision is not too far back. It merely increases the chances 
 of the following: 
 
 11. Accident. Bleeding into the Anterior Chamber. The 
 presence of any considerable hemorrhage in the anterior chamber 
 at this stage is objectionable because it obscures the field of sub- 
 sequent operation. 
 
 Preventive. Avoid too large a conjunctival flap and too pro- 
 longed cocain effect. 
 
 Remedy. Flood the eye gently with warm boric acid solution 
 and stroke the cornea softly with the back of the Graefe spoon, 
 applying, the while, a pointed cotton sponge to the incision, and the 
 blood will usually come out. If necessary depress the posterior 
 lip of the cut, or insert the tip of the spatula while stroking upward 
 with the spoon. If this does not accomplish the removal of the 
 blood, a flattened canula attached to a bulbous aspirator may be 
 used. The cannula should be sterilized in the flame of a spirit lamp, 
 as it is very difficult to sterilize a small-bored instrument by other 
 methods. It is better surgery, however, to leave a little blood in the 
 anterior chamber than resort to the cannula, for every additional 
 instrument introduced into the eye adds to the danger of infection. 
 
 12. Accident. Air in the anterior chamber. After introducing
 
 IMMEDIATE ACCIDENTS, ETC. 507 
 
 the cystotome, we sometimes become aware of a bubble of air in the 
 anterior chamber. This comes from lifting the corneal flap, while 
 introducing the instrument, and causing a vacuum beneath. The 
 same accident may occur through inserting the forceps for iridec- 
 tomy. It may be prevented by gliding the aforesaid instruments in 
 more deftly. 
 
 Remedy. A few, gentle, upward strokes of the back of the spoon 
 upon the cornea will usually drive it out. Though if some of it be 
 left behind it is not supposed to be harmful, as it is soon absorbed. 
 However, in an otherwise perfectly normal extraction performed 
 by the author, in which this accident occurred, the operation was 
 followed by panophthalmitis, although the air was immediately 
 removed in the manner just described. Therefore it appears safer 
 to irrigate the anterior chamber after such an accident, in order to 
 thoroughly wash out any infection introduced by this bacteria-laden 
 bubble of air. 
 
 13. Accident. Failure to make capsulotomy comes of either a 
 dull-pointed cystotome or of so depressing the handle that the con- 
 vexity of the lens prevents contact of the point with the capsule. 
 Or the capsule may be too tough, in which case, particularly, if 
 the zonule is weak and the vitreous is fluid, the cataract, capsule, 
 and all will simply be depressed beneath the instrument or move 
 with it in attempting to make the cut, no matter how sharp the 
 cystotome. 
 
 Through too much grinding the cystotome often loses it proper 
 form or model and becomes an insignificant remnant an anomaly 
 and then it should be discarded. The surgeon should be as 
 exacting as to shape and keenness in the cystotome as in the knife. 
 
 Too much caution in making the capsulotomy cannot be exercised. 
 Actual pression is inexcusable. There is no step of this very delicate 
 operation of extraction that so strongly exacts a fine sense of touch. 
 If one does not sense nicely the force of the scratch, the zonule is 
 torn and the ciliary processes are lacerated. By watching closely, 
 one may in most cases be assured of a complete incision in the 
 capsule by seeing the cataract suddenly rise. Yet, as this is not 
 always apparent, he may be unaware of his failure until, in attempt- 
 ing to express the lens, that body refuses to respond to the wonted 
 pressure.
 
 508 EXTRACTION OF CATARACT. 
 
 The remedy consists in again going through the act, this time 
 being more careful as to the condition and manipulation of the 
 instrument. 
 
 It may chance in essaying the capsulotomy that the cataract is 
 observed to follow the movements of the cystotome. This indicates 
 a tough capsule or a ruptured zonule or both, and one must be 
 extremely wary in the delivery of the lens lest there be escape of 
 vitreous. If it is quite evident that the capsule cannot be cut 
 sufficiently without luxation of the lens, recourse may be had to the 
 capsulotomy forceps. If these extract only the capsule and not the 
 cataract with it, the open sharp hook would be the writer's preference 
 as the traction instrument to use. First, however, unless the pupil 
 behaved unusually well, it were safest to make iridectomy. 
 
 14. Accident. Inadequate wound opening. The causes of this 
 have been previously enumerated. Like the incomplete cystotomy, 
 the operator does not always realize the presence of it until the lens, 
 while presenting in a normal manner, yet fails, even with pretty firm 
 pressure, to advance. The signs of an insufficient section are un- 
 mistakable, however, as soon as the spoons are applied and the 
 wound yawns, for then the small inner opening is brought to view, 
 against which the lens bumps ineffectually, and to unduly force its 
 exit would be most prejudicial, as even should the effort succeed, 
 the iris and cornea would be wantonly bruised and the cataract 
 would probably be shot out by an explosion of vitreous. 
 
 The fault may be one of several. The remedy, however, is to 
 enlarge the incision, which may be done either with sharp-edged and 
 blunt-pointed knife (Desmarres) or with scissors. The smallest 
 blunt-pointed strabismus scissors, curved on the flat, are excellent 
 for the purpose. 
 
 15. Accident. Rigidity of the pupil. This rarely occurs if 
 there has been fair mydriasis when the operation was begun. 
 The pupil does not always respond to the atropin. In any event, 
 if the sphincter does not yield to rather prolonged pressure moder- 
 ately applied, for there is no need to hurry perhaps the wisest 
 alternative is to make a small, one-snip iridectomy which comprises 
 little more than the sphincter itself. Knapp recommends first 
 trying to push the iris back over the lens with the wire loop; and 
 Panas practised snipping of the pupillary border with the De Wecker
 
 IMMEDIATE ACCIDENTS, ETC. 509 
 
 forceps-scissors both are masters in their art and wholly worthy of 
 emulation. 
 
 16. Accident. Erratic behavior of the lens. Cataracts with 
 small, hard, or discoid nuclei, especially those with degenerated 
 liquid cortex and frail zonules or shrunken lenses, are apt to prove 
 capricious when we try to drive them out. One of their peculi- 
 arities is to become agglutinated to the posterior surf ace of the cornea, 
 as if by suction, and so long as the lower spoon is pressed below the 
 cornea, the lens will not budge. If the condition be not recognized 
 at once and tactics changed, a gush of vitreous is sure to follow. 
 
 The remedy is merely to slide the spoon up onto the cornea, 
 dislodge the cataract, and push it out. 
 
 Another freak of such cataracts is to slip up behind the iris, 
 or even where iridectomy has been made the upper edge of the lens 
 may lodge behind the incision. This, too, exposes to turning over 
 of the lens and vitreous escape. 
 
 The remedy which has always served the writer in this emergency 
 is to push the crystalline down by means of the little iris spatula, 
 then to proceed with the delivery in the regular way. Others 
 favor the cystotome, but the spatula is easier of insertion and quite 
 effectual. Failing with this, the open sharp hook is the thing. 
 
 Again, there is a class of pasty, sticky cataracts that, in spite of an 
 ample incision, will hang and choke the opening, and if urged too 
 strongly may pop out suddenly, entraining loss of vitreous. 
 
 The remedy is, while the operator applies just enough force to 
 hold the mass well up, for a, handy assistant to dig the cystotome or 
 sharp hook into the edge and deliver it by a sort of siuewise rolling 
 motion. Or the operator himself may do this with the edge, of one 
 spoon while holding the lens up by pressure with the other. It 
 only remains in this connection to discuss that rather startling 
 vagary, 
 
 The Sinking of the Cataract into the Vitreous. Fortunately, a 
 very rare complication, but, when met, the operator must be prompt 
 to act or all is lost. I have seen one of the most skilled and tact- 
 ful ophthalmic surgeons the world has ever produced fail utterly 
 to deliver such a recalcitrant lens, and have seen others, almost as 
 proficient, reduce the globe to a hopeless wreck when confronted 
 with the accident. One of them placed the left thumb behind the
 
 510 EXTRACTION OF CATARACT. 
 
 incision and the right, beneath the cornea and then approximated 
 them, expelling cataract, vitreous body, and all. The cause of this 
 occurrence is usually the complete tearing away of the zonule in an 
 eye with liquid vitreous. 
 
 Various instruments have been used and advised for reclaiming 
 the lens under these conditions, as also for delivering it when the 
 vitreous is presenting or escaping; these include almost all the 
 spoons, hooks, loops, and scoops from Daviel's down. The fenes- 
 trated spoon of v. Graefe, the delicate wire loops of Weber and 
 Snellen, and the vectis of Taylor, each of them has stood its advo- 
 cates in good stead. The writer's preference, however, is for a 
 modification of the sharp hook, commonly attributed to Tyrell and 
 by some to Jaeger, but originated, I believe, by Beer. This sur- 
 geon designed and employed the instrument as a tenaculum to draw 
 out the iris in the operation of iridectomy. The modification con- 
 sists merely in making the hook much less curved than is that of the 
 regular pattern. Instead of being bent back upon itself, like a but- 
 ton hook, it is about the shape of a miniature strabismus hook 
 (v. Graefe's model), only, of course, sharpened. This straighten- 
 ing out of the bend is to enable the point to catch readily in the 
 lens substance, whereas the highly curved form might slip off (see 
 chapter on Instruments). With such an instrument, insinuated flat- 
 wise at the opening, pushed downward behind the cataract without 
 turning, until the point is opposite to that body, then turned for- 
 ward and thrust into it, it is surprising how easily, and with what 
 slight disturbance of the vitreous, the refractory cystalline may be 
 slid along the anterior wall of the globe and out at the incision. 
 Its displacing effect, as compared with any kind of spoon or even 
 with the wire loop, is practically nil. 
 
 In the event, however, of the lens turning turtle and dropping 
 entirely out of sight, the sharp hook should not be plunged to the 
 very bottom of the vitreous chamber, for fear of its fouling the inner 
 tunics of the globe. If the cataract must be "fished" for the 
 depths of the vitreous dragged, as it were then a delicate wire 
 loop would be the safer instrument to employ: 
 
 A few ophthalmic surgeons of great repute, among whom may be 
 mentioned Snellen, 1 advise the bandaging of the eye into whose 
 
 1 Graefe- Saemisch Handbook, Operationslehre, p. 47.
 
 IMMEDIATE ACCIDENTS, ETC. 511 
 
 vitreous the lens has sunken and waiting twenty-four hours, when, 
 as was often the case after depression, the lens will probably have 
 returned to its place. The wound is then reopened with the spatula 
 and the cataract extracted with a traction instrument, either loop 
 or hook. 
 
 17. Accident. Presentation or prolapse of vitreous. When this 
 occurs in the uncomplicated cataracts, it is traceable, as a rule, to 
 one of two causes spasm of the orbicularis, squeezing on the part 
 of the patient or to some fault in the technic of the operator. 
 Large or prominent eyeballs are peculiarly liable to vitreous loss 
 from "nipping" or from pressure of the speculum, for obvious 
 reasons. Another cause, already alluded to (page in), is found 
 in the bar of the old-style lid-holder. Still another, the reclining 
 posture of the patient in a chair, is said to be attended more often by 
 this accident than the recumbent one on a table. 
 
 The preventive for the first is to see that the brow is properly 
 supported or he blepharostat held up. Inexperienced operators 
 would do well to have a trained assistant hold the lids apart with 
 retractor and fingers, dispensing with the blepharostat. 
 
 When the blame, if it may be so termed, rests with the surgeon, 
 it may be laid to inattention or inadvertence in some step of the 
 operation, such as too great pression upon the fixation forceps or 
 upon the cystotome, to insufficient opening of the capsule or cornea, 
 to cutting beyond the equator of the lens in making the capsulotomy, 
 etc. It may also happen in our efforts to remove the cataract re- 
 mains after expulsion of the more consistent portion of the lens, 
 which will be treated of later. We have often heard eye surgeons 
 declare that they did not mind a moderate loss of vitreous, and we 
 have often seen apparently permanent good sight, etc., in an eye 
 that had lost vitreous in the extraction. Nevertheless, it is a danger- 
 ous contingency and one most scrupulously to be avoided. Not the 
 least serious nor the least common of its sequelae is extensive de- 
 tachment of the retina and this has a way of creeping slowly and 
 stealthily, so that months or even years may elapse before the worst 
 comes. 
 
 Remedy. Whether the vitreous is only on the point of escaping 
 or is actually in the act, the speculum must be removed at once and 
 left out. For the subsequent steps of the operation, the upper lid
 
 512 EXTRACTION 07 CATARACT. 
 
 should be hold back by the finger or by the Desmarres retractor. 
 It is best to press the lid up tightly beneath the roof of the orbit with 
 the retractor in order to discourage any contraction of the orbicularis. 
 If the lens is still in the eye, whether or not the capsule has been 
 incised, it should be delivered with a traction instrument (the sharp 
 hook already referred to). 1 Any attempt to express it would only 
 lead to further loss of vitreous. The cataract having been ex- 
 tracted, the protruding vitreous should be cut off close to the in- 
 cision by means of delicate curved scissors, and the iris, if prolapsed, 
 should also be cut off, as to try to replace it would most likely en- 
 tail another gush of vitreous. Jf practicable, all vitreous remains are 
 to be Hushed out of the conjunctival sac by copious warm irrigation, 
 as they strongly invite inl\vtion. The sooner the wound can be put 
 in fair shape and the eye dressed, the better. Both eyes should be 
 carefully bandaged, and the patient should be kept very quiet for a 
 few days. This subject will be again considered under Extraction 
 of Complicated Cataracts. 
 
 18. Accident. I''..\-trnsion or entanglement of the iris at the incision 
 is usually caused by a sudden out -gush of aqueous. This escape of 
 aqueous is most often produced by pressure upon the globe from 
 without, either by the operator with his instruments or by the 
 patient with his orbicularis It is often quite an unavoidable 
 occurrence. 1 there is an extensive prolapse, especially if the iris 
 is torn, it were best to excise a small portion at once. If there is 
 merely a catching up of the membrane or only a slight extrusion 
 it may be reduced. Before setting about it, it were well to pause, 
 again closing the eye. and covering the lids lightly with the wet 
 cotton. When the lids are opened, it is not uncommon to find that 
 the iris has replaced itself. If not, a few drops of he boric acid 
 solution are applied, and w th the spatula, wet with the solution, 
 the wound is softly patted, or. as advsied by Knapp, the globe beneath 
 the cornea is pressed upon in such a way as to cause the wound to 
 
 1 1 have more recently arrived at the conclusion that there is a less 
 radical and a better way to deal with some of these cases of vitreous previous, 
 if one may be allowed the expression. Take for instance, one of attempted 
 simple extraction in which the vitreous comes before the lens. Instead 
 of resorting to the policy of at once delivering the cataract at any price, 
 stop the operation, put the eye in the best condition possible, and apply 
 the dressing. Then, by subsequent intervention, with the patient in 
 narcosis and with the help of the Angelucci fixation of the globe, there 
 may be a much better chance of sa ving" the eye and of restoring the sight .
 
 IMM; ,TC. 513 
 
 gape and drop the iris from its lips. Failing in this to restore it, 
 the spatula is introduced edgewise at the incision,, with a sort of 
 slicing motion, which corrects the middle portion. Then, if there 
 be still any caught in the angles, they are gently poked back into 
 place with the end of the instrument. 
 
 19. Accident. Collapse of the cornea. If this membrane is very 
 thin and the subject is aged, especially if much cocain has been 
 used, as soon as the lens is expelled, the convexity of the cornea 
 becomes reversed, a more or less deep concavity taking its place. 
 This hampers the manipulation of lens remains and dealing with 
 the iris, and if la-vage of the anterior chamber has a place, this must 
 be it. There could, at any rate, be no objection to the filling of 
 the anterior chamber with warm normal salt solution merely to 
 facilitate maneuvers relative to the cortex and iris. This is not a 
 serious casualty, and usually all that is necessary is simply to wait 
 a few minutes for the anterior chamber to refill. The eye should 
 be protected by a piece of wet cotton in the meantime. 
 
 20. Accident. Expulsive or retrochoroidal hemorrhage. This 
 deplorable calamity, which is always fatal to the sight and usually 
 to the globe, though it comparatively seldom befalls, comes to the 
 experienced operator and to the tyro alike, and without warning. 
 He. in whose practice it has never occurred, has much to be thankful 
 for. The writer is one of these lucky individuals, for with a total 
 of more than 1,200 extractions, and a still greater number of iridec- 
 tomies, he has yet to meet with this catastrophe. 1 The predisposing 
 cause is usually degeneration of the vascular system (arteriosc'ero- 
 sis) and the immediate cause is violence to, or straining of, the 
 walls of the vessels through the opening of the globe, causing a 
 rupture. The two long posterior ciliary arteries, because of the 
 manner in which they pierce the sclera. and owing to, the directness 
 of their blood columns, are peculiarly liable to this form of hemor- 
 rhage. Most often the break occurs just within the sclera, and it 
 is supposed to be produced by the dropping away of the vitreous 
 after the incision is made. Glaucomatous eyes are especially 
 subject to it, and, in these, it is as apt to follow iridectomy as it is 
 
 1 Since writing the above I have had two such accidents one 48 hours 
 after an extraction, the other immediately attending an iridectomy 
 for glaucoma. 
 
 33
 
 514 EXTRACTION OF CATARACT. 
 
 extraction. It can be classed among both the immediate and the 
 consecutive accidents. 
 
 If the bleeding takes place during the operation, the first sign of 
 it is spontaneous gaping of the wound. Then, if the source of it 
 is far back, either the lens or the vitreous appears. At the same 
 time the patient complains of great pain and utters a series of 
 groans that are of themselves distinctive of his misfortune. This 
 groaning may, indeed, be the first warning. Whether it be lens or 
 vitreous that first escapes, it is soon followed by a gush of blood. 
 If the rupture is well forward, the blood may escape in advance of 
 the other structures. Often retina and choroid are eventually 
 expelled. So great is the force exerted by the accumulating hemor- 
 rhage, that once, for example, while an onlooker at an operation of 
 iridectomy for glaucoma, I saw a large, firm crystalline (transparent) 
 forced out, entirely intact, through a rather small keratome incision. 
 Although in order to make its exit, it had to elongate, like an ameba, 
 yet it never halted for an instant. Patients with palpable 
 signs of arteriosclerosis should, in view of the possibility of such 
 hemorrhage, be handled most gingerly when it comes to extraction. 
 Especially should one guard against sudden escape of aqueous, 
 undue pression with fixation forceps, spoons, or cystotome, and 
 pulling upon the iris. 
 
 Prevention. It is prevention or nothing. It is safe to conclude 
 that most of the victims of expulsive hemorrhage after extractions 
 and iridectomies are persons with degenerated vascular systems and 
 abnormally high blood pressure. Even normal arterial tension is 
 dangerously great for such operations with certain forms of degenera- 
 tion. What more rational, then, along with other preparatory meas- 
 ures, than to make routine practice of testing the blood pressure. 
 If high, say above 140 mllm., and the patient's age and general signs 
 make the situation at all precarious, a course of treatment could, 
 with impunity, be given, calculated to lower the pressure, at least 
 for the few critical days. Among the measures to be resorted to are 
 blood-letting by venesection (see chapter on "Paraoperative 
 Technic"), free saline purgation, veratrim viridis, sodium nitrite, 
 etc.; though such medication is of doubtful efficacy in advanced 
 arteriosclerosis. Continual tests are made with the sphygmoman- 
 ometer to ascertain if the treatment is of any avail. When sufficient
 
 ACCIDENTS, ETC., CONSECUTIVE TO EXTRACTION. 515 
 
 time can be had before the operation, the prolonged administration 
 of the iodids and the making of a preliminary iridectomy are 
 advisable. The extraction should follow within a few days or a 
 week of the iridectomy, while the intraocular tension is still low. 
 Other precautions are narcosis gas and ether, or, if everything is 
 favorable chloroform for the operation; and sedatives, such as 
 codein, chloral, cocain, or morphin, immediately before and after 
 the operation, and the avoidance of mydriasis. Both eyes should 
 be snugly bandaged after the extraction, a protective mask put on, 
 and the patient be under the constant surveillance of a trained 
 nurse or trusted attendant. 
 
 Remedy. There is little that can be done. Remove all ex- 
 traneous pressure, cut off the vitreous, if prolapsed, coapt the 
 lips of the wound as well as possible and apply a compress! ve 
 bandage to both eyes. Give the sufferer a dose of morphin and put 
 him to bed where he should be placed in a half-reclining posture. 
 The ultimate lot of the majority of these eyes is enucleation or 
 atrophy of the globe. 
 
 21. Accident. Yawning or upheavcl of the lips of the icound. In 
 rare instances this is apparent or else there is a tendency for one 
 lip to override the other vicious coaptation. The former occurs 
 without actual presentation of vitreous. De Wecker asserts that it 
 is sometimes the result of puncture of the hyaloid fossa, in attempts 
 to rid the eye of lens remains, and is due to a rising intraocular 
 pressure which may be detected by palpation, the resistance actually 
 increasing under the finger. Another symptom is the pushing 
 upward of the iris. He warns against making further pressure on 
 the globe, as it would precipitate escape of vitreous and advises 
 immediate instillation of eserin solution and bandaging. 
 
 ACCIDENTS, ETC., CONSECUTIVE TO EXTRACTION. 
 
 Prolapse or Incarceration of the Iris. This is a casualty that 
 sometimes intervenes between the operation and the firm healing of 
 the incision, and is, in most instances, produced by some force that 
 causes the wound to open, such as coughing, sneezing, straining, 
 striking the bandage over the eye with the hand or against some 
 object or the impact of a faulty dressing. It is by some also
 
 EXTRACTION OF CATARACT. 
 
 attributed to swelling of abandoned cortex. So long as the lips of the 
 wound are closed, and before they have actually united the anterior 
 chamber is filled with he aqueous humor, at which time compara- 
 tively slight pressure is sufficient to cause a parting of the lips, 
 when the aqueous gushes out, carrying the iris with it. The patient 
 is then often, though not always, aware of a sudden change in the 
 feeling of the eye, and that organ, from having been relatively 
 
 FIG. 240. Slicing movement with spatula. 
 
 comfortable, becomes uneasy. There is pain or a feeling as if a 
 foreign body had gotten into the eye, and the dressing beneath is 
 found moist from lacrimation. Objection has often been made to 
 mydriasis after simple extraction, on the ground that it favors 
 prolapse of the iris. With this the writer does not agree. Until 
 the anterior chamber reforms the pupil remains contracted. 
 After closure of the wound the mydriasis returns. Now, should 
 the wound suddenly reopen, the iris, with pupil enlarged, will
 
 ACCIDENTS, ETC., CONSECUTIVE TO EXTRACTION. 517 
 
 offer less resistance to the quick outrush of the aqueous than if 
 its pupil were small. 
 
 These are conditions that demand immediate attention, i.e., 
 removal of the bandage and inspection of the eye. If the iris be 
 found in the wound and is sufficiently free to admit of the procedure, 
 the eye is cocainized, the iris is replaced with the spatula, as described 
 a few paragraphs back, and eserin instilled (Fig. 240). If this be 
 impracticable the only alternative is to make an iridectomy. In- 
 deed, in but few instances are we allowed any other. Now and 
 again when cicatrization is pretty well established, a small hernia 
 or projection of the iris is noticed, for which a searing by means 
 of a small galvanic electrode proves a most efficient remedy. 
 A recent hernia may sometimes be manipulated with smooth-jawed 
 forceps and spatula, till thoroughly mobilized, sn pped off, the iris 
 replaced, the opening seared w thin the galvanocautery, and 
 eserin instilled; though myotics, as a rule, are of little avail. 
 
 Many times, undoubtedly, this rush of aqueous is induced by 
 something which takes place at the first dressing of the eye, most 
 often by pressure that is brought to bear upon the lids in first 
 open ng them, either by the physician's thumb or by the patient's 
 orbicularis (see After-treatment). 
 
 H. Beckles Chandler, of Boston, contributes an article to Knapp's 
 Archives for January, 1904, entitled, "Report of 312 Cases of Cata- 
 ract Extraction with a Small Peripheral Buttonhole of the Iris." 
 This opening is made by excising, by means of small iris forceps, 
 whose teeth "are at the tip end," "and scissors whose blades are 
 very thin," a circular piece of the iris, one millimeter in diameter 
 and "as near the root of the iris as possible." The corneal section 
 is exactly in the sclero-corneal junction and the buttonhole is made 
 after delivery of the lens. According to the author, it serves the 
 double purpose of a sluice-gate for preventing prolapse and of a 
 vent through which to milk out the cortex that slips up behind the 
 iris. In the 312 extractions reported, there was iris prolapse in 
 but four, and two of these were " the direct result of violence." 
 
 It has long been a mooted question as to whether or not iridectomy 
 really tended to prevent prolapse and incarceration of the iris. Panas 
 reports iris prolapse in 5 per cent, of simple extractions. Becker says 
 this accident more frequently follows the combined than the simple
 
 518 EXTRACTION OF CATARACT. 
 
 operation, and gives statistics based on an anatomical examination 
 of 17 eyes after simple extraction, in which iris tissue was found in 
 the wound three times, or 18 per cent., while in 15 eyes examined 
 after combined extraction it occurred 10 times, or 60 per cent. 
 Kollner reports 289 incarcerations following 1,284 combined extrac- 
 tions in the clinic of Prof. Michel, of Berlin, i.e., in 22 per cent, 
 of the cases. The wide variation in these reports may be accounted 
 for in part by some observers basing their deductions on the gross 
 findings in the living subject, while others resort to careful examina- 
 tion of the enucleated eye, as did Becker. Differentiation must 
 also be made between those cases of prolapse and incarceration 
 following the combined extraction and those occurring after extrac- 
 tion subsequent to a preliminary iridectomy. 
 
 Cystoid cicatrix is one of the very late after-complications 
 following cataract operations and iridectomies, where there was 
 healing of the wound with the iris included. A fold of iris protrudes 
 in the form of a hernia or a small sinus leading into the anterior 
 chamber remains beneath the conjunctiva where the iris is en- 
 tangled, and an ever increasing sac of aqueous is the result. The 
 first-mentioned form is most dangerous, as nothing intervenes be- 
 tween the external world and the interior of the eye but the attenu- 
 ated and degenerated iris, \vhich really amounts to a partial 
 staphyloma anterior. Then let there be acquired a septic condition 
 of the conjunctiva or of the lacrimal canal, and infection with 
 panophthalmitis is likely to occur at any moment. Besides, the 
 iris is drawn more and more into it, thus interfering with vision, and 
 the growing vesicle becomes inconvenient and unsightly. 
 
 The galvanocautery, repeated a number of times if necessary, and 
 a long continued compression bandage is the best remedy. If the 
 second- mentioned variety is in question, the cyst should be freely 
 incised, the underlying fistula sought and well cauterized. 1 Another 
 sequel of these complications is high or incorrigible astigmatism. 
 Something is to be hoped for in the experimental incisions as a 
 remedy for this defect. 
 
 Retroversion or involution of the iris is another rare phenom- 
 enon after extraction. This consists in a turning backward of a 
 portion or even all of the pupillary border. Most often it is the 
 
 1 Berry, Oph. Review, xxi, 88.
 
 ACCIDENTS, ETC., CONSECUTIVE TO EXTRACTION. 519 
 
 upper portion, which gives much the appearance of a coloboma. 
 Jt is particularly liable to occur after escape of vitreous during the 
 operation. The shrinking back of the extruding process of that 
 body pulls the iris back with it, or in some cases actual connective 
 tissue bands form, by which the iris becomes tied, as it were, to 
 the vitreous. Once, in a case of soft cataract where I had made 
 discission, the entire iris disappeared, simulating aniridia, and it 
 required several instillations of eserin solution to reinstate the 
 membrane. 
 
 Iritis and cyclitis, when encountered in an eye after cataract 
 operations, do not differ materially in character from these inflam- 
 mations when arising from other causes. Indeed, the same pre- 
 disposing causes are often operative in both instances. Owing to 
 the changed relations, however caused by the operation, and to 
 the absence of the lens, etc., these diseases in aphakial eyes present 
 phases that are not found under other circumstances. One of these 
 concerns the peculiar distortions and the closure of the pupil. 
 The disease may vary in severity from an insignificant localized 
 inflammation and a tiny synechia at a spot where there has been a 
 minute rupture of the sphincter, of the pupil, through all grades of 
 iritis, synechia posterior, occlusion and closure of pupil, cyclitis 
 with glaucoma, or general uveitis with phthisis bulbi; or even sym- 
 pathetic ophthalmia may result. 
 
 These processes are excited by violence to the iris and ciliary 
 bony in some part of the operation, by the iris getting into the 
 incision, by the implantation of microbes, etc.. but most often. 
 perhaps, by abandoned lens remains. And just here, another 
 word as to the importance of freeing the eye of all cortical residue. 
 as nearly as possible, at the proper time of the operation. The 
 most experienced and observant ophthalmic surgeons all agree a- to 
 their pernicious effects when left in any quantity. In attempting, 
 therefore, a simple extraction, when one is convinced that certain 
 otherwise inaccessible cortex lurk- behind the upper portion of the 
 iris, an iridectomy it imperative. The most treacherous, of course. 
 are the Iran-parent remain.- that do not -how any opacity until a 
 day or two after theoperation. as. for example, those from the nuclear 
 cataract, that will cling to the capsule, e-pecially the posterior half 
 and elude the best directed effort. Then, by their swelling, crowd-
 
 520 EXTRACTION OF CATARACT. 
 
 ing, etc., start the mournful train of symptoms that so often prove 
 the bane of the operator and the undoing of the eye. 
 
 The treatment that is best for these same affections in general 
 is also best for these. Locally, atropin, hot applications, leeches 
 to the temple, subconjunctival injections of salt or mercurial 
 solution, etc. Internally, calomel, salicylates, pilocarpin hypo- 
 dermics, etc., and attention to any predisposing dyscrasy. If there 
 is any amount of lens matter in the eye, it should be seen to that the 
 pupil does not contract, if it is in the power of atropin or any other 
 mydriatic to prevent it. A considerable quantity of fluffy or 
 flocculent lens remains is well tolerated by the eye and is not to be 
 feared. 
 
 Infection suppuration "puss-wound" of the Germans- 
 may be either endogenous or exogenous, and the exogenous infection 
 may primarily involve either the corneal incision or the anterior 
 chamber or both. Under prevailing methods and with favorable 
 surroundings, this dreadful contingency is infrequent. A surgeon 
 may now make two or three hundred consecutive extractions without 
 once encountering it. Yet, again, it may be his fate to have it occur 
 in several cases in quick succession. With properly prepared 
 patient and paraphernalia and with a normal tear canal and con- 
 junctiva, the source of the infection is always a mystery, and we 
 may thank our stars that we are so often spared the unforeseen evil. 
 Anatomical and bacteriological examination have shown that grave 
 forms of endogenous infection may be due to capillary microbian 
 embolism of the vessels of the retina and choroid and that these 
 may contain the same bacteria that have produced a general infec- 
 tion. Surgical interference seems, under these circumstances, to 
 render susceptible to infection eyes that otherwise would be immune. 
 
 Owing to the nature of the poisoning agent, or to the treatment 
 instituted, or, it may be, to the qualities existing in the eye or the 
 system, the suppuration will be of every grade from that which will 
 terminate with slight sloughing of the lips of the wound, leaving 
 merely a broad cicatrix, on through a middle grade, affecting all the 
 structures anterior to the ciliary body, to that so overwhelming in its 
 virulence as to practically destroy the eye in a single night. It 
 seems that vitreous humor in the wound is, of all things, the most 
 inviting to pygenic bacteria.
 
 ACCIDENTS, ETC., CONSECUTIVE TO EXTRACTION. 521 
 
 If present, the trouble usually begins within twenty-four hours, 
 and hardly ever beyond seventy-two hours from the time of operating. 
 Bach says that infections appearing earlier than forty-eight hours 
 after the operation come from the instruments. Dor states that in- 
 fections coming after forty-eight hours and before seventy-two 
 hours are from the conjunctiva and not from the instruments. 
 Most infections occurring after four days are probably endogenous. 
 At the onset of the infection generally, not invariably, there is pain, 
 lacrimation, etc. Inspection of the eye shows puffiness of the lids, 
 edema of the conjunctiva, mucous or mucopurulent discharge, 
 gray softening of the lips of the incision, and, if the process has got 
 well under way, yellowish streaks leading from the wound into the 
 deeper parts of the globe, and a turbid, greenish glimmer of the iris. 
 A rarer form of infection is that which originates in the iris or vitreous, 
 and comes somewhat later than wound suppuration; indeed, before 
 its onset healing of the incision has generally been effected. The 
 origin of the poison in these cases is believed usually to be endogen- 
 ous. In spite of the most vigorous measures, the usual end of a rank 
 infection is panophthalmitis. Now and then, by the very early 
 recourse to energetic treatment, however, not only is the globe 
 saved, but useful sight as well. As our science advances, the aspect 
 of these cases grows less discouraging, just as their occurrence 
 becomes less frequent, and one is not expected to give up, as formerly, 
 but, on the contrary, to make a desperate fight for it in every instance. 
 
 For the prevention of infective processes after operations that 
 necessitate opening of the globe, De Wecker conceived the idea 
 of making peritomy, loosening up the conjunctiva and putting in a 
 purse-string suture, making the extraction (or other operation), 
 then drawing the conjunctiva together, thus covering with it the 
 entire cornea. This procedure has been practised lately by Ellet, 
 of Memphis. Kuhnt, of Konigsberg, for the same purpose, 
 loosened the conjunctiva only around the upper half or two-thirds 
 of the cornea, drew it down and sutured it to the episcleral tissue at 
 either side opposite the center of the cornea. Gifford, of Omaha, 
 makes use of the purse-string suture surrounding the entire cornea 
 and ending below, but dissects up only that encircling tin- upper 
 half. After the cataract operation, he ties the suture which pulls 
 the conjunctiva effectually over the incision.
 
 522 EXTRACTION OF CATARACT. 
 
 Aside from the preventive measures already enumerated, mention 
 must be made of the internal administration of potassium iodid. 
 L. Dor, before the French Congress of Ophthalmology of 1901, 
 reported experiments upon animals whereby he had demonstrated 
 that one to two grams of potassium iodid given the day before 
 the operation had power to prevent all inflammatory phenomena 
 in eyes inoculated with cultures of the staphylococcus pyogenes 
 aureus in doses sufficient to produce panophthalmitis in the eyes of 
 control animals. Certainly, a simple and harmless prophylactic 
 which could easily be added to the routine of preparation. 
 
 Treatment. Calomel, salicylates, milk-punches, quinine and 
 strychnin, leeches to the temple. Locally, the hourly (night and 
 day) moderate irrigations of very hot 1/2000 or i 1000 bichlorid 
 solution, immediately followed by copious ones of hot boric acid 
 solution. Subconjunctival injections of the salts of mercury and 
 the injection of antiseptics into the anterior chamber, etc. I have 
 recently seen such an eye apparently saved by the deep (subtenon- 
 ian) injection of the cyanid of mercury i/iooo, 8 to 12 minims at a 
 time, every twenty-four or forty-eight hours. Cautery of the in- 
 cision is practised by some after reopening it. This is followed by 
 irrigation of the anterior chamber with mild antiseptic solutions. 
 French surgeons are partial to the use of methylene blue, both 
 internally and externally, in these infections, but the practice has 
 never been popular in the United States. Haab introduces into the 
 anterior chamber soluble rods impregnated with iodoform. 
 
 Filtration Chemosis. In those cases where the cornea! flap has 
 included some portion of the conjunctiva, the incision in the latter 
 occasionally unites firmly before there is healing of that in the 
 underlying cornea, hence, if the aqueous now escapes, it will ac- 
 cumulate between the sclera and the conjunctiva. The opalescent, 
 edematous swelling which results, is of unmistakable appearance 
 being free from redness, and changing its location in obedience to 
 the law of gravity. The progress of the eye is not seriously inter- 
 fered with, and no special intervention is called for. 
 
 Iritis, cyclitis, and glaucoma, secondary to the extraction, have 
 already been considered (see p. 519). 
 
 Late Wound Healing. This phenomenon is recognized by 
 the persistent or intermittent absence of the anterior chamber for
 
 ACCIDENTS, ETC., CONSECUTIVE TO EXTRACTION. 523 
 
 several days, or even weeks, after the operation. The delayed 
 union is most likely the result of shreds of capsule or iris, particles of 
 the lens, clots of blood, or portions of vitreous that lie in the cut and 
 prevent union. It has been thought by many to be one of the causes 
 of secondary glaucoma 1 through entrance of the corneal epithelium 
 into the anterior chamber, and there piling up in the angle of the 
 iris; and by causing adhesions between iris and cornea, etc. It 
 also leads to the grooving or guttering of the wound. \Yhen dis- 
 covered the danger from suppuration is usually passed, the thing 
 needful being to keep both eyes carefully bandaged, to enjoin 
 quiet and rest, to prevent prolapse of the iris, and, in most cases all 
 will be well. The least movement of the globe causes a "working" 
 of the iris toward the incision, and a crowding against the tra- 
 beculum, or blocking of the iridic angle. When iridectomy has ac- 
 companied the extraction, this working of the iris results in the 
 swollowing up of the pillars of the coloboma by the inner lips of the 
 corneal wound, and in adhesions between iris and cornea. 
 
 The eye should be carefully inspected with a view to the possible 
 discovery of the cause and the removal of the non-healing element. 
 If no obstruction is detected and the leakage persists, a spatula may 
 be passed through the wound with a slicing motion, provided the 
 union has not progressed too far, and the eye copiously douched 
 with warm boric solution. Iridectomy has often been resorted to 
 with the effect of causing immediate closure. Just how this acts, I 
 am not prepared to explain. Arlt thought that the constant outflow 
 of aqueous in delayed union was a means of preventing suppuration, 
 and rather welcomed the accident, as have others since. 
 
 Striated Cornea, or as it has also been named, striped keratitis 
 (Heymann), though it can hardly be called an inflammation, refers 
 to a singular appearance presented by the cornea (noticeable at the 
 first dressing) after certain extractions through an inadequate 
 incision and one whose summit was rather far within the limbus. 
 The distinguishing feature is a great number of fine gray lines a 
 true striation extending downward varying distances from the 
 cut. They have been thought by C. Hess to be wrinkles in the 
 posterior layers of the cornea due to the stretching and rubbing of 
 the flap incident to the violent deliver}- of the cataract. De Wecker 
 
 i Meller, v. Graefe's Arch., lii 3, and Ophth. Review, Nov., 1901.
 
 524 EXTRACTION OF CATARACT. 
 
 considered the appearance to be the result of simple retention of 
 the lymph in the channels adjacent to the wound due to traumatism 
 and not to imbibition of liquid or infiltration. He looked upon it 
 as a quite innocent condition, exceping in the event of an accompany- 
 ing violent iris reaction, when the vertical striae are seen to be crossed 
 by a horizontal set. If all eyes upon which extraction has been 
 made were closely scrutinized with a magnifying glass under strong 
 focal illumination, this condition would, to a degree, doubtless be 
 found in a large number. The treatment consists only in ordinary 
 care and bandaging. Dionin is usually indicated. 
 
 Glaucoma, secondary to the operation, is not a frequent sequel, 
 but is said to follow in i% after the combined operation, and less 
 often after the simple. Aside from predisposition to the disease, 
 among the local exciting causes are abuse of atropin, abandoned 
 lens remains, incarceration of iris or of the capsule, rudeness in 
 delivering lens or in the capsulotomy, or anything that tends to the 
 excitation of uveitis. Delayed union of the wound has been set 
 down as a factor for the reasons alluded to under that head. 
 
 However, one should not always look to the eye alone for the 
 cause of the glaucoma. There are times when the disease is un- 
 doubtedly due to a more remote systemic condition. This may 
 be some kind of autointoxication, as from renal insufficiency; or it 
 may be a form of discrasy, like gout or syphilis. According to 
 De Lapersonne, uric acid retention tends to excite glaucoma by the 
 production of a species of edema of the vitreous. These facts serve 
 to emphasize the importance of a thorough physical examination 
 in connection with the operation of extraction. In this way one may 
 at times be greatly aided in the choice of a remedy with which to 
 combat a complication be enabled, for example, to cut short an 
 attack of glaucoma by measures other than surgical. 
 
 The combined operation, because of the frequent involvement 
 of some part of the iris in the healing of the incision, is thought 
 to favor glaucoma more than is the simple. When the tension is 
 obviously due to swelling cortex behind the iris after simple extrac- 
 tion, iridectomy should be immediately resorted to and whatever 
 is feasible of the offending material removed. In the great majority 
 of instances, however, the cortex will have become encapsuled or 
 so adherent that its attempted riddance is out of the question. In
 
 ACCIDENTS, ETC., CONSECUTIVE TO EXTRACTION. 525 
 
 some of the milder forms the process can be stopped by the use of 
 pilocarpin or eserin, but prompt iridectomy or anterior sclerotomy 
 (paracentesis) will be required in all the others. 
 
 Postoperative lunacy, senile dementia, delirium loquace, 
 etc., are various names that refer to a mental disorder that is not 
 uncommon after the extraction of senile cataract. The degree 
 varies from slight confusion of thought and incoherence of speech to 
 violent maniacal frenzy. The predominant idea throughout is that 
 of having been deserted, left in darkness or among strangers when 
 in dire distress a state akin to what is known as nostalgia. The 
 sufferer wants to go home and continually calls for ihose nearest or 
 dearest. He wants to flee from his persecutors, and herein lies the 
 greatest danger. It is not to the lame eye indeed, it is astonishing 
 how seldom aught injurious ever comes to it but it is the life and 
 limb of the patient. Thought or conceit of that organ does not enter 
 into his plight. He wants to get away and, in the severe cases, he 
 goes, and if not restrained, in seeking an exit, he tries to scale the 
 walls, to climb the door, to throw himself out of the window, or over 
 the railing of the stairs. So that the list of fatal casualities from this 
 cause is nothing short of appalling. 
 
 The subject was fully discussed at the 1903 meeting of the 
 American Ophthalmologic Society, as the result of an admirable 
 paper then read by Kipp, of Newark, N. J., and published in 
 Knapp's Archives, July 19, 1903. In the January, 1904, number 
 of Knapp's Archives, C. E. Finlay, of Havana, Cuba, calls attention 
 to a paper by C. Fromaget, of Bordeaux in the Annalcs d\n-atlisth}iu\ 
 cxxiii, p. 183, in which "he considers the delirium following eye 
 operations the result of an autointoxication, most often uremic, 
 and due to the accumulation in the system of certain excrementi- 
 tious products brought about by some renal insufficiency, and which 
 is made patent by a diminution in the amount of urine, in its specific 
 gravity or in the proportion of urea." Dr. Finlay cites a case of 
 his own in support of Fromaget's theory. 
 
 Whatever else may contribute to this ailment the toxic effect of 
 mydriatics or what not it is certain that confinement in a strange 
 place and darkness are very largely responsible; the bandaging of 
 both eyes, total darkness in the room, etc. For the same reasons, 
 there are many individuals, both old and young, who are unable to
 
 526 EXTRACTION OF CATARACT. 
 
 sleep where, on awaking in the night, they cannot see a light. Be 
 the latter ever so faint, it answers the purpose. 
 
 Kipp advocates that, where the distance is not inconvenient, the 
 patient be taken home in order that he may recover his faculties. 
 The next best thing is to have a member of his fami'y come to him 
 and coax him back to reason; or, if this cannot be done, the soothing 
 must be left to those in attendance. Bromids and chloral are 
 sometimes of avail, though it is often impossible to induce the 
 patient to swallow anything. The well eye, if there be one, and 
 it is occluded, should be uncovered at the first signs of the dis- 
 turbance, and the patient must be watched and guarded 'without an 
 instant's intermission. Knapp, in De Schweinitz's, " Diseases of the 
 Eye," commends hypodermic injections of hyoscin (hydrobromate) , 
 gr. i/ioo pro dosi, to control the mania. 
 
 Atropin Dermatitis. The well-known idiosyncrasy whereby 
 the local use of atropin or kindred drugs causes a peculiar, nasty, 
 greasy swelling and inflammation of the skin of the lids, must be 
 watched for and, if shown, another mydriatic, such as duboisin or 
 hyoscin, substituted. Usually this suffices, though rarely each one 
 has the same effect and must all be abandoned. 
 
 Hyphema, or hemorrhage in the anterior chamber, which is an 
 occasional occurrence, is more often noted after the combined, than 
 after the simple extraction, and was especially frequent after the 
 Graefe modified linear. The predisposing cause is hyperemia 
 of the iris, and the exciting one either a blow or a strain, or it means 
 a threatened iritis. In the latter event, it is an indication for 
 atropin, salicylates, etc. 
 
 Spastic or senile entropion of the lower lid, induced by band- 
 aging, is a condition much to be apprehended after extraction. 
 Eyes have been lost through want of timely observance of it. If 
 the lower lid shows the slightest tendency to roll in, measures, such 
 as strapping it down to the cheek with collodionized gauze or strips 
 of rubber adhesive plaster or the putting in of an Arlt suture, must 
 be taken at once. 
 
 Kianopia, kianopsia, blavinopsia, or blue vision, is a very 
 common accompaniment of the early attempts of an eye to see after 
 the extraction from it of a senile cataract nuclear cataract in 
 particular. Becker thought that it is due to the diffusion of light
 
 CORNEAL FLAP EXTRACTION COMBINED WITH IRIDECTOMY. 527 
 
 by thin layers of cortex and that the disappearance of it was the 
 result of the absorption of the latter. 
 
 The more commonly accepted explanation of the phenomenon is 
 that the light, entering the eye, has for a long time been filtered 
 through a yellow medium the amber-colored lens; and when, 
 upon removal of this, white light is again admitted, it is the com- 
 plement of the yellow, or the strongly contrasting blue, that pre- 
 vails until the eye becomes accustomed to the change. The phe- 
 nomenon soon disappears. 
 
 Erythropsia, or red vision, is declared by some observers to be 
 more common after extraction of senile cataract than blue vision. 
 Such has not been my experience. Fuchs accounts for it in this 
 connection, as follows: the aphakic eye is more disposed to it be- 
 cause the lens has fluorescent properties and, moreover, in old 
 people, is yellow. It, therefore, while present, prevents the 
 entrance into the eye of great numbers of the rays of short vibrations 
 at the violet end of the spectrum, and its absence, allowing the free 
 entrance of these, soon causes, in these eyes long unused to such light, 
 exhaustion of the retina, like snow-blindness. 
 
 SIMPLE PERIPHERAL CORNEAL FLAP EXTRACTION 
 COMBINED WITH IRIDECTOMY. 
 
 In discussions of the relative merits of the simple and the com- 
 bined operations for the extraction of cataract, the decision of the 
 argument is supposed to rest upon one's answer to the question, 
 "If your own eye were to be operated upon, which method would 
 you choose ?" My reply would be, " It would depend upon the kind 
 or stage of the cataract and upon what surgeon was called to make 
 the operation." 
 
 The ultimate success of the operation of extraction does not 
 depend so much upon the particular mode that is adopted of l he- 
 several in vogue, as might at a glance be supposed. It is a question, 
 largely of personal equation. Ophthalmic surgeons characterized 
 by the greatest aptitude in this most exacting of operations, as, for 
 example, Knapp, with a record of four thousand extractions, most 
 all prefer the simple method. They may have had their periods of 
 disaffection in regard to it, but they have ended by coming back to it
 
 528 EXTRACTION OF CATARACT. 
 
 in nearly every instance. Indeed, I doubt not, were the originators 
 of iridectomy, in connection with extraction, alive to-day in this 
 era of antiseptic surgery, they would be among the strongest ad- 
 vocates of the simple extraction. For it must be remembered that 
 v. Graefe, with the small iridectomy he made in conjunction with 
 his postcorneal linear section, and Jacobson, who a year or two later 
 operated downward with a very broad iridectomy, both sought by 
 means of the coloboma not to avoid iris complications or to favor 
 the removal of lens remains, but to lessen the chances of suppuration 
 and panophthalmitis. 
 
 In skillful hands the simple operation is the safer and better in 
 every way. If, on the other hand, the operator is wanting in 
 experience or is not sure of his technic, then, perhaps, in the in- 
 terests of all concerned, his choice should be for the combined or, 
 better still, for extraction after a preliminary iridectomy. The 
 writer's observation and experience confirm him in the belief that, 
 all things else being equal, there are fewer accidents both during and 
 after the operation of simple extraction, and that when these do 
 occur, they can be better dealt with. Nevertheless, iridectomy in 
 relation to operations for cataract has, and will ever retain, an 
 important place, whether it precedes the extraction by a certain 
 period or is coincident with it. 
 
 Indications for the Combined Operation. Among the 
 cataracts that require it may be mentioned those whose capsules are 
 adherent to the iris, unripe cataracts, or those having a quantity 
 of soft, transparent cortex, diabetic cataracts, and those attended by 
 a rigid pupil, or one irresponsive to mydriatics; as also the luxated 
 and tremulous cataracts. These indications, it may be added, are 
 not always apparent when the exigencies of the operation are being 
 discussed. Hence, in preparing the instruments for any cataract 
 operation where iridectomy has not already been performed, the 
 iris scissors and forceps must never be omitted. 
 
 As to the kind of iridectomy, there are a number of opinions and 
 practices. A few years back, the majority of operators made 
 what is called the " keyhole" coloboma, requiring for its proper 
 fashioning, three snips of the scissors. The first, straight from the 
 pupillary border to the periphery of the iris; the second, along 
 the periphery to form the base of the coloboma, and the third, from
 
 CORNEAL FLAP EXTRACTION COMBINED WITH IRIDECTOMY. 529 
 
 the latter, straight back to the pupil again. This form is now more 
 specifically identified with iridectomy for glaucoma, for which it is 
 the most effective. Recently the prevailing choice, excepting, 
 of course, in those cases complicated by glaucoma, is for the one- 
 snip section, such as has been for a long time the kind made for 
 optic coloboma. It obviates as effectually the difficulties of the 
 extraction and more effectually some of the dangers. It is simpler 
 and quicker in the performance, less painful, causes less deformity, 
 and its coloboma, being free from the long, flabby pillars, with their 
 sharp corners that characterize the keyhole pupil, the risks of pro- 
 lapse and incarceration of the iris are not so great. 
 
 The size of the piece of iris excised need not, as a rule, be large. 
 All that is requistite, usually, is the resection of a small bit of the 
 sphincter alone, but its exact dimensions must be left to the judg- 
 ment of the operator. As to the manner of procedure, it does 
 not differ materially from that of the same operation made for 
 other purposes (see chapter on Optic Iridectomy). When one 
 expects before making the corneal incision to cut the iris also, 
 leaving of a conjunctival flap is not so imperative, though it is 
 desirable in any event. 
 
 The idea of making the iridectomy some weeks previous to the 
 extraction, occurred first to Mooren, of Berlin, in 1862. He 
 applied it to all the cases of cataract that seemed to demand iridec- 
 tomy, whereas we of to-day limit it to those only where the com- 
 bined operation seems inexpedient, such as the beginning of progress- 
 ive cataract in feeble subjects and in eyes characterized by posterior 
 synechia and glaucoma. It is also applicable to most of those 
 enumerated as suitable for the combined operation. The same 
 methods are pursued, excepting, of course, that the incision is 
 made with the lance instead of the Graefe knife. The shape and 
 extent of the coloboma are regulated as in the combined extraction. 
 Be it understood, however, that in a case of glaucoma associated with 
 cataract, a long postscleral section and a broad peripheral pre- 
 liminary iridectomy are de rigueur. 
 
 The writer has had no experience with buttonholing the iris, as 
 practised by a few opthalmic surgeons and which is treated of in 
 the chapter on Accidents Consecutive to Extraction. This consists 
 in picking up a small fold midway of the iris zone and cutting out 
 
 34
 
 53 
 
 EXTRACTION OF CATARACT. 
 
 a tiny ellipse. The idea is that this hole shall form a sluice gate, 
 as it were, for the aqueous in case of after-opening of the incision, 
 thereby preventing prolapse or impalement of the iris. 
 
 Variations of Technic. The different steps of the operation for 
 cataract extraction with the corneal flap, as described in a previous 
 chapter, are by no means constant, but are 
 subject to many modifications and changes, 
 according either to the peculiarities of the 
 case, or to the views of individual operators. 
 It is the purpose of this section, therefore, to 
 cite some of the changes in, or departures 
 from, prevalent methods, or, rather, from the 
 methods already described. 
 
 Holding the Lids Apart. Some surgeons 
 prefer to operate for cataract without the 
 blepharostat, instead, having an assistant 
 perform this service with his fingers or with 
 the Desmarres retractors. The fingers alone 
 are unreliable, especially in the event of a 
 squeezing subject. The retractors, or at 
 least one retractor for the upper lid, is a safe 
 and effective means of holding the lids. A 
 new and highly efficient retractor is that 
 devised by Fisher, of Chicago. Shown in 
 Fig. 241. Its handle is of spring steel, and 
 lies over the frontal bone. Thus both the 
 handle of the instrument and the hand that 
 holds it are out of the way of the operator. 
 
 Fixation of the Globe. One may employ 
 a fixation forceps provided with a locking 
 device, but this does not conform to the later 
 and more approved ideas. Many unpleasant 
 accidents have occurred as a result of the 
 lock, for it is apt to prove stubborn in an emergency, and is, on the 
 whole, best dispensed with. An excellent method of fixation, and 
 one peculiarly adapted to use in connection with deeply set eyes, is 
 that of Czermak. This consists in grasping the tissue at the middle 
 of the inferonasal quadrant of the corneal limbus, in lieu of that
 
 VARIATIONS OF TECHNIC. 531 
 
 situated immediately below. By this mode the leverage exerted 
 upon the globe by the knife, in beginning the incision, is over- 
 come. Besides, the handling of the forceps is not interfered with 
 by contact with the lower lid-holder of the blepharostat. 
 
 Angelucci's Fixation. Angelucci, of Palermo, has given us a 
 procedure that was truly an inspiration on the part of its eminent 
 originator. This is to rotate the globe far downward and to seize, 
 with strong fixation forceps, the tendon of the superior rectus. 
 In this way not only is the eye perfectly steadied, but the upper lid 
 is held out of the way. Moreover, squeezing and attempts to roll 
 the globe upward, on the part of the patient, are done away with, 
 there is no tendency toward gaping of the wound, and the eye can 
 be closed on the instant when this is needful. This method is 
 further treated of under modified forms of extraction. The other 
 recti tendons may be similarly utilized. 
 
 Making the incision or corneal section. This lies either exactly 
 in the apparent sclero-corneal junction throughout (with or without 
 the conjunctival flap) or in this position for the lower two-thirds 
 of its course and is turned forward for the last third, ending a line 
 or two short of the upper limbus. Or the same form and direction 
 may be adhered to, while the position is just forward of the junction. 
 The extent of the incision varies somewhat with every operator 
 at one time through mere accident and at another because of a 
 definite object to be attained, as, for example, when the lens is 
 thought to be large and firm, or vice -versa. Rarely does it include 
 as much as half the corneal base (one-half the diameter), and more 
 rarely still, as little as one-third (one-fourth the diameter), the 
 average being about two-fifths of the diameter, or about 7/16 of the 
 circumference. 
 
 Conjunctival Bridge. The conjunctival flap has in some 
 instances been left undivided posteriorly. Pensier, of Avignon, 1 
 and Vacher, 2 of Orleans, hoping thereby to more surely prevent 
 vitreous loss prolapse and inclusion of the iris from simple extraction, 
 conceived the idea of leaving a broad strip of conjunctiva uncut at 
 the summit of the incision, then delivering the lens and removing the 
 
 1 " L'extraction sous conjunct! vale de la cataract," Ann. d'oc., 1899, T. 
 cxxii, p. 267 et 1900. 
 
 2 "Operation de la cataracte par le precede a pont scleroconjonctivul," 
 xiii. Congr. intern, des sc. med., sect, d'opht., Paris, 1900.
 
 532 EXTRACTION OF CATARACT. 
 
 cortex from beneath this bridge. They made upward section. 
 Desmarres is said to have operated similarly, with downward sec- 
 tion, nearly sixty years ago. Others left the bridge only until the 
 blepharostat was removed, in order to prevent vitreous escape, and 
 then divided it before proceeding with the extraction. 
 
 Subconjunctival Extraction. Czermak went further and 
 evolved his "conjunctival pouch" operation (Fig. 242). Czermak' s 
 object was to render the eye safer from both primary and secondary 
 prolapse and infection, especially to protect the wound during the 
 period of healing, from outward contamination, and to avert pro- 
 lapse of the iris. The section was made downward when iridectomy 
 
 was to be omitted, and upward when 
 not. The incision was begun with a 
 3 mm. broad Graefe knife by punctur- 
 ing the anterior chamber via a long 
 conjunctival route, withdrawing the 
 knife, then extending the conjunctival 
 cut downward and outward (or up- 
 ward and outward, as the case might 
 be), and undermining the conjunctiva 
 FlG . about the site of the proposed incision. 
 
 The latter was completed by means 
 
 of scissors. The lens was delivered, and the cortex worked out in 
 the usual manner, the spoon or the spatula being manipulated 
 beneath the conjunctiva in the pouch. The few advantages sought 
 were more than offset by the added difficulties and complications 
 incident to this mode of procedure; though in a few selected cases 
 the operation with downward section is of positive value, for instance, 
 in very deeply sunken eyes and those whose conjunctival sacs are 
 much atrophied, as from old trachoma. It has been often observed 
 that gaping of the incision occurred when made beneath the con- 
 junctiva or even with too large a flap of this membrane. 
 
 Suturing of Corneal Wound. First done, after extraction, by 
 Williams, of Boston, in 1867, and since tried by many operators, 
 notable among whom are Mendoza, Kalt, Czermak, L. Miiller, 
 Bourgeois, and Schweigger. The thread has been inserted in several 
 ways, usually engaging the cornea, on the one hand, and the con- 
 junctiva and episcleral tissue on the other, but never passing entirely
 
 THE OPENING OF THE CAPSULE. 
 
 533 
 
 through the cornea. Some, like Czermak, put the thread in after 
 completing the section; others after only partially making the cut, 
 and yet others, before beginning it. Bourgeois, 1 of Reims, in 
 addition to the corneal suture, made a special form of outward 
 section. The corneal suture has not proven a preventive of pro- 
 lapse or incarceration of the iris, as it was hoped; nor does it hasten 
 cicatrization. Besides, it is difficult to place, it prolongs the oper- 
 ation, it harasses the patient, and the knot in the thread is a source 
 of irritation. 
 
 FIG. 243. Forms of capsulotomy. The circle represents the dilated pupil. Those 
 incisions that make angles whose bases are toward the corneal incision are bad because 
 their flaps and tags get into the wound to cause iris prolapse and to delay healing, 
 a, Von Graefe. b, Von Graefe, (crucial), c, Von Arlt. d, Von Arlt. e, Weber, 
 f, DeWecker. g, Knapp. h, Czermak. i, Agnew. 
 
 Suturing of the conjunctival flap has also been tried and with 
 equally unsatisfactory results. 
 
 Opening the Capsule. From David's time down to the 
 present, the prevailing method of opening the capsule has been to 
 cut or scratch it by means of a pointed instrument either a straight 
 or an angular needle with one or both edges cutting, or a combi- 
 nation of knife and needle. The position and extent of the cut have 
 been much varied (see Fig. 243). That is to say, theoretically they 
 have been of such and such forms, but, in reality, the figure assumed 
 by the rent in the anterior capsule has, doubtless, been a very non- 
 descript sort of affair. Knapp has said of it, "mostly, it (the 
 capsulotomy) consists in an extensive and promiscuous laceration." 
 The particular style or direction of the capsulotomy is generally 
 supposed to have some bearing upon the healing process and, also, 
 
 i Annales d'oculist, Jan., 1901, p. 10.
 
 534 EXTRACTION OF CATARACT. 
 
 upon the frequency of secondary cataract. Unquestionably, that 
 manner of capsulotomy which gives the greatest number of stray 
 fragments or shreds would be the kind most often to exert an evil 
 influence upon the wound healing, but over its power to affect the 
 density of the membranous remains or secondary cataract one has 
 but little control. The author believes, with Panas, that it is not so 
 much the method pursued in the cystotomy, as the amount of 
 abandoned lens remains that predisposes, or not, to the formation 
 of secondary cataract. 
 
 A number of operators, first and last, have followed the example 
 of the Barons de Wenzel (father and son), who in the latter part of 
 the 1 8th century (about 1786), began the practice of making the 
 capsulotomy with the point of the corneal knife or keratome 
 chemin faisant, as they expressed it; i.e., after making the puncture, 
 the point of the knife is advanced to the pupil, depressed till in con- 
 tact with the capsule, a certain movement is made to incise the 
 capsule, and, following this, the counterpuncture is made, and the 
 section completed in the ordinary way. Among those w r ho have 
 of late years revived this old method have been Gayet, of Lyons, 
 and Galezowski and Trousseau, of Paris. The last operator goes so 
 far as to employ no other instrument in the entire operation of 
 simple extraction save the Graefe knife. 
 
 The guiding principle in the making of the capsulotomy and 
 corneal section simultaneously is the lessening of the hazards of 
 the operation by the insertion of the fewest instruments possible. 
 Now however commendable this may be and clever as is the feat, 
 it is not good surgery. Each of the operative steps is of too great 
 importance to be accomplished by a bungling compromise which is 
 disparaging to both. For, as to the capsulotomy, it is apt to be 
 insufficient and wrongly placed If there is an opaque liquid 
 (Morgagnian) within the capsule, this escapes, thus obscuring the 
 field and embarrassing the operator; and if the capsule is resisting, 
 there is greater risk of rupturing the zonule. It also inclines to 
 jaggedness of the corneal incision and premature escape of the 
 aqueous, all of which but tends to vitiate the result. 
 
 Daviel practised plucking out, or arrachement, of the anterior 
 capsule when it was th ckened, etc. De Wecker, of Paris, thought 
 to advance the status of cataract extraction, especially in regard to
 
 CLEARING OUT LENS REMAINS. 535 
 
 immunity from after-cataract, by tearing away all or a portion of 
 the anterior capsule as a systematic measure, and withdrawing it 
 from the eye. For this he had constructed a pair of specially 
 designed forceps, with sharp back teeth, which he named, "forceps- 
 cystotome." These he used with more or less regularity for a time, 
 and could boast of having his example followed by such men as 
 Schweigger, Knapp, and Fuchs but the procedure has mostly 
 fallen into merited disuse, saving for a few chosen cases such as 
 lenses with opaque capsules, for the removal of which the pro- 
 cedure and the forceps still serve admirably. Its shortcomings are 
 in many respects similar to those of combining the cystotomy with 
 the corneal section, viz., uncertainty as to the extent and character 
 of the opening and rupture of the zonule from the pressure that 
 must be made in order to seize the capsular membrane. It is 
 difficult of accomplishment through a small pupil. 
 
 I prefer Knapp's peripheral capsulotomy to others because it 
 gives the most rationally situated opening for the exit of the lens; 
 it lends itself to the horizontal manipulation of the cystotome; 
 being close up under the incision, the impulse of the lens as it rises 
 in the direction of least resistance can be readily observed. 
 Where an iridectomy has been made, the coloboma affords an open 
 field for nearly the requisite length of the incision; yet, a small 
 round pupil does not interfere with its proper making, since the 
 extremities can easily be extended beneath the iris. It has not been 
 proven as has been asserted that it leads oftener than any other 
 method to the formation of after-cataract. 
 
 Expelling the Lens. For this, instead of using spoons, ex- 
 ternally applied to the globe, some surgeons resort to pressure with 
 the fingers, placed either directly upon the eyeball or acting through 
 the medium of the lids. When we reflect how utterly impracticable 
 it is to rid the fingers, the conjunctiva, the cilia, and the orifices along 
 the lid margins of bacteria, the clumsiness of this measure is 
 lost sight of, and we wonder only at its uncleanliness surgically 
 
 speaking. 
 
 Clearing Out Lens Remains. Irrigation of the anterior 
 chamber for washing out the cortex has been variously tried, as to 
 the instrument, the technic, and the quality of the liquid employe- i. 
 and, for the most part, abandoned, it being ineffective for any but
 
 536 EXTRACTION OF CATARACT. 
 
 the light, fluffy, and more innocuous kind and, at the same time, too 
 often provocative of unfavorable reaction. Panas has been re- 
 ferred to as the originator of this process, which is an error, as his 
 lavage was purely to free the anterior chamber of possible sepsis. 
 Its real origin goes much farther back even to Guerin, and the 
 year 1773. It was little practised, however, till revived by Heymann, 1 
 who used physiologic salt solution for cleansing the eye of blood. 
 Since that few have not, at some time, tried it, in conjunction with 
 extraction, yet few also have become advocates of it as a routine 
 practice. The chief exponent of the measure in this country is 
 Lippincott, 2 of Pittsburg; and the latest model of his irrigator is 
 probably the most suitable instrument for the purpose. Lately a 
 small coterie of ophthalmic surgeons at Bordeauxs have insisted 
 that the double-cannula piston syringe, for simultaneous injection 
 and aspiration, is the only fitting instrument. A review of the sub- 
 ject by the present writer is to be found in the Ophthalmic Record 
 for March, 1905. 
 
 Fuchs, of Vienna, actually puts a spoon, similar to Desmarres', 
 into the anterior chamber and ladles out the remaining cortex. 
 This seems a bold proceeding, though it works to the entire satis- 
 faction of its distinguished partisan, which counts in its favor. 
 
 COMPLICATED AND SOFT CATARACTS AND SPECIAL 
 MODES OF EXTRACTION. 
 
 Under this heading may be classed all those cataracts that do not, 
 generally speaking, admit of being handled according to the methods 
 already described or by the treatment to w T hich other methods are 
 better adapted. Among these may be mentioned shrunken, ad- 
 herent, dense membranous, tremulous, dislocated and soft, swollen 
 cataracts causing glaucoma after discission. A brief discussion of 
 them in the order of their importance follows. 
 
 Linear Extraction. This term refers to the manner of making 
 the incision (full linear incision has already been spoken of). 
 To-day, when one uses the term, it means merely an incision with 
 the lance-knife or keratome, and is the kind best fitted for several va- 
 
 1 Klin. Mbl. f. Aug., 1864, S. 305. 
 
 2 Am. Jour, of Oph'y., July, 1904. 
 
 3 Archives d'ophtalmologie, Feb., 1905.
 
 COMPLICATED AND SOFT CATARACTS. 537 
 
 rieties, of cataract notably, shrunken cataracts, those membranous 
 cataracts that are too dense or too tough for ordinary discission, 
 zonular cataracts, and for the extraction of those swollen lens masses 
 that, after discission, cause serious reaction, such as high tension, 
 etc. In truth, it is my belief that the keratome could, in many 
 instances, be used with advantage to supersede the Graefe knife. 
 
 Advantages of the Keratome. Its wound heals with exceptional 
 readiness and kindliness. This is probably owing to the fact that 
 it lies chiefly in one plane, without notching and other unevenness. 
 The aqueous humor can be better controlled, i.e., it can be more 
 surely held back or evacuated with greater discernment; hence, also, 
 the iris behaves better; the act of making the cut is less startling 
 to the patient and he remains more quiet, thus reducing the risks. 
 So, for these and other reasons, the incision can be more accurately 
 placed. The most commonly urged objection to the keratome for 
 cataract extraction is that the wound opening is too small. If one 
 will practise on pigs' eyes, the making of a surprisingly large open- 
 ing, of very short wound canal, is speedily arrived at. The essentials 
 are that the blade be extra broad, that in starting the cut the lane 
 of the blade be held about at a right angle to the corneal curve until 
 the point enters the anterior chamber, then depressed till it is parallel 
 with the plane of the iris, holding strictly to this and advancing 
 until the point cannot be pushed any further. Then the heel of 
 the knife is turned to the side where the cutting lacks most, holding 
 if possible to the same plane, and the incision is extended while 
 withdrawing the blade. It is my custom, when a long cut is 
 needed, to begin not in the vertical meridian, but a little to the 
 left of it, and finish by lengthening it to the right. The eye must 
 be carefully steadied during this final maneuver, the knife held 
 very firmly, and the sweep that makes the extension be executed not 
 too swiftly, else the patient may wince, or the direction of that 
 part of the incision be faulty or dangerous. In this way. the 
 anterior chamber being of normal or greater than normal depth, a 
 wound opening measuring a centimeter or more quite ample for the 
 exit of an average sized lens can, after a little preliminary practice, 
 as suggested, be quite readily accompl shed. It is most suitable 
 for purposes of extraction when it lies, throughout, barely anterior 
 to the apparent sclero-corneal junction.
 
 538 EXTRACTION OF CATARACT. 
 
 If, after all, the incision seems inadequate, it can be enlarged 
 with scissors or blunt-curved knife. That these, or one of them, 
 are at hand, ready prepared and extra sharp, goes without saying. 
 If a conjunctival flap is desired, it may be first fashioned with 
 forceps and scissors, then turned down, over the cornea, and the 
 keratome incision proceeded with. 
 
 Shrunken, adherent, and dense capsular are several qualities 
 often found in a single cataract. They are most frequently met 
 with in old traumatic cataracts, particularly those that have been at 
 some time attended with partial absorption or inflammatory proc- 
 esses, and are characterized by calcific and connective-tissue 
 degeneration. Not unlike these, in many respects, are the shriveled 
 and generally anomalous varieties of congenital cataract. These 
 and the dislocated cataracts, in short, all that are not best dealt 
 with by the flap operations, previously described, or by discission, 
 are proper subjects for extraction with keratome incision. In but 
 few is the use of the cystotome indicated. In that form where there 
 is considerable posterior synechia with dense anterior capsular 
 opacity which makes the plucking out of the latter with the 
 back-tooth forceps impracticable it is best to make preliminary 
 iridectomy. This will expose a greater area, wherein, when it comes 
 to the extraction, a fair and sufficient capsulotomy can be made and 
 the lens expelled in the regular manner. A subsequent discission 
 of the thick membranous cataract which is left behind is usually 
 sufficient to establish a good pupil. In the event of dense anterior 
 capsular cataract without a great deal of posterior synechia, with- 
 drawal with the capsule forceps is a good procedure. It may 
 happen that the lens will come out with it so much the better; 
 but it is well to watch closely and be prepared for this contingency 
 
 Whenever preferable, from inability to dilate the pupil or any 
 cause, to make iridectomy in these peculiar cases, the preliminary 
 is the best. There will then be no blood in the anterior chamber 
 to hamper the extraction, the degree of traumatism w r ill be less and, 
 moreover, one learns something of the character of the patient 
 before reaching the more critical operation of extraction. An 
 upward iridectomy and extraction are preferable, though the position 
 of the least number of iris adhesions or of a dislocated lens will 
 sometimes furnish reasons for departing from the rule. In all save
 
 COMPLICATED AND SOFT CATARACTS. 539 
 
 those in which a regulation capsulotomy is feasible, a traction instru- 
 ment for the getting out of the cataract will be necessary. My 
 preference is for the open sharp hook for the lenses and the blunt 
 hook or iris forceps for the mats. Each operator must decide 
 as to whether local or general anesthesia be employed in a given 
 case. I have made a great number of extractions of complicated 
 cataracts, many of which were luxated, and I have not resorted to 
 general anesthesia as many as three times. 
 
 For the better elucidation of this subject, permit the citing of 
 actual cases illustrative of the several kinds of cataracts and of the 
 methods alluded to in this chapter, wherein they were put by the 
 author to a practical and successful test. 
 
 Case i. Example of Extraction of a Shrunken, Lightly 
 Adherent Cataract, with Calcific Degeneration of the Anterior 
 Capsule. Stewart S., age 22, farmer. Came to me September 15, 
 1903. At age of 7 years received blow in the right eye from end of 
 stick in the hand of a small brother. In due time the sight of the 
 eye failed and the pupil looked white. The central portion of the 
 cataract was snow-white and dense. The iris was adherent below, 
 while the rest of the pupil dilated fairly well. The denser portion 
 of the cataract was about the size of the normal pupil, the rest was 
 gray with radiating streaks of white, and the whole looked shrunken. 
 
 The operation occurred September 17, 1903, at the Passavant 
 Hospital. Cocain. Incision with broad keratome was made at the 
 upper sclero-corneal junctipn and the point of the knife made to incise 
 the zonule below. While the upper lid was held back by an assist- 
 ant, De Wecker's capsulotomy forceps, or forceps cystotome, was 
 introduced, the thick portion of the capsule was seized and with- 
 drawn. This set free the small, hard, opaque lens, about the size 
 and shape of a lentil. Behind this the small sharp hook, of well 
 open pattern, was inserted flatwise, then turned point forward and 
 the lens caught and delivered. After closing the eye and waiting a 
 few moments, the iris, although it had been pulled slightly into the 
 wound, was found again in place with round pupil. There was no 
 loss of vitreous. The eye recovered promptly, but with little vision, 
 owing to rupture of the choroid caused by the original injury. 
 The patient returned to his home in Iowa on the 26th of the same 
 month.
 
 540 EXTRACTION OF CATARACT. 
 
 For cases of complete posterior synechia with cataract, where 
 an attempt at iridectomy would but result in stripping off the outer 
 layers, leaving the uvea on the capsule, and where the anterior 
 chamber is extremely shallow, the operation of de Wenzel 'might 
 be resorted to. The elder de Wenzel, about a century and a 
 quarter ago, devised an operation for that forlorn class of cases 
 characterized by very extensive or total posterior synechia with 
 thickened anterior capsule or atresia of the pupil, shallow anterior 
 chamber, etc., that is not a bad procedure to-day. It was the 
 making of a large corneal flap just as for the ordinary extraction, 
 except that it included the iris and lens. In other words, the knife 
 was made to pass through these tissues as if they did not exist. 
 Then as much as was practicable of the iris flap was excised, and 
 the lens expelled by external pressure. Snellen, " Operationslehre," 
 of the Graefe-Saemisch Handbook, p. 46, cites the case of an eye 
 upon which he himself made the de Wenzel operation with 
 brilliant success. 
 
 Case 2. Example of Extractions of Congenital Capsule- 
 lenticular Cataract. Agnew's Modified Hook Operation. 
 This is the method by which, while serving as house surgeon, I had 
 seen Dr. Agnew, of New York, make extraction in similar cases, 
 at the Manhattan Eye and Ear Hospital. I know that his first 
 hook extractions were made as follows : 
 
 He first introduced a strong needle through the cornea, infero- 
 temporally (for the right eye), passed it through the lower junction 
 of cataract and zonule, gave it a rocking motion to enlarge the 
 opening slightly, held the needle there to fix the eye, made keratome 
 incision above, and put in a blunt hook. He then withdrew the 
 needle and inserted the hook at the opening made in the cataract 
 by the needle, pulled out the cataract and had an assistant cut its 
 zonule off as one would the iris in iridectomy. He had aban- 
 doned this method before my connection with the hospital and 
 before I became familiar with his work. 
 
 Archie K., age 16 months, German. Brought by his parents May 
 3, 1888. Born with "white pupils." There were also convergent 
 strabismus and nystagmus. The pupils dilated freely under 
 mydriatic. Cataracts were exactly alike in both eyes. The central 
 portions, occupying an area above the size of the normal pupil, were
 
 COMPLICATED AND SOFT CATARACTS. 541 
 
 dense, thick, and chalky-white, of irregularly rounded outline. 
 Radiating from these were numerous streaks of white and gray, in 
 places so thin as to be almost transparent, the whole having a 
 wrinkled appearance and apparently containing no soft material. 
 Evidently, not a case for either discission or dilaceration. Advised 
 extraction. 
 
 June 15, 1888. Agnew's blunt-hook operation, the technic of 
 which is as follows: Right eye. Pupil dilated. Chloroform. 
 Superior keratotomy with lance-knife or iridectomy knife, point 
 pushed far in and thrust through the cataract, or rather through 
 the zonule, below the thicker portion, and behind the lower border 
 of the pupil. While an assistant steadied the eye with the fixation 
 forceps, I took the blunt hook in the left hand and iris scissors in 
 the right, introduced the former at the wound, inserted the point 
 in the cut made through the cataract below, made slow traction, at 
 the same time giving the handle of the hook about a quarter turn 
 on its long axis, so as to pass the crook flatwise through the incision, 
 drew out all the thicker portion of the cataract and cut off the 
 adherent zonular shreds close to the cornea. No loss of vitreous, 
 no iris complications. Quick recovery with round black pupil. 
 
 August 2, 1888. The same operation was made on the left eye. 
 Same result, except that a single adhesion occurred below, where the 
 iris was so drawn upward as to produce a heart-shaped pupil. This 
 was later freed by discission and the pupil became round. The boy 
 was last seen in August, 1897, when I made advancement of the left 
 externus for the correction of the squint. At this time, when 
 sent back to his home in Ohio, there was no strabismus, the nystag- 
 mus was hardly perceptible, and the vision of each eye, with lens 
 of +10 D, was 20/70. The reduced vision being due to lack of 
 development of the retinae and choroidea, common to these cases. 
 
 I have since, in numerous instances, availed myself of the great 
 advantages afforded by this procedure, and always with most grati- 
 fying results. It is specially applicable to certain forms of congenital 
 cataract, such as the irregular zonular type, that are of stunted 
 growth, and are more or less apaque throughout; also to the dry 
 largely membranous ones, named by Schmidt "aride si'ln/iicnsi-" 
 cataracts. The measure is equally suitable for the extraction of 
 many of the shrunken traumatic cataracts. A trained assistant is
 
 542 EXTRACTION OF CATARACT. 
 
 needed, particularly if narcosis is employed, to fix the globe, after 
 the incision is made, leaving the operator free to use both hands in 
 manipulating hook and scissors. 
 
 Case 4. Example of Extraction of Large, Slightly Luxated, 
 Tremulous Morgagnian Cataract. Angelucci's Fixation. 
 Robert Cummings, age 64, shoemaker. Admitted to the Illinois 
 Charitable Eye and Ear Infirmary, October i, 1903. Left eye be- 
 came inflamed and sight impaired twelve years ago, and has since 
 been subject to frequent attacks of pain and redness with gradual loss 
 of vision. Lost sight of right eye six weeks or two months ago. 
 Condition on admission: right eye slightly red; cataract of an even 
 whiteness; iris molded to the lens, and both very tremulous; pupil 
 responds to mydriatic. The lens is misplaced slightly inward. 
 Anterior chamber rather deep, T normal, fair perception of light, 
 field and projection faulty. Left eye dusky red, globe very soft. 
 Myosis. Iris adherent to anterior capsule of lens, the latter being 
 thick and white. Bare perception of light, with field of vision and 
 projection lacking. 
 
 Seeing that capsulotomy is out of the question in the extraction 
 of a dislocated lens, the incision is followed immediately by the 
 delivery of the lens with a traction instrument. The incision is 
 sometimes best made with the Graefe knife, though occasionally 
 with the keratome, and the operator must use his judgment, in view 
 of the size and relation of the lens to its surroundings. 
 
 For the extraction made in this case, the writer availed himself 
 of the method of fixing the eye and of holding it open, devised by 
 A. Angelucci. 1 
 
 October 5, 1903. Preliminary iridectomy of right eye. Following 
 the excision of the iris, notwithstanding the fact that the patient's 
 behavior was the very best and nothing was pressing on the eye, a 
 small quantity of thin vitreous flowed from the wound. After this, 
 all went well and the eye was quiet by the zoth of the month. 
 Through the large coloboma, the milk-white cataract could be seen 
 extending very far out, i.e., the equator of the lens was not yet 
 in view. The problem that now presented itself, was how to extract 
 the cataract with promise of smallest loss of vitreous. Resolved to 
 try the method of Angelucci. This is to hold the globe by seizing 
 
 1 Arch, di ott., vol. v, fasc. 3-4.
 
 COMPLICATED AND SOFT CATARACTS. 543 
 
 with strong fixation forceps (no catch) the tendon of the superior 
 rectus muscle. This was put into execution October 29th, and my 
 sincere thanks, as well as those of the patient, are due the noted 
 Italian surgeon for a measure that was truly an inspiration. 
 
 The eye was cocainized, the upper lid held back, the patient told 
 to look down, and the whole tendon of the superior rectus was 
 caught, not in a fold, but by placing a jaw of the forceps on either 
 side of it. A free upward section of the cornea was made with a 
 small Graefe knife, the open sharp hook was inserted behind the 
 lens, dug into it, and, at the first pull, the capsule ruptured and 
 there gushed out of the incision a great quantity of liquor morgagnie. 
 It did not get in front of the lens, yet after its escape the pupil was 
 black no cataract was to be seen. The first thought was, of course, 
 that the hard nucleus had dropped into the vitreous chamber. 
 On peering sharply into the coloboma, however, there appeared the 
 merest glint of gray. Still keeping a firm hold on the tendon, the 
 hook was carefully passed flatwise behind this faint opacity, point 
 turned forward and drawn out. With it came a very large nucleus 
 of inky blackness. Strange to relate, not a drop of vitreous was 
 lost, for not only did the grip on the superior rectus steady the globe 
 perfectly, but it served three other most important functions, viz., it 
 held back the upper lid, it so paralyzed the muscle that there was 
 not the least tendency of the eye to roll upward, and, most essential 
 of all, it caused strong tendency to closure of the wound. Fixation by 
 the ordinary method, below the cornea, would have had the opposite 
 effect, and there would certainly have been an outflow of vitreous. 
 The eye recovered without accident and the patient was discharged 
 Nov. 23d, with corrected vision of 20, 70. Under treatment the 
 left eye became quiet. I have a number of times since, in cases 
 where there was likely to be loss of vitreous in an extraction, resorted 
 to the Angelucci fixation, and always with the greatest satisfaction. 
 
 Case 5. Example of Extraction of Cataract Dislocated and 
 Lying in the Anterior Chamber. William Pearson, age 34, coach- 
 man. Admitted to the Eye and Ear Infirmary, October 15, 1892. 
 Recurrent severe inflammation and loss of sight of the right eye. 
 Eye has been operated upon elsewhere (iridectomy) and had since 
 remained quiet, though with a cataract. The day before coming 
 to the hospital, while bridling a horse, the animal in shaking its
 
 544 EXTRACTION OF CATARACT. 
 
 head, struck the patient a severe blow on the right temple, when 
 he immediately felt that something had happened to the bad eye. 
 Condition on admission: Right eye painful, conjunctiva injected, 
 large cataractous lens in anterior chamber, upward coloboma 
 of the iris. Vision nil. Left eye normal. Operation at once. 
 
 Eserin was used, but owing to the previous iridectomy, it had 
 scarcely any effect upon the pupil. While the eye was being put 
 under cocain, I remarked to those around that it would be neces- 
 sary to introduce a needle to hold up the lens, else it might drop 
 through the large opening into the vitreous. The words were 
 scarcely uttered before, through a quick movement of the eye, the 
 cataract disappeared in the manner suggested. I then turned the 
 man over on his stomach with his face projecting beyond the end of 
 the table and asked him to let me manipulate his head as if it were 
 not attached to his body. By this means the cataract was brought 
 again into the anterior chamber. He was turned on his right side, 
 a delicate Bowman needle was inserted, from the nasal limbus, 
 behind the lens, he was turned further so as to lie somewhat on his 
 back, a downward section of the cornea made and the cataract ex- 
 tracted without other accidents. Recovery was prompt and the eye 
 appearing normal afterward, save for the old coloboma. 
 
 Case 6. Example of Extraction of Swollen Lens Causing 
 Severe Secondary Glaucoma After Discission for High 
 Myopia. The citation of this case serves more, perhaps, to point a 
 moral than to adorn a chapter on the surgery of the eye. Sophia 
 Lee, 12 years old, Chinese girl, came under treatment May 5, 1900, 
 wearing loD over both eyes. Could no longer see well at a distance 
 with her glasses. Tests then show r ed R. V. = 2/200; 20/50 w 16. 
 L. V. =2/200; 20/70 w i6. Cylinders did not improve. Ophthal- 
 moscope showed small conus and very striking fundus tigree in both 
 eyes. Advised discissions. 
 
 September n, 1900, tentative discission in left eye, very slight 
 reaction; September 20, 1900, more thorough discission in left eye. 
 Crystalline very soon broke up and by February i, 1901, had all 
 disappeared, leaving a small capsular band across the pupil. Test 
 showed, L. V. =10/200; 20/30 +w 2.5 c ax 155. April i, 1901, 
 first slight discission in right eye. No special reaction. April 
 23, 1901, more decided operation capsule and lens well incised.
 
 EXTRACTIOX OF THE LENS IN ITS CAPSULE. 545 
 
 Lens slowly broke up. About May 6th there was considerable 
 swelling of lens and some pain. Eserin was instilled which seemed 
 to relieve the symptoms, and the child was given a solution of the 
 same to use at home. Saturday, May 8, T normal and' eye fairly 
 quiet. 
 
 Although under instructions to report often, and though she had 
 been very faithful in her attendance at my office, I did not see her 
 again until Wednesday, May 12, 1901. The eye had been very 
 painful since Saturday evening (the 8th), the T was very high and 
 the eye very red. Her mother had objected to her going out, on 
 account of the condition of the eye. I at once made superior kera- 
 totomy with keratome. A quantity of soft lens material followed the 
 withdrawal of the instrument. A thin spatula was inserted to hold 
 back the iris and to form a chute for the remaining masses, and by 
 manipulation of a hard-rubber Graefe spoon on the anterior surface 
 of the cornea, most of them came out. The iris .was not disturbed. 
 The eye immediately became comfortable, was bandaged, and, with 
 twenty-four-hour dressings, after a few days, seemed to have re- 
 covered. On examination of the field, however, it was found lacking 
 on the nasal side. In spite of treatment the defect persisted and 
 to-day it extends barely to the left side of the center. R. V. = 
 20/200 w + 2cx 90. The vision of the left, with glasses, is now 
 (Jan., 1904) 20/30 + 2, and she reads the finest print. Has been 
 regularly in school for the past two years. I should never again, 
 under such circumstances, allow the patient to stay at home, but 
 should insist by all means upon the hospital. 
 
 EXTRACTION OF THE LENS IN ITS CAPSULE. 
 
 Beer, in Vienna, at the close of the i8th century, tried plunging 
 the lance-knife, with which he made the corneal incision, into the 
 lens, mobilizing the latter, completing the section, then expelling the 
 lens by pression. Often, however, the cataract came out with the 
 knife. The first recorded extractions of the cataract and capsule 
 intact were made by Samuel Sharp, of London, in 1753. The 
 famous Gottingen surgeon, August Gottlob Richter, took it up 
 twenty years later, or about the year 1773. So, for one hundred and 
 fifty years eye surgeons have striven for that ideal a safe method 
 35
 
 546 EXTRACTION OF CATARACT. 
 
 of extraction of the lens in its capsule, applicable to senile cataract 
 in general thus, once for all, doing away with two of the great 
 evils the residual cortex and the secondary cataract. After giving 
 it a fair trial, meanwhile endeavoring to correct its faults, these 
 illustrious surgeons relinquished it and fell in with redination 
 instead. 
 
 After completing the corneal incision, Richter expressed the lens 
 by steady and gentle squeezing of the globe. Beer, at a later 
 date (1790), introduced a needle at the incision, transfixed the 
 cataract, and by moving it about in various directions loosened the 
 zonule, and then extracted by external pressure. They both operated 
 downward, by large linear incision, and without iridectomy. The 
 method found few imitators and soon fell into disrepute, until 
 revived, in 1845, by Christisen. This operator made pressure 
 upon the globe just before finishing the corneal section, to cause 
 the lens to break its zonule and to present at the wound, completed 
 the section, and expressed. 
 
 From 1865 to 1889, the brothers Alexandre and Hermann 
 Pagenstecher, of Wiesbaden, went extensively into the work and, 
 by a long series of extractions, attempted to popularize it, while 
 still making the Graefe modified linear incision. Alexandre Pagen- 
 stecher added to it a broad iridectomy, then delivered the lens 
 by means of his broad shallow spoon. Later they adopted the 
 large corneal flap extraction, adhering still to the spoon delivery, 
 but only for the more obstinate lenses that did not respond readily 
 to pressure. The surviving brother, Hermann Pagenstecher, 
 has relinquished the measure save for exceptional cases. As a 
 result of the favorable reports of the operation by these very able 
 surgeons, it was taken up by many others in this country by Knapp 
 and Roosa. 
 
 The last-mentioned surgeon, in 1884, after a visit to Wiesbaden, 
 made a number of intracapsular extractions, but soon became dis- 
 couraged by the very high percentage of vitreous loss. He essayed 
 the breaking of the zonule by pressing down upon the lens with the 
 knife, just after making the counterpuncture, slightly turning the 
 back of that instrument toward the anterior capsule the while. 
 
 Still more recently (1895) the late Gradenigo, of Naples, under- 
 took it. After making corneal section, he introduced a small and
 
 INDIAN" METHOD. 547 
 
 specially constructed blunt hook, which he called a zonulotome, 
 tore the zonule below, and expelled the lens. Delgado first mobil- 
 ized the lens by entering a needle through the cornea, as if for 
 discission, withdrew it, made a large peripheral (scleral) incision 
 upward, iridectomy, and expulsion of cataract. In short, a great 
 variety of ideas for division or rupture of the zonule have been put 
 into practice. Yet any procedure whereby the zonule is torn or cut 
 before efforts are made to express the lens is open to the serious 
 objection that the vitreous is more likely to present itself at the 
 wound in advance of the lens, thus rendering worse than useless 
 further attempts to expel the cataract by external pressure. 
 
 "IXDIAN" METHOD. 
 
 Of more than passing interest for the past 12 or 14 years has been 
 the exploitation of extraction in the capsule, by extraocular manip- 
 ulation, under the name of the "Indian method"; and in the 
 same connection one is accustomed to see or to hear the name of 
 Major Henry Smith, of Jullundur, Punjab, India. Herbert, in his 
 most excellent work on Cataract Extraction, 1908, p. 252, says: 
 "The work in India was begun by Mulroney, at Amritsar in the 
 Punjab, in 1890. He made a downward section without iridectomy, 
 and expelled the lens by manipulation. In 1893, M45 f these 
 operations were performed as Amritsar. Henry Smith, at Jullundur, 
 also in the Punjab, adopted the method, but preferably with an 
 upper section, and laterly with iridectomy. Obtaining better results, 
 he has expanded the work greatly. Now the extractions at Jullun- 
 dur number about three thousand per annum. According to Arnold 
 Knapp, the operating season at Jullundur comprises only 6 weeks 
 spring and autumn, about 1,000 extractions occurring in the spring 
 and 2,000 in the fall 42 days for 2,000 or nearly 50 every day. 
 In the year from May 31, 1904, to May 31, 1905. 'Smith extracted 
 2,616 cataracts in their capsules, and only 151 with capsulotomy. 
 With this extraordinary experience he has clearly and authoritatively 
 established expression as the correct method of delivering the k-ns 
 in its capsule, and has shown that it is applicable to the large 
 majority of senile cataracts." 
 
 The operation, as performed by Major Smith, given in his own
 
 548 
 
 EXTRACTION OF CATARACT. 
 
 words, is as follows: "An incision is made upward, beginning in 
 the corneo-scleral junction and ending well within the cornea. It 
 includes a little less than half the circumference of the sclero-cornea. 
 I personally prefer the incision finished in the cornea without a 
 
 conjunctival flap, as the flap is more or less in the way. An iri- 
 dectomy may or may not be done, according to the operator's fancy. 
 The speculum is now removed, the assistant draws down the lower 
 eyelid, with the face of his thumb placed on the skin below it; with
 
 INDIAN" METHOD. 549 
 
 his other hand he lifts the upper eyelid forward with a large-sized 
 strabismus hook (Fig. 244), in his first three fingers, as if he were 
 lifting the contents of the orbit out of the socket, and not lifting it 
 toward the brow, using the ring and little finger of the same hand to 
 draw back the brow and orbicularis muscle. This does not imply 
 any violence on the part of the assistant. 
 
 "The operator now places the end of a large-sized ophthalmic 
 spatula (Fig. 245), on the left side of the cornea over the junction 
 of the middle and lower third of the lens. He places the end of a 
 large-sized blunt-pointed strabismus hook over the corresponding 
 position to the right of the spatula (Fig. 246). He makes steady 
 pressure backward toward the optic nerve with this spatula, and 
 he makes similar pressure with the strabismus hook except that 
 in making pressure with his strabismus hook he draws it backward 
 and forward across the cornea. The edge of the lens at the wound 
 will be seen to tilt forward and the clear vitreous will be seen be- 
 tween it and the scleral margin of the wound. As soon as this 
 occurs, the pressure with the spatula should practically cease and 
 the same stroking movement of the strabismus hook should be 
 continued, its position not being altered on the cornea at first, but 
 the direction of the pressure exerted through it should be altered 
 gradually more and more in the direction of the wound until it 
 finally folds the cornea beneath the lens; at this stage the lens is 
 delivered. The iris should be replaced if prolapsed. The assistant 
 should then let go the eyelid, and the patient's eye should be 
 dressed up. 
 
 "I may here state that my experience now extends to about 20,000 
 cataract extractions, about 17,000 of which have been in the capsule, 
 and amongst the latter have been many immature cataracts, 
 especially in recent years." 
 
 Major Smith lays great stress on two points, viz., that the pressure 
 be gradually applied, and that plenty of time be allowed in delivering 
 the lens. If the first point is not observed the capsule is apt to 
 burst, and neglect of the second is sure to result in loss of vitreous 
 or other complication. "The pressure exerted is moderate, slow 
 and continuous, gradually relaxing in amount, as the lens is seen to 
 be well on its outward way. The process must be done slower, 
 and with much more deliberation than in the capsule laceration
 
 550 EXTRACTION OF CATARACT. 
 
 operation. The continued pressure quickly tires out the iris, which 
 dilates and allows the lens to emerge very like the process of par- 
 turition. If the expression be attempted rapidly, the capsule will 
 probably burst just as it is coming out. If this accident does 
 happen, it is best to keep up the pressure with the hook, so that the 
 capsule does not retract, and try and gently drag it out with a pair 
 of ordinary dissecting forceps applied to the part outside the wound. 
 The broad hold so secured will often succeed in drawing out the 
 whole of it with its contained lens matter." 
 
 "When the lens is halfway out . . . a clear point of vitreous will 
 occasionally appear in the wound behind the lens. . . . The spoon 
 in the left hand . . . should be pushed beneath the lens through 
 the clear point and the lens suspended on it. Once the lens is 
 supported on the spoon the strabismus hook can be used as before 
 to drive out the lens, the spoon merely coming with the lens, but 
 not drawing it out. ... If we attempt to lift out the lens on the spoon 
 merely, the capsule will give away with exceeding frequency." 
 
 "In addition to this occasional insertion of the spoon, the iris 
 forceps have sometimes to be introduced to seize ruptured capsule. 
 If the capsule has retracted, we should try by gentle stroking to 
 press out its contained lens matter, . . . and if the capsule be evi- 
 dent to the eye, we may make an attempt to catch it with an iris 
 forceps and fetch it out. Where no accident occurs the only instru- 
 ment introduced into the globe is the knife. Ordinary dissecting 
 forceps are used for seizing ruptured capsule lying in the wound." 
 
 Iritis followed where the capsule was left behind in about 5 per 
 cent, of the cases, and only 0.34% out of the 2,616 were failures: one 
 due to suppuration; one due to hemorrhage; and in another the eye 
 shrunk after an extensive loss of vitreous. Iritis was, he thought, 
 not due to bruising, but to the retention of lens matter and capsule. 
 
 In consequence mainly of Smith's reports many ophthalmic 
 surgeons all over the world have been emboldened to make trial 
 of the method. In the United States alone the number of would-be 
 imitators of Major Smith has been a large one. So far as the writer 
 has been able to inform himself, however, practically all have given 
 up the method, deeming it inadmissible save for an occasional 
 selected case. The chief reasons for their disaffection toward it 
 will be found in the following paragraphs.
 
 "INDIAN" METHOD. 551 
 
 The enthusiastic reports of this Anglo-Indian surgeon have led to 
 another attempted revival of this coveted form of extraction, and it 
 will be interesting to those not immediately concerned to watch the 
 results. 
 
 1. The High Percentage of Vitreous Loss. This is the greatest 
 objection to extraction of the encapsuled lens, and the one that will 
 probably forever prevent its adoption as a routine measure. More- 
 over, it is to this great drawback that most of the others here enu- 
 merated owe their origin. The dire consequences directly and 
 indirectly traceable to this accident have already been treated of 
 under accidents immediate and consecutive. They include expul- 
 sive choroidal hemorrhage, suppuration, acute iridocyclitis, slow 
 and prolonged uveitis, all classes of iris complications, hyalitis, 
 glaucoma, detachment and degenerations of the retina, etc. Major 
 Smith in several large series of such extractions reports vitreous 
 escape vary ing between 6 and 8%. Herbert says, "No other operator 
 has succeeded in approaching this low percentage." Of the 
 hundreds of skillful ophthalmic surgeons who have attempted 
 the operation few have reported as low as 25%, and most of them 
 something between 30% and 50%. While the same surgeons, 
 operating in the usual manner, with capsulotomy, have kept the 
 percentage down to from i to 6%. 
 
 2. Rupture of Capsule. No matter how clever the operator, 
 he can never be certain of delivering the lens with its capsule intact. 
 At the hands of Major Smith himself the capsule breaks in 5 to \ 
 of cases at those of otKers in 16', and upward. If. as most 
 often happens, the capsule must then be left in the eye, the condi- 
 tions are worse than if ordinary extraction had been choosen. For 
 it must be remembered that the rupture occurs in most instances 
 when the cataract is nearly delivered, that is, when the zonule 
 has been torn away from its supports, thus leaving the capsule free 
 to get into the corneal wound. This leads to delayed union. It 
 is likely, too, that the abandoned capsule contains cataract matter, 
 and the whole forms a crumpled mass, more potent for trouble, 
 perhaps, than the smooth encapsuled cortex remaining after other 
 
 methods. 
 
 3. Iris Complications. Owing to the relatively great frequency 
 of vitreous loss, also to the extent of the primary incision, the proper-
 
 552 EXTRACTION OF CATARACT. 
 
 tion of prolapses, incarcerations, retractions, inversions, and distor- 
 tions of the iris is inevitably greater with this kind of extraction. 
 If vitreous has presented or escaped, it makes impossible the reposi- 
 tion of a prolapse either at the time of the operation or afterward, 
 and it just as effectually prevents dealing with the pillars of the 
 coloboma that are more often caught by the incision in the " Indian" 
 operation. 
 
 4. Toilet Difficulties. Ophthalmic surgeons are practically 
 a unit as to the great importance of a finished toilet after extraction. 
 This means not only replacing of the iris, but seeing that there is nice 
 coaptation of the lips of the wound, that the conjunctival flap is in 
 its place, and that there are no shreds of fibrine clinging to the 
 incision. And, lastly, it means a gentle douching of the conjunctival 
 sac. None of these things can be properly done if vitreous has 
 escaped. Even in the more successful instances, the absence of the 
 support afforded by the zonule and capsule, together with the large 
 coloboma and the extensive incision, make it risky to perform a 
 proper toilet. 
 
 5. Technical Difficulties. That the operation makes greater 
 demands not only upon one's skill, but also upon one's judgment, 
 upon the sense of touch and upon that almost intuitive sense, 
 which, when exercised to the fullest, is so much to be relied upon in 
 averting disaster, all are agreed. Many of the difficulties hinge upon 
 knowing how much pressure is required, and where best applied 
 to loosen the lens or the zonule from its attachments, and to follow 
 it up in the safest and surest manner till the cataract is delivered. 
 Several have confessed to having, on occasion, failed to deliver 
 the lens, notwithstanding an ample incision, because the degree of 
 pressure required was greater than they dared to make; so they 
 desisted and had recourse to capsulotomy. 
 
 6. Injury to the Cornea. The considerable and prolonged 
 rubbing and trituration of the cornea with the blunt hook, which 
 is a part of the technic, cannot but be deleterious to that membrane. 
 Dr. Greene, of Dayton, the foremost exponent of the operation 
 in this country, told the writer that he had changed the site of said 
 rubbing, etc., to the sclera-corneal junction or beyond it, in conse- 
 quence of having observed traumatic keratitis after some of his 
 Indian extractions.
 
 "INDIAN" METHOD. 
 
 553 
 
 , . Unsightliness. The frequent loss of vitreous, with its draw- 
 ing effect upon the iris, the leaving of the iris caught in wound and 
 the big coloboma, made yet greater through these influences, all 
 combine to make a very ugly eye; though this is doubtless less of 
 an objection among the dark faces and dark irides of India than 
 among white people. 
 
 8. Expulsive hemorrhage is said to occur oftener after intra- 
 capsular extractions, which, in view of all the circumstances, is not 
 to be wondered at. 
 
 9. Postoperative astigmatism, according to Czermak and 
 others, is more pronounced after this method. 
 
 \Yhen the time arrives that the average operator can rid the eye 
 at once of cataract, sub-capsular cortex, and capsule with as little 
 ultimate damage to the integrity of the organ as it now incurs from 
 the best chosen of other methods, opthalmic surgery will have made 
 an enormous step in advance. That such a time has not arrived 
 no one can deny, and few perhaps are so optimistic as to believe 
 that it is near. 
 
 Suction or Aspiration. Next to reclination this is the most 
 ancient means of ridding the eye of cataract, though applicable only 
 to the softer kinds. It is said to have been practised in some of the 
 Asiatic countries, as Persia, in very remote times, while it is certain 
 that the Arabians employed it early in the Middle Ages. It con- 
 sisted originally in introducing a hollow needle through the sclera 
 into the lens and, by some means of suction, usually the mouth, 
 evacuating the cataract. At times a small incision was first made 
 through which to pass the canula. Early in the past century it 
 had found favor in the eyes of the Italian surgeons, one of whom, 
 Pecchioli, improved on the older method by first making keratonyxis 
 (discission) and after the lens matter was well broken up, inserting 
 a hollow needle and aspirating. In England, during the early 
 sixties, the operation, for a few years, numbered among its prose- 
 lytes such distinguished men as Teale, Lawson, and even Bowman. 
 The last-mentioned invented an aspirator for the purpose (Snellen). 
 
 The last revivals of it were in Brussels, Belgium, about 1875, by 
 Coppez and by Redard, the latter of whom, as recently as 1887, 
 devised an aspirator which did away with the reversed syringe, as the 
 suction engine, reverting, in this particular, to the ancient type and
 
 554 EXTRACTION OF CATARACT. 
 
 substituting the mouth. By its advocates the method was deemed 
 proper for just the class of cataracts for whose removal the surgeons 
 of to-day make either discission or linear extraction, viz., recent 
 traumatic cataracts, the yet unexplained soft cataracts of young 
 children, and those that occur spontaneously in adults under middle 
 life. 
 
 Couching, depression, reclination, displacement, abaisse- 
 ment, are all terms used to denote the most ancient form of cataract 
 operation so ancient, indeed, that the tracing of its origin is lost 
 in the remotest antiquity. It may be mentioned that Willburg, of 
 Nuremberg, had in the year 1785 advised a form of reclination and 
 depression, which was to turn the lens straight over backward, the 
 hinge being directly below so that it rested, anterior surface up- 
 ward, on the lowest segment of the ciliary body. There were two 
 methods of making the ancient operation one by introducing a 
 thorn or other needle-like instrument through the center of the 
 lower segment of the cornea (ker atony xis) obliquely upward through 
 the pupil into the 'middle of the upper segment of the crystalline, 
 elevating the handle, with the cornea for a fulcrum, and thus forcing 
 the cataract directly down, without turning it, between vitreous and 
 ciliary body. The other accomplished the same result, but the 
 instrument was thrust into the lens through the sclera (scleronyxis) 
 near the horizontal meridian, six or eight millimeters back of the 
 sclero-corneal junction. Wilburg punctured the sclera in the 
 horizontal meridian, and four or five millimeters from the limbus, 
 with a flat needle which he guided between the iris and capsule, 
 preferring rather to hug or even to tear the latter, in order to avoid 
 the iris. He then applied the flat of the needle to the front of the 
 lens, above its middle, and tipped it over backward. 
 
 Depression, discission, and suction remained the only surgical 
 measures ever undertaken for the relief of blindness from opacity 
 of the crystall ne until Daviel hit upon a better. Yet, strange to 
 relate, after more than fifty years, the progress of the operation for 
 extraction had been so slight that in the last years of the i8th and 
 the early years of the igth century this primitive method of depres- 
 sion had staunch defenders among the most renowned ophthalmic 
 surgeons Richter, de Wenzel, and Beer. 
 
 During the first decade' (1803) of the last century, Scarpa gave a
 
 COUCHING OR DEPRESSION. 555 
 
 fresh impulse to its popularity by so modifying the operation as 
 to turn the cataract downward and outward, so that it lay with its 
 anterior surface inward and its posterior against the infero-temporal 
 portion of the ciliary body (true reclination), instead of pushing it 
 straight down into the vitreous (true depression), as his predecessors 
 had done. 
 
 The last of the great champions were Sichel and Desmarres, 
 beside many others of lesser fame. Not because they lacked 
 personal knowledge or experience with the discovery of Daviel 
 for they had, for the most part, labored faithfully and perseveringly 
 to give it the precedence it deserved but for the reason that the 
 immediate results of the procedure were disheartening. They 
 naturally returned to the method by which they were spared the 
 oft-recurring visitations of suppuration that incubus of the earlier 
 eye-surgeons notwithstanding the fact that the ultimate benefits 
 were even then vastly in favor of extraction. For, sooner or later, 
 most of the lenses dislocated into the vitreous caused serious dis- 
 turbance, detachment of the retina, various forms of uveitis, etc., 
 or the sight restored by the operation was subsequently lost again 
 by the reappearance of the cataract at its normal site not an in- 
 frequent event. 
 
 Since, in the opinion of certain ophthalmic surgeons, the operation 
 of reclination, or couching, is not altogether obsolete, a description 
 of the most recent mode of performing it that of Scarpa may not 
 be amiss. 
 
 The following instruments are required; blepharostat, fixation 
 forceps and a stop-needle similar to Bowman's, only slightly curved 
 on the flat, the distance from the point to the shoulder, or stop, 
 being about one centimeter. According to usage, the surgeon 
 and patient (the latter with pupil dilated) sit facing each other, 
 though there is no good reason why an operating-table should 
 not be used. The lids are propped open, the globe is steadied in the 
 usual way, and the needle, with its convexity directed upward, is 
 entered at the temporal side, four millimeters back of the sclero- 
 corneal junction, and very slightly below the horizontal meridian. 
 Thus, the long axis of the wound is placed in a meridian of longitude, 
 insuring the minimum of traumatism to the ciliary zone. As soon as 
 the spear portion has entered completely the posterior chamber,
 
 556 EXTRACTION OF CATARACT. 
 
 the convexity of the shaft is turned forward, the instrument pushed 
 inward, either between the posterior surface of the iris, or, which 
 would be more likely seeing the space is nil or very slight 
 beneath or through the anterior capsule itself. Then on until the 
 point nears the inner border of the pupil, somewhat above the center, 
 or until the stop touches the sclera. Holding the stop firmly against 
 the sclera, as a fulcrum, a movement of the handle is made whereby 
 the cataract is swung out and down so as to rest with its posterior 
 surface between the insertion of the external and that of the inferior 
 rectus. 
 
 Having pressed the cataract lightly down against the ciliary body 
 and choroid, it is held so for a few moments, the better to insure its 
 remaining there, the movement of the handle is reversed and the 
 convexity of the needle brought back against the iris, when a pause 
 is made lest the lens bob up and have to be depressed a second time. 
 The quarter turn is made to again put the convexity upw r ard, when 
 the instrument is withdrawn in the same position as when introduced. 
 Among the immediate accidents of the operation were dislocation 
 into the anterior chamber, the breaking up of the lens, and the 
 entanglement of the needle in iris or nucleus of the cataract. 
 
 When the first fruits of the labor of v. Graefe and his disciples 
 with the linear method became apparent, the day of reclination began 
 to decline. It grew darker and darker with the perfection of the 
 flap extraction, and it was totally eclipsed in Europe and America 
 by the advent of aseptic surgery. It is still extensively practised by 
 native surgeons in several of the As-iatic countries. 
 
 Captain Henry Smith 1 reports having extracted sixty-nine 
 cataracts from the eyes of natives of India that had formerly been 
 couched and afterward rose to obstruct the pupil. One could 
 imagine circumstances under which the operation would still be 
 admissible. 
 
 Discission. This operation, which consists in puncturing or 
 cutting the lens with a needle or a small knife, like that of depression, 
 is also of very ancient origin, and was mentioned by Galen as 
 having been practised by the "ancients." Indeed, the idea was 
 but the natural outcome of the displacement measure, seeing that 
 in case the lens matter was liquid, or only semisolid, and the 
 
 1 Ind. Med. Gaz., xxxvi, p. 224.
 
 DISCISSIOX. 557 
 
 depression needle entered the capsule which by design or accident 
 often happened the cataract would disappear by absorption. 
 Hence acupuncture would, as it really did, become the logical 
 treatment for those soft cataracts that were not suitable for 
 depression. 
 
 Ambrose Pare gave new life to the operation, calling it sclerotico- 
 puncture, for the needle was introduced by way of the sclera until 
 1797, when Conradi, 1 a pupil of Richter, devised the modern route 
 through the cornea, and, under the name keratomyxis, the operation 
 became general. Langenbeck 2 was the first to employ a mydriatic 
 belladonna in this connection, which greatly facilitated matters. 
 The sphere of the operation is at the present time limited to soft 
 lenses, such as the recent or undegenerated traumatic and all the 
 cortical cataracts of young or relatively young subjects, the trans- 
 parent lenses of high myopia, those congenitally displaced, and, 
 in a somewhat modified form, to secondary or after-cataract. The 
 operation also has a small field of usefulness for congenital zonular 
 or lamellar cataracts in children and young adults. It may be 
 stated, in passing, that the surgical treatment of these cases is not 
 attended with the same degree of satisfaction as that of other 
 varieties. If the zone of opacity is small, not larger than a good- 
 sized pupil, the best operation is optical iridectomy, preferably 
 inward and slightly downward. It is only when the area of the 
 cataractous circle is large that a lens operation is to be considered. 
 Then it becomes a choice between one of the forms of extraction 
 and discission. For my part, I prefer the latter, although it may 
 mean three to five repetitions, the last of which is usually a dilacer- 
 ation of dense membrane. 
 
 The time of life beyond which discission of cataract, that would 
 appear to be moderately soft, is impracticable has not been definitely 
 decided upon. Certain it is, however, that the age once fixed as 
 the limit has been more than doubled. Knapps mentions having 
 made the operation with success in the eyes of persons thirty-seven. 
 The case cited below, in which discission was made for high myopia, 
 is a shining example of its feasibility at thirty-five and thirty-six. 
 
 i Arnemann's Magazine, 1797, i, p. 61. 
 
 aC. J. M. Langenbeck, Bibl. f. Chirurgie, 1809. 
 
 3 Norris and Oliver's "System," vol. iii, p. 811.
 
 558 EXTRACTION OF CATARACT. 
 
 Mrs. J. K., age 27, Jewess. Seen first Jan. 5, 1892. High myopia, 
 right; high myopic and astigmatism, left. Had been cured of trachoma 
 and vascular keratitis. Conical cornea in both eyes. R. V. =2/200; 
 20/100+ i w 20 D. L. V. = 5/200; 20/100 + i w 15 s O 5 cyl. 
 ax 135. Under atropin the following lenses were prescribed : Right 1 8 
 D; Left, 15 s O 5 cyl. ax, 135. Saw patient no more until Nov. 14, 
 1899. Age now 35. Test then showed; R. V. = 2/200; 20/100 w 25 
 D; L. V. = 4/200; 20/100 + w 20 s O 3 cyl. ax 150. Advised dis- 
 cission which was' done in the right eye, Dec. 15, 1899. 
 
 The first operation consisted in a mere pricking of the anterior capsule. 
 Little or no effect. One week later a bolder discission. Lens slowly 
 disappeared. To be brief, the first or slight operation on the left eye was 
 made Oct. n, 1900. The patient was now 36 years old. By Feb. i, 1901, 
 the lens had entirely disappeared. The remarkable features of the case 
 are the prompt absorption of the lenses following the second or thorough 
 discissions and the ultimate refractive and visual results, which in Septem- 
 ber of 1903, were as follows: Right eye, with 4 cyl. ax 120 V. = 20/20 
 + 4. Left eye, with 2.5 s O 2.5 cyl. ax 110 V. = 20/30 + i. For 
 reading, added +3 and +2. The corneal cones, in consequence of the 
 operations and the prolonged bandaging, had in great measure subsided. 
 
 Many of us have seen ready absorption in much older persons 
 after traumatism of the lens. A striking instance once came 
 under my observation. A machinist, aged 49, was struck in the eye 
 by a flying chip of brass. The man came immediately for treatment. 
 A thin sliver of the metal was seen with its proximal extremity within 
 the anterior chamber and its distal buried deeply in the crystalline. 
 It was removed through the enlarged corneal wound. Absorption 
 of the resulting cataract was affected in an incredibly short space 
 of time, and good sight was restored to the eye. 
 
 In my service at the Illinois Eye and Ear Infirmary, about two 
 years ago, I made discission for cataract in case of a woman past 
 45 first upon one eye, then upon the other. The first cataract 
 disappeared promptly. The loosened hard nucleus of the second 
 fell into the anterior chamber causing some irritation, and was 
 extracted through a small linear (lance) incision by means of a 
 sharp hook. The result was perfect in both eyes. 
 
 True, after the disappearance of all the cortical portion of the 
 lens, in subjects verging on, or actually in, middle life, a tiny hard 
 nucleus may occasionally drop down either behind or in front 
 of the iris, and there become the source of considerable irritation. 
 But this can be easily extracted through a small incision with the 
 lance keratome by means of the open sharp hook. Fortunately, 
 these dense lens remains usually fall into the anterior chamber, 
 where they are less provocative of harm and whence they are 
 extricable with less risk and difficulty than if located in the posterior
 
 DISCISSION. 559 
 
 chamber. In the latter situation even a small nucleus can excite 
 secondary glaucoma, as I have good reason to know by recent ex- 
 perience with such an instance relative to a thirty-year-old man. 
 In the event of the nucleus having dropped down behind the iris it 
 might be got into the anterior chamber by placing the patient on 
 his stomach upon an operating-table, with the head hanging over 
 the end and so manipulating and jarring it as to cause the nucleus 
 to enter the front chamber by gravity. 
 
 These facts, together with the added confidence inspired by the 
 use of the Graefe knife and its insertion at the base of the cornea, 
 have led me of late years to make discission in a number of cases 
 for which formerly only extraction would have been thought of. 
 
 The great majority of operators make true keratonyxis, using 
 some form of needle or combination of needle, and small knife 
 Knapp's for example and pierce the clear cornea two or three 
 millimeters from the limbus. Following the most worthy example 
 of H. Pagenstecher, the writer has for a number of years, and with 
 ever increasing gratification, substituted a small model of the 
 Graefe knife for the needle, and instead of going through clear 
 cornea, enters the instrument at the limbus or a trifle back of it. 
 The following will suffice for a description of the operation in 
 general, the surgeon making his choice of needle, knife-needle, or 
 Graefe knife. 
 
 Operation. The pupil having been previously dilated, the 
 patient is placed either upon an operating-chair or upon the table. 
 The operator, if he be ambidextrous, stands behind the chair or at 
 the head of the table for either eye, manipulating the knife with 
 the hand which corresponds to the eye in question. Otherwise, in 
 operating the left eye, he stands on that side with his own left side 
 against the chair or table. The instruments are the blepharostat, 
 fixation forceps (without a catch) and a Graefe knife whose blade 
 is somewhat smaller than that of the average or regulation pattern, 
 and very sharp both as to point and edge. Recently at the Eye and 
 Ear Infirmary, while speaking of the requirements of the knife for 
 discission, one of the internes, Dr. Fullenwider, suggested removing 
 the cutting quality of the blade, save for the part to be actually 
 engaged in the capsule and lens. The idea was so rational that 
 I have since had put in order, for this purpose, a knife whose edge
 
 5 6 
 
 EXTRACTION OF CATARACT. 
 
 is sharp for only six or eight millimeters from the point. With this, 
 wounding of the iris and needless cutting of the base of the cornea 
 with undue escape of aqueous are avoided. The illumination is 
 either daylight or artificial, focused on the eye through a large lens. 
 A drop or two of 4% cocain solution is instilled, and after a wait of 
 five minutes the blepharostat is put in place, the eye is flooded 
 with warm boric acid solution, the excess of which is sponged away. 
 
 FIG. 247. Discission. 
 
 A good firm hold is taken of conjunctiva and episclera with the 
 fixation forceps close to the limbus on the nasal side; the knife is 
 made to perforate the cornea (edge toward the operator) exactly in 
 the outer sclero-corneal junction, encroaching even on the con- 
 junctiva, in the same manner as in making the puncture for flap 
 extraction (Fig. 247). It is pushed in, following the plane of the 
 cornea! base, until the point is opposite the center of the pupil, when, 
 if it be the first discission in the case, the handle is raised and 
 the center of the capsule merely punctured. If not the first, the
 
 DISCISSION. 561 
 
 point of the knife is made to swing in the central meridian of the 
 lens till it approaches the pupillary margin just across from the 
 operator below always with the ambidexter the handle elevated, 
 and the blade pushed slantingly into the lens substance, taking 
 care not to go through the posterior capsule. The handle is then 
 rotated away from the operator and a free incision is made in the 
 crystalline. The knife is now once more put into the horizontal 
 position, as on entering, and rapidly withdrawn. This last move 
 would better be a quick jerk which best assures what is most de- 
 sirable, viz., the leaving behind of aqueous, shreds of capsule, and 
 particles of the lens. 
 
 Before abandoning the needle or knife-needle and the puncturing 
 of clear cornea in making this operation, I had come to regard the 
 operation of discission as being quite as formidable as that of extrac- 
 tion itself, whether undertaken for cataract or pupillary membrane. 
 Statistics prove that it is really a dangerous operation. Hardly 
 an operator of fair experience but has had at some time very serious 
 reaction follow "a simple needling." The perils incident to the 
 ordinary needle operation were strongly brought out and emphasized 
 by the well-known, world-wide inquiry of Landolt, instituted some 
 years ago. 
 
 Since adopting the Graefe knife and the extreme peripheral place 
 of entry, the procedure has to me lost all its terrors, and I no longer 
 hesitate to make as many repetitions of it as are needed in a given 
 case. The reasons for the superiority of the knife, modified as 
 stated above, are: 
 
 1. The cross-section of a properly made modern modification of 
 the Graefe knife is an ever-increasing wedge which, while entering 
 without a jog, effectively keeps back the aqueous. 
 
 2. It cuts better than the needle or knife-needle, both of which 
 mostly tear, and the edged portion, having some length, allows more 
 leeway, i.e., the blade may move slightly in or out, yet still be 
 enabled to cut the capsule. Best of all, it permits one to impart to 
 the blade that delicate, almost imperceptible, sawing movement so 
 essential to incision especially desirable with membranous cataracts. 
 
 3. All the trenchant needles have round shanks whose diameter 
 is smaller than is the width of the blade, making a sort of shoulder 
 where the two meet, so that they ream out a hole and permit the 
 
 36
 
 562 EXTRACTION OF CATARACT. 
 
 aqueous to escape. This, in view of the changed character of the 
 aqueous that is secreted after sudden evacuation of the anterior 
 chamber i.e., that it is much richer in albuminoid substances 
 renders it highly desirable that there be no escape during the 
 operation. With the method in question one is able to make a 
 number of discissions, both for primary and secondary cataract, 
 without ever losing a drop of aqueous. Again, the trenchant 
 needles go into the anterior chamber with a start that is apt to carry 
 them too far, and they come out with a pop, and are prone to pull 
 bits of capsule into the corneal opening, there to lie inviting in- 
 fection and preventing healing. 
 
 The advantages of the peripheral point of entry, or conjunct! val 
 route over that which is further in, are: 
 
 1. It lies in the vascular zone where closure and healing are im- 
 mediate. 
 
 2. It affords the opportunity of penetrating the cataract or 
 capsule in a very slanting manner, which makes the act of cutting 
 more positive and makes it easy to avoid going through the posterior 
 capsule and wounding the vitreous. 
 
 If, for example, one wishes to cut a sheet of paper with a knife, 
 his task is much easier if he holds the blade at an acute angle with 
 the plane of the paper than if held at or near a right angle. 
 
 Bandaging for twenty-four to forty-eight hours after the operation, 
 and atropin throughout the treatment, constitute about all the 
 needed after-measures in most instances. 
 
 ACCIDENTS AND COMPLICATIONS. 
 
 Like those incident to extraction, those after discission are both 
 immediate and consecutive, though by far the most serious pertain 
 to the after treatment. 
 
 Among the more frequent immediate accidents are wounding 
 of the iris, premature escape of aqueous, rupture of zonule (disloca- 
 tion) injury to the ciliary processes by tugging and tearing, plunging 
 the instrument into the vitreous, and, as already referred to, the 
 dragging of portions of capsule lens or vitreous into the corneal 
 wound. The best means of avoiding them, while in the main quite 
 obvious, do not, even as regards the most skillful, always keep them
 
 ACCIDENTS AND COMPLICATIONS. 563 
 
 from happening. Perhaps the greatest desideratum is that the point 
 and edge of the knife be as sharp as it is possible to make them. 
 
 With regard to the consecutive accidents or the reactive 
 processes so far as they go, they are, with one exception, the same 
 as follow extraction, being iritis, iridocyclitis, and pus infection, and 
 require the same treatment. The exception alluded to is glaucoma, 
 caused by the swelling of the lens matter after incision of a soft 
 cataract or of the transparent crystalline. If the subject of such an 
 operation is under 30 years of age, this is not an uncommon oc- 
 currence. Hence, in operating for the first time in a given case, 
 the cut in the capsule should be purely tentative a mere pricking of 
 the capsule. Next time, there having been no special reaction, the 
 effort may be bolder. Often a lens will rapidly disappear from a 
 tiny puncture. But they must all be closely watched, and at the 
 first signs of high tension an incision made with the keratome and as 
 much of the lens matter got out as is practicable, holding the iris 
 back with the spatula as indicated (p. 494). 
 
 Of course, eserin may be tried, but unless the tension subsides 
 within a very few hours, the extraction must be made, else the sight 
 is jeopardized. If the patient is timid or nervous, a general 
 anesthetic would better be administered for the extraction, as the 
 tension and hyperemia are bars to local anesthesia. The conse- 
 quences of a linear extraction are not nearly so much to be dreaded 
 as a few days of secondary glaucoma. Fukala, the originator of 
 operations upon the lens for high myopia, states that latterly he 
 makes discission in these cases, expecting later, when breaking up 
 and swelling of the crystalline occurs, to make extraction. 
 
 Secondary cataract, after-cataract, capsule-lenticular cata- 
 ract, membranous cataract, all refer to some form or degree 
 of opacity, occurring in the pupil after the lens proper has disap- 
 peared. It may be the result of accident (traumatism) or of one 
 of the surgical measures, extraction or discission. The first are 
 more rarely met with, the second, the busy ophthalmic surgeon 
 encounters constantly, and it is to these, therefore, that this chapter 
 chiefly relates. 
 
 It is composed of varying masses of encapsuled, normal or 
 degenerated lens matter, the remains of the lens capsule, more or 
 less thickened by proliferation of its endothelium, and particularly
 
 564 EXTRACTION OF CATARACT. 
 
 when there has been inflammatory processes in connection with its 
 formation, the addition of a certain amount of organized plastic 
 material. Their density varies from that of a web so delicate as to 
 be invisible by ordinary means to that of a mat so thick and compact 
 as to exclude any but strong light from the depths of the eye; yet 
 between these two extremes it is present, to a degree, in practically 
 all eyes after removal of the lens. Even the extraction of the lens 
 in its capsule, though it leads less often to secondary operations, does 
 not do away with them altogether. 
 
 When one considers the different views of leading eye surgeons 
 as to the relative frequency of operable secondary cataract, one is 
 at a loss to explain their great disparity. As Panas puts it, " Between 
 Knapp, who advises discission in every case (after extraction) , and 
 Gayet, who intervenes only exceptionally, one must know how to 
 choose a golden mean." This, however, is putting it rather strong, 
 for Knapp acknowledges to making the operation in only 70% 
 of cases. The degree of amblyopia produced by the after-cataract 
 is what should determine whether or not a discission be made. 
 Knapp does not operate if the visual acuity is above 20/50. Certainly, 
 the secondary operation is called for if the vision is 20/70 or less 
 in consequence of the membrane. 
 
 As has already been stated, the principal cause of secondary 
 cataract, at least of the kinds that call for operative interference, 
 are abandoned lens masses that remain adherent to, or entangled in, 
 the capsule after extraction, and are specially prone to follow such 
 operations upon unripe cataracts. Add to this the other causes of 
 inflammation, such as indiscriminate laceration of the capsule, 
 bruising, tearing and incarceration of the iris, and we have not much 
 further to seek for the origin of consecutive membranous cataract. 
 
 Hypermature and sclerosed cataracts, although they sometimes 
 present certain mechanical difficulties in delivery and are subject 
 to the same inflammatory reactions, expose one less often to secondary 
 cataract than the forms before alluded to. Here truly an ounce 
 of prevention is better than a pound of cure. Having a knowl- 
 edge of the conditions that are chiefly instrumental in the production 
 of secondary cataract as well as of the fact that, notwithstanding 
 the greatest skill in making the primary operation and the utmost 
 care in the after-treatment, either a considerable number of supple-
 
 SECONDARY CATARACT. 565 
 
 mentary operations or some grade of blindness is inevitable 
 our management of the case may be such that it will not only materi- 
 ally diminish the chances of secondary cataract, but it will also 
 put us in better position to cope with it when it does occur by 
 leaving the eye more nearly in its normal state. 
 
 As to the length of time that should elapse between the extraction 
 and the discission, no definite period can be fixed. It is not prudent, 
 in any case, to interfere while there are any remaining traces of 
 irritation from the primary operation, because of the liability of 
 the opening in the membrane to speedily close again. It would 
 be well to wait from one month to six weeks after the most favorable 
 recovery from the extraction. From then on the operation may be 
 made at any time. Then, too, there is great variation in the time 
 at which the secondary cataract begins to dull the sight. The 
 latter may remain good for several months or even several years, 
 then fail from this cause. However well-timed the "needling" or 
 successful, it does not insure against the necessity for another at 
 a later date. 
 
 There are several surgical measures that are employed to free 
 the pupil when obstructed in this manner, and the choice of one will 
 depend upon the character of the membrane in question. In most 
 instances, it will be some kind of discission or incision, seeing 
 that this is the simplest and safest means, and quite as effectual 
 as any for the usual thin variety of after-cataract. Having decided 
 upon discission, then, we will say, what sort of instrument 
 shall we use for the cutting of the membrane? For, as its name 
 implies, the operation is one of cutting, not tearing. It must of 
 necessity have a trenchant edge. Now, this the ordinary spear- 
 pointed needle, used by so many operators, possesses, it is true, 
 but in a very limited degree, and its wound, instead of being a clean 
 incision, is a jagged rent. One of the knife-needles is a far more 
 suitable instrument, and Knapp's is the best of these. My preference- 
 is for the Graefe knife, selected and prepared as described in the 
 chapter on Discission, and for the same reasons as there given. 
 The other instruments are the same as for discission in general, 
 viz., blepharostat and fixation forceps. 
 
 The pupil is dilated as widely as possible. The illumination of 
 the field of operation, for the whiter or denser membranes, may be
 
 566 EXTRACTION OF CATARACT. 
 
 bright daylight, but for the thinner or less conspicuous ones a 
 stronger is required, such as the focusing on of the light of an 
 Argand burner or that of a ground incandescent electric bulb by 
 means of a handglass. Another good light is that of the portable 
 electric bull's-eye thrown onto the eye from one side by an assistant. 
 If oblique focal illumination is employed, the assistant must be 
 careful not to focus on the eye a sharp image of the flame, but to 
 have it a trifle within or beyond the focusing point, as this gives a 
 more even and a larger area of light. Also a little unsteadiness will 
 not be so apt to cause it to fail the operator at the critical 
 moment. 
 
 The eye, the instruments, and the operator all having been as 
 scrupulously prepared as if for an extraction, excepting that only- 
 one or two drops of 4% cocain solution are required, in what manner 
 shall the membrane be divided ? According to the principles stated 
 on page 560, the knife must be entered at the limbus, but the precise 
 point of entry must be governed by the formation of the membrane 
 with which we have to deal in other words, by the position and 
 the direction of the denser bands which compose it, for these 
 cataracts are never of uniform thickness or opacity throughout. It 
 will be found a great help to study each membrane by strong focal 
 illumination and a magnifying glass or with the ophthalmoscope 
 and transmitted light beforehand. The streaks more often run 
 crosswise or obliquely than vertically, at any rate, after the per- 
 ipheral capsulotomy, so that the knife is best inserted at some place 
 along the outer corneal limbus farthest from the ends of the 
 more prominent bands in order to cut athwart them. Here it is of 
 the greatest advantage to be able to wield the knife with either hand, 
 as should the portion about which one is most concerned, lie hori- 
 zontally and near the upper border of the right pupil or the lower 
 border of the left, it could be more easily divided and with less risk 
 of injury to the iris and ciliary body by holding the knife in the left 
 hand. Assuming that the bulk of the opacity is vertically across 
 the center of the right pupil, the operator stands facing the top of 
 the patient's head with the knife in the right hand (edge up), and 
 the puncture is made in the horizontal meridian at the limbus, 
 and precisely as if for extraction. 
 
 The point is pushed in, horizontally, just above the iris, till it is
 
 SECONDARY CATARACT. 567 
 
 opposite the center of the pupil, the handle is rotated in the horizon- 
 tal plane toward the operator to bring the edge below the thicker 
 bands, or the back of the blade is made to approach the lower 
 pupillary border. The handle is elevated (in the vertical plane) 
 and the point made to pierce the cataract very slantingly, then the 
 handle is depressed (in the horizontal plane) making the blade cut 
 upward until the incision nears the upper pupillary border, when 
 the last movement of the handle is reversed, to bring the blade 
 again to the horizontal, and suddenly withdrawn, meanwhile holding 
 the eye very firmly with the forceps. 
 
 The elasticity of these membranous cataracts is sufficient, in 
 most instances, to convert the incision into an oval opening. More- 
 over, there are many times a number of tiny posterior synechia 
 so that the mydriasis produced by the atropin tends also to stretch 
 open the cut. There is one rather singular feature relative to the 
 behavior of the membrane, which is occasionally shown when 
 engaged by the edge of the knife, that it is well to bear in mind. 
 Instead of dividing at once, it will allow itself to be pushed along, 
 doubled over the edge, and seem not inclined to yield; but simply 
 stop the progress of the knife. Wait for a moment, and the severed 
 bands will be seen to fall away in a clean incision. No decided 
 sawing is needed. Whether it is the fine tremor of the hand which 
 holds the knife or the insensible movement of the eye, something 
 acts to induce this final parting. As before stated, however, the 
 smallest of sawing motions best insures a prompt and smooth incision, 
 and this can be easily arid safely accomplished with the knife here 
 employed. 
 
 Now and then, previous to extraction, there has been a thickening 
 of the central portion of one or both capsules, and the ensuing 
 secondary cataract is not of the kind that can be easily incised, 
 being frailly connected with the zonule and most resistant just where 
 the cut should be faultless. The same is true of that variety of 
 congenital cataract which is composed of a mass of connective tissue 
 or the latter mixed with chalk. If one succeeds in the discission, 
 the two sides are apt to fall together again and reunite, or the whole 
 mass is merely pushed to one side without being at all divided. 
 It afterward drifts back, and the operation counts for naught. It 
 often happens, however, that a simple discission an>wers perfectly
 
 568 EXTRACTION OF CATARACT. 
 
 in just such a case, and it is, perhaps, best to make at least one trial 
 of this method before resorting to a more complex one. 
 
 Posterior Discission. Much has been said concerning this 
 procedure, devised some years ago by Da Gama Pinto, of Lisbon. 
 It consisted in incision of the membranous cataract from behind 
 by a knife passed through the sclera. The method has had few 
 supporters. It was advocated, however, at the Lucerne Con- 
 gression in 1904 by no less a personage than De Lapersonne, suc- 
 cessor to Panas, who then described his technic and a special knife for 
 the operation. At the same meeting Da Gama Pinto himself stated 
 that because of having observed two cases of detachment of the 
 retina after the procedure, he had abandoned it, and had returned 
 to the anterior method, using Knapp's knife-needle. 
 
 Arrachement. Having failed, recourse may be had to plucking 
 out or tearing out (arrachemenf) of the membrane. This consists in 
 making, first, a small moderately peripheral corneal incision with 
 the lance-knife, inserting thereat a pair of capsule forceps and 
 pulling out the thickened membrane; or making use of the small 
 blunt hook and proceeding exactly as described in case of the con- 
 genital cataract cited on page 557. 
 
 Dilaceration has for its end the creation of an aperture permeable 
 to the rays of light in the center of a cataractous pupil by rending 
 and prying asunder the opposite halves of the obstruction. It 
 is applicable to almost any of the thicker secondary cataracts, but 
 peculiarly so to those very thick, tough, and adherent ones that some- 
 times follow absorption or partial absorption of the lens due to 
 severe injury; as also to those that come after operations for primary 
 cataract that have been attended by accidents or succeeded by 
 inflammatory reaction. The chief advantage of dilaceration over 
 discission is that it obviates any injury to the ciliary processes from 
 dragging. 
 
 The method usually employed is that devised by Sir William 
 Bowman, 1 and is known as Bowman's Double Needle Operation. 
 The instruments are lid speculum, fixation forceps, and two delicate 
 sharp stop-needles. If possible, the pupil is dilated. The lids 
 are propped open, the eye douched with warm boric acid solution, 
 the globe steadied with the forceps, held in the left hand, and one 
 
 'Med. Times and Gazette, 1852.
 
 DIVISION WITH SCISSORS. 569 
 
 needle passed through the c'ornea, in the horizontal meridian, 
 about two or three millimeters from the limbus, and the point 
 pushed into the center of the cataract. The eye is now steadied 
 by the needle, the forceps is dispensed with, and the other needle 
 is similarly inserted on the opposite side and its point also made 
 to enter the center of the cataract. If the two needles are properly 
 adjusted, their two spear-shaped blades will lie flatwise, one 
 against the other, in the horizontal plane of the eye. Now the 
 two handles are made to approach each other, thus separating the 
 points, like opening the blades of a pair of scissors, until a satisfactory 
 orifice is torn through the cataract. A pause is then made in order 
 to fix the fragments, then the first movement of the handles is 
 reversed, and they are withdrawn in the same sense that they were 
 entered. The distance from the point of the needle to the shoulder 
 or stop ought not to be so great as to allow deep wounding and 
 stirring of the vitreous for fear of exciting a hyalitis. Eight milli- 
 meters to one centimeter is ample, and twelve milimeters, which 
 is a common length, is too great. 
 
 The after-treatment of discission, arrachement, and dilaceration 
 is, as a rule, neither long nor eventful. Immediately the operation 
 is completed, the eye is dressed in the same manner as after extrac- 
 tion. The patient may be permitted to walk from the operating- 
 table to his room. At the end of twenty-four hours the eye should be 
 inspected, and if all signs are propitious at the end of forty-eight 
 hours, a shade or medium smoke coquilles may be substituted for 
 the dressing. It is wise td insist that the patient be moderately 
 quiet and free from exposure for some days and that he does not 
 pass from observation under ten days or two weeks. 
 
 Division with Scissors. There will always be a small class 
 of after-cataracts to confront us that is adapted to none of the 
 methods just described. Where the cataract is quite dense and 
 attached to the iris or where the pupil is much misplaced outward 
 from the center or much contracted. In fact, the conditions are 
 very similar to those that call for iridotomy. Here some form of 
 tiny scissors may take the place of needle or knife. This necessitates 
 the making, first, of a fairly extensive corneal section, which is ac- 
 complished much in the same manner as for iridectomy, the difference 
 being that it is desirable to make a small opening in a given part of
 
 570 EXTRACTION OF CATARACT. 
 
 the cataract at the same time, in order to give ingress to one blade of 
 the scissors. When it is not practicable to utilize the keratome 
 in this way one must have recourse to scissors having at least the 
 under blade provided with a keen point with which to start the cut 
 in the capsule. The corneal incision is so located as to lie parallel 
 with, and accessible to, that portion of the membrane which is to 
 be divided. A steep puncture is made with the lance keratome 
 in the exact sclero-corneal junction, and, if possible, the opening is 
 made in the cataract with the same forward thrust of the knife; 
 when not possible or feasible, the blade is partly withdrawn, its 
 point placed at the spot for the opening, and again pushed forward. 
 Having failed in this, the sharp blade of the scissors may be used. In 
 any case the thinnest part of the cataract is chosen for the opening. 
 It is important that the scissors be extremely delicate and of excep- 
 tional sharpness. De Wecker's ordinary model is entirely too large. 
 Those shown in plate VII, No. 86, are suitable, or the straighter 
 ones, No. 85. The scissors are passed into the anterior chamber 
 closed, then opened, and the lower blade made to enter or to cut 
 the opening in the cataract, and to further divide it as wished. 
 If cutting in a single direction does not seem to give a sufficient 
 pupil, a second snip may be made diverging from the same point 
 of entrance into the membrane, or, provided the original opening 
 in the capsule, as made with the keratome, is long enough, two 
 convergent snips may be made, and the triangular piece thus 
 excised be extracted with the iris forceps (see Kuhnt's and 
 De Wecker's iridotomies). Seeing that loss of vitreous is the bug- 
 bear of this operation, the Angelucci fixation, described on page 542, 
 is most appropriate, as it serves effectually to fix the globe, while, 
 at the same time, it tends to hold the corneal wound closed, thus 
 keeping back the vitreous. Any one of the four recti tendons may 
 be grasped, so long as it is on the same side of the cornea as is the 
 location of the keratotomy. It is essential that both eye of patient 
 and hand of operator be perfectly steady. 
 
 ARTIFICIAL RIPENING. 
 
 The extremely slow development of some species of senile cataract, 
 especially after the time when the sight has become greatly interfered 
 with, has always been a source of grievance to which both patient
 
 ARTIFICIAL RIPENING. 571 
 
 and surgeon have been victims. Especially is this true of certain 
 incipient nuclear cataracts, with \vhich is associated a high degree 
 of amblyopia, yet hardly any visible opacity, even of the lens center, 
 and the cortical portion is perfectly transparent. Owing to the 
 considerable difference between the index of refraction of these two 
 portions, the vision may be reduced to the counting of ringers at a 
 distance of two feet barely sufficient, under favorable conditions, 
 to go about with, yet by looking in with the ophthalmoscope, a 
 fairly bright reflex may be got through the center of the pupil with- 
 out, however, any details of the fundus. But with the pupil widely 
 dilated and looking through the periphery, the optic nerve and the 
 vessels of the retina can be defined with tolerable clearness. In 
 other words, it is not so much the transmission of light that is inter- 
 fered with, as that the retinal image is spoiled by diffraction. This 
 state of the lens may persist with little or no change for an indefinite 
 period. Then there are the irregular forms of cortical cataract 
 that are often equally tedious and troublesome. 
 
 The methods employed or devised to hasten the ripening of 
 these immature cataracts may be divided into four groups: 
 
 I. Discission of anterior or posterior capsule or of both anterior 
 and posterior capsule of the lens. 
 
 II. Massage, either indirect through the cornea (the anterior 
 chamber having been evacuated), or direct immediately upon the 
 lens. 
 
 III. Intracapsular injection of aqueous humor, normal salt 
 solution, or other liquid. 
 
 IV. The External Application of Heat to the Eye. 
 
 I. As early as 1811, Gibson, of London, tried discission a few- 
 days previous to the linear extraction as a means of hastening the 
 maturity of cataracts of this kind. This he did for the dual purpose 
 of causing rapid opacifying of the outer cortex and, through the 
 entrance of the aqueous humor, the loosening of the lens substance 
 from its capsule. Muter, in 1815, resorted to similar practice. 
 On account of the subsequent swelling of the lens and the generally 
 unsatisfactory extraction which followed, the procedure was not 
 popularized; although forty years later, in 1858, Moren, of Heidel- 
 berg, again proposed this method for the artificial ripening of 
 cataracts.
 
 572 EXTRACTION OF CATARACT. 
 
 In 1364, v. Graefe 1 endeavored to improve upon the method by 
 making three operations in succession. First, an upward iridectomy. 
 Second, after some three weeks, a crucial opening of the anterior 
 capsule with Bowman's needle. Third, after several days, a flap 
 extraction. His aim was twofold rapid maturation of the cataract 
 and, through the proliferation of the endothelium of the capsule, 
 to cause a loosening from it of the cortex. The end did not justify 
 the means. 
 
 T\venty years after the introduction of the v. Graefe operation, 
 Stellwag, in 1886, proposed the discission of the posterior capsule 
 by means of a scleral puncture. This suggestion was modified by 
 Businelli in 1888, w r ho proposed discission of both anterior and 
 posterior capsules. 
 
 II. Seventeen years after v. Graefe modified the simple discission 
 for maturation of cataract, another method was devised by Foerster, 2 
 of Breslau, which had a host of imitators and modifiers and in- 
 augurated a veritable boom in this line. This surgeon made a 
 preliminary iridectomy and immediately, while the anterior chamber 
 was empty and the crystalloid was in contact with the cornea, 
 made massage through the latter by means of the back of a Graefe 
 hard-rubber spoon or the heel of a strabismus hook; then, after 
 a few weeks, the extraction. 
 
 The omission of the iridectomy and indirect massage through the 
 cornea, after evacuating the anterior chamber by means of a simple 
 puncture, was recommended by Meyer at the Copenhagen Congress 
 in 1884. In 1885, direct massage of the lens itself was advocated by 
 Rassander, and a little later (1888) Bettman, of Chicago, performed 
 a similar operation with an instrument of his own design. Direct 
 massage was accomplished by following the paracentesis with the 
 introduction of a blunt instrument through the corneal incision and 
 gently triturating the lens. In some instances this procedure was 
 accompanied by iridectomy, a la Foerster. Although this operation 
 had many advocates, it has ever had many harsh critics, among 
 them De Wecker, who termed it the "still-born operation," and, in- 
 deed, it seems fraught with danger. Except in the hands of the 
 most skilled, there is liability of damage in many ways. A little too 
 
 1 Archiv. f. Ophthal., x, a. 2, S. 209. 
 
 * Foerster, Archiv. f. Augenheilk., xii,3, 1881.
 
 ARTIFICIAL RIPENING. 573 
 
 much pressure on the spatula during massage will produce luxation 
 of the lens. A delicate brittle capsule may be ruptured and followed 
 by rapid swelling of the lens and secondary glaucoma. Unavoidable 
 injury to the iris may produce extensive adhesions or even irido- 
 cyclitis. Moren reports one case followed by abscess of the cornea 
 and another by iridocyclitis and insidious phthisis bulbi. It is 
 generally conceded that it is contraindicated in atheromatous sub- 
 jects, because of consecutive glaucoma, and in cataracts accompanied 
 by choroidal lesions. After some ten or twelve years of experiment- 
 ing and discussing, the cause of artificial ripening was not advanced. 
 The operation was about as formidable as the subsequent extraction, 
 yet the perplexities of the latter were in no way lightened by it. On 
 the contrary, it was by many thought to increase its difficulties. 
 
 III. Intracapsular Injection. MacKeoun, 1 basing the idea 
 on an observation of Sir Wm. Bowman to the effect that, when the 
 crystalline, in its capsule, was put in a vessel of water, by osmosis, a 
 separation occurred between the lens substance and the envelope, 
 conceived the notion of maturing cataracts by injecting a few drops 
 of water by means of a Pravaz syringe. More recently, 1899, Jocqs, 
 of Paris, proposed the same measure, only substituting for the water 
 a small quantity of the aqueous humor of the eye concerned, which he 
 injected by means of special apparatus devised for this purpose. 
 Whether or not Jocqs ever tried the method on the human being, 
 I do not know. He believed that the capsule was not left open, 
 but through some experiments instituted by Mellinger, of Basle, it 
 has been demonstrated tha't cataracts thus produced are only trau- 
 matic ones with laceration of the capsule. Spataro experimented 
 on the eyes of 23 rabbits with Jocqs' method and produced 17 cases 
 of severe iritis and 2 cases of glaucoma. He also proved, by control 
 animals, that the injection of aqueous humor was much more 
 provocative of unpleasant reaction than was that of distilled water 
 or of normal salt solution. 
 
 IV. Since the observation of Wathen, in 1885, to the effect that 
 exposure of the eye to high degrees of heat, cataract often fol- 
 lowed, a number of similar reports have occurred in ophthalmic 
 literature. Meyhofer, for example, found among 506 glass-blowers 
 59 cataract patients, 42 of whom were under 40 years of age. And 
 
 i Ophth. Society of Great Britain and Ireland, 1885.
 
 574 EXTRACTION OF CATARACT. 
 
 out of 30 workers in a glass factory, Hirshberg discovered 5 who, 
 in their 4oth year had cataracts. Arlt records like experiences. 
 Hess declared, from experiment, that high degrees of heat destroyed 
 the epithelium lining the anterior capsule, and thus interfered w T ith 
 the nutrition of the anterior lens fibres, resulting in cataract. With 
 the knowledge of these facts, Wolf berg (Die Ophth. Klinik. No, 52, 
 1904) conceived the idea of opacifying the lens by means of a hot-air 
 douche. For the purpose he invented an apparatus which he calls 
 a "Kalo-visator," by which a stream of air, heated to form 70 to 
 100 C., is passed from a spirit lamp, through an asbestos tube, whose 
 mouth is held close to the closed lids. He estimated that the 
 temperature of the air that reaches the eye varies between 70 and 
 80 C. The applications are made for five minutes, two or three 
 times a day, for eight successive days. This usually insures the 
 desired ripening. He uses it after discission in high myopia, and 
 after iridectomy in senile cataract. 
 
 Bahr, of Mannheim, at the Congress of Lucerne, in 1904, advo- 
 cated the making of a paracentesis in immature cataracts, accom- 
 panied by direct massage of the lens with a spoon or a spatula, as 
 others before had done, but with the difference that he recommended 
 a somewhat forcible massage, lasting two minutes, and that the 
 extraction should follow after only five days. He declared that not 
 only did the lens shell out of its capsule more readily after this 
 procedure than after natural maturation, but that, owing to the 
 new vessels at the site of the incision consequent upon the first 
 operation, healing was more prompt. It cannot be denied, however, 
 that such rubbing of the lens at the hands of any but the most skillful, 
 would often lead to dislocation and loss of vitreous and other com- 
 plications in the extraction. 
 
 Artificial ripening is now deemed inexpedient by the great 
 majority of ophthalmic surgeons, excepting in a very small pro- 
 portion of well-selected cases. When it is resorted to, the method 
 usually chosen is that of Foerster, viz., iridectomy and massage 
 through the cornea with the back of a Graefe hard-rubber spoon. 
 
 HISTORICAL. 
 
 Although it has been variously hinted and asserted that cata- 
 ractous lenses were removed bodily from the human eye by the
 
 HISTORICAL. 575 
 
 ancient surgeons and those of the Middle Ages, yet prior to the 
 last decade of the i;th century, all that was said in this connection 
 seems to have rested on mere assumption. In fact, previous to the 
 period just alluded to, it was not known that cataract had aught 
 to do with the crystalline, but was thought to be a sort of pellicle or 
 film situated in front of that body. The discovery that cataract 
 consisted in opacity of the lens, was made by the French surgeon- 
 oculist, Antoine Maitre-Jean, in the year 1691. He examined, 
 postmortem, the eyes of a woman in whose case, five weeks before 
 her death, he had made depression in both eyes, and there he found 
 the opaque lenses lying behind the lower portions of the irides. 
 It was not, however, until 1705, after a memorial presented to the 
 Paris Academy of Sciences by the younger Brisseau, that the truth 
 as to their identity became generally known. 
 
 It is recorded that Blancard, of Amsterdam, had, in the last 
 decade of the i7th century, proposed the extraction of cataract, 
 and that Johann Conrad Freytag, of Zurich, had, between 1692 
 and 1698, actually undertaken to remove portions of a dislocated 
 lens from the anterior chamber through a corneal incision. 
 
 The first authentic record of a cataract extraction from a living 
 subject was that of Charles de Saint- Yves, surgeon to the Hospital 
 of St. Lazare, at Paris, in 1707. It was of a lens that, after having 
 been depressed, found its way into the anterior chamber, and the 
 operation was undertaken for the relief of pain, the eye having been 
 sightless. One year later, St. Yves and another surgeon, Francois 
 Pourfour du Petit, extracted a similarly dislocated lens which, two 
 years before, had been couched. This last case not only served to 
 add proof to the idea that cataract was not a veil in front of, but 
 cloudiness within, the lens itself, but also to demonstrate the true 
 function of the crystalline; for, with the aid of a strong convex glass, 
 the patient was able to read with the operated eye. The presence 
 of the lens within the eye had always been considered absolutely 
 essential to sight. 
 
 Mery, who assisted in the operations of St. Yves and Petit ,was 
 the first to conceive and propose the idea of extracting, through a 
 corneal incision, a cataract from behind the pupil. 
 
 These were some of the forerunners of the operation for the extrac- 
 tion of the lens from its normal site, as first practiced, also by
 
 DESCRIPTION OF PLATE IX. 
 
 r. De la Faye, 1752, curved on the flat. 
 
 2. Poyet, 1753. 
 
 3. Tenon, 1757. 
 
 4. Von Graefe, 1855. 
 
 5. Daviel, 1750. 
 
 6. DeWenzel, 1762. 
 
 7. Samuel Sharp, 1753. 
 
 8. Warner, 1754. 
 
 9. Beranger, 1757. 
 
 10. Pamard, 1759. 
 
 11. Barth, 1795. 
 
 12. Beer, 1800. 
 
 13. Richter, 1770. 
 
 14. Young, 1756. 
 
 15. Jaeger, 1873, right and left. 
 
 1 6. Inouye, 1900. 
 
 17. Weber, 1867. 
 
 18. Taylor, 1900, right and left. 
 
 57 6
 
 I'l.ATK IX. 
 
 37
 
 HISTORICAL. 579 
 
 a Frenchman, the immortal Jean Jacques Daviel toward the end 
 of the year 1747. It was while making unsuccessful efforts to couch 
 a cataract that it occurred to him to open the lower portion of the 
 cornea and remove the obdurate crystalline, which he immediately 
 proceeded to do, and with most gratifying results. The eye recovered 
 promptly and retained good vision. Like a number of his predeces- 
 sors, Daviel had already extracted fragments of cataracts that had 
 wandered into the anterior chamber after depression, 1 and his 
 experience in this line, added to the success of the extraction 
 just related, incited him to further attempts in the same direction, 
 and from that time he began the systematic extraction of cataracts. 
 He was aware of the shortcomings of the older operation and he 
 pinned his faith to the possibilities of the new one. 
 
 In 1750, he was called to Mannheim to operate on a member of 
 the royal family, and while there made three extractions, the details 
 of which he narrated in a letter to a friend in Paris, which constitutes 
 the first description of his methods. By the time he contributed 
 his notable memoir on the subject to the Paris Royal Academy of 
 Surgery (Nov., 1752), he had made 206 extractions, with satisfactory 
 results in 182 instances. 
 
 Daviel's Manner of Operating and the Instruments he Used. 
 Patient and operator sat in chairs facing each other. He began 
 his corneal incision near the lower limbus by inserting there a 
 small lance-shaped knife, or broad two-edged needle, with curved 
 shank. The small cut thus made he extended in either direction 
 by means of a similar but smaller and blunt-pointed instrument. If 
 obliteration of the anterior chamber and flabbiness of the cornea 
 interfered with this mode of extension, he substituted small 
 scissors. Of these there were two pairs, one curved on the flat and 
 to the right, with the right blade blunted, and the other curved on the 
 flat and to the left, with the left blade blunted for the corresponding 
 sides. With these he carried the incision around parallel with the 
 limbus in each direction to a point a little above the pupil, which 
 means that it included quite a little more than one-half of the cornea 
 (Fig. 248). He afterward limited the extent to one-half the circum- 
 ference (see cut). He lifted this large flap with a gold or silver 
 
 i David's first case of this kind was in the year 1745, and the subject was 
 the hermet of Aiguille, in Province. The eye was lost by suppuration.
 
 580 EXTRACTION OF CATARACT. 
 
 spatula, and incised the anterior capsule with a small curved, two- 
 edged needle, loosened the cataract further, if need be, with the 
 spatula, and delivered by external pressure upon the lower lid. 
 Broken masses of the lens were laded out with a tiny elongated gold 
 or silver scoop, the same that is in use by many for other purposes 
 and by a few for the same to this day. If the iris got into the 
 incision, it was returned to the anterior chamber by manipulation of 
 the spatula and, occasionally, after unusual 
 wounding of the iris, the injured portion was 
 excised. 
 
 It will be seen from the foregoing, there- 
 fore, that, notwithstanding the lapse of 160 
 years, the best efforts of all of his successors 
 and the many modifications and changes 
 that have been suggested, aside from the 
 
 relatively slight variations in technic, Daviel's 
 FIG. 248. Daviel, 1750. J 
 
 operation was not essentially different from 
 the most approved at the present time. 
 
 Let us note some of the phases through which the corneal section 
 has passed and some of the forms and alterations that have charac- 
 terized the cataract knife. 
 
 Changes in the Incision. When one contemplates how impor- 
 tant is the role played by the primary section or opening of the globe, 
 its position, form, and extent, in the operation of extraction, it is 
 truly remarkable how near it still is in these respects to Daviel's 
 conception. True, he made the corneal flap downward (excepting 
 that for a short time, while in his last days, he experimented with a 
 new triangular, or ogival flap, which he tried outward and also upward 
 as well as downward) as did all of his successors, w r ith but few 
 exceptions, for more than a century. In 1784, Pierre Pamard, 
 of Avignon, made an upward section. This surgeon had adopted 
 Daviel's operation as early as 1758, and had striven earnestly to 
 improve it. He broke away from tradition sufficiently to operate 
 his patient lying. He used a lance-shaped knife of his own invention, 
 as also a sharp hook with which to steady the eyeball. The elder 
 Baron de Wenzel, in 1766, using his broad double-edge knife, made 
 an upward and outward flap, and his son, Michel Jean Baptiste de 
 Wenzel, about 1800, was one of the pioneers of the upward method.
 
 HISTORICAL. 581 
 
 In Germany, among the first enthusiastic advocates and modifiers 
 of Daviels's operation, was August Gottlob Richter, the justly 
 celebrated surgeon of Gottingen, whose labors extended over some 
 twenty years, or from about 1770 to 1790. He, too, made downward 
 section, including one-half the cornea, with a knife like that of 
 Beranger, of Bordeau, save that for a short distance it was double- 
 edged (Fig. 249). 
 
 The work of Richter was carried on by Barth, of Vienna, and by 
 his successor, the great Beer, the teacher of Graefe, Langenbeck, 
 and the elder Jaeger. To the latter he became also father-in-law. 
 Barth is said to have devised, in 1795, the triangular cataract knife 
 commonly accredited to Beer. Barth changed the edge of the 
 
 FIG. 249. Richter, 1780. FIG. 250. Barth & Beer, 1795. 
 
 Beranger knife from convex to straight, claiming for the latter form 
 better cutting qualities and, like Daviel and Richter, made a down- 
 ward flap, including half the corneal base (Fig. 250). It may be 
 mentioned that almost all of the operators, from Daviel down to the 
 time of Beer yes, even to the time of Desmarres extracted with- 
 out the use of either lid speculum or fixation appliance, which fact 
 speaks well for their prudence as well as for their dexterity. Richter 
 and Beer, operating, respectively, in Germany and Austria, so im- 
 proved the instruments in short, so advanced the status of the 
 operation that their methods have been termed classic; and, as a 
 further tribute, their additions to the measure were adopted in the 
 home of Daviel by the two greatest living ophthalmic surgeons. Sichel 
 and Desmarres. (For other reference to Richter and Beer, see sec- 
 tion on Extraction of the Lens in its Capsule.) 
 
 Another school of surgeons, beginning with Palucci, in 1752
 
 5 82 
 
 EXTRACTION OF CATARACT. 
 
 (Fig. 251), and later, Santerelli, in 1795, sought to renew the linear 
 extraction, though their efforts were not strongly seconded (Fig. 252). 
 This was the form as instituted by Saint- Yves and Petit, the fathers 
 of extraction, and, as if to mark the centenary of their discovery, 
 a revival of linear extraction was v inaugurated by Gibson, of Lon- 
 don, in 1811, and by Friederick Jaeger, of Vienna, in 1812. Indeed, 
 it was the latter who gave the operation the designation, linear. 
 
 This movement had its culmination in Great Britain, having 
 been given great impetus by Travers (1814) and Burton, of London 
 (about 1820). The former was especially instrumental in forward- 
 ing it, and the fruits of his activity are visible in the latest phase of 
 the operation. He strove for a minimum incision, and for a 
 
 FIG. 251. Pelluci, 1752. FIG. 25 2. Santerelli, 1795. 
 
 method free from loss of vitreous and iris complications, also for one 
 less difficult in the making, seeing that with such an incision, 
 blepharostat and fixation forceps could be used with more confi- 
 dence. He first limited his form of extraction to soft cataracts. 
 With a reclination needle, he dislocated the lens into the anterior 
 chamber, then extracted it through a small linear corneal incision. 
 Traver's wound was made above and included just i /4 of the corneal 
 margin, hence it became known as Traver's Quarter Section (Fig.253). 
 Later he applied this kind to extraction in general, not limiting it to 
 certain soft cataracts, and those that had been previously broken up 
 as by discission, using a sort of thin spoon to deliver the lens. In 
 after years Sir William Bowman and the elder Critchett, of London 
 (1864), reverted to the Travers' operation, though they extended, 
 with scissors, the incision begun with the keratome, so as to in- 
 clude 1/3 or more of the corneal base, added an iridectomy, and
 
 HISTORICAL. 
 
 583 
 
 employed a thin, broad, curved spoon or spatula as the traction 
 instrument (scoop extraction). 
 
 In the meantime, Albrecht v. Graefe, of Berlin, had begun his 
 brilliant though brief career. After Daviel, he who made the most 
 profound impression upon the principles and the art not only of the 
 surgery of cataract, but upon the science of ophthalmology as a 
 whole, was von Graefe. At the early age of thirty he had sounded 
 the depths and the shallow's of the two methods of linear and flap 
 extraction. He recognized their respective failings and advantages. 
 From the suppurations and lack of coaptation of the flap extraction, 
 he sought refuge (1853) in the more prompt healing of the linear 
 incision placed in the sclera; and from the iris, capsule, and cortex 
 
 FIG. 253. Travers, 1812. FIG. 254. Von Graefe, 1859. 
 
 complications, in the removal of the contiguous portion of the iris, 
 as first definitely recommended, as a part of the operation, by 
 Schifferli, of Jena, in 1776. In this he reverted to the operation of 
 Travers, making a small incision in the upper limbus, adding iri- 
 dectomy, and delivering the lens by means of the clumsy spoons 
 devised by his assistant, Waldau. He confined the operation to 
 the softer forms of cataract or to those with soft cortex and small 
 hard nucleus. But for the sclerosed, more voluminous senile 
 cataracts he still made the flap extraction. Little by little he 
 raised and extended the incision of Travers, until it approached 
 more nearly to the linear, in effect, until it was finally placed 
 wholly in scleral tissue, substituting for the lance-knife his straight 
 narrow Schmalmesser (1859). (Fig. 254). 
 
 Although Daviel never relinquished his early manner of making 
 the section, i.e., beginning with his small lance-knife and enlarging
 
 584 EXTRACTION OF CATARACT. 
 
 with knife and scissors, his friend and colleague, George de la Faye, 
 as early as 1752, suggested a narrow bistoury, curved on the flat, for 
 making the entire flap at one cut (Plate IX, No. i). This one- 
 instrument idea was put into execution, about a year later, by Samuel 
 Sharp, of London, though with a triangular knife of his own design 
 (Plate IX, No. 7). There jwere thus, in the very beginning, the 
 three leading models of the corneal knife, viz., David's, De la Faye's, 
 and Sharp's. These are the precursors, of which all that have 
 since been devised are but modifications. 
 
 David's (Plate IX, No. 5) was the parent of the trowel form (de 
 Wenzel's, Weber's, etc.) of which the modern representative is the 
 lance-keratome. Sharp's found its counterparts in the various 
 half-dart forms (Beranger's, Pamard's, Himly's, and Jaeger's) 
 whose latest survivor is the Beer's knife; while De la Faye's was 
 the progenitor of the narrow, straight type now in general use, 
 coming down through that of Poyet, Tenon, and v. Graefe. 
 
 It must be remembered that the true Graefe Schmalmesser was of 
 decidedly different pattern from that which still bears the name, and 
 is the almost universally accepted form. A glance at Plate IX. No. 4 
 will at once make the difference apparent. The original Graefe blade 
 was longer and broader, the edge and back were perfectly parallel 
 up to within some three or four millimeters of the end, whence the 
 blade was two-edged to the point, i.e., the tapering portion was 
 two-edged. 
 
 It is now more than fifty years since v. Graefe devised his so-called 
 modified linear incision, though, to speak technically, it was not 
 what its name implies, but a high or scleral and conjunctival flap 
 of low arc. It began on either side, one and one-half to two milli- 
 meters behind the sclero-corneal junction, and was carried upward 
 and forward, with a slight curve, and ended with a small con- 
 junctival flap, barely posterior to the junction. In conjunction he 
 made a very broad and very peripheral iridectomy. Graefe suc- 
 ceeded thus in making a perfectly coapting and quickly healing in- 
 cision which greatly reduced the frequency of infection, but at the 
 expense of other disasters which more than offset its advantages. 
 
 Among these, on account of the proximity of the cut to the zonule 
 and the ciliary body, were a large proportion of vitreous Josses 
 (about one in seven), and because of the tremendously peripheric
 
 HISTORICAL. 585 
 
 iridectomy deep uveitis, with punctate keratitis, and almost 
 constantly recurring entanglements of the iris and shreds of capsule 
 in the angles of the incision, leading to drawing upward of the iris, 
 to dense secondary cataract, and to closure of the pupil. Moreover, 
 it was but natural that in addition, and as sequels to these mishaps, 
 the still greater terrors, glaucoma and sympathetic ophthalmia, 
 became more obtrusive. 
 
 De Wecker 1 says: "Personne ne pourra nier que les ophthalmies 
 sympathiques, presque inconnues au temps de Daviel, Wenzel, Beer, 
 Sichel et Desmarres, n'aient fait leur triste apparition que depuis, 
 d'apres Jacobson et de Graefe, on a pousse 
 davantage la section vers la region sclero- 
 ticale, et qu'on s'est rapproche plus en plus 
 de Tangle iridien, mis en outre k deconvert 
 par 1'excision de 1'iris, generalisee comme 
 methode operatoire." 
 
 For these reasons this master was soon 
 constrained to alter his course. As Panas 2 
 expresses it, "De Graefe with his well- 
 
 FIG. 255. Von Graefe, 1867. 
 
 known sincerity in matters scientific, was 
 
 the first to indicate the weak points of his method." Consequently 
 he brought his incision further forward, approaching more nearly 
 the small corneal flap, and reduced the size of his iridectomy 
 (Fig. 255). Having heard much of the brilliant results achieved 
 by Bowman and Critchett, with their scoop extraction, and, to 
 again quote Panas, " Desirous of observing their work, in the fall 
 of 1864, he made a trip to London, and on his return to Berlin, 
 he made 118 extractions after the English mode. Among the num- 
 ber, he had n total failures by panophthalmitis or consecutive 
 cyclitis, 28 occlusions of the pupil, that necessitated ultimate 
 intervention, and n abundant losses of vitreous; not to mention 
 the fact that, in many cases, the ejection of the lens remains was 
 laborious and often incomplete." 
 
 So, with indomitable perseverance, he strove, till, by his modified 
 flap 'operation and the accession of the compre-ssive bandage- 
 about 1864 he was at last able to announce that in ooo consecutive 
 
 i Traite conplet d' Opht. de Weckerand Landolt, vol. ii, p. 1016. 
 * Panas, Maladies des Yeux, vol. i, p. 576.
 
 5 86 
 
 EXTRACTION OF CATARACT. 
 
 extractions he had a loss by panophthalmitis of but 5%. About 
 this time, Graefe's colleague, Jacobson, came to the front with his 
 conception of the flap extraction. This consisted in a downward 
 section, situated one-half millimeter behind the conjunctival limbus 
 or in the opaque cornea, and included just one-half of the corneal 
 base (Fig. 256), and was combined with an enormous iridectomy. 
 Through the efforts of these two surgeons, ere the dawn of antisepsis, 
 the occurrence of suppuration, after cataract extraction, was 
 reduced to at least one-half what it had formerly been 
 
 Following close upon Graefe, Jacobson, Bowman, and Critchett 
 came De Wecker, of Paris, about 1869, offering his combined oper- 
 ation. Its feature was an upward corneal flap, two to three milli- 
 
 FIG. 256. 
 Jacobson, 1864. 
 
 FIG. 257. 
 De Wecker, 1869. 
 
 FIG. 258. 
 De Wecker, 1875. 
 
 meters high, made by an incision beginning in the sclera, on either 
 side, and ending in the limbus, thus having scleral ends "Extrac- 
 tion combinee a petit lambeau" The length of De Wecker's incision 
 was n millimeters, whereas v. Graefe's linear was 10 millimeters 
 (see Fig. 257). This he afterward (1875) altered to his two milli- 
 meters high, purely corneal flap, exactly in the upper limbus, and 
 including just 1/3 of the corneal circumference " detachment of the 
 superior third of the cornea" and, most important, returning to the 
 method of Daviel in that he omitted the iridectomy "Extraction 
 simple a petit lambeau" (Fig. 258). 
 
 For the fashioning of his section De Wecker used a knife modeled 
 after that of v. Graefe, though hardly more than half the width, and 
 gradually increasing in thickness, at the back, from point to heel, 
 until at the shank it was one millimeter through. Something the
 
 HISTORICAL. 587 
 
 shape of a three-cornered steel file. While this particular pattern 
 has not been perpetuated, it undoubtedly was the forerunner of the 
 changes that have culminated in the type in general use at the 
 present momnet. (For description of said type, see chapter on the 
 Management of Instruments.) 
 
 Thus, after wandering up and down the world for more than a 
 century and a quarter, undergoing many vicissitudes, alternately 
 nourished, starved, and forsaken, do we see the operation of extrac- 
 tion enter into its rightful heritage in the land of its birth. For it 
 was the notable contribution of De Wecker 1 in 1875, to tne Paris 
 Academy of Sciences, that sounded the 
 knell of abaissement and reclination, and 
 antisepsis gave the coup de grace. Previous 
 to this there had never been a time when 
 the latter procedures were not extensively 
 practised and that, too, by the shining lights 
 of ophthalmology. Over and over again 
 would they drop extraction to take up the 
 primitive method. 
 
 T i i *u- u- i i j FIG. 259. Weber, 1867. 
 
 To conclude this history, already too 
 
 lengthy, here follows brief mention of a few other modes of making 
 the keratotomy that were devised in the scant years prior to De 
 Wecker's paper. 
 
 About the year 1867, Adolph Weber, 2 of Darmstadt, had con- 
 structed, for making the linear incision, a broad lance-knife, some- 
 thing after the model of the old Santerelli knife of 1795. It differed 
 from the modern wide iridectomy knife only in having a blade concavo- 
 convex, in the transverse sense, with the convexity directed upward 
 (Plate IX, No. 17). It was designed to make an incision similar 
 to Graefe's modified linear, only less peripheral and downward 
 (Fig. 259). It was probably deserving of a longer life. 
 
 Kuchler's Incision.' About the same time that Weber invented 
 his knife, his colleague and fellow townsman, Kuchler, conceived 
 the idea of applying to extraction an incision he had, in 1853, 
 
 1 Wecker, Comptes Rendus de 1'Acadamie des Sciences, T. Ixxx, p. i 294. 
 
 2 Arch. f. Ophthal., xiii, p. 187. 
 
 3 Kuchler. Ueber die Querextraktion des Staars Memorahilien, xii, 
 i, 1867, and die Querextraktion des grauen Staars der Erwachsenen, Erlan- 
 gen, V. ? 8, p. 37, 1868.
 
 5 88 
 
 EXTRACTION OF CATARACT. 
 
 designed and employed in operating for anterior staphyloma. It 
 was nothing more nor less than an actual transverse section of the 
 cornea, lying exactly in the horizontal meridian, and extending from 
 base to base (Fig. 260). And, by the way, this \vas the only true 
 linear cut that was ever made for such a purpose. Kiichler called 
 it Querextraktion. Although a very poor surgical measure, its name 
 serves to perpetrate a passable English pun. 
 
 Liebreich's 1 Incision. This was a modification of the v. 
 Graefe linear incision, made downward, and with the narrow knife 
 (Fig. 261). Puncture and counterpuncture w r ere made about two 
 
 FIG. 260. 
 Kuchler, 1868. 
 
 FIG. 261. 
 Liebreich, 1872. 
 
 FIG. 262. 
 Ed. Jaeger, 1873. 
 
 millimeters below the horizontal meridian and one millimeter back of 
 the corneal base. The edge was directed downward and forward, 
 cutting in a gentle curve, and coming out two or three millimeters 
 above the lower limbus. The iridectomy was omitted. 
 
 Jaeger's 2 Incision. Edward Jaeger, of Vienna, with the idea of 
 accomplishing the Graefe peripheral linear incision by a single for- 
 ward cutting movement, as his grandfather, Beer, made the Daviel 
 large flap, constructed a pair of knives, or as he called them, Hohl- 
 messers, one for the right eye and the other for the left (Plate IX, 
 No. 15). If flattened out, their blades would have been like the 
 Beer knife only longer and narrower. Instead of being flat, however, 
 they were concavo-convex in their sagittal planes; and, in order to 
 conform to the curve of the Graefe incision, they were introduced 
 with the concavity forward (see Fig. 262). They proved to be 
 
 1 Liebreich. Eine neue Methode der Cataract Operation, Berlin, 1872. 
 Also Saint Thomas Hospital Reports, vol. ii, p. 259. 
 
 2 Der Hohlschnitt. Vienna V. 80, p. 23, 1873.
 
 HISTORICAL. 
 
 589 
 
 more ingenious than practicable. His incision was similar to v. 
 Graefe's, but longer by three millimeters. 
 
 Lebrun's 1 Incision. Under the name, "Extraction with a 
 small median flap," Lebrun, of Brussells, contrived a purely corneal 
 incision. With a medium-sized Graefe knife, edge directed upward 
 and slightly forward, he made puncture and counterpuncture slightly 
 below the horizontal meridian, exactly in the limbus. The cut 
 extended up, with a light forward curve, and ended at the junction 
 of the upper with the middle third of the vertical meridian of the 
 cornea, or about on a level with the upper border of the average 
 pupil (Fig. 263). Warlomont called this the Belgian Method. De 
 
 FIG. 263. Lebrun, 1872. FIG. 264. Von Arlt, 1874. 
 
 Fir.. 865.- IIorntT, [88 |. 
 In sclcral tissue. 
 
 Wecker added that, in point of prudence, it might better be termed 
 the neuter method. 
 
 The graver faults of these sections, lying well within the trans- 
 parent cornea, are want of coaptation, contact with the pupillary 
 border of the iris while the anterior chamber is empty, causing the 
 iris to become entangled, slow healing, from being far from the 
 blood supply (liability to infection), and high degrees of astigmatism 
 in cicatrization. One of the very complications that it was the aim 
 of such sections to obviate was, if anything, yet more frequent. \ i/.. 
 picking up of the iris by the incision. This fact helped to disprove 
 the old rule that the nearer the incision to the sclent, the more urgent 
 an iridectomy. 
 
 i Lebrun Mfthode de'extraction de la catunu tc par un prucol.' a 
 lambeau median spiro-cylindrique. Trans. London Inte: 
 p. 216, 1873.
 
 59 
 
 EXTRACTION OF CATARACT. 
 
 THE MODERN CORNEAL INCISION. 
 
 "L'operation de la cataracte, c'est la section." Terrien. 
 
 In view of the foregoing considerations, relative to the various 
 forms of the primary incision for the extraction of cataract, it would 
 seem a fitting close to the subject to define just what constitutes a 
 proper section; for it is on this that, in great measure, we rely for 
 success in the operation. What is its particular configuration, 
 extent, and position as most approved at the present time ? We have 
 
 noted some of the faults of 
 the highly peripheral or scleral 
 sections (p. 584) and of those 
 that lie far in the opposite 
 direction (p. 589). It may be 
 stated, then, that an inter- 
 mediate position is desirable; 
 and the one chosen is precisely 
 at the junction of the cornea 
 and the conjunctiva, the direc- 
 tion of the flap being upward 
 superior keratotomy and 
 ending with or without a con- 
 junctival flap; the whole sec- 
 tion lying in a plane parallel 
 with that of the base of the 
 cornea (Fig. 266). 
 As regards the proper extent of the incision, or, in other words, 
 its length as measured around the corneal base, there have been no 
 definite limits fixed, nor is it practicable to do so, except approxi- 
 mately. There must be some latitude in the matter. We have 
 seen how very objectionable is a wound too small, yet, how seem- 
 ingly little it matters if it be larger than necessary. Therefore, 
 knowing the uncertainties of the act, one may so begin his section 
 as to favor the chances of erring on the safe side, i.e., of needless 
 length. The supposed size of the cataract, for example, or the 
 particular difficulties that are apprehended in a given case, of 
 necessity, influence the operator's judgment in selecting the points of 
 puncture and counterpuncture. Manifestly, these two points mark 
 
 FIG. 266. Modern incision for cataract.
 
 THE MODERN CORNEAL INCISION. 59! 
 
 the lower bounds of the incision, and are supposed to be on the same 
 horizontal level. Assuming that these terminals can be accurately 
 placed as desired which at the hands of the experienced operator 
 is pretty certain and that the cut will unerringly follow the limbus 
 from start to finish, one might with tolerable certainty give a uniform 
 configuration, position, and extent. Now, such infallibility is not 
 possible to the skillful, even in operating on pig's eyes in a mask, 
 much less so, to all degrees of dexterity, in dealing with the 
 living human eye, in subjects possessed of all grades of sense and 
 sensitiveness. 
 
 Hence, the making of a uniformly satisfactory corneal section 
 is, perhaps, the most difficult feat in all surgery a feat to which 
 the greatest has never attained. Agnew, with all the marvelous 
 precision of his art, and De Wecker, startlingly brilliant as he was, 
 I have seen baffled in their aim in this particular. True, if one 
 were satisfied to habitually make an unduly large section, the thing 
 might be easier. 
 
 In order to locate the site of puncture and counterpuncture, it 
 has been customary, with most operators, to select a certain fraction 
 of the corneal circumference that shall be detached: Daviel, 1/2 to 
 10/16; Travers, 1/4; Critchett and De Wecker, 1/3; Panas, 2/5, etc., 
 the idea being to bisect the extremities of this chosen arc as puncture 
 and counterpuncture. To me, a readier way has always seemed 
 the fancying of a sort of scale marked upon the vertical diameter of 
 of the corneal base, and to choose thereon the level of the two 
 points. In other words, to place the horizontal chord of the arc 
 and not the arc itself. It will be seen by looking at Fig. 267, that 
 Travers' quarter section arc included about 1/6 of said diameter; 
 Critchett's and De Wecker's 1/3 arc just 1/4 the diameter, and 
 Stellway v. Carion's and Panas' 2/5 arc about 1/3 of the diameter. 
 
 Now, Travers' section is obviously too small for other than in- 
 strumental delivery of any ordinary cataract, although it were made 
 in the plane of the greatest corneal curve, viz., the base, and with the 
 curve of both wound openings parallel, which, of course, would 
 mean as near as possible to the true linear section (Fig. 268). 
 Critchett's and De Wecker's, if it could be made ideal, i.e., exactly in 
 the base and with the minimum of difference in the size of outer and 
 inner wound openings, should be adequate for any ordinary senile
 
 EXTRACTION OF CATARACT. 
 
 cataract. Several things may conspire, however, to make this im- 
 possible, as a shallow anterior chamber, an intractable patient, early 
 escape of the aqueous, etc. It may be set down, therefore, that a flap 
 whose height (or breadth) is equal to one-third of the diameter of the 
 
 FIG. 267. 
 
 a a. Vertical diameter. The divisions represent millimeters. 
 
 b b. One-fourth the circumference or a little over one-seventh the diameter. 
 
 cc. One-third the circumference or one-fourth the diameter. 
 dd. One-third the diameter 
 
 ee. Two-fifths the circumference j TheSe tw fal1 approximately together. 
 //. Two-fifths the diameter. 
 g~g. One-half the diameter also one-half the circumference. 
 
 corneal base or about equivalent to two-fifths of the circumference, 
 as recommended by Stellwag and Panas if made with due regard 
 to the rule of the procedure, will afford an ample opening for the 
 largest lens, and leave margin enough to cover slight irregularities. 
 What are the rules or principles to be observed in the fashioning
 
 THE MODERN CORNEAL INCISION. 
 
 593 
 
 of the flap or of the incision ? Aside from those already mentioned 
 as to position and extent, the most important has reference to the 
 configuration, and may be thus concisely stated: Let there be the 
 leas possible difference between the sizes of the inner and outer icound 
 openings (the minimum length of "wound-canal," as the Germans 
 call it) . How to accomplish this result ? The briefest answer to this 
 
 p IG 2 g QO. Optic axis. B B. Plane of corneal base. LL Linear inci-i<-ii. 
 
 PP. Positive inclination. AT AT. Negative inclination. //. hidectomy incision. 
 
 question is, avoid splitting the cornea. Make the breadth of the lip 
 of the incision at a given point approximate the thickness of that 
 portion of the cornea (Fig. 269). This is best effected, first, by 
 holding the blade of the knife perpendicular (or nearly so) to the 
 tangent of the corneal curve in making the puncture, then clepn-s. 
 ing the handle (in the backward sense, or toward the patient's 
 temple), all the while pushing the point of the blade to a point 
 opposite the center of the pupil, and again depressing the handle 
 38
 
 EXTRACTION OF CATARACT. 
 
 (this time in the downward sense, or toward the patient's feet) to 
 make the counterpuncture. This gives the most direct wound 
 angle, in both vertical and horizontal planes, that it is possible to 
 make. 
 
 FIG. 269. Ideal section. 
 
 The wound-lips at the counterpuncture can never be so steep as 
 at the puncture (Fig. 270), because they must be made with the 
 blade in the horizontal position. The object here, then, is to keep 
 
 FIG. 270. 
 
 the knife down close to the iris so as to go most directly through the 
 cornea. The further back the counterpuncture the larger the 
 opening, or at least, the more nearly in the limbus; but the de-
 
 THE MODERN CORNEAL INCISION. 
 
 595 
 
 ceptive refraction which makes the knife appear much nearer than 
 it really is must be borne in mind (see description of operation on 
 p. 488). In this way, although the inner angle of the incision is 
 
 FIG 271. Split in finishing. 
 
 less direct than the outer, not only is an ample opening insured, 
 but there is less risk of making the lips too slanting in the rest of 
 the section (See Fig. 271). 
 
 FIG. 272. Counter-puncture loo far forward. 
 
 By the time the two punctures are made, cutting upward 
 is already under way, as it were, the knife is held strictly to the 
 limbus, on both sides, and, as the edge disappears in the upper
 
 596 
 
 EXTRACTION OF CATARACT. 
 
 iridic angle, if a conjunctival flap is desired, it (the edge) is turned 
 backward to emerge beneath the membrane. 
 
 I look upon this flap, identified with Desmarres, as one of the 
 keys to the situation, not alone in simple extraction, but in the 
 combined as well. It is not prone to become misplaced, but clings 
 to its original site with singular pertinacity, and heals solidly in 
 a few hours, thus holding the incision closed; and to be held shut 
 favors primary union, absence of iris complications, and many other 
 untoward happenings. It need not be in the way of the subsequent 
 
 FIG. 273. Split at all points. 
 
 operations, such as delivery of the cataract and cortex and the 
 toilet of the eye, as it is easy enough to turn it over onto the cornea. 
 As for any hemorrhage, that may be occasioned by it, that is not 
 to be considered at all. Just before final closure of the eye it 
 must be seen to that the flap is nicely coapted not caught in the 
 cut, etc. 
 
 Could one determine with anything like certainty before operating 
 the dimensions and consistency of the cataract, the size of the flap 
 or of the section might be planned to suit the individual case. 
 Since this is not feasible, it is better to err on the side of prudence 
 and safety, by making it unnecessarily large, than to attempt the 
 regular practice of making it comparatively small. While, of course, 
 on general principles, small wounds are less vicious in every way 
 than large ones, with aseptic precautions and placed in the vascular
 
 THE MODERN CORNEAL INCISION. 597 
 
 zone, there seems to be no appreciable difference in the coaptation 
 and healing properties of incisions that include from 1/3 up to as 
 much as 1/2 of the circumference, especially if the conjunctival 
 flap is made. For those operators who prefer to transfix the cornea 
 by one straight forward movement of the knife, with puncture and 
 counterpuncture in one plane, and for beginners, and all who lack 
 confidence in themselves, the larger sections offer fewer obstacles.
 
 CHAPTER XII. 
 OPERATIONS UPON THE ORBIT. 
 
 FOREIGN BODIES. 
 
 In view of the peculiarities of the subject, it is thought best to give 
 a few preliminaries before touching upon the operative measures of 
 foreign bodies in the orbit. The latter are, for the most part: i. 
 objects that have entered the orbit, as flying missies from explosions, 
 such as fragments of iron or stone, and leaden balls; and 2. pieces 
 left behind from articles that have been thrust into the cavity, 
 like parts of sticks, stubs, pens, pencils, the ferules of umbrellas, 
 etc. Hence, those most liable to these accidents are those who 
 handle explosives or fire-arms and children who run with long, 
 pointed implements in their hands. A large percenatge also come 
 from stooping suddenly amidst stumps and stalks of vegetation. 
 They usually penetrate by way of the skin of the lids or by that of 
 the conjunctiva. Rarely, in their entry, they perforate the bony 
 wall of the orbit, and, still more rarely, enter through the temporo- 
 sphenoidal fissure. The distal extremity of the longer objects not 
 infrequently penetrates one of the adjacent sinuses or the cranial 
 cavity. It often happens that little children, because of their age, 
 and older persons, because of their confusion at the moment of the 
 accident, are not aware of anything having entered in the vicinity 
 of the orbit; the only way it is discovered being through the secondary 
 disturbances excited by the foreign body. Doubtless, in many 
 instances, the intruder becomes so thoroughly encapsuled that 
 it never causes any disturbance. This can be readily inferred from 
 the marvelous manner in which, time and again, the orbital tissues 
 have been known to tolerate foreign bodies. Enormous things 
 have remained 'there for years without producing the slightest reac- 
 tion. It is probable that to this cause are due many of the cases 
 of paralytic squint, without a history, and of unaccountable mono- 
 lateral amblyopia. Yet, it is a good thing for those who are uncon- 
 
 598
 
 FOREIGN BODIES. 599 
 
 sciously carrying around foreign bodies in their orbits that they don't 
 know it. When they have trouble from this source there is time 
 enough to do something. Sooner or later, however, most of these 
 orbital foreign bodies are serious enough in their effects, causing 
 not only ocular paralysis and blindness from injury to the orbital 
 nerves, but septic cellulitis, osteoperiostitis of the walls, and even 
 meningitis and death. Primary involvement of the eyeball is 
 relatively rare. 
 
 Diagnosis. In all the recent cases the foreign body in the orbit 
 should be removed at once, if practicable. There may be the history, 
 of a foreign body without the local evidences, or there may be the 
 evidences without the history, or both history and evidences may 
 be available. In the first instances the wound of entrance may 
 have healed or it may be overlooked. It is surprising how large an 
 object can pass through the lids or conjunctiva and, after a day or 
 two, leave no apparent trace. Or, if a trace be found, how insignifi- 
 cant it will seem. Owing to the position of the eye at the time of 
 the penetration and the different position at the time of the examina- 
 tion, although the injury may be fresh, it frequently happens that 
 a probe cannot be made to follow the track. The probing must 
 be carried out on thoroughly aseptic principles. The probe can 
 usually find the foreign body after a surrounding abscess has broken 
 through to the outside. Palpation is often useful, as, by judicious 
 pressure at different points, the sence of touch can be made to 
 extend a long way into the, orbit. When it can be done, the end of 
 the object which has been thrust into the orbit should be carefully 
 examined for signs that any part has been separated from it. In 
 children who have developed exophthalmos or other symptoms 
 of orbital cellulitis, for lack of a diagnosis, look for foreign body as 
 the cause. It is estimated that in 75' ,' of the cases, the foreign body 
 is situated beneath the upper inner angle of the orbit. If other 
 means of diagnosis fail to locate the foreign body, or, after having 
 been located by other means, then in order to get an idea of the form 
 and size of the object, one should have recourse to the X-rays. 
 The methods to be followed with them are precisely the same as 
 those given for the localization of foreign bodies in the eye. 
 
 Surgical Measures. As before suggested, those that are not 
 likely to give any trouble are best let alone, be they recent or old.
 
 600 OPERATIONS UPON THE ORBIT. 
 
 The great majority of the recent and a goodly per cent, of the old 
 will, however, demand interference. Having located the foreign 
 body, it is commonly got at by incision through the skin. As 
 many structures are gone through as is necessary to bring the 
 object within reach, sparing, as much as possible, all those that it 
 would be disastrous to wound. If it is thought best to remove at the 
 site of entrance and there is still an opening, this will need enlarge- 
 ment. The incision or enlargement extends horizontally or, 
 better, parallel with the rim of the orbit, and must be free enough to 
 allow plenty of room to work. For extra large foreign bodies 
 situated close to the roof of the orbit, it is sometimes the considerate 
 thing to shave the eyebrow and make the cut along the mid-line 
 of its hair-follicles, so as to hide the resulting scar. If suppuration 
 is present, the foreign body will, most likely, yield easily to the 
 traction of forceps or to that of a powerful magnet. If not, the 
 cutting may have to be extended down around it before it will come 
 without too much violence. Should the foreign body be of some 
 brittle material, easily broken, like dried wood, or wood and bark, 
 it is advisable, after removing a piece, to look for more. Not long 
 since, the writer extracted in this way three successive sections of a 
 dead twig, the aggregate length being 21/2 inches. The removal 
 having been accomplished, the cavity is cleansed, and, if aseptic, 
 the tarso-orbital fascia is brought together with absorbable sutures, 
 and the skin opening closed with silk; if septic, a drain is put in 
 and only the extremities of these openings are sutured. In the event 
 of the foreign body having pierced the cranium, unless suppuration 
 is in progress or the injury is recent, it had better not be withdrawn. 
 If it only enters a sinus, it should be removed, whatever the con- 
 ditions. When the object is near the apex or in the spheno-palatine 
 fossa and the globe is intact, the safest means of getting at it would 
 be by an osteoplastic operation, after the method of Kronlein. But 
 if the state of the eye is hopeless, as regards both vision and appear- 
 ance, enucleation and then removal of the foreign body would be 
 preferable to the Kronlein.
 
 RESECTION OF THE OUTER WALL OF THE ORBIT. 
 
 60 1 
 
 TEMPORARY RESECTION OF THE OUTER WALL OF 
 THE ORBIT. 
 
 KRONLEIN'S OPERATION. 
 
 About twenty years ago, two general surgeons, working inde- 
 pendently of each other, conceived of this operation, whereby the 
 remoter depths of the orbit are made much more accessible than by 
 any former method. These men were Wagner, of Germany, and 
 Kronlein, of Switzerland. W r agner's idea was in connection with 
 fractures and other injuries of the skull, among which were foreign 
 bodies lodged near the apex of the orbit, and Kronlein's was to 
 facilitate the removal of tumors 
 of the orbit, particularly the 
 deep-seated dermoids. To 
 Kronlein is due the credit of 
 having evolved suitable technic, 
 he calling the procedure, Osteo- 
 plastic Resection of the Outer 
 Wall of the Orbit. 
 
 Kronlein's Operation. The 
 eyebrow and the hair about the 
 temple are shaved and the pa- 
 tient narcotized. The first step 
 of the operation is the incision 
 of the soft parts. This de- 
 scribes an arc on the temple, 
 having its convexity directed i-'io. 274. 
 
 forward (Fig. 274). It begins 
 
 over the semicircular ridge of the frontal bone, above the angular 
 process, and two centimeters above the fronto-malar articulation 
 The topography of the bone here is pronounced, and the different 
 features easily distinguished by feeling. The cut runs downward 
 and forward till about flush with the outer rim of the orbit, where 
 it begins to turn backward, to be carried along opposite the upper 
 border of the zygomatic arch, near the middle of which it stops. 
 The first portion is through only skin, fascia, and a little into the 
 muscle. The middle and latter portions are down to the bone.
 
 6O2 OPERATIONS UPON THE ORBIT. 
 
 The whole length of the cut, in adults, would be about 8 cent meters. 
 It is important that it be not too small, also that its course be mapped 
 out with great precision. The periosteum is now incised along the 
 orbital rim, lifted up with a good sharp elevator, and loosened all 
 along the outer wall of the orbit. An assistant holds the contents 
 of the orbit out of the way. The loosening is continued, working 
 from above downward, till the spheno-maxillary fissure is reached. 
 This marks the location of the lower edge of the wedge of bone that 
 is to be removed. It has been generally recommended to stick the 
 elevator or a probe in here to indicate the apex of the wedge 
 Knapp advises against it, as encouraging deep infection. Besides, 
 instead of the apex of the wedge being at the forward end of the 
 spheno-maxillary fissure, it is further back or nearly midway of 
 the fissure. 
 
 Second Step. This is the cutting of the bone, and is accom- 
 plished with the aid of sharp, flat chisels, which are sometimes sup- 
 plemented by delicate saws, such as band, wire, chain, or electro- 
 motive circular. Here an assistant may hold an instrument at the 
 point that denotes where the two converging bone cuts are to join. 
 This will be, as before intimated, well toward the middle of the 
 spheno-maxillary fissure. The fissure is located by the leaving off of 
 hard bone at that place, and by the peculiar tense, yet elastic, mem- 
 brane that is stretched across it. The base of the wedge comprises 
 the bridge of strong bone between the orbit and the zygomatic fossa 
 at the outer rim of the orbit (Fig. 275). It extends from just above 
 the frontomalar suture downward to a point nearly on a level with the 
 lower orbital rim, or a distance of about 3 centimeters. The length 
 of the wedge is about 4 centimeters. For severing the heavier bone, 
 viz., the angular process of the frontal and the orbital process of the 
 malar, some kind of saw Gigli's, for example would be a most fit- 
 ting instrument, as it would not only make the task an easier one, but 
 it would favor the subsequent coaptation and healing, whereas, to 
 do it with a chisel, necessitates the taking out of a chipping space. 
 The upper bone cut as made first, working with the chisel from be- 
 fore backward. The cut extends from above the junction of the 
 malar and the frontal, backward and downward at an angle of 
 about 45 degrees, to the point indicated along the spheno-maxillary 
 fissure. When working in the thin bone, it is best to work rather
 
 RESECTION OF THE OUTER WALL OF THE ORBIT. 
 
 603 
 
 from within outward, and to use only the corner of the chisel, and 
 very slight taps of the hammer, else the bone will be shivered, or the 
 chisel will break through and wound the structures beyond. The 
 aim is also to neatly cut the periosteum covering the outer side of the 
 wedge at the same time. Care must be exercised here or the cut 
 may go too high and enter the cranial cavity. The lower cut is made 
 next, beginning on the malar, about 3 centimenters below the be- 
 ginning of the upper cut, and running almost horizontally back- 
 
 FIG. 275. The heavy black lines show bone cuts. 
 
 ward to the spheno-maxillary fissure. The forward end of the 
 fissure reached, the cut may be extended to the apex of the wedge 
 with strong scissors. There should be no dissection of the soft 
 parts from the outer surface of the wedge of resected bone. Now, 
 the whole flap, made up of soft tissues and detached bone, is ready 
 to be swung back out of the way. All that stands in the way of 
 getting at the orbital contents is the wall of periosteum that had 
 lined the inner aspect of the wedge. This is cut with blunt-pointed 
 scissors along the lower border of the external rectus, back of the 
 apex of the wedge, and the two leaves are held out of the way with
 
 604 OPERATIONS UPON THE ORBIT. 
 
 tenaculums. Now the retrobulbar compartment of the orbit is 
 opened up. If the tumor, or foreign body, be on the outer side of 
 the cone of recti muscles, it may be removed at once, or if it is de- 
 sirable to get at the posterior pole, or if on the inner side, the ex- 
 ternus must be got out of the way. If it suffices merely to pull it 
 aside, so much the better. If not, it is divided just where the 
 tendonous portion begins, and a substantial absorbable suture is put 
 through the two ends, for the double purpose of holding them for 
 the time being, and of uniting them on the completion of the opera 
 tion. With the blunted scissors, the fibrous capsule of the globe is 
 incised so as to expose the opticus. This nerve is the land-mark. 
 By opening up the wound to its fullest capacity, and with good il- 
 lumination, the optic nerve can be seen from its disappearance in the 
 sclera to its emergence from the optic foramen. During further 
 operation the globe is drawn forward and inward, and the orbital 
 fat is pushed back with a Jager or an Axenfeld spatula. Special 
 care must be exercised not to injure the abducens. Other structures 
 to be avoided are the lacrimal gland, the trochlear nerve, the in- 
 traorbital nerve, and the (unnecessary wounding of) capsule of 
 Tenon. Through breaking the capsule of the gland a fistula could 
 arise. Much traumatism of the capsule of Tenon might result in 
 crippled ocular motility. 
 
 The orbital portion of the operation having been completed, the 
 cavity is irrigated, the cut ends of the externus are approximated and 
 the suture secured, the aponeurosis is nicely arranged, the incision 
 in the periosteum is sutured with catgut, the big flap is replaced, 
 and the original incision is closed with silk sutures. The usual 
 dressing. The sutures are removed after 3 or 4 days. The healing 
 is usually prompt. The operation, though somewhat tedious, is 
 neither difficult of execution nor attended with any peculiar dangers. 
 
 Modifications. There have been a number of these, but none of 
 them has meant any radical departure from Kronlein's method. 
 They have had reference chiefly to the form and position of the first 
 incision, and to the size of the wedge of bone resected. In fact, its 
 dimensions in the operation just described, are in excess of those in 
 the original operation. The cut in the soft parts is also more ex- 
 tensive. On occasion, these cuts may be made yet more compre- 
 hensive. Czermak, for instance, has, in this way, removed a part
 
 RESECTION OF THE OUTER WALL OF THE ORBIT. 605 
 
 of the floor of the orbit, in addition to the outer wall, employing a 
 tiny chain saw, starting it at the back and cutting forward by pulling. 
 Others, again, have gone much further, making resections, definitive 
 and temporary, of parts of the frontal, exposing the dura, disarticu- 
 lating the malar, etc. Haab's criticism of this method is that it is 
 getting outside the sphere of the ocular surgeon, while the simpler 
 measure is well within it. Schuchardt and others have suggested 
 forms of the saw and manners of sawing. Of course, to saw from 
 behind forward, a perforation must be made through the coverings 
 of the spheno-maxillary fissure through which to start the saw. 
 This is the difficult and exacting part of it. 
 
 Of the changes in the first incision, a noteworthy one is that of 
 Parinaud and Roche. With the view of doing away with the con- 
 spicuous scar left on the temple by the older method, these surgeons 
 recommend a quadrilateral flap with its base directed forward. 
 The incision begins at the outer extremity of the eye-brow, runs 
 horizontally backward a distance of 5 centimeters, then vertically 
 downward 5 centimeters, and, lastly, 5 centimeters horizontally 
 forward. The skin covering the inclosed area is loosened to the 
 base and turned over forward; after which the operation is pro- 
 ceeded with as per Kronlein. Haab's objection to this method is 
 on the score of possible interference with nutrition of the deeper flap 
 containing the bone, hence complications in healing. 
 
 Indications for Kronlein's operation are : 
 
 1. Retrobulbar tumors of the orbit, such as dumb-bell dermoid, 
 cysts, etc., including cavernous angioma (Knapp 1 and a few others). 
 Sattler, 2 of Leipsic, for example, and Golowin,3 each has by this 
 method actually ligated off and extirpated the affected vessels in 
 a case of pulsating exophthalmos. 
 
 2. Tumors of the optic nerve and of its sheath. 
 
 3. Foreign bodies lying deep in the orbit, making their extraction 
 from in front a menace to the soft structures, particularly those of 
 considerable volume, or those that have become fast in the adjacent 
 bones. 
 
 4. Phlegmon of the orbit, especially when there is, or is likely to be, 
 an abscess at the apex, communicating with the posterior ethmoid 
 
 1 Knapp, Archives of Oph., vol. xxv. 1896. 
 
 2 Sattler, Graefe-Saemisch, vol. vi, chap. xi. 
 
 3 Golowin, Zeits. f. Augenh., iv, S. 194.
 
 606 OPERATIONS UPON THE ORBIT. 
 
 cells or the sphenoid sinus, or a strangulating periostitis about the 
 optic foramen, etc., causing great lowering of vision without the other 
 characteristic signs of suppurative cellulitis. 
 
 5. Certain cases of syphilitic or tubercular osteo-periostitis of 
 the orbital wall. 
 
 6. To get at the posterior pole of the globe for operations upon the 
 sclera (as Miiller's resection for detachment of the retina) or for 
 the extraction of intraocular cysticercus in that region. This 
 last would scarcely ever need to be resorted to in this country. 
 
 7. The elucidation of puzzling cases that could depend upon 
 some trouble in the retro-bulbar orbit. 
 
 8. The extirpation of the ciliary ganglion in glaucoma absolutum. 
 
 9. All tumors of considerable size lying near the outer wall of 
 the orbit, as, for instance, carcinoma or sarcoma of the lacrimal 
 gland, whose extirpation from in front would seriously endanger 
 the function of any important nerve or other structure. With 
 this operation there is feeling and fumbling in the dark, risk- 
 ing to wound the larger vessels at the back of the globe, for in- 
 stance, thereby causing atrophy of the choroid or retina in an eye 
 whose sight might otherwise have been preserved. One is not 
 justified in sacrificing the appearance of even a blind eye if it can be 
 possibly avoided. 
 
 THE REMOVAL OF TUMORS OF THE ORBIT. 
 
 Tumors that are favorably situated, that is, those that do not lie 
 behind or below the globe, and some of the deeper ones beneath 
 the roof or in the upper inner angle, can be removed without 
 resorting to a Kronlein operation by incisions either through the 
 skin or through the conjunctiva. The various forms of cyst, and 
 congenital angiomata may nearly all be extirpated in this way. 
 The same may be said with respect to many of the sarcomata and 
 other tumors. 
 
 The diffuse, progressive angiomata, especially in young subjects, 
 often admit of complete eradication. Knapp has given some excel- 
 lent points in this connection. He says: "To treat them with liga- 
 tion, the injection of coagulating substances, electrolysis, galvano- 
 causis, and the like is very unsatisfactory. The only way to cure
 
 THE REMOVAL OF TUMORS OF THE ORBIT. 607 
 
 them is by extirpation. This should be done out of the healthy 
 surroundings, avoiding cutting of the tumor. If only the afferent 
 and efferent vessels are divided, which is, of course, unavoidable, 
 the bleeding would not be excessive, for they, like all other orbital 
 vessels, are small and soon stop bleeding. To avoid cutting into 
 the tumor, and also to diminish the bleeding during the operation, 
 I have pressed a horn plate through the cojnunctival sac, firmly against 
 the bony wall of the orbit behind the tumor. This has served me a 
 good purpose in dealing with some vascular tumors in the inner 
 part of the orbit, which had pierced the lids and spread outside in 
 the skin. I extirpated the orbital portion, from the posterior 
 limit to the inner surface of the lids, but did not attack the palpebral 
 portion at all. There was no more hemorrhage than in the extirpa- 
 tion of a fibroma. I expected the palpebral portion to shrink after 
 its supply vessels had been cut off, which it did." 
 
 The best position for the skin incision is somewhere along the 
 orbital rim. In this way the tumor is not only made most accessible, 
 but the resulting scar is least conspicuous. Above, it is hidden by 
 the supercilia, and in the other parts of the circuit at least masked 
 by the natural sulcations of the skin. If the conjunctival route 
 is chosen, it may be made in the fornices, or, in case of tumors at 
 the nasal side, vertically at the semilunar fold. Cutaneous incision 
 external to the inner canthus means cutting of the canaliculi or the 
 lacrimal sac, as well as division of the internal canthal ligament, 
 and is to be avoided if possible. The severence of the ligament 
 is of small moment, comparatively, seeing that the fragments can 
 be united with catgut, and the damage repaired. For tumors at 
 the temporal side, when relatively small, and well forward, it were 
 well to make the first step a free canthotomy and enlarge the ensuing 
 conjunctival opening to the required size. A remarkably clear 
 field for operating, in case of large tumors beneath the roof, at the 
 supero-nasal angle, or around the lacrimal gland, may be obtained 
 by shaving the brow, then beginning the incision on the med an line 
 at the base of the nose, (fronto-nasa 1 suture) extending it first up- 
 ward to the level of the supercilia, thence through the median line 
 of the hair-follicles of the eyebrow, then curving downward along 
 the outer rim, to end on a line with the external canthus. This 
 includes all the tissues down to the periosteum. Whenever possible,
 
 608 OPERATIONS UPON THE ORBIT. 
 
 the supraorbital nerve must be spared. The wound is gradually 
 opened up into the cavity under the roof, and the flap thus formed 
 is turned down over the palpebral fissure. In this way the writer 
 has removed a dumb-bell cyst of unusual size, and a plexiform 
 neuroma the size of a man's thumb long axis fore and aft. These 
 tumors reached back so far that in feeling with the little finger for 
 their posterior attachments one could feel the sphenoid fissure. 
 By pressing the contents of the orbit downward and forward the 
 space is much increased in the vertical sense. It is obvious that 
 it can be similarly increased in other positions by pressing away from 
 the tumor, but hardly so much as from above. 
 
 Technic. This can only be given in a general sort of way. The 
 incision, be it cutaneous or conjunctival, is carefully deepened and 
 retracted until the tumor can be seen, or,- at least, felt. It is 
 loosened from its surroundings mainly with the blunt dissector 
 whenever possible. When this is not practicable, the blunt-pointed 
 scissors or the grooved hand-chisel is used, but always guided by 
 the tip of the finger, being always sure of the nature of the tissue 
 which is being divided. Of the scissors, those curved on the flat 
 are the most suitable, and, in snipping, the concavity is kept next 
 to the tumor, and only small bites are taken. Moreover, the scissors 
 should be small and delicate, so as not to take up unnecessary room. 
 If the tumor is a cyst whose size or shape increases the difficulties, 
 it may be drawn forward as far as possible and an incision made in 
 the wall just long enough to allow of the contents being pressed 
 out or sufficient of the contents to facilitate the extirpation when, 
 before proceeding further, the cut is either closed tightly by stitching 
 with strong silk or the sack is drawn forward at this point in a neck, 
 around which a ligature is securely tied. In either instance, after 
 the tying, the ends of thread are left long, to serve as handles by 
 which to manage the tumor. In case of the more solid growths, a 
 strong thread can be put deeply through the forward part to answer 
 the same purpose. When using forceps for holding the mass, they 
 should have broad jaws, and be provided with a lock, so that they 
 may be handed to an assistant without risk of letting go their hold. 
 A ligature, however, insures a firmer hold and is less in the way. 
 Every sign of the tumor having been removed, the cavity is copiously 
 irrigated with hot sublimate solution, about 1-2000. Whenever
 
 THE REMOVAL OF TUMORS OF THE ORBIT. 609 
 
 it can be accomplished, the tarso-orbital fascia should be closed with 
 absorbable sutures. The skin or the conjunctival wound is sutured 
 with silk. 
 
 Exostoses of the orbit are rarely fit objects of surgical inter- 
 ference, notwithstanding the fact that the affection is not uncommon. 
 In the great majority of instances operation is contraindicated 
 either because of the exceeding slow growth and harmlessness of 
 the tumor or because of the danger that would likely attend efforts 
 at its removal. Their favorite points of origin are the roof and the 
 inner wall of the orbit just the places that the surgeon must hold in 
 greatest respect. The next most frequent site is the upper inner 
 angle, where the exostosis usually springs from the frontal sinus. 
 Their recognition is, as a rule, not difficult; the sense of touch alone 
 being sufficient with which to make the diagnosis, on account of 
 their stony, fixed, lobulated feel. Radiography may be valuable 
 for their diagnosis, as well as to get an idea of form and size. With 
 regard to their manner of attachment to the orbit, they vary from the 
 broadly sessile through all grades of the pedunculated, to those 
 exceptional ones that are held merely by fibrous tissue and are 
 movable. If it can be demonstrated that one has to do with an 
 exostosis that is movable or has a narrow pedicle, and it is giving 
 inconvenience or threatens any serious trouble, it is removable from 
 almost any part of the orbit. This is the kind that originates in or 
 about the frontal sinus. Not infrequently, however, they extend 
 into the cranium as well, and one must beware of them. Most 
 of those that arise from any part of the bone below the horizontal 
 diameter of the orbit may be attacked with impunity, whether it 
 extends beyond this cavity or not; but always for some good reason 
 other than the bare presence, such as interference with function, 
 deformity, etc. 
 
 In operating, first lay the tumor bare by making adequate incisions 
 through the overlying tissues, by one of the rules already given. 
 Incise and peel back as much of the thickened periosteum as it is 
 possible to save. When practicable, one of the tiny saws should 
 be used to detach the growth. If 'not, mallet and grooved chisel 
 or the hand-gouge are chosen. The cutting with the chisel should 
 be close down to the base, the "chip" being taken from the side 
 of the tumor, and the taps of the hammer as light as is consistent 
 
 39
 
 6lO OPERATIONS UPON THE ORBIT. 
 
 with fair progress. These precautions tend to prevent the breaking 
 out of a hole at the base of the exostosis. The abscission completed, 
 the periosteum is carefully arranged over the site, stitched, if 
 necessary, with catgut, and the openings in fascia and skin closed as 
 usual. 
 
 INCISIONS OF THE ORBIT. 
 
 These are of two kinds, evacuant and diagnostic. They are both 
 made with the patient in narcosis if there is no reason to the contrary. 
 Evacuant incisions, as the name indicates, are made with the object 
 of draining the tissues of serous infiltration, extravasation of blood 
 or of pus. They are most frequently called for in abscesses of the 
 orbit, and in the more acute stages of cellulitis; in the latter not only 
 for drainage, but also for their relaxing effect upon the tense, densely 
 infiltrated tissues. If relief is not prompt in these cases, serious 
 complications arise from the pressure, such as necrosis of the 
 retinal elements, necrosis of the cornea and lids, etc. As soon as the 
 swelling threatens injury, therefore, free incisions are to be made 
 in that part of the orbit which is most involved, regardless of the 
 formation of pus, and sufficiently deep for drainage, even if they 
 penetrate almost to the apex. The manner of making them is by 
 puncture, or thrust; but, unless the knife is fairly broad, it does not 
 suffice to draw it straight out as it went in, but a little sawing motion 
 is needed, or the knife is tilted forward in withdrawing, to extend 
 the cut slightly. The most suitable instrument is a long, slender 
 bistoury, either straight or slightly curved, or a full-sized Beer's 
 knife. Both point and edge must be of irreproachable keenness. 
 The incision can be started from theconjunctival sac for the shallower 
 parts of the orbit, but for the deeper, they should start in the skin 
 somewhere within the zone bounded on the inside by the cone of 
 recti muscles, and on the outer side by the rim of the orbit. The 
 safest places for the profounder incisions are just beneath the 
 middle third of the eyebrow and any point below, from that level 
 with the outer canthus to that perpendicular to the wing of the nose. 
 The knife should be held with its flat toward the globe, and made 
 rather to hug the bony wall of the hollow cone of the orbit than to 
 encroach too much upon the soft parts; and, it goes without saying,
 
 EXENTERATION OF THE ORBIT. 6ll 
 
 that the most important structures are to be scrupulously avoided. 
 A narrow strip of antiseptic gauze is passed down to the bottom of 
 each cut by means of a tent-probe. This should fit loosely that it 
 may serve as a drain, and not be stuffed in tightly, to act as a stopper. 
 Diagnostic, or exploratory, incisions are such as are made 
 with the view of ascertaining the exact nature of a lesion hidden more 
 or less deeply from view. They are executed by thrusting or lancing, 
 as are the evacuative kind, or by cutting, with the edge of a scalpel, 
 carefully through the tissues. The first mode would be allowable 
 only in the event of a liquid lesion if, in other words, distinct 
 fluctuation was found. Then its quality might be determined by 
 causing it to escape through a simple puncture. If, on the other 
 hand, the injury concerned a tumescence of greater consistence, the 
 incision should be carried slowly and discriminately through the 
 successive layers covering the mass, until the latter is exposed. 
 If mere inspection of it enables one to judge of its character, well 
 and good. If not, a portion may be excised for microscopic ex- 
 amination. It must be borne in mind, however, that certain of the 
 softer sarcomata are incited to tremendous activity by interfering 
 in this manner, and must be handled very conservatively. Above 
 all, one must not be tempted into plunging a knife into one of these, 
 with the view of drawing off a supposed fluid. 
 
 EXENTERATION OF THE ORBIT. 
 
 Also called evisceration, refers to an operation whereby the con- 
 tents of the orbital cavity are more or less completely removed, and 
 accordingly, the exenteration is designated as total or partial. 
 Total exenteration means the removal of the entire contents, in- 
 clusive of all the periosteal lining, with sometimes the cleaning 
 out of adjacent cavities, such as the middle nasal fossa, the maxillary, 
 frontal, and ethmoidal sinuses, and even the spheno-maxillary 
 fossa through the fissure of that name. Partial exenteration never 
 comprises sacrifice of the periosteum, and, in many instances, not 
 necessarily that of a certain portion of the other contents. Either 
 method may involve the removal of one or both lids, provided 
 the disease at fault has not already destroyed them. One or the 
 other procedure is indicated in all cases where enucleation or a
 
 6l2 OPERATIONS UPON THE ORBIT. 
 
 Kronlein operation cannot or has not resulted in the eradication 
 of an orbital growth which may be considered a source of danger. 
 The occasion for making exenteration is rare, and when resorted to 
 the total form is most often the better to select. With the perfection 
 in methods of diagnosis, like the ophthalmoscope and the micro- 
 scope, of the surgical treatment of tumors, to say nothing of their 
 treatment by radiation, the sphere of exenteration has become still 
 more limited. The partial method is called for in those instances 
 where, upon the enucleation of the globe for an intraocular malig- 
 nant growth, it is found that there has been a slight extension outside 
 of the sclera; or in cases of some of the more circumscribed tumors, 
 and those of the optic nerve and its sheath; or cavernomas, that have 
 got beyond the bounds of the muscle funnel, particularly toward 
 the nasal side, as evinced by th direction of the exophthalmos, 
 etc. By far the greater number of partial exenterations, however, 
 will be undertaken in such affections as the softer sarcomata of the 
 orbit, or those of epithelial cancer that have extended deeply into this 
 cavity; the last purely with the object of getting surplus tissue out of 
 the way, preparatory to treatment by radiation. It is quite possible 
 to change the operation to the total form after having begun it as a 
 partial, and will doubtless be found desirable at times. 
 
 Technic of Total Exenteration. Narcosis; preferably ether, 
 or by means of ethyl chlorid or nitrous oxid, if the subjects are 
 children or elderly individuals with reduced vital force. The first 
 step of the operation is the making of a canthotomy, which should 
 extend at least one centimeter beyond the bony rim of the orbit. 
 The lids are then everted and stretched wide apart with lid forceps 
 or clamps. The second step is the circumcision of the soft parts. 
 With a highly convex scalpel a deep cut is made the entire length 
 of the lower conjunctival fornix, and down to the bone forming 
 the corresponding rim of the orbit. This is continued upward, 
 along the outer cul-de-sac, inward above, and downward at the nasal 
 side, to meet the first cut, carrying it boldly to the rim all the way. 
 Here the lacrimal canal is to be avoided. The reason for beginning 
 the cut below is to reduce interruption from bleeding to the minimum. 
 The third step is the loosening of the periosteum. This is incised 
 just on the brink of the orbit all the way around. The inner lip 
 of this incision is loosened up slightly at the outer wall, a long,
 
 EXENTERATIOX OF THE ORBIT. 613 
 
 flexible spatula or elevator is inserted, and the loosening thus begun 
 is carried back to the apex, first at the outer side, then above, and 
 lastly, at the nasal side. Whenever the spatula encounters firm 
 resistance at any spot, the blunt-pointed, curved scissors are brought 
 to its aid. This will occur, for example, at the origin of the inferior 
 oblique, at the pulley of the superior oblique, and at the internal 
 check ligament. The membrane strips off so easily, that after 
 it is well started, the finger can help. In working with the spatula 
 where the bone is very thin, as over the zygomatic fossa, without 
 and over the delicate lacrimal bone opposite, every precaution 
 must be taken to avoid puncturing. The same with regard to the 
 two large fissures. When the periosteum is thoroughly loosened 
 at all points save at the sphenoid fissure and the optic foramen, the 
 nerves and vessels passing through those openings, together with 
 the muscle origins, constitute the remaining pedicle of the orbital 
 contents. The fourth step is the cutting of this pedicle. A pair of 
 strong blunted scissors is introduced at the upper, inner angle and 
 pushed back, their extremities hugging the bone, to find and snip 
 the opticus as it emerges from its foramen, and the upper and inner 
 muscle attachments. The scissors blades must not be shoved far 
 astride the nerve, or else the ophthalmic artery, lying just to its outer 
 side, will be wounded. If this happens there will be a gush of scarlet 
 blood. It were better to take more than one snip. Now the cone 
 of tissue is held toward the nasal side, while a pair of strongly curved 
 Cooper scissors are inserted at the supero-temporal roof and pushed 
 straight back, their convexity corresponding to the concavity of the 
 roof, to find and cut the structures that pass through the sphenoidal 
 fissure and the outer and lower muscle attachments. There should 
 be no traction on the contents while these cuts are being made. It 
 were possible thereby to cause intracranial hemorrhage. The 
 combination scissors and vessel-clamp of Warlomont or Bettmann 
 have been recommended for these acts. The greatest objection 
 to them is their cumbersomeness. The exenteration is complete. 
 
 The bleeding will be profuse. Copious douching of the cavity 
 with hot sublimate solution, 1-2000, is now in order, both for its 
 styptic and its antiseptic properties. There need be no fear of 
 applying this freely. After this, a wad cf antiseptic gauze that lia> 
 a ligature put through it (after Czermak) is pressed back into the
 
 614 OPERATIONS UPON THE ORBIT. 
 
 apex, not too tightly, a long strip of gauze packed in on top of it, 
 and a pad of cotton laid on the lids, held on by a strip tied around 
 the head. After these have been in for a few minutes, or long 
 enough for the active bleeding to cease, they are removed the wad 
 by its string the cavity is lightly packed with one long strip of 
 bichlorid gauze well covered with vaseline to keep it from adhering 
 to the sides of the cavity, the incision at the outer canthus is sutured 
 and the bandage is put on. 
 
 Should the bleeding persist in spite of the tampon, adrenalin, the 
 persulphate of iron, or even the thermic cautery may be called into 
 requisition. The dressing should be changed once or twice a day, 
 and the orbit irrigated, in order to keep it sweet. 
 
 The technic of partial exenteration is very like that just de- 
 scribed, the greatest difference being that just sufficient of the cone 
 of soft parts is removed to accomplish the object sought whether 
 it be a relatively small tumor mass, or to prepare the cavity for the 
 ray treatment. Usually almost everything is cleared away down to 
 the periosteum. This is accomplished as nearly as possible by stub 
 scissors and blunt dissection, without the aid of sharper instruments. 
 
 The cavity is soon covered with a luxuriant growth of granulations, 
 even partly filled with them. These, in process of organization and 
 contraction, draw the lids inward, producing a ghastly cup. This 
 can be, in great measure, prevented by opening up the cavity be- 
 tween the lids and the orbit about the time the granulations are at 
 the height of their growth, and putting in a lead or a tin plate covered 
 with Thiersch grafts, raw side out an artificial conjunctival sac, 
 as it were. 
 
 One or both lids may have to be removed because of infiltrations 
 of the growth, or, as said before, they may have been already 
 destroyed by the disease. The defect thus left may be covered 
 later by a pediceled graft from the temple, or by Thiersch grafts. 
 The plan suggested by Noorden, of covering the entire cavity with 
 epithelial grafts the moment the operation is finished, does not give 
 as good cosmetic results as when one waits for the granulations to 
 partly fill the orbit. 
 
 When there was no involvement of the lids, Langebeck, in order 
 to preserve them, in a case of very large tumor, circumcised them, 
 except a pedicle, 2 centimeters wide, at the usual side. The
 
 EXEXTERATIOX OF THE ORBIT. 615 
 
 skin of this area was dissected up to the pedicle, and turned over 
 the nose, to be stitched back in place after the enucleation. 
 
 The writer, in the case of a young woman with recurrence of 
 sarcoma in the region of the lacrimal gland, after enucleation and 
 partial exenteration had been resorted to in vain, was enabled to 
 save the lids and the conjunctival sac. The incision extended from 
 about 2 centimeters below the outer canthus around the upper rim, 
 to end in the median line of the nose. The flap thus outlined was 
 dissected up without injuring the conjunctiva, the exenteration made 
 and the flap returned. When the lids are conserved, there is gen- 
 erally an unseemly gaping of the palpebral fissure. To obviate this, 
 Kiister recommends tarsorrhaphy of all save the inner angle. In 
 such cases, the writer would suggest thorough resection of the tarsi, 
 and the preservation of the follicles of the cilia. 
 
 Knapp says that exenteration sometimes saves or prolongs life, 
 and sometimes shortens it. And Panas, "Unfortunately, recidiva- 
 tions are always to be feared, and, in cases of sarcoma, especially 
 glioma, the tumor is reproduced with desperate tenacity, and all 
 the more quickly in proportion as the interventions are repeated."
 
 CHAPTER XIII. 
 
 THE REMOVAL OF FOREIGN BODIES FROM THE 
 INTERIOR OF THE EYE. 
 
 Foreign bodies within the eye are threatening or dangerous to the 
 integrity of the organ in accordance with: 
 
 1. The degree and nature of the traumatism they produce in 
 entering. This may be due to direct wounding or, as in case of hot 
 substances, to burning. 
 
 2. The condition of the injury with respect to infection, either 
 carried in by the foreign body itself or occurring from without. 
 This may vary from absolute immunity to the presence of sepsis 
 in the greatest virulence. 
 
 3. Their location. Those lodged in, or in contact with, the 
 uveal tract, causing the greatest reaction; next, those in the vitreous 
 body; then, the retina, and, lastly, those in the lens. 
 
 4. Their chemical composition. Such as are readily oxidizable, 
 like copper and iron, being more potent for evil than the noble metals 
 or even than lead and zinc. Copper, according to the investigations 
 of Leber, has the property of giving rise not only to violent uveitis, 
 but also to suppuration, whether in connection with pathogenic'germs 
 or not. The different intraocular tissues exhibit about the same 
 relative tolerance of the decomposition as of the presence of the 
 foreign body. 
 
 5. The extent to which they become encapsuled, i.e., with or- 
 ganized blood-clot or inflammatory exudations. 
 
 6. The duration of their abode. The longer the time, the less 
 likely they are to give trouble. 
 
 7. Their qualities with respect to diagnosis, recognition, or 
 localization. Glass, for example, is one of the most difficult of 
 substances to find with the eye and to extract because of its trans- 
 parency. True, it is rather opaque to the X-rays. Others, again, 
 are transparent to these rays, and escape observation through ob- 
 scuration of the media. Still others, of whatever composition, elude 
 all forms of search by their minuteness. 
 
 616
 
 ANTERIOR CHAMBER. 617 
 
 Anterior Chamber. Probably less than 25% of the foreign 
 bodies that enter the eye find lodgment in this chamber. If 
 they have great velocity or striking force, they mostly go beyond, 
 and if the contrary, the great majority fail to pass beyond the cornea 
 and sclera. Many of those that do stop here are of the transplanta- 
 tion kind, i.e., the extraneous substance is carried in by the implement 
 that makes the corneal wound, instead of making an opening for 
 itself. In this way cilia, bits of bark, earth, etc., get in, and, in 
 addition, an implantation cyst of the iris may develop. With the 
 exception of the lens, the anterior chamber tolerates foreign bodies 
 better than does any other part of the eye: hence, one may be 
 more deliberate in putting into effect plans for their removal than 
 if they were in the uvea or the vitreous. If obscured by blood, one 
 may usually wait for the latter to be absorbed. If the history 
 indicates the presence of iron or steel within the eye, steps should, 
 meanwhile, be taken to locate it, and if found in this place, it 
 should be at once removed. Infection also requires prompt action. 
 This is not to intimate that any foreign body should be allowed to 
 remain in the anterior chamber if there is a fair chance of removing 
 it. Far from it. The usual mode of determining their presence 
 is by ocular inspection, aided, if need be, by direct and reflected 
 illumination, and by the binocular, or stereoscopic loupe. Often 
 the closest scrutiny and the strongest focal illumination are necessary. 
 Siderosis of the iris, or the characteristic iron-rust tint, is a pretty sure 
 sure sign that a foreign body is in that membrane or elsewhere in the 
 uvea, or has been. In rare instances the foreign body may be got out 
 through the wound of entrance, though this may have to be enlarged; 
 if of iron, with a magnetized probe, with the tip of a hand magnet, or, 
 without inserting an instrument, with the giant magnet; if nonmag- 
 netic, with Knapp's spoon or with suitable forceps. Nearly all, 
 however, will necessitate incision at another place. Even in case of 
 still patent entrance wounds, if the body is small, and has lodged at a 
 distance from the wound, it is best to make an incision at a near-by 
 point. The removal is facilitated if the keratotomy lies close down 
 to the iridic angle, so that the substance can slide out on the iris 
 without being caught behind the posterior lip of the cut. It is 
 desirable that the traction instrument pry the incision open as 
 little as possible, to avoid needlessly spilling the aqueous. When
 
 6l8 THE REMOVAL OF FOREIGN BODIES. 
 
 the anterior chamber is empty, the foreign body is caught between 
 the iris and the cornea, and if the foreign body is angular, or jagged, 
 it will then catch or sink deeply into the iris and be impossible to 
 extricate without undue violence. A sharp projection may, in 
 this way, be even driven through the capsule of the lens, causing 
 traumatic cataract. If working under such difficulties, lay a pad of 
 cotton, wet with boric acid, over the closed lids, and wait for the 
 secretion of more aqueous. There is no need of hurrying. In the 
 event of its being a bit of iron or steel, there is no question but that 
 it should be got out with a magnet, the one question being as to 
 the kind of magnet, magnetized nickel-plated iron probe (or solid 
 nickel), tip of hand-magnet, or the giant magnet. Great attracive 
 force is rarely needed, and if exerted will often cause a prolapse of 
 iris, hemorrhage in the anterior chamber, and pain and wincing 
 on the part of the patient. A magnetized probe is a poor instrument 
 as compared with a properly constructed hand-magnet. There 
 would be many an occasion on which the control of the current 
 causing the traction would be of decided advantage. Most eye 
 surgeons agree in pronouncing the smaller magnet more fitting 
 than the larger when it comes to work in connection with the anterior 
 chamber. Sometimes a silver or horn iris spatula can be of great 
 assistance by slightly prying open the incision, and by holding 
 back the iris. Its use is especially recommended if there is a ten- 
 dency of the cut to strip the foreign body off the traction instrument, 
 be it probe or magnet tip. If the foreign body is fast too tightly, 
 either by being pinched between cornea and iris or by entanglement 
 in the latter, to come out with moderate attraction, and if waiting for 
 the chamber to reform, together with the use of the spatula, do not 
 help matters, it were better to resort to the iris forceps for its with- 
 drawal than to throw on the full power of a giant magnet. This 
 seizing the foreign body with the forceps is of course at the risk of 
 bringing the surrounding portion of the iris out with it. The best form 
 of iris forceps is that without teeth, having, instead, slight serrations 
 athwart the inner aspect of the jaws. A forceps with teeth is apt 
 to make the foreign body jump away. In seizing the foreign body 
 as little of the iris should be included as can be. Yet as much as 
 comes out with the forceps were best snipped off. A clean coloboma 
 is better than a mangled and poorly replaced segment of iris. An
 
 ANTERIOR CHAMBER. 
 
 619 
 
 iridectomy, however, is by no means inevitable in these cases. Haab 
 declares that he has not found it necessary to resort to it in extracting 
 iron from the anterior chamber with his large magnet. Even when 
 the fragment has lodged firmly in the iris at the time of the accident, 
 it is sometimes possible to draw it free into the anterior chamber 
 with the magnet before making the corneal section. Failing to do 
 
 FIG. 276. Use of hand-magnet for foreign bodies in anterior chamber. Forefinger 
 is on make and break button. 
 
 so, excision of the surrounding portion of the membrane is unavoid- 
 able. Indeed, if the bit of metal stands up well abovet he iris, i.e., 
 is held merely by the loose, fibrinous anterior portion thereof, incision 
 and forceps extraction alone may better suffice dispensing with 
 the magnet. I saw my colleague, Wilder, recently remove such 
 a foreign body in this manner without disturbing the iris, notwith-
 
 620 THE REMOVAL OF FOREIGN BODIES. 
 
 standing the fact that it had been there for a long time. Foreign 
 bodies that lie so as to involve the uveal lining of the iris are not so 
 well-borne as the more superficial ones. The above points in technic 
 apply equally well to foreign bodies of the iris and to those that are 
 free in the anterior chamber. 
 
 The most suitable tip for the hand-magnet in this connection is 
 the short, thick, curved one, which rapidly tapers to a point. Its 
 wedge-like form serves to widely separate cornea and iris while the 
 foreign body is being withdrawn (Fig. 276). The current should 
 not be turned on until the extremity of the tip is about in contact 
 with the piece of metal. 
 
 In the Posterior Chamber. It has been denied that foreign 
 bodies ever find their way primarily into the posterior chamber. 
 That its existence is only assumed, there being really no place 
 between the anterior capsule of the lens and the posterior surface 
 of the iris. That those bodies that have got in between had first 
 been in the anterior chamber and secondarily while the patient 
 was in the recumbent posture, for instance slid over the pupillary 
 border. With this in view, Hodge advises that mydriatics be 
 omitted when dealing with a foreign body loose in the anterior 
 chamber. A case reported by the writer in Knapp's Archives would 
 seem to disprove these assertions. It was that of a chemist who had 
 a glass flask burst in his face. There was a flap-like perforation 
 of the cornea, and straight back of it an abrasion of the lens capsule, 
 but no corresponding trace in the substance of the crystalline. The 
 eye was kept under constant observation for two weeks, during 
 which time there were several exacerbations of iritis. Repeated 
 and exhaustive searches were made for a foreign body by myself 
 and others. None was found. The eye became quiet enough for 
 the patient to leave the hospital. He went home, and shortly after 
 his arrival, while stooping to examine the grate-bars in his furance, 
 he f e t a peculiar startling sensation in the eye. The eye became 
 red and painful, and he came direct to my office. The first glance 
 showed a cube-shaped bit of glass lying at the bottom of the anterior 
 chamber, having undeniably dropped through the pupil at the 
 moment the head was lowered and the pain had occurred. It was 
 promptly removed, but with iridectomy, and the eye has given 
 no further trouble. Now, this man came for treatment immediately
 
 IN Illl. VITREOUS. 621 
 
 upon receiving the injury, his pupil hiul not been dilated, neither 
 had he lain down. The glass had evidently stuck lightly to the 
 front surface of the lens for a short while, then worked its way down 
 into the posterior chamber. 
 
 In the Lens. The crystalline is wonderfully tolerant of foreign 
 bodies. So much so that it will sometimes retain perfect trans 
 parency for months, or even years, with one imbedded deeply in its 
 substance. Even fragments of copper have nothing like the dele- 
 terious effect on it that they have in other parts of the eye. Often 
 the worst that ensues is a cataract, and this may be only partial. 
 No one would, of course, think of making discission of such a 
 cataract and thus risking to turn the foreign body loose in the eye. 
 To extract it would be justifiable, but only under certain condition-. 
 among which would be a defective fellow eye, signs of irritation 
 from the foreign body, or the fact of the patient living in a remote 
 district, etc. These remarks refer only to the cases of kno\\n 
 foreign bodies in the lens, (liven a transparent lens with foreign 
 body visible therein and a perfectly quiet eye, certainly no inter\en 
 tion would be warranted, save, perhaps, in the event of the substance 
 being iron or steel. The great surety and safety with which the 
 magnet and a skillful operation could deal with the situation might 
 probably would overbalance the risk of lea.\ing it there. 
 
 In the Vitreous. The surgery of this subject is of recent date. 
 This is one of the few fields that surgeons in ancient, and olden 
 times in general, fought shy of. The first authentic record of ihe 
 removal of a foreign body that had been wholly within the vitreous 
 chamber was that by Albrecht von (Iraefe, about 05 years ago, 
 Then followed similar operations by Kdouard Jaeger, of Vienna: 
 Critchett, of London, and by Desmarres, of Paris. 'The extraction 
 was with forceps, through the wound of entrance or through a 
 scleral incision. 
 
 It is an etablished fact that at least 001005';; of the foreign bodies 
 that are driven into the depths of the eyeball come to n-^i in i In- 
 vitreous chamber. Experience has proved that 65 to 70% of the 
 vitreous foreign bodies are magnetic, i.e., of iron or steel. Not \<> 
 exceed one-third, then, are left to be treated by surgical nie.-iM 
 other than magnet operations. The latter will be referred to 
 further on.
 
 622 THE REMOVAL OF FOREIGN BODIES. 
 
 A foreign body in the vitreous is a very grave affair, whatever its 
 nature. Sooner or later, with but few exceptions, the sight is lost, 
 and in the vast majority the eye itself is destroyed. Worse still, a 
 large percentage of the instances of sympathetic ophthalmia have 
 occurred in consequence of a foreign body in the vitreous of the 
 fellow- eye. Some sort of intervention, then, is the rule. After 
 what manner proceed ? In this connection are offered the following 
 indications for intervention and abstention, partly adapted from 
 Coppez: 
 
 1. If the foreign body is voluminous and has penetrated with 
 considerable force, apparently destroying the globe at once, and 
 panophthalmitis is imminent, exenterate or enucleate immediately. 
 
 2. If the traumatism is moderate and the media are sufficiently 
 clear to admit of seeing it, or it can be definitely located by any means, 
 one might, by an ample meridional scleral incision, and with the 
 aid of a suitable traction instrument say a forceps, a spoon, or a 
 hook and guided by a mirror secured in front of the eye of the 
 operator, essay to catch and withdraw it. 
 
 3. If the media have lost their transparency, thus shutting off 
 any view of the interior of the eye, and other methods of localization 
 prove negative, although there may be fair perception of light 
 and the eye remains irritable exenteration. 
 
 4. If there is no perception of Tght and it is kno\vn that there is a 
 foreign body present, and the eye is sensitive or irritable, exenter- 
 ation at once. 
 
 5. If an eye with a foreign body in the vitreous is perfectly quiet, 
 particularly if some time has elapsed since it entered, it is probably 
 well encysted. Here, whether the eye is hopelessly blind or not, 
 intervention is not indicated. Instead, the patient is instructed 
 to watch closely and to report any signs of disturbance in the eye 
 to a competent oculist. This is particularly true of certain small 
 particles that can be seen with the ophthalmoscope. 
 
 6. Not having succeeded in removing a foreign body and if the 
 reaction is serious and the ultimate good of the eye is dispaired of, 
 exenteration or enucleation, when possible, there and then. It is 
 the proper thing in all the desperate cases to inform the patient 
 that, in case the foreign body is not recovered, the removal of the 
 eye or its contents m'ght be the only other expedient, and to get
 
 MAGNET OPERATIONS. 623 
 
 his consent to the further operation if the operator deemed it ad- 
 visable. As to the choice between exenteration and enucleation, the 
 first is preferable except in cases where there would be risk through 
 its selection of overlooking a dangerous foreign body in the orbit. 
 
 In all recent cases it is most imperative that steps, looking to the 
 riddance of the eye from a foreign body be taken at the earliest 
 moment possible. The same may be said of the old cases that have 
 but lately become inflamed because of the presence of one. More- 
 over, the mere fact that foreign bodies have been known to lie in the 
 vitreous from 20 to 40 years without inciting mischief is no sign that 
 this will happen in any given case. Nor is great length of abode 
 within the eye of necessity a bar to intervention. 
 
 Magnet Operations. The history of the removal of foreign 
 bodies from the vitreous has been made mainly since the use of the 
 magnet in the surgery of the eye. The first tentative in this con- 
 nection was an ineffectual one by Meyer, of Minden, in 1842. The 
 next, perhaps, was by Dixon, of London, in 1859, who succeeded in 
 removing part of the blade of a pair of scissors that had been in the 
 vitreous for four weeks. The steel could be indistinctly made out 
 through the pupil. By means of a large, permanent magnet it wa> 
 drawn close to the outer wall of the globe and extracted with forceps 
 through a scleral incision. The eye was lost. It is only since 1870 
 that the magnet has acquired any real importance in the ophthalmic 
 world. Previously, all eyes with foreign bodies in the vitreous had 
 been considered either as doomed or else as bearing the sign 
 "hands off!" Hence, no 'nstrument had been designed for the ex- 
 traction of a foreign body from any part of the interior of the eye. 
 Knapp's spoon-hook for foreign body in the anterior chamber was 
 about the first. In 1875, M'Keown, of Belfast, went further than 
 had Dixon, in that he inserted the tip of a magnet through a scleral 
 opening into the vitreous, and succeeded not on'y in removing the 
 foreign body, but also in saving the eye. This was the first instance 
 in which the magnet was made to enter the eye. His example \\u> 
 soon followed by his compatriots, Snell and MacHardy, who 
 published articles commending the method. The idea was taken 
 up by Knapp, Griming, and others in America; Griming giving 
 a very effective and convenient permanent hand magnet. To 
 Hirschberg, of Berlin, however, belongs the credit of having rendered
 
 624 THE REMOVAL OF FOREIGN BODIES. 
 
 the procedure practicable. This was through the invention, in 
 1879, of his electro-magnet. Notwithstanding he length of time, 
 this instrument has held its own, and is still the favorite of its kind. 
 It is a most valuable acquisition to the eye surgeon's outfit, and has 
 the remarkable record of having extracted up to 75 and 85% of 
 magnetic intraocular foreign bodies. Many of the failures were 
 doubtless due to the fact that the metal had not been located. The 
 magnet, together with a storage battery to energize it, can be easily 
 carried. Or it may be put in connection with the wires for interior 
 incandescent lighting. Hirschberg has recently had constructed a 
 more powerful hand-magnet. These magnets have lifting powers 
 ranging from i / 2 to 2 pounds sufficient for all ordinary work and 
 with the addition of accumulators, etc., their pull may be still 
 further increased. It seems strange to note that, as late as 1881, 
 Dr. Paul Berger, of Paris, found but 31 instances in all literature of 
 extraction of a foreign body from the posterior segment of the globe. 
 Sulzer, realizing that the horse-shoe form g ven the ordinary per- 
 manent magnet furnishes the greatest relative tractive force, has 
 modified the Hirschberg magnet thus: The core is of soft iron in 
 the form of a horse-shoe, with ends closely approximated The 
 extremity comprising the two poles is made of two separate parts, 
 isolated, magnetically, by a piece of copper, on the opposite side of 
 which they diverge like a fork whose two tines fit into the members 
 of the core. 
 
 In 1 88 1, MacHardy suggested approaching the eye supposed to 
 contain a magnetic foreign body to a large magnet, actuated by a 
 powerful electric machine, with the view of ascertaining if there 
 would be any sensation in the organ indicative of the presence of the 
 metal. 
 
 In 1886, Hirschberg began his valuable series of publications 
 detailing his experiences and his views relative to work with his 
 electric hand-magnet (Fig. 276). 
 
 In 1892, Haab, of Zurich, conceived his "giant" electro-magnet, 
 and found that with it a magnetic foreign body could be drawn from 
 the farthest limits of the vitreous chamber, through the lens and 
 pupil, into the anterior chamber, by the mere application of the tip 
 of the magnet to the cornea. At the International Congress at 
 Rome in 1893 ne recommended the "giant" electro-magnet not only
 
 MAGNET OPERATIONS. 625 
 
 for diagnostic purposes, but for the extraction of the foreign body 
 as well. Haab's great magnet consisted of a soft iron core, 60 
 centimeters long and 10 thick, and weighing more than 75 pounds. 
 This was wound thickly with small copper wire, the whole weighing 
 300 pounds. Obviously, this is too heavy an instrument for carry- 
 
 FIG. 277. 
 
 ing. Since its appearance, many modifications have been manu- 
 factured, some still more powerful, and others, while but little in- 
 ferior as to the force they exert, are so condensed, as to size and 
 weight, as to make them readily portable. These are attached 
 to the ordinary lighting circuits, of 70 to no volts, having a strength 
 
 4 o
 
 626 THE REMOVAL OF FOREIGN BODIES. 
 
 of 20 to 33 amperes, with or without rheostats. The current may 
 be either continuous or interrupted. Storage batteries can be also 
 employed to stimulate them, the minimum current for the ordinary 
 giant magnet being one of 30 volts. The large magnets have lifting 
 forces vary ng from 1/2 pound to 2 pounds. They are supported 
 on tables, like Haab's, or suspended by pulleys from the ceiling, 
 like Mayweg's, or pivoted by universal joints to a wall-bracket, like 
 Volkman's. One of the handiest I have seen is that of the Victor 
 Electric Company, of Chicago (Fig. 277). It is hung by a movable 
 articulation to an adjustable arm, similar to the davit of a boat. 
 This, in turn, rests on a platform with rollers. At first costly, the 
 price has now been so far reduced that these magnets are within 
 reach of almost any specialist, and each of them who has not access 
 to an eye hospital where the instrument is kept, should possess 
 his own. 
 
 Both large and small magnets are furnished with tips of varying 
 forms and lengths. To increase the length of the tip, however, 
 and to reduce its thickness are equivalent to increasing the distance 
 of the magnet from the eye, and as the attractive force is in inverse 
 ratio to the square of the distance, short, blunt tips will, on the 
 whole, prove more satisfactory. In order to increase the suction 
 area, as it were, or sticking surface of the tip, instead of being round 
 or cylindrical, they are better made ovoid or elliptic (in cross-section) . 
 
 Localization. Taken as a whole, the results of magnet opera- 
 tions are not so brill ant as some might be led to imagine especially 
 when a liberal allowance is made for unreliability of statistics. 
 According to Hurtzeller, who has gone over these very carefully, 
 out of 313 attempts to extract steel or iron from the vitreous, only 
 65% succeeded. Of these, a certain degree of vision was preserved 
 in 22%. It is acknowledged that more than half of the entire number 
 eventually came to enucleation how many more are not reported. 
 Doubtless, the number of successes would have been much higher 
 had the -most approved methods of localization been employed, 
 or could they have been. This is the greatest essential What 
 are the means to this end ? They are : 
 
 1. Circumstantial evidence. 
 
 2. Ocular Inspection.
 
 INSPECTION. 627 
 
 3. The ophthalmoscope. 
 
 4. The sideroscope. 
 
 [" a. The fluoroscope. 
 
 5. The roentgen rays., i.e., j b. The radioscope. 
 
 1 c. Radiography. 
 
 Circumstantial Evidence. By far the greater number of 
 fragments or missiles that strike the eye are so minute, and so lack- 
 ing in velocity and impact that they fail to enter at all. Of those 
 that penetrate the vitreous chamber, the big ones have mostly 
 caused destruction of the eye directly or indirectly before it 
 reaches the surgeon. The vast majority of those he is called 
 upon to seek in the vitreous, and to extract, are small that is to 
 say, just large enough so that, when traveling at the rate of 
 ordinary flying particles, they have striking force sufficient to 
 pierce the cornea, iris and lens, or the sclera and its coverings. 
 Larger ones, traveling with greater speed, such as bird-shot, are 
 more apt to pass through the entire bulbus. The circumstances 
 of the accident, examination of tools, etc., may give an idea as to 
 the form and size of the foreign body; and the direction of the flying 
 particle w.th reference to the position of the eye at the time of 
 the injury may suggest its location. Upon the size of the foreign 
 body depends, in great measure, the size of the wound. But it 
 must be remembered, that a long, slender projecti e will, if it strikes 
 endwise, leave but an insignificant wound, and vice versa. 
 
 Inspection. If the injury is recent, there are usually objective 
 as well as subjective signs of it. These are: Externally, redness 
 and swelling of the lids, and of the conjunctiva, and evidences of a 
 wound. If the latter is in the cornea, there will be, internally, 
 a corresponding one in the iris or in the lens, or in both, not always 
 visible. The track of the foreign body through the crystalline may 
 be in evidence it may not be as it is often by way of the zonule. 
 There is often blood, and sometimes pus, in the anterior chamber, 
 and this may hide the signs in iris and lens. When visible, these 
 consecutive wounds give a good idea of the direction of the foreign 
 body, and something as to its location. If the wound is in the 
 sclera it, too, has a story to tell as to the size and direction of the 
 foreign body. Again, inspection may fail of results here, because
 
 628 THE REMOVAL OF FOREIGN BODIES. 
 
 of swelling and inflammation. It is well to bear in mind not to 
 give undue credence to the statements of the average patient. 
 
 The ophthalmoscope, in the relatively few instances when it 
 reveals the foreign body, is the best means of localization we have 
 for the posterior half of the vitreous chamber, as, in addition to 
 the exact spot, it shows something of the size of the foreign body 
 and something of the nature of the bed in which it lies. It is also 
 useful in tracking the metal through the media, by means of traces 
 of blood, exudate, air-bubbles, etc. At times, when not capable 
 of revealing the thing itself, it may, at least, indicate its hiding 
 place. Rarely it shows siderosis of the vitreous in the vicinity of 
 the foreign body. 
 
 The Sideroscope. The first to apply the principle of the 
 magnetic needle for the purpose of ascertaining the existence of 
 iron in the eye was Poolly, of Brooklyn, \vho, in 1880, published 
 the results of his experiments in Knapp's Archives. Shortly after- 
 ward Thompson and Widerman each suggested a form of galvan- 
 ometer. These contrivances, while based on true scientific laws, 
 proved insufficient for detecting the presence of any but relatively 
 large masses of metal. In 1894, Gallemaerts presented to the French 
 Society of Ophthalmology the magnetometer of Gerard, which was 
 an improvement on the instrument of Pooley, it having had the power 
 of responding to a bit of iron within the eye weighing as little as 
 1/2 milligram. This should be sensitive enough of all practical 
 purposes of diagnosis, seeing that the weight of the particle is rarely 
 below 2 milligrams. The sideroscope of Asmus, which has had 
 considerable vogue, was still more sensitive than that of Gerard. 
 Like that of the latter, the needle is suspended with a single long 
 strand of the silk-worm's web. The only material difference is that 
 in the Asmus sideroscope the ordinary magnetic needle is inter- 
 changeable with an astatic needle. The variations of the needle 
 are observed from a distance of 3 or 4 meters through a telescope 
 similar to that used by surveyors. The greatest objection to this 
 form is its extreme sensitiveness, making, when near objects of 
 iron or trolley and arc-light mains, for instance, its readings mislead- 
 ing. Hirschberg is the inventor of a sideroscope, or " Eisenspaher," 
 somewhat less sensitive and much less complicated than that of 
 Asmus. In it he dispenses with the telescope, and has a small lamp
 
 RADIOGRAPHY. 629 
 
 flame reflected onto the scale that indicates the oscillations of the 
 needle. The manner of operating the sideroscope is to approach 
 the needle to different parts of the globe and note its deflections; 
 these are greater the nearer and heavier the piece of iron. It is 
 difficult to manage. Knapp, in referring to the Asmus model 
 says: "To handle it requires the patience of a saint.'' With Hirsch- 
 berg's also, the same precautions must be taken relative to the 
 proximity of iron or of electric currents. Even particles of iron in 
 the hair or beneath the scalp such as iron-workers are apt to have 
 will affect the needle. 
 
 Roentgen or X-rays furnish the best known means of locating 
 foreign bodies in the vitreous chamber, whether the substance be of 
 iron or of other material opaque to them. From the time of their 
 discovery by Roentgen, of Wiirzburg, until 1896, the refracting 
 media of the eye were thought to be opaque to these rays. The 
 crystalline, in particular, with its index of refraction so nearly the 
 same as that of glass, was considered impervious to them. This was 
 the explanation offered as to their invisibility. In March, 1896, 
 Van Duyse made the first radiograph of a foreign body in the eye, 
 and the delusion was dispelled. 
 
 X-rays afford so far three methods of application to the local- 
 ization under discussion, viz. : fluoroscopy, radioscopy, and radiog- 
 raphy. The first two depend for their value upon the properties 
 possessed by certain substance of becoming luminous under the 
 influence of the X-rays, such as the platino-cyanid of barium and 
 calcium tungstate. In the fluoroscope, a small screen covered with 
 one of these materials is fitted to a dark-chamber that can be held 
 to the eyes of the examiner. In a darkened room the screen is 
 placed close to the eye to be examined, i.e., against the face or the 
 temple. The Crooks tube is set in operation from a point opposite, 
 and the observer sees a skiagram of the eye and the other tissues 
 through which pass the rays coming to the screen, and he is sup- 
 posed to determine whether, in addition to the normal shadows, 
 there is that of a foreign body. Unless the subject be a child, whose 
 bones are more permeable, or the foreign body be rather large, 
 these methods are unsatisfactory. 
 
 Radiography. This gives the most exact and approved means 
 of localization of any yet discovered. It owes its worth to power
 
 630 THE REMOVAL OF FOREIGN BODIES. 
 
 of the X-rays to make an impression upon an ordinary sensitized 
 photographic plate. The skiagram is thrown onto the plate and, 
 after ordinary development of the latter, is reproduced in negative 
 form, i.e., the shadows are the clearer or lighter places. A positive 
 printed from this constitutes the radiograph. When viewed from 
 the glass side of the negative, the lights and shadows appear in their 
 true relations not reversed, so that a positive is not always needed. 
 There are three ways of utilizing the radiograph for the localization 
 of foreign bodies in the eye and orbit. These may be desig- 
 nated as: 
 
 1. The graphic. 
 
 2. The stereoscopic. 
 
 3. The geometric. 
 
 i. The Graphic. This consists in making two exposures w r ith 
 the eye at the same distance from the tube, but with a change of 90 
 in the view-point. For the right eye, for example, the plate would 
 be placed against the right temporo-palpebral region and the tube 
 at the left this for the first exposure. For the second, the order 
 would be, the plate against the closed lid of the right eye and the tube 
 back of the head, and slightly to the right side, in both instances 
 having the point of emission of the rays as nearly as possible in line 
 with the center of the eyeball that is exposed. The two views will 
 give the approximate position of the foreign body with respect to 
 the center of the globe and to the sclera, provided certain guide- 
 marks are employed in connection with the exposure, and a control 
 radiogram of about the same aged subject, with limits of the globe 
 outlined (Fig. 291) be used in the viewing. This is the quickest 
 way, and sufficiently accurate for most cases. It would have to be 
 an urgent case, with the necessary apparatus at hand, that could 
 not wait for it. The localization could be effected, if need be, on 
 the wet plate immediately after fixing. Two circles, each with a 
 radius of about 1/2 inch (somewhat smaller for a child), could be 
 struck on the film or the glass, its position regulated by the guide- 
 marks and by the control picture. One of the best indicators of 
 the position of the globe in the radiograph is one of the tiny wire 
 eye-masks of Webster Fox, particularly the one having a circle to 
 fit round the cornea. With this in place, and having the eye fix
 
 METHOD OF SWEET. 63! 
 
 an object so as to make the circle coincide or parallel with that 
 of the circle of the cornea base, a fairly accurate guide is obtained 
 for plotting the sclera in both views. It must be seen to in the lateral 
 exposure that the plate is parallel with the sagittal plane of the eye, 
 and, in the other, that this plane is perpendicular to the plate. 
 
 2. The Stereoscopic. This method involves the psychic element 
 that is concerned in binocular single vision. In other words it 
 gives to the otherwise flat skiagram its third dimension, enabling 
 one to perceive the relative positions of the objects there outlined in 
 relief or perspective as well as laterally. The points of emission 
 of the X-rays from the tubes during the exposure are separated 
 horizontally by a distance corresponding to that between one's 
 eyes, the rays from each made to fall on its own half of the plate, 
 thus producing a double radiograph. The resulting skiagram is 
 viewed with a stereoscope. The process is well adapted to physical 
 examination elsewhere, but p oorly to that now under consideration 
 chiefly on account of lack of definition because of the smallness of 
 the object sought, of the heavy bone structures through which the 
 rays must pass, and the feeble illumination. 
 
 3. The Geometric. This method is based on the principles of 
 geometry as applied to mathematics; that is, the result is obtained 
 by the construction of diagrams or actual working models, together 
 with numerical calculation. There have been a number of plans 
 worked out on these lines by different individuals, some simpler, 
 some more complicated; some requiring elaborate paraphernalia, 
 some scarcely any beside the X-ray apparatus. They start from the 
 same beginning, and all arrive at substantially the same result, 
 but by different routes. As a beginning, two shadows, or projec- 
 tions, of the foreign body in connection with the shadows of two or 
 three other near-by objects of known position, are photographed 
 on the same plate. Both exposures are made with a single tube, 
 which is moved a definite distance between the two, or they are made 
 simultaneously, by using a pair of tubes. The exact location of the 
 foreign body is then determined by triangulation. The result is 
 accurate to a degree, in all of them. Only two, as being among those 
 most often chosen, will be dwelt upon at any length here. One is by 
 Sweet, of Philadelphia, and another by Guilloz, of Nantez. 
 
 Method of Sweet. Sweet, of Philadelphia, has designed a local-
 
 632 
 
 THE REMOVAL OF FOREIGN BODIES. 
 
 izing method consisting of two metal indicators, one pointing to the 
 center of the cornea and the other situated to the outer canthus at a 
 known distance from the first.* Two exposures are made in order 
 to give different relations of the shadows of the indicators and of 
 the body in the eyeball, one with the ray tube horizontal or nearly 
 so with the plane of the indicators, and the other \vith the tube 
 below this plane. 
 
 The principle of this method may be understood from the pro- 
 spective drawing, Fig. 278. 
 Rays coming from the light 
 situated at A cast shadows of 
 two ball-pointed rods and an 
 object in the eyeball, and give 
 the view shown on the sur- 
 face C. In this instance the 
 tube is in front of the vertical 
 plane of the two indicators, 
 and consequently the shadow 
 of the center ball will be 
 thrown back of that of the 
 outer ball. When the light is 
 carried below the plane of the 
 two indicators, the shadows of 
 
 / *' 
 
 /// the two rods are formed on 
 
 B M the surface D, and the shadow 
 
 FIG. 278. Principle of method of 'localization, of the foreign body in the eye 
 
 (Hansell and Sweet.) . . 
 
 assumes a new position. It 
 
 the distance of one of the indicating rods from the center of the 
 cornea is known, and the distance between the two indicators is 
 measured, the position of the metal in the eye may be determined, 
 since the shadow of the foreign body preserves at all times fixed 
 relation to the shadows of the indicating balls in whatever position 
 the light is placed. 
 
 Accurate localization requires that the axis of the eyeball shall be 
 parallel with the two indicators and with the photographic plate, 
 
 * The methods of Sweet and their description are taken partly from the 
 work of Hansell and Sweet on "Diseases of the Eye," and partly from a paper 
 read by Sweet at the meeting of the American Ophthalmological Society, 
 July, 1909.
 
 METHOD OF SWEET. 
 
 633 
 
 FiG. 279. Indicating 
 apparatus secured to side 
 of head. (Hansell and 
 Sweet.) 
 
 that one of the indicating balls be opposite to the center of the 
 cornea and at a known distance from it, and that both indicators are 
 at a measured distance from each other. The plate-holder and in- 
 dicators have been combined into a special apparatus which is bound 
 to the side of the head, as shown in Fig. 279. The arrangements 
 of the parts of this apparatus are such that the indicators, while freely 
 adjustable, are always parallel to each other and to the plate, and 
 the two balls are perpendicular to the plate and 15 cm. distance 
 between their centers when the apparatus is 
 in place. It is necessary that the patient 
 rotate the eyeball to bring the ocular axis 
 parallel with the plane of the photographic 
 plate, and that the operator adjust the indica- 
 tors so that the center ball is opposite to the 
 center of the cornea. 
 
 To determine the position of the foreign 
 body in the eye, two circles are drawn repre- 
 senting the horizontal and vertical sections of 
 the normal adult eyeball, and upon these are 
 marked the situation of the indicating balls at the times the radio- 
 graphs are made. 
 
 Lines are drawn through the shadow of each of the indicating 
 balls on the two radiographs. On the negative made with the tube 
 horizontal and parallel with the plane of the indicators, a measure- 
 ment is made of the distance the shadow of the metallic body is 
 above or below the shaded of each of the indicators. This distance 
 is entered above or below the spots representing the two indicators 
 on the diagram of the vertical section of the eyeball. Thus, in the 
 radiograph (Fig. 280) the distance'of the foreign body below each 
 indicator (OS and NS) is entered below the spots A and B, front 
 view, Fig. 281. A line drawn through the points C and D gives 
 the direction of the X-rays at the time the shadow of the foreign body 
 was cast upon the plate. 
 
 Similar measurements of the distance the shadow of the foreign 
 body is below the shadow of each of the indicators are made on the 
 second negative, and these measurements are likewise entered below 
 the points A and B, representing the two balls on the vertical sections 
 of the eyeball. These measurements are AF and BF. A line
 
 634 
 
 THE REMOVAL OF FOREIGN BODIES. 
 
 drawn through the points E and F gives the direction of the rays 
 when the second negative was made. Since these two lines in- 
 dicate the plane of the shadow of the foreign body at each exposure, 
 the intersection of the lines must be the location of the metal in the 
 eye as measured above or below the horizontal plane of the globe 
 and to the temporal or nasal side. 
 
 To determine the distance of the foreign body back of the center 
 of the cornea, the negative made with the tube horizontal is taken, 
 and the distance is measured that the shadow^of the ball opposite 
 the center of the cornea lies posterior to that of the external ball. 
 
 FIG. 280. Radiograph made with tube near plane of indicators. (Hansell and Sweet.) 
 
 This distance is entered directly above the external ball on the 
 diagram representing the horizontal section of the eyeball. A line 
 drawn from K through he center ball gives the direction of the rays 
 at the time the radiograph was made. On the same negative is 
 measured the distance that the shadow of the foreign body is back 
 of the shadow of each of the indicators, and these distances, B J 
 and A H, are entered on the diagram. A line drawn through the 
 points J and H and, since this line represents the plane of the shadow 
 of the foreign body, the point at which a perpendicular drawn from 
 the situation of metal, as shown on the vertical section of the eyeball, 
 intersects this line indicates the situation of the body back of the 
 center of the cornea. If the position of the tube from the eye has
 
 METHOD OF SWEET. 
 
 635 
 
 been measured, its distance is indicated on the line drawn from K 
 through the center ball A. A line through J to this point indicates 
 the divergence of the rays. This means of determining the position 
 of the plane of shadow of the foreign body is more accurate than 
 when the measurement is made of the sjiadow of the body above 
 each of the balls, and should be followed especially if the body is 
 some distance away from the anterior segment of the globe or is in 
 the orbit. 
 
 Horizontal 
 section. 
 
 Front view. Side VIEW 
 
 FIG. 281. Diagram of position of foreign body in eyeball. (Hansell ond Swi-ct.) 
 
 If the foreign body has passed into the orbit, the rotation of the 
 eyeball to insure parallelism of the ocular axis with the plane of 
 the plate leads to a slight error in the determination of the position 
 of the metal. To eliminate this error necessitates a knowledge 
 of the angle of the orbit with the plate or, its equivalent, the amount 
 of deviation of the eyeball from the primary position and the con- 
 sideration of this angle in plotting the diagrammatic circles 
 representing the eyeball.
 
 636 THE REMOVAL OF FOREIGN BODIES. 
 
 The indicating apparatus is secured to the side of the head 
 corresponding to the injured eye, and the tube placed about 12 or 
 15 inches to the opposite side and slightly forward. The patient 
 is in the recumbent posture to insure steadiness of the head. After 
 the indicating rods have been adjusted, the patient fixes an object 
 about 5 to 10 feet distant, so placed that the visual axis of the 
 injured eye shall be parallel to the photographic plate. An exposure 
 of from one to two minutes will clearly outline the bones of the orbit 
 and secure a shadow of any body opaque to the rays in the eyeball 
 or in its neighborhood. 
 
 Sweet's New Localizer. At the last meeting of the American 
 Ophthalmological Society, July, 1909, Sweet presented a simplified 
 method of localization. The new form of apparatus exhibited in 
 this connection, while it embodies the same principles as that just 
 described, is so constructed that it relieves the operator of the 
 necessity of making measurements from the radio- 
 graphs or of drawing any lines to represent the 
 planes of shadow. "In the new apparatus the 
 planes of shadow of the foreign body are accu- 
 rately determined by the instrument without the 
 FIG. 282. 
 image of cross- nece ssity on the part of the operator of taking 
 
 wire and cornea, measurements from the plates or in drawing lines 
 on the chart. The tube-holder, indicating ball, 
 and plate-holder are upon a movable stage, and therefore preserve a 
 known relation to each other which does not vary. The angle of the 
 rays with the eyeball and the distance of the tube from the plate 
 are always the same, so that one indicator is sufficient, and this 
 consists of a small steel ball supported in a metal ring. The setting 
 of this ball opposite the center of the cornea is made by means of 
 adjusting screws conveniently placed on the frame of the instru- 
 ment. Accuracy in the measurement of the distance of the in- 
 dicating ball from the center of the cornea is secured by means of a 
 telescope and reflecting mirror. The mirror gives an image of a 
 cross-wire and a lateral image of the cornea. Through the telescope 
 the observer adjusts the instrument until the image of the cross- 
 wire is in direct contact with the image of the summit of the cornea. 
 (Fig. 282.) When the adjustment is made, the indicating ball is 
 exactly 10 mm. from the center of the cornea. A miniature incan-
 
 SWEET'S NEW LOCALIZER. 
 
 637 
 
 descent lamp, mounted in an adjustable shade, illuminates the side 
 of the nose of the patient, insuring a well-lighted image of the cornea 
 and cross-wire. 
 
 "Instead of a ball of cotton or other object for fixation, as in the 
 older method, a circular mirror is placed at a distance of 12 inches 
 above the injured eye. The patient gazes in the mirror and sees a 
 reflected image of the injured eye and the circular celluloid disk 
 with the steel indicating ball in its center. After the ball has been 
 
 FIG. 283. (Sweet.) 
 
 adjusted to a point opposite the center of the cornea of the injured 
 eye, the patient by fixing the ball with the seeing eye prevents any 
 movement of the eye during the exposures and holds the visual line 
 of the injured eye parallel with the plate. 
 
 "In order to shorten the time of making the radiographs and 
 lessen the possibility of any movement of the patient or apparatus 
 in changing plates, the two exposures in the new apparatus are 
 made upon one plate, metallic shutters protecting those portions 
 of the plate which are not to be exposed to the rays.
 
 6 3 8 
 
 THE REMOVAL OF FOREIGN BODIES. 
 
 "The tube-holder contains the usual cylindrical lead glass shield 
 for protecting the operator from the action of the rays, with the 
 customary lead diaphragm. The central orifice of the diaphragm 
 is covered with aluminum, which offers little obstruction to the 
 rays, but lessens the risk of any unfavorable action of the rays upon 
 the patient and guards against possible damage to the eyes in the 
 event of breakage of the tube. The tube-holder slides upon a 
 graduated rod, and the first exposure is made with the indicator at 
 
 FIG. 284. (Sweet.) 
 
 zero, in which position the rays pass in a direction corresponding 
 with the horizontal plane of the eyeball. The second exposure is 
 made with the tube at its farthest point to the right or left of the 
 first position, depending upon which eye is to be examined. The 
 illustration (Fig. 283) gives a view of the complete apparatus. 
 
 "Since the relative position of the tube in reference to the indicating 
 ball and the photographic plate remains fixed and known, it is 
 readily seen that the direction of the X-rays in passing through the 
 eyeball must follow a definite course, which is always the same for
 
 SWEET'S NEW LOCALIZER. 
 
 6 39 
 
 the two separate exposures. It is, therefore, possible to indicate 
 on the localization chart the direction of the rays at the two exposures, 
 and this has been done in the chart, a copy of which is reproduced 
 in Fig. 285, reduced in size one-half. Only those lines representing 
 rays 2 mm. apart are reproduced, but each line is drawn with the 
 
 CHART FDR DR.SWEET'S IMPROVED BrtLoCAuZER. 
 
 FIG. 285. Localization chart, with lines representing course of the .v-rays <>m-- 
 half actual size. (Sweet.) 
 
 required amount of divergence to indicate the rays as coming 
 from a point the distance of the tube from the photographic plate. 
 "METHOD OF EMPLOYING THE \i \v LOCALIZER. The apparatus 
 is arranged as shown in Fig. 284. The patient lies with the head 
 on a platform of hard fibre, with a pillow beneath the shoulders 
 and a small sand-bag under the head and neck. The upright
 
 640 THE REMOVAL OF FOREIGN BODIES. 
 
 supports for holding the head are now adjusted by means of the 
 wheel i, and the jointed part of the apparatus, J, containing the 
 indicator is brought down in position. The indicating ball, G, 
 is now roughly adjusted until it is opposite the center of the cornea 
 and about 12 or 15 mm. distant. The patient looks w r ith the unin- 
 jured eye into the mirror, M, and fixes upon the iris or cornea of the 
 injured eye, or, better, upon the indicating ball in the center of the 
 celluloid disk. The indicating ball is now carefully adjusted directly 
 over the corneal center by means of the wheels 2 and 3, and the 
 correctness of the position verified by observation through an 
 opening in the mirror, M. The operator then adjusts the light of 
 the small electric lamp so that the side of the nose next the injured 
 eye is illuminated, but the light is not thrown into the eye. With 
 this area lighted it is possible to see clearly through the telescope, 
 T, when the cross-wire is exactly tangent with the summit of the 
 cornea. The movement necessary to secure this position of the 
 wire is made by means of the adjusting wheel 4. When the image 
 of the cross-wire touches the image of the corneal summit, the 
 indicating ball is exactly 10 mm. from the eyeball. 
 
 "The photographic plate is inserted beneath the spring clips, 
 C C, the shutters, S S, moved so that the center area is open (Fig. 
 283), and the tube-holder adjusted to the zero-point on the sliding 
 scale. The current is turned on, and one exposure made. The 
 tube-carriage is then moved to the limit of the sliding rod, always 
 in the direction of the chin of the recumbent patient (to the end 
 marked R if the radiographs are made of the right eye, and to L 
 if of the left eye). The upper shutter is moved to cover the exposed 
 central portion of the plate and uncover the upper unexposed 
 portion. The current is again turned on and the second exposure 
 made. The time of exposure for the second picture should be 
 about one and a half times that of the first, to allow for the increased 
 distance of the tube from the eye. 
 
 "After the plate is developed it is placed in the frame, P (Fig. 283), 
 containing the key-plate or focal coordinates (Fig. 286), with the 
 film side of the radiograph next to the key-plate. The radiograph 
 is moved until the shadow of the indicating ball of the first exposure 
 is in apposition with the middle ball on the key-plate and the heavy 
 horizontal line of the radiograph parallel with the horizontal line
 
 SWEET'S NEW LOCALI/KR. 
 
 641 
 
 on the plate. Holding the frame to the light, there is noted the 
 position occupied by the shadow of the foreign body with respect to 
 the vertical lines of 'C' and 'D.' A reading is made of the line 
 or lines which pass through the body, and this is transferred to the 
 corresponding lines of the 'C' or 'D' scale of the chart, to the 
 right or left side, depending on which eye is under examination. 
 Without moving the plate the 'E' reading is similarly made and 
 transferred to the chart. To take the 'A' or 'B' reading, the 
 plate is shifted slightly until the image of the indicating ball on the 
 
 'RIGHT 
 
 LETT 
 
 T 0' 
 
 ICs 
 
 20 
 
 30 
 
 50 
 
 10 
 
 20 
 
 30 
 
 FIG. 286. Plate showing focal coordinates three-fourths actual size. (SweetJ 
 
 second exposure coincides with the 'Right' or 'Left' ball of the 
 vertical coordinates 'A' or 'B.' The line or lines of the 'A' 
 or ' B ' coordinates which cross the shadow of the body are noted 
 and indicated on the 'A' or 'B' lines of the chart. The hori- 
 zontal coordinate 'E' should be the same in both readings. If 
 the focus point on the anode of the tube was accurately set by the 
 cross-lines on the lead-glass shield of the tube-holder, the images 
 of the indicating ball on the plate will coincide simultaneously with 
 those on the transparent key-plate, and it will then not be neces- 
 sary to reset the plate to read the position of the 'A' and 'B' 
 coordinates. 
 
 "After the three readings have been transferred to the chart, the 
 
 41
 
 642 
 
 THE REMOVAL OF FOREIGN BODIES. 
 
 point of crossing of the 'A' or 'B' and the 'C' or 'D' lines is 
 found, which gives the location of the foreign body in reference to 
 the front view of the eyeball, indicating its situation above or below 
 the center of the cornea and to the nasal or temporal side of the 
 vertical plane. Where a vertical line from this point crosses the 
 'E' reading on the horizontal section of the globe it gives the 
 depth of the body in the eyeball or orbit. In bodies of large size 
 both ends should be localized to give the position in which the body 
 rests in the globe. The situation of the body on the side view is 
 determined by transferring its measured depth from the horizontal 
 
 FIG. 287. Radiograph of foreign body in eye three-fourths actual size. (Sweet.) 
 
 section and its distance above or below the horizontal plane from 
 the front view localization. 
 
 "The new apparatus is based upon the same general principles 
 as was the old, but its mechanical features eliminate some of the 
 errors that may occur in the use of the present instrument through 
 carelessness of the operator in making the measurements and 
 transferring them to the chart. The inexperienced worker in eye 
 localization is also relieved of the necessity of studying out the 
 position of the tube and the direction of the lines of shadow at the 
 two exposures: The construction of the new apparatus insures that 
 these factors are positively determined and recorded. The accuracy 
 of the localization depends only upon the care with which the
 
 MKTIIOD OF GUILLOZ. 643 
 
 operator adjusts the indicating ball opposite the center of the cornea 
 and at the definite and fixed distance from it. After the exposures 
 are made and the plate developed, the determination of the situation 
 of the foreign body is simply a question of reading from a key-plate 
 and transcribing these readings to the chart." 
 
 Mackensie Davidson secures equally accurate results in the 
 localization of foreign bodies in the eyeball by means of special 
 form of apparatus and the use of particles of fuse wire placed at 
 points near the orbital margin. The planes of shadow of the foreign 
 body at the two exposures and their point of crossing are indicated 
 by means of threads. 
 
 Method of Guilloz. Two tubes, capable of separate adjustment, 
 have their anticathodes on the same level. A sensitized plate, 
 enveloped in black paper, is placed, horizontally, 50 centimeters 
 below them. A fine wire fastened around the plate gives the 
 projection of the line joining the anticathodes, and two metallic 
 guide-marks, placed on this line, indicate the centers of emission. 
 Three metallic guide-marks are glued about the orbital rim of 
 the subject, one just external to the supraorbital notch, one directly 
 below, and the third at the external rim. The subject lies with the 
 side of the head which corresponds to the affected eye resting on 
 the plate. The eye is immobilized by having the subject fix some 
 Qbject immediately in front of it not in the median line. 
 
 The two tubes are set in action, and the exposure made to last 
 from two to four minutes. Thus are obtained double shadows, 
 or biconic projections, i.e'., of the metallic markers, as also of the 
 foreign body. These biconic projections are transformed either 
 by a diagram or by calculation into right-angular lines that give 
 the distance between the markers themselves and their distances 
 from the foreign body. The distance between the markers being 
 directly measurable, one thus obtains a verification of the result. 
 Moreover, before beginning the calculations, or the drawing of the 
 diagram, it is necessary to be assured that the lines joining the 
 homologous points of the double images are parallel with the line 
 left on the plate by the wire that has been stretched across it. 
 
 Guilloz has demonstrated on the head of a cadaver that the method 
 is exact to the fraction of a millimeter. The manner in which the 
 head reposes on the plate does not have to be determined in accordance
 
 644 
 
 THE REMOVAL OF FOREIGN BODIES. 
 
 with the findings. It is only necessary to see that the head and the 
 eye remain immovable during the exposure, a fixation apparatus 
 not being necessary. Be it understood that the degree of precision 
 that we have indicated is that obtained geometrically; this is not 
 usually the case when the localization geometrically attained is 
 transformed to conform to the three markers in the anatomic 
 
 localization it may be by 
 reason of the variable dimen- 
 sions of the orbit or it may 
 be owing to the mobility of 
 the eye. 
 
 The distances of the 
 foreign body from the three 
 guide-marks having been 
 determined, it remains to 
 make the anatomic localiza- 
 tion. This is accomplished 
 with the aid of markers by 
 employing an instrument 
 which is nothing more than a 
 compass with four branches, 
 each of which may be set for 
 whatever inclination or what- 
 ever length is desired (Fig. 
 288). The head of the 
 compass is formed of a plate 
 through whose center runs the median branch, and carries on its 
 periphery the three upper articulations of the arms that support the 
 other branches. The central branch is a graduated, rectilinear, cylin- 
 drical stem, sliding, w r ith light friction, in a hollow shaft one centi- 
 meter in length. This, at its center, passes through a copper ball 
 to which it is soldered, and which works in a spherical concavity 
 situated partly in the plate and partly in a flange fastened by three 
 screws on top of the plate. A little turn given to one of these screws 
 renders the articulation rigid, by pressure, and permits only the 
 sliding of the graduated branch in its collar. Each lateral arm is 
 biarticulate, the upper extremity being attached to the plate by a 
 ball-and-socket joint similar to that described for the central branch, 
 
 FIG. 288. Method of Guilloz for localization 
 of foreign bodies (iron or~steel), in the eye.
 
 METHOD OF GUILLOZ. 645 
 
 and which can be made rigid by the action of a thumb-screw. The 
 lower part of each arm is fitted with a hinged articulation, carrying 
 a short, hollow cylinder, through which slides a lateral branch, and 
 that is also provided with a thumb-screw to make it rigid. 
 
 Assuming that the distances separating the guide-markers, one 
 from the other, is known, as also those of the foreign body from 
 said guide-markers, to adjust the compass a triangle, A B C, is con- 
 structed (Fig. 289), whose sides represent the distances between the 
 guide-markers. The points of the lateral branches of the compass 
 are placed on the three points of the triangle and set with the thumb- 
 screws. The central stem is pushed down to fall at the point X in 
 
 y 
 FIG. 289 
 
 the triangle, and the distanceXA, XB, and XC are found by stepping. 
 Now, to facilitate the regulation of the compass, take a bit of per- 
 forated lead, X, attach to three other bits of lead, A, B, and C, by 
 wires; the points of the branches are struck into the corresponding 
 leads, and the central branch is pushed down until the wires are 
 stretched. The compass thus adjusted, the distances are verified 
 by means of ordinary dividers, and he arrangement is perfected by 
 stepping. The result obtained, the central stem is set tight by the 
 screw in the flange, and the mark on the graduated scale that is 
 flush with the top of the collar, is noted. 
 
 If the compass were placed on the subject's head the points of the 
 lateral branches in contact with their corresponding guide-markers. 
 the direction of the central stem would indicate the position of the 
 foreign body, for if it were pushed down to the point noted on the 
 scale, its point would rest upon the said body. The process is not 
 only accurate, but simple. The shadows on the photographic plate 
 (or positive), together with the known distance of the tubes from
 
 646 THE REMOVAL OF FOREIGN BODIES. 
 
 the plate, furnish all the information needed to determine the 
 situation of the foreign body. 
 
 The general plan is illustrated by the accompanying figure 290: 
 Let B represent the foreign body S S' the points of emission of 
 the rays from two tubes at once or from the same tube in different 
 positions. The conic projection of B on the plate P gives us the 
 two points b, b'. The positions of S S' and b b' are known, and their 
 distances, one from another, are measurable. Hence, to determine 
 the position in space occupied by B, all that is required is to join 
 b' to S', and b to S, either by real lines, as of wire in the apparatus, 
 
 FIG. 290. Guilloz's method of localization of iron in eye. 
 
 or by lines traced on a diagram wherein the points S S' and b b' have 
 been placed. This first process absolutely determines the point B 
 holds in space. Its relative position can then be ascertained with 
 relation to certain guide-marks. 
 
 To Control the Eye. The direction of the eye should be the 
 same at the time of the exposure (or exposures) to the rays as at the 
 time of the surgical intervention. Omit this precaution and the 
 whole procedure of localization comes to naught. A small sheet of 
 metal is pierced with a round opening the size of the cornea. When 
 this is placed in front of the eye it is easy to make the circle of the 
 cornea correspond to that of the aperture. To this sheet of metal 
 are fastened three legs or processes that extend just to the centers of 
 the guide-marks placed on the orbital rim. At any time that it be- 
 comes desirable to reproduce the position the eye was in at the time
 
 POSITIONS OF HEAD AND TUHK. 647 
 
 of the exposure, it suffices merely to place the processes on the cor- 
 responding guide-marks, then cause the cornea and the opening to 
 coincide. Guilloz claims to have accurately located by the foregoing 
 method a piece of steel weighing only i milligram. None of 
 the methods are infallible. The severest tests of the two just given 
 are when dealing with a very minute foreign body situated far at the 
 opposite side of the eye from the tube, or in line with the denser bone 
 shadows that are interposed. Here they may fail. 
 
 Choice of Relative Positions of Head and Tube. To obtain 
 a radioscopic view or to make a radiographic exposure of the eye 
 that shall be least obstructed by surrounding bone are matters 
 worth considering. Figs. 291 to 294 are from radiographs of the 
 
 FIG. 291. Perpendicular. 
 
 orbital region made by Guilloz, and are adapted from Volume IV 
 of the French Encyclopedia of Ophthalmology. The black circle 
 represents the globe of the eye. These pictures were made with 
 the view to ascertaining, by shifting the relative positions of tube 
 and head, how great is the interference of the heavy shadows of 
 surrounding bone with the area occupied by the eyeball. The left 
 eye is in question; i.e., the plate is fixed to the left temple. In each 
 instance the distance from tube or point of emission of the X-rays- - 
 from the photographic plate is 60 centimeters, and the plate is 
 placed parallel with the sagittal plane of the head. In the first 
 exposure, Fig. 291, the long axis of the head was at right angles 
 to the tube. About one-half the shadow of the eye is covered by the 
 dense shadow of the external rim of the orbit. Now. in proportion 
 as the tube is moved forward, or as the head is inclined to the right.
 
 648 THE REMOVAL OF FOREIGN BODIES. 
 
 the circle representing the globe is disengaged more and more from 
 the dark streaks of bone shadow. The second exposure, Fig. 292, 
 was made with the tube at an inclination of 10 to the first, Fig. 
 293 at 20, and Fig. 294 at 30. It will be seen that in the last 
 
 FIG. 292. At an inclination of 10. 
 
 radiograph the globe stands out clearly defined in a relatively 
 shadowless space. At a still further inclination, the disengagement 
 would be even more complete, but the distortion caused by the 
 obliquity of the projection would be so pronounced as to render the 
 result valueless. 
 
 FIG. 293. At an inclination of 20. 
 
 The X-rays serve to locate most species of wood, glass, stone, and 
 all the other metals as well as iron and steel. 
 
 The proper distance of the tube from the plate is from 40 to 50 
 centimeters (16 to 20 inches). Since the rays emerge from the anti-
 
 COMPARISON OF THE METHODS OF LOCALIZATION. 649 
 
 cathode divergent like a cone, the further away the plate, the more 
 magnified, yet the less distinct the shadows and the longer the ex- 
 posure. The center of the anticathode should be in line with the 
 center of the rotation of the exposed eye. To have the subject in 
 the recumbent posture during exposure is conducive to accuracy, 
 as the motions imparted to the head by the heart, in breathing, and 
 by the muscles concerned in equilibrium are then most nearly 
 eliminated. It is advisable to cover the eye not concerned better 
 still, to bandage it firmly. The patient may lie on the back with 
 the plate bound to the temple and the tube at the opposite side or 
 
 FIG. 294. At an inclination of 30. 
 
 on his side, with the temple on the plate and the tube or tubes 
 directly above. When the foreign body has but recently entered 
 the eye, it may be susceptible of movement in obedience to the laws 
 of gravity. It would then be important that the same position be 
 assumed in exposure and in extraction. 
 
 The clangers and inconveniences of the X-ray to both examiner 
 and examined should not be ignored. They mainly concern the 
 skin of the operator's hands and the skin and hair of the patient's 
 head. Trophic disturbances are common brown discoloration, 
 erythema etc. Gangrene, with subsequent deformity of the fingers, 
 can occur. 
 
 Comparison of the Methods of Localization. To put it con- 
 cisely, circumstantial evidence, the patient's statements or those of 
 others, and ocular inspection are all very good as far as they go, 
 but cannot be trusted to any considerable extent. The ophthal- 
 moscope is preferable to any other means, but, unfortunately, it is
 
 650 THE REMOVAL OF FOREIGN BODIES. 
 
 so handicapped with restrictions that it seldom has an opportunity. 
 The sideroscope has the advantage of being ready, favoring despatch, 
 and also of indicating whether or not the foreign body is magnetic. 
 Its use, however, is limited by its sensitiveness to surroundings and 
 by its inability to respond to very small foreign bodies when situated 
 in the posterior segment. Moreover, it takes no cognizance of 
 foreign bodies other than those of steel or iron and is troublesome 
 to manipulate. Of the X-ray methods the graphic is a method of 
 expedience, and, in common with the others in the same group, it 
 can make known the presence of a foreign body of other material 
 than iron and gives an idea of form and volume. Radioscopy and 
 fleuroscopy are serviceable on occasion, i.e., for the larger foreign 
 bodies, but, as a rule, are unreliable. The objections to stereoscopic 
 radiography have already been given. So that, after all, geometric 
 radiography is the method of general utility, since it tells nearly all 
 that any of the others can and tells it more accurately; though, as 
 has been seen, it, too, has its limitations, not the least of them being 
 the time it consumes. Yet, w r ith everything at hand, the negative 
 radiograph can be produced in half an hour. 
 
 The Technic of Magnet Operations. It is assumed that the 
 piece of metal has been located in the vitreous by one of the modes 
 just given, or else that this has been impracticable and that the 
 time has come to operate. Shall it be the smaller, hand-magnet, 
 or the giant, or both ? This is a matter of choice and circumstance. 
 For the case in point we will select the smaller, but have the other 
 in reserve, and will discuss the pros and cons of the two instruments 
 further on. Indeed, those who are in no way prejudiced may, 
 on occasion, have recourse to both at a single sitting. The eye is 
 prepared and the patient is put upon the table and narcotized. 
 Unless there is some good reason to the contrary, it is best to have 
 him asleep, in order to insure freedom from pain and squeezing, 
 with needless escape of vitreous. If the injury is recent and the 
 wound is in the sclera, and the foreign body has been located nearby, 
 the coverings of the globe are incised and retracted and the bleeding 
 is stanched. At this stage, if the wound is well back, fixation 
 forceps are employed to gently rotate the eye without pressure. 
 The tip of the magnet is inserted a very little w r ay, without previous 
 enlargement of the scleral openings, if it be adequate. If not, it is
 
 THE TECHXIC OF MAGNET OPERATIONS. 651 
 
 extended sufficiently with blunt-pointed scissors. When the tip 
 is thought to be near the metal, the circuit is completed by pressing 
 the button on the magnet, holding the magnet still for a few seconds. 
 If the foreign body is attracted to the tip, and is of fair size, there 
 will be a slight shock, and a click denoting that it is caught. All 
 that remains is to withdraw the tip, all the while pressing down the 
 button. Should the foreign body be very small, there will be no 
 evidence of having brought it to the magnet, and the instrument 
 must be withdrawn and the tip examined. A tightly coapting wound 
 may tend to strip off the foreign body. In that case its lips will 
 have to be parted with tiny, nonmagnetic retractors or a more 
 suitable tip substituted. It need hardly be stated that neither iron, 
 steel, nor nickel instruments are admissible at the time the magnet 
 is working; they must be of brass, aluminum, German silver, hard 
 rubber, etc. Those that are not used in conjunction with the magnet, 
 such as scissors and knives, may be of the usual kind Not succeed- 
 ing at first in bringing out the object sought, the tip may be inserted 
 again and again, gently feeling about in the vicinity, making and 
 breaking the circuit at intervals, and taking care not to disturb the 
 vitreous more than is prudent. Poking and fishing desperately 
 and deep are disastrous and inexcusable, whether the foreign body 
 has been definitely located or not. Failing still, resort should be 
 had to the more powerful magnet rules for the manipulation of 
 which will be given later. Having recovered the foreign body, the 
 site of the operation is cleansed, the scleral opening, if large or 
 inclined to gape is closed by a fine, absorbable suture _ or two, 
 superficially placed, he membranous opening sutured with black 
 silk, and the eye bandaged. Often it is better to omit stitches from 
 the sclera. The metal not having come to light, it is a question of 
 more accurate localization and another magnet operation, of 
 exenteration, of enucleation, or of temporizing, and its decision 
 must be left to the judgment of those in charge. 
 
 Supposing that the wound of entrance is not available through 
 which to extract; that the foreign body has been located at a distance 
 from it; or that it has long since healed; or tha'. penetration has 
 been by way of the cornea. In any case the scleral incision is 
 in order. This should be as near to the foreign body as the situation 
 will allow. If making it in an unfavorable spot i.e., unfavorable
 
 652 THE REMOVAL OF FOREIGN BODIES. 
 
 to the general good of the eye can be avoided by going in just a 
 little to one side of the metal; this ought to be done. In this manner 
 the recti muscles, the trunks of the vorticose veins, the larger vessels 
 of the retina, etc., may escape needless injury. All things else being 
 equal, the best place for the incision is that recommended by Arlt 
 between the tendons of the externus and inferioris. The next best, 
 between the latter and the internus. The tissues overlying the 
 sclera are incised, meridionally, for a distance greater than is desired 
 for the deeper cut. Retraction and stopping of the blood, as before. 
 The scleral incision is made with a good Graefe knife, either by 
 puncture and counterpuncture or by shallow perpendicular 
 puncture, for one extremity, and slight sawing to complete. It 
 should lie in the middle of the first opening and parallel with it. 
 Its length, to be adequate, will usually be about one centimeter. 
 The rest of the operation is carried out as described in the preceding 
 paragraph. 
 
 Operation with the Giant Magnet. The greatest authority on 
 the handling of this instrument is its inventor, Professor Haab, 
 hence, most of the points here given are borrowed from him. The 
 surgeon, assistant, and spectators put aside their watches to prevent 
 damage to their mechanisms. The patient, with eye made ready, 
 sits on a strong, firm stool, facing the working end of the magnet. 
 There are certain advantages in having the instrument suspended 
 in pivotal joints. Great store is set by having the patient in such 
 a position that the head can be freely moved by the operator in every 
 direction, so that he can give notice of sensations produced by the 
 foreign body, and by having him conscious. Moreover, it is ap- 
 propriate that the patient be suffered to start back when he is hurt 
 by any movement of the foreign body, and get away from too strong 
 a pull which might do harm. This he could not do were he re- 
 cumbent. Therefore, both operating-table and narcosis are dis- 
 pensed with. A drop of cocain may be instilled. If the patient is 
 docile, neither speculum nor fixation forceps are used, as they would 
 simply be in the way. Haab no longer employs a rheostat, but 
 allows the current to go directly to the instrument, increasing and 
 decreasing the force by advancing and retiring the subject's head, 
 and making and breaking the current by means of a pedal. There 
 can be no objection to the rheostat provided it does not materially
 
 OPERATION WITH THE GIANT MAGNET. 
 
 653 
 
 decrease the attractive force, and that there is a switch between it and 
 the magnet. An assistant is stationed at this, whose sole duty is to 
 throw it "On!" and "Off!" at these words of command. Another 
 assistant is commissioned to do the illuminating with some form of 
 artificial light; another to work the lever of the rheostat, if there is 
 one. If the wound of entry is still patent, it is usually chosen for the 
 
 FIG. 295. 
 
 point of exit also, though it may need to be slightly extended. When 
 in the sclera, conjunctiva and other superjacent tissues are got out of 
 the way by incising and retracting, and the scleral opening i-> 
 cleaned up by snipping off tags and shreds that extrude. If the 
 course of the foreign body in the eye has been traced, one endeavors 
 to make it retrace the same. By so doing, additional wounding of 
 the structures is avoided. The hair of the subject is snugly covered
 
 654 THE REMOVAL OF FOREIGN BODIES. 
 
 by a rubber cap. The operator grasps the head with both hands, 
 and directs the patient to relax his neck, and not to resist motions im- 
 parted by the hands (Fig. 295). The eye is approached to the tip in 
 such a way that the attractive force will be exactly in line with the track 
 of the foreign body. If no rheostat is employed, the eye is brought 
 within 4 or 5 inches of the magnet; when the rheostat is used, the eye 
 is brought up till its wound is about in contact with the tip, and the 
 aid at the rheostat is told to turn on a few amperes the milder 
 the draw with which the foreign body comes, the better. If here is 
 no result, the current is turned on or the eye approached more 
 and more, till the full capaci y of the magnet is reached. There 
 still being no result, one proceeds to jerk at the foreign body by 
 making and breaking the current in quick succession; and, failing 
 in this, sidewise pulls are given to loosen the metal. Should the 
 patient wince or speak of pain in the eye, the pull is at once changed 
 to the original direction. When the foreign body presents at the 
 opening its delivery may have to be helped by separating the lips 
 or with the forceps. A sharp lookout is kept for the appearance 
 of the foreign body, especially for a very minute one that may have 
 attached itself to the tip of the magnet, so as not to drop and lose 
 it by breaking the circuit. All these procedures having proved 
 fruitless, one is not justified is giving up completely, but should, 
 after a wait of some hours or a day, make a second effort; even 
 after that, a third. Haab relates instances where he made trials 
 on several days in succession, then succeeded. Between whiles, 
 a great deal might be gained by localization. 
 
 If the scleral route is decided upon as the way out for the foreign 
 body, irrespective of the preexistence of a scleral wound, the steps 
 are about the same as those detailed for the small magnet, except 
 that no sort of extension point is inserted at the opening. With proper 
 localization and a powerful magnet, such as the giant is supposed to 
 be, contact of the tip with the outer lips of the incision should be the 
 limit. 
 
 Drawing the Foreign Body from the Vitreous into the 
 Anter or Chamber. When no scleral opening exists, and the for- 
 eign body is not too large, the stronger partisans of the giant magnet 
 advocate this, then extracting through a corneal incision rather 
 than removal directly from the vitreous by means of a scleral in-
 
 LOOSENING. 655 
 
 cision. Here, if the foreign body is in the posterior segment, the 
 tip of the magnet is applied to the summit of the cornea, so that, in 
 coming forward, it will not engage in the ciliary body. A piece of 
 metal once caught in the soft corrugations there, either primarily or 
 secondarily especially if it is sharp and angular is most difficult 
 to extricate. If the lens is already much wounded or cataractous, 
 the attraction may be kept up, as begun, until the foreign body is 
 seen to enter the anterior chamber. If, on the other hand, the 
 crystalline seems normal or but little injured, as soon as there has 
 been any evidence of advancement on the part of the foreign body 
 or it has come up behind the back surface of the lens, the direction 
 of the attraction is shifted to a point near the limbus so as to cause 
 the metal to travel around by the zonule. Now, one must watch 
 closely for any bulging forward of the iris produced by the foreign 
 body. The impact against this sensitive membrane is often first 
 made known by a sudden move by the patient. The current is in- 
 stantly shut off and tip changed to the opposite side, in order to 
 make the foreign body pass through the pupil. To have the latter 
 dilated facilitates this step. If any special difficulties seem to lie 
 in the way of getting the foreign body readily through the pupil, it 
 were better to make an iridectomy just over the point where the 
 foreign body lies in the posterior chamber. Once landed in the 
 anterior chamber, the metal is dealt with according to the rules 
 already given. 
 
 Loosening. When the foreign body is fast in any of the tunics 
 of the globe or is densely encapsuled, the chances of getting it with 
 even the most powerful magnet are greatly lessened. A valuable 
 office filled by the big magnet in these cases is the loosening of the 
 metal. When possible, its exact location is ascertained beforehand. 
 The patient is placed on a stool in front of the magnet, and the tip 
 is applied to the globe or approached close to it, in the immediate 
 vicinity of the foreign body, in such a way as to pull it sidewise. 
 Every means must be used to obtain the full strength of the magnet. 
 And it may be necessary to go all around the foreign body, pulling 
 from every point; shutting the current off and on in quick succession 
 now and again. The patient is instructed to be on the alert for any 
 sensation indicative of movement on the part of the foreign body, 
 such as a jar or vibration, a flash of light, or a pain in the eye, and
 
 656 THE REMOVAL OF FOREIGN BODIES. 
 
 to tell of it at once. A change having been felt, before the fe: 
 body could be intelligently extracted it might be necessary to rel 
 it. If this could be done with the ophthalmoscope, so much the 
 better. Certainly, before thinking of a scleral incision through 
 which to extract, localization should be essential. Were the 
 foreign body situated in the ciliary body or in the root of the iris, 
 to draw it forward might only make matters worse, and to cut down 
 upon it under these conditions at once would hardly be proper. 
 The preferable way would be to draw it first backward, and. if 
 possible, slightly inward, that is, with respect to the center of the 
 vitreous. "When practicable, this should be done on that side of 
 the sclera adjacent to the foreign body. Having moved it. relocation 
 or not, and removal according to one of the approved methods. 
 It is well, always to remember that success depends in great measure 
 upon localization. If. on the contrary, the foreign body refused 
 to budge, then one need not hesitate to make incision over it and 
 to attempt its extraction with one or both of the magnets and. if 
 need be. with the aid of probe and forceps. The fact that the cut 
 would lie in the ciliary zone need no longer be a bar. 
 
 Relative Merits of Small and Large Magnets. To a consider- 
 able extent the impression seems to prevail that, as regards this 
 subject, ophthalmic surgeons are divided into two camps one led 
 by Hirschberg and the other by Haab. As a matter of fact, there 
 are many who are more uncompromising in this affair than is either 
 of the gentlemen just named. Hirschberg not only uses the large 
 magnet when occasion requires it, but he has actually had constructed 
 a larger one than that of Haab. And he of Zurich? Well, he 
 often employs the hand-magnet in connection with the anterior 
 chamber, and has been known to do so for foreign bodies behind 
 the iris. To quote his own words: "When shall the small magnet 
 be used? Answer: Within the bounds of the vitreous as little as 
 possible; within those of the anterior chamber as you will." Un- 
 questionably, each has its advantages and each its limitations, if 
 not its drawbacks, and both are absolutely indispensable in this 
 kind of work. None have better proven their worth than their 
 illustrious inventors themselves Hirschberg in more than 350 
 instances, Haab in more than 300. 
 
 It is certain that the small magnet is easily portable, that it is more
 
 RELATIVE MERITS OF SMALL AND LARGE MAGNETS. 6" 
 
 manageable, and now, with the more powerful model, reinforced to 
 the utmost, a lifting capacity can be obtained that almost makes 
 it equal to some of the so-called "giants." In a case of recent 
 foreign body in the vitreous the hand-magnet has been able to draw 
 the metal through the lens and into the anterior chamber; and to 
 extract one through a scleral opening without letting the tip come 
 in contact with the globe. Again, there have been cases where 
 neither the sideroscope nor the giant magnet got any response from 
 a foreign body in the vitreous, yet it was extracted by the small 
 magnet through a scleral incision. It may be pretty safely asserted 
 that most authorities are decidedly against drawing the foreign 
 bodies from the vitreous into the anterior chamber unless the wound 
 of entrance has been through the cornea. And Mayweg, who is 
 recognized as an impartial as well as an able critic, has compiled 
 careful statistics tending to prove that the scleral route, with incision, 
 gives the best results even with the giant magnet. It would seem, 
 then, that the fault of the scleral route did not lie with the incision. 
 With what is it? Probably insufficient localization, disregard of 
 the vitreous, etc. 
 
 The great distinctive feature of the giant magnet is that it has a 
 drawing power far in excess of that of the hand-magnet, thus permit- 
 ting extraction from without; and not, as has been so generally 
 asserted, the fact that it does not necessitate further opening of the 
 globe. This same power has led, in some quarters, to a contempt 
 for localization or for diagnosis as to the mere presence of a foreign 
 body, the claim being that if one is present, there is a good chance of 
 bringing it out if not, no harm is done. Hirschberg declares that 
 it is precisely that enormous strength that constitutes the dar. 
 and condemns its employment for diagnostic purposes. He denies 
 its efficiency in this capacity, and says that he has seen more than 
 a dozen cases in which such trials proved negative; neverthele- 
 piece of metal was located and extracted through a scleral incision 
 in each. Hirschberg considers the large magnet useful in loosening 
 foreign bodies that are held fast, and particularly so in removing 
 small ones that lie in the remote parts of the vitreous chamber, 
 as also for cases of long standing. In recent cases Haab very justly 
 rates the importance of localization as secondary to that of quick 
 extraction, but insists upon the value of knowing the situation of 
 42
 
 658 THE REMOVAL OF FOREIGN BODIES. 
 
 the wound, and the track inside of the eye. When the injured eye 
 is on the verge of panophthalmitis, every minute counts. 
 
 After all, it seems to be pretty generally conceded or implied 
 that localization, scleral incision (if no open wound already exists) , 
 and the use of the large magnet constitute the most eligible procedures 
 for most cases of iron or steel in the vitreous chamber. Hirschberg's 
 "Three Principal Causes of the Insuccess of Magnet Operations" 
 read almost like a defense of the large magnet and an accusation of 
 the small. They are: 
 
 1. Loss of the eye from inflammatory processes after successful 
 extraction of the foreign body. 
 
 2. Insufficient traction power in the magnet. 
 
 3. Too firm an anchorage of the metal in its bed. 
 He might have added : 
 
 4. Insufficient measures of localization. 
 
 It must be admitted, however, that in many instances the drawing 
 of the metal from the vitreous into the anterior chamber and its 
 removal thence by means of the hand magnet through an appro- 
 priate incision constitutes a most elegant and satisfactory operation.
 
 INDEX. 
 
 Abadie's irito-ectomy, 424 
 Abaissement of cataract, 554 
 Abrasion of the cornea, 375 
 Accidents after cataract extraction, 
 
 5*5 
 
 after cyclodialysis, 408 
 in cataract extraction, 503 
 in discission, 562 
 in enucleation, 471, 473 
 in iridectomy for glaucoma, 450 
 in trephining of the cornea, 395 
 in trephining of the sclera, 408 
 
 Actual cautery, 377 
 
 application of, 372 
 
 in corneal ulcer, 379, 380 
 
 Adams' operation for ectropion, 281 
 
 Adults, young, linear extraction of 
 cataract in, 536 
 
 Advancement of tendon for squint, 
 169, 189, 200205. (See 
 also Squint.) 
 age limits for, 200 
 choice of method, 201 
 of extraocular muscles, 169 
 general considerations on, 200 
 
 205 
 
 of levator tendon, 236 
 for secondary squint, 198 
 of Tenon's capsule, 183 
 
 After-cataract, 563 
 
 after treatment, 569 
 arrachement for, 568 
 causes, 564 
 dilaceration for, 568 
 discission for, 565 
 division with scissors, 569 
 posterior discission for, 568 
 technic of operation for, 566, 
 
 567 
 
 time to operate, 565 
 Age limit for cataract operations, 
 
 478 
 for discission of soft cataract, 
 
 557 
 
 for enucleation, 476 
 for muscle operations, 200 
 Agnew's blunt hook operation, 540 
 eye-douche, 39 
 lacrimal knife, 64 
 
 Agnew's methods for anterior 
 
 synechia, 426 
 of irito-ectomy, 423 
 operation for enucleation, 459 
 
 for peritomy, 3 53 
 
 Air bubbles in anterior chamber, 506 
 Amputation of globe, anterior, 417 
 
 posterior, 418 
 Anel's syringe, 129 
 Anesthesia in enucleation, 476 
 in extraction, 485 
 in iridectomy, 436 
 general, 1 2 
 infiltration, n 
 local, 10 
 Anagnostakis-Hotz operation for 
 
 entropion, 257, 258 
 Angelucci's method of fixation in 
 cataract operations, 530, 
 
 542, 543. 57 
 
 Ankyloblepheron, Langier's oper- 
 ation for, 325 
 Anterior capsule, arrachement of, 
 
 534, 568 
 
 opening of, in extraction, 534 
 chamber, blood in, 426, 456, 
 
 506 
 
 foreign bodies in, 617 
 irrigation of, 494, 535 
 pus in, 382 
 
 lens capsule (See Anterior Cap- 
 sule.) 
 
 sclerotomy, 400 
 De Wecker's, 402 
 indications for, 403 
 Panas', 401 
 Vicenti's, 402 
 
 staphyloma, Critchett's opera- 
 tion for, 390 
 De Wecker's operation for, 
 
 39 1 
 history of surgery for, 389, 
 
 39 1 
 
 Knapp's operation for, 390 
 synechia, operation for 425, 
 
 426 
 
 Applications of heat, cold, etc., 44 
 Applicators, 34 
 A] i] living causatics, 43 
 Aqueous humor, escape of, during 
 corneal incision, 504 
 
 659
 
 66o 
 
 INDEX. 
 
 Argyll- Robertson's suture for ectro- 
 
 pion, 279 
 
 Arlt. (See Von Arlt.) 
 Arrachement of capsule after cata- 
 ract, 568 
 
 in extraction, 534 
 of iris in iridectomy, 449 
 Artificial vitreous body, 416 
 ripening operations, 570 
 by discission, 571 
 by hot air, 571 
 by incision and massage, 572 
 by intracapsular injections, 
 
 573 
 
 Asepsis, i 
 Atropin dermatitis after extraction, 
 
 526 
 
 before extraction, 483, 516 
 before iridectomy, 43 5 
 Autoplasty, by cutaneous grafts, 
 
 39, 33 
 
 French method, 289 
 Indian method, 296 
 Italian method, 318 
 
 B 
 
 Bader's knives, 65 
 
 Ball, introduction of glass or gold, 
 
 in eye, 465 
 
 Balance, Priestly Smith's, for test- 
 ing knives, 122 
 Bandages, 14, 15 
 binocular, 20 
 monocular, 19 
 Bandaging, 1 5, 2 1 
 Beard's cystotome, 66 
 
 exenteration knife-spatula, 76 
 fixation forceps, 93 
 hooks for closing wounds, 278 
 knife, 62 
 
 lacrimal sounds, 125 
 operation for advancement, 178 
 for ectropion, 283 
 for entropion, 264 
 for exenteration, 413 
 for ptosis, 241 
 for shortening, 190 
 for total symblepharon, 336, 
 
 338 
 
 speculum, in, 197 
 Beer's knife, 63 
 Beer-Wecker operation for cornea 1 
 
 staphyloma, 390, 391 
 Bishop's operation for ptosis, 232 
 Bistouries, 63 
 Blasius' method of blepharoplasty, 
 
 298 
 Blepharoplasty, 276 
 
 by cutaneous grafts, 309 
 by sliding flaps, 292, 295 
 Fricke's operation, 297 
 French method, 289 
 
 Blepharoplasty, Indian method, 
 
 296 
 
 Italian method, 318 
 varieties of, 288 
 Blepharoptosis or ptosis, 228 
 Blepharostats, 107, 112 
 Blood in anterior chamber, 456, 
 
 506, 526 
 letting, 52 
 local, 52 
 
 by venesection, 51, 54 
 Blue vision after extraction, 526 
 Blunt hook, 69, 447 
 Bonnet's, enucleation operation, 458 
 Bowman's double needle operation, 
 
 568 
 operation of slitting the canal- 
 
 iculus, 134 
 stop needle, 68 
 Bridge coloboma, 431, 454 
 Brossage for trachoma, 357 
 Bruns' advancement, 187 
 Brushes, 34 
 
 Bulging cicatrix after cataract ex- 
 traction, 518 
 
 Buller's ligation of canaliculus, 139 
 Burnett's iridectomy, 446 
 Burow's method of blepharoplasty, 
 2 95 
 
 Canaliculi, ligation of, 139 
 
 slitting of, 134 
 Canaliculus knife, Agnew's, 64 
 
 Weber's, 64 
 Canthoplasty, 216, 220 
 Capsule, forceps, 97 
 
 advancement of Tenon's, 183 
 
 opening of, 490, 507, 533 
 Capsulotomy in extraction of cat- 
 aract, 490, 507, 533 
 Carter, Brundenell, Iridectomy, 445 
 Cataract, abaissement for, 554 
 
 accidents during extraction, 503 
 after extraction, 515 
 
 adherent, 538 
 
 after- (see also After-cataract), 
 
 563 
 
 age of subject, 478 
 among glass-blowers, 573 
 artificial ripening of, 570 
 
 by discission, 571 
 
 by hot air, 573 
 
 by incision and massage, 572 
 
 by intracapsular injections, 
 
 573 
 
 aspiration or suction, 553 
 astigmatism after, 553 
 capsular, extraction of , 538, 568 
 capsulo-lenticular, 563 
 collapse of cornea in, 513 
 complicated, 536
 
 INDEX. 
 
 66 1 
 
 eye in ex- 
 
 Cataract, condition of 
 
 traction, 478 
 of lens in extraction, 480 
 of patient in extraction, 478 
 
 congenital, 537 
 
 couching for, 554 
 
 counter-puncture, 488 
 
 depression for, 554 
 
 diabetic, 478 
 
 diplopia in, monocular, 481 
 
 discission for, 556 
 
 dislocated, 543 
 
 displacement for, 5 54 
 
 "don'ts" in extraction of, 496 
 
 expression of, 492, 535 
 
 expulsive hemorrhage in extrac- 
 tion of, 513 
 
 extraction of senile. (See Ex- 
 traction of Cataract.) 
 
 incision for extraction, 488, 
 508, 531, 580, 590 
 
 iridectorny in, 527, 530, 538 
 
 knife, 580, 584, 588 
 Graefe, 64, 584 
 
 lamellar (see also Cataract, 
 zonular), 429 
 
 luxated, 542 
 
 membranous, 563 
 
 needle operation for, 556 
 
 nucleus after discission, 558 
 
 operations for, 478 
 
 reclination of, 554 
 
 ripening of, artificial, 570 
 
 secondary. (See After-cata- 
 ract.) 
 
 shrunken, 538 
 
 simple, extraction of, 486 
 
 soft, extraction of, 536 
 
 suction method for, 553 
 
 tremulous, 542 
 
 urine in, 482 , 
 
 zonular, 429 
 Caustics, 43 
 Cautery, actual, 377 
 
 corneal, 377, 380 
 
 electric, 377 
 
 galvano-puncture, 386 
 
 Paquelin, 377 
 
 thermic, 377 
 
 Cellulitis, orbital incisions for, 610 
 Chalazion, operation for, 213, 216 
 Chandler's iridectomy in cataract 
 
 extraction, 448, 517 
 Changing of dressings, 29, 501 
 Check ligaments, operation upon, 
 M 192 
 
 Chemosis, filtration, after cataract 
 
 extraction, 522, 553 
 Chloroform, as anesthetic, 12 
 Choroid, detachment of, in cyclo- 
 dialysis, 408 
 
 hemorrhage from, 513 
 
 Choroidal hemorrhage, 513 
 Cicatricial ectropion, 276 
 operation for, 277 
 
 entropion, 250, 276 
 dressing for, 270 
 Cicatristomy of De \Yecker, 402 
 Cicatrix bulging after cataract ex- 
 traction, 392 
 Cilia. (See Eye Lashes.) 
 
 forceps, 98, 209 
 Cilium forceps, 98, 209 
 Circumcising cornea, 352 
 Clark's tendon tucker, 186 
 Cleansing the eye, 29 
 Cocain, 10 
 
 Cold applications, 44 
 Collapse of cornea during cataract 
 
 extraction, 513 
 Coloboma, 429, 431, 448, 449 
 
 in extraction, 448 
 
 in glaucoma, 449 
 
 in optical iridectomy, 429 
 Combined excision for trachoma, 
 
 3 6 4 
 
 extraction of cataract, 527 
 Condition of eye for extraction, 478 
 of iris and pupil for extraction, 
 
 479 
 Congenital ptosis, 228, 249 
 
 cataract, discission in, 537 
 Conical cornea, operations for, 386, 
 
 389 
 
 Conjunctiva, operations on, 321 
 Conjunctiva! flap, 489 
 
 suture, 531 
 Corelysis, 424 
 
 Wenzel's, 424 
 Cornea, abrasion of, 375 
 
 circumcising, 352 
 
 cautery of, 379 
 
 collapse of, in extraction, 513 
 
 conical, 386 
 
 foreign bodies in, 371 
 
 galvano-puncture of, 386, 388 
 
 incision of, 380 
 
 infected ulcer of, 384 
 
 massage of, 385 
 
 operations on, 371 
 
 paracentesis of, 381, 383 
 
 splitting of, 505, 594 
 
 staphyloma of, 389 
 
 tattooing of, 396, 400 
 
 ulcers of, 384 
 
 Corneal incision in cataract extrac- 
 tion, 488, 508, 531, 580, 
 
 590 
 
 staphyloma, operation for, 389 
 transplantation, 393 
 
 partial, 395 
 
 total, 395 
 
 trephine, 395 
 
 Von Hippel's, 395
 
 662 
 
 INDEX. 
 
 Cortical substance, removal of, 493, 
 
 535 
 
 Coremorphosis, 429 
 Cotton, 14 
 
 Couching cataract, 554 
 Counter-puncture, 488 
 Critchett's advancement operation, 
 171 
 
 exenteration of globe, 411 
 
 extraction of cataract, 582 
 
 iridesis, 430 
 
 tenotomy, 162 
 Corneal incision in opening anterior 
 
 lens capsule, 533 
 Curets, 75 
 Cutaneous grafts in operation for 
 
 ectropion, 309, 330 
 Cyonid of mercury injections, 50 
 Cyclodialysis (Heine), 406 
 
 complications of, 408 
 
 contraindications of, 408 
 
 indications for, 407 
 
 results of, 408 
 Cyst, Meibomian, 216, 220 
 
 of anterior chamber, implan- 
 tation, 408 
 Cystoid cicatrix, 392 
 
 after cataract extraction, 518 
 
 after iridectomy for glaucoma, 
 
 433, 434 
 
 operations for, 392, 393 
 Cystotomes, 66, 67 
 
 Beard's, 66 
 
 Graefe's, 66 
 
 Knapp's, 66 
 
 Cystotomy, 490, 507, 533 
 Czermak's subconjunctival extrac- 
 tion, 531, 532 
 
 operation for symblepharon, 
 
 33 
 
 treatment of entropion from 
 bone lesions, 309 
 
 D 
 
 Da Gama Pinto's posterior discis- 
 sion, 568 
 
 Daviel's operation for cataract, 579 
 
 De Grandemont's operation for 
 ptosis, 238 
 
 Dementia after extraction, 525 
 
 Denonvilliers' operation for restora- 
 tion of lower lid, 299 
 
 Dermic grafts in operations for 
 
 entropion, 310 , 
 
 preparation of, 312 
 
 Dermo-epidermic grafts, 314 
 
 Descemet's membrane, detachment 
 
 of, in cyclodialysis, 408 
 in corneal cautery, 380 
 
 Desmarres' elevator, 77 
 
 Detachment of conjunctiva in enu- 
 cleation, 459 
 
 Detachment of Descemet's mem- 
 brane in cyclodialysis, 408 
 of retina following prolapse of 
 
 vitreous, 511 
 of retina, posterior sclerotomy 
 
 for, 409 
 
 trephining sclera for, 408 
 De Wecker's advancement of 
 
 Tenon's capsule, 183 
 combined sclerotomy, 402 
 enucleation, 464 
 
 for staphyloma, 391 
 iridotomy, 420 
 operation for ptosis, 231 
 pince-ciseaux, 88 
 tattooage of the cornea, 396 
 De Wenzel's cataract extraction, 
 
 54 
 
 knife, 580 
 
 incision for extraction, 540, 580 
 Dianoux's operation for entropion, 
 
 259 
 Dieffenbach's method of blepharo- 
 
 plasty, 284, 289, 293, 294 
 advancement, 169 
 Dilaceration of secondary cataract, 
 
 568 
 
 Dilatation of punctum, 123 
 Discission, 556 
 
 accidents incident to, 562 
 age limit for, 557 
 artificial ripening by, 571 
 Bowman's double needle, 568 
 knife for, 559, 561 
 point of entrance for knife, 562 
 technic of, 559 
 with scissors, 569 
 
 two needles, 568 
 
 Dislocation of lens in extraction, 510 
 Dissector, blunt, 68 
 Divergence secondary to tenotomy, 
 
 159, 198 
 
 Division of after cataract by scis- 
 sors, 569 
 optic nerve, 469 
 muscles in enucleation, 461, 
 
 463, 469 
 Double-transplantation operation 
 
 for pterygium, 343, 349 
 Douches, 38 
 Douching, 39 
 
 Dransart's operation for ptosis, 230 
 Dressings, 14 
 
 for ectropion, 270 
 for entropion, 270 
 for excision of lacrimal gland, 
 
 157 
 
 sac, 152 
 
 for extraction, 498 
 after operation in linear extrac- 
 tion of cataract, 498 
 Droppers, 35
 
 INDEX. 
 
 66 3 
 
 E 
 
 Ectropion and blepharoplasty, 276 
 
 general remarks, 287 
 Argyll-Robertson's suture for, 
 
 279 
 
 cicatricial, 277 
 cutaneous grafts in operation 
 
 for, 309 
 
 Fricke's operation for, 297 
 from bone lesions of orbit, 
 Tripier's operation for, 309 
 Czermak's treatment of, 309 
 Fukala's suture for, 280 
 mechanical, 277 
 
 measures for, 278 
 of lower lid, 277 
 operations for, 277 
 paralytic, 277 
 senile, 277 
 
 Snellen's suture for, 278 
 spastic, 276 
 
 Electrolysis of lacrimal canal, 141 
 of pterygium, 348 
 for trichiasis, 212 
 Electromagnet, 623, 624 
 Elephantiasis of eyelid, 228 
 Elevator, Desmarre's, 77 
 
 Fisher's, 530 
 Enophthalmos after advancement, 
 
 200 
 Entropion, 250 
 
 cicatricial, 255, 276 
 and trichiasis, conclusions, 271 
 choice of marginal graft, 271 
 lower lid, operations for, 274, 
 
 276 
 organic, operations for, 255, 
 
 276 
 
 senile, operation for, 2 50 
 spastic, operations for, 2>$o 
 ulcer of cornea after operations 
 
 for, 273 
 Enucleation, 457 
 
 accidents, immediate, 471 
 
 consecutive, 473 
 Agnew's method, 459 
 detachment of conjunctiva in, 
 
 459 
 division of straight muscles in, 
 
 461, 463, 469 
 
 general considerations, 468 
 history of, 458 
 indications for, 474, 476 
 in panoophthalmitis, 475 
 in sympathetic ophthalmitis, 
 
 476 
 
 hemorrhage after, 471, 473 
 modifications of, 463 
 perforation of sclera in, 471 
 resection of optic nerve in, 410 
 scissors, 83, 87, 470 
 
 Enucleation, severance of optic 
 
 nerve in, 469 
 suture after, 471 
 sympathetic inflammation 
 
 after, 465 
 
 technic of, 459, 468, 471 
 Vienna method for, 459 
 Von Arlt's method for, 459, 463 
 Epicanthus, operations for, 225 
 Epidermic grafts, 314, 330 . 
 Epilation of eyelashes, 209, 211 
 
 forceps, 98, 209 
 
 Eserin after simple extraction, 517 
 Esotropia, i 58 
 Ether, 12 
 Everbusch's operation for ptosis, 
 
 236 
 
 skin grafts, 315 
 Eversion of eyelid, 206 
 
 of lacrimal puncta, 137 
 
 of puncta, internal tarsorrhaphy 
 
 for, 222 
 
 Evisceration, 411 
 of eyeball, 411 
 
 sympathetic inflammation af- 
 ter, 465 
 Examination in cases of foreign 
 
 body in eyeball, 627 
 Excision of tarsus, 224, 362, 364 
 combined, for trachoma, 364 
 for pterygium, 340 
 Exenteration of orbital cavity, 6n, 
 
 614 
 
 of sclera or globe, 411 
 Beard's, 413 
 De Wecker's, 412 
 Gifford's, 413 
 indications for, 415 
 sympathetic inflammation 
 
 after, 465 
 Exophthalmos following tenotomy, 
 
 167 
 
 Exostosis of orbit, 609 
 Exotropia, i 58 
 Expression for trachoma, 3 58 
 
 of cataract, 53 5 
 Expressor, Kuhnt's, 358 
 Expulsive hemorrhage from choroid, 
 
 5i3 
 
 in cataract extraction, 492, 535 
 External tarsorrhaphy, 220 
 Extirpation of lacrimal gland, i 55 
 of sac, 141, i 53 
 of tarsus, 224 
 Extraction of cataract, 478 
 
 accidents immediate, 503 
 
 consecutive, 515 
 
 after treatment, 500 
 
 age of patient, 478 
 
 Angelucei's fixation in, 530 
 
 anesthesia in, 485 
 
 atropin poisoning after, 526
 
 664 
 
 INDEX. 
 
 Extraction of cataract, blood in an- 
 terior chamber, 506, 526 
 blue vision after, 526 
 blunt hook, 540, 541 
 capsulotomy in, 490, 507, 533 
 chemosis filtration, 522, 553 
 choice of operation, 527 
 clearing out lens remains, 53 5 
 closure of wound, 522 
 collapse of cornea in, 513 
 combined, 527 
 condition of eye, 478, 479 
 of lens, 480 
 of patient, 478 
 conjunctival flap, 489, 506 
 
 suture, 532 
 
 corneal suture in, 53 1 
 cortical matter after, 493 
 counter-puncture, 488 
 cyclitis after, 519 
 cystoid cicatrix, 518 
 cystotomy in, 490, 507, 533 
 Daviel's, 579 
 
 delayed healing after, 522 
 delivery of lens in, 492, 535 
 dementia after, 525 
 "don'ts" in, 496 
 double, 481 
 dressing after, 498 
 
 first, 501 
 
 erythropsia after, 527 
 expression of lens in, 492, 53 5 
 expulsive hemorrhage after, 
 
 filtration chemosis, 522, 553 
 first dressing after, 501 
 fixation of globe in, 487, 530, 
 
 S3 1 
 
 gaping of wound after, 515 
 general considerations, 478 
 glaucoma after, 524, 544 
 healing after, 522 
 hemorrhage after, 513 
 history of, 574 
 holding the lids apart in, 530 
 in capsule, 545 
 
 accidents and complica- 
 tions 550, 553 
 incision for, 488, 508, 531, 
 
 580, 590 
 
 Indian method, 547 
 indications for, 528 
 infection after, 520 
 insanity after, 525 
 intracapsular, 545 
 
 accidents and complica- 
 tions, 550, 553 
 intraocular hemorrhage after, 
 
 iridectomy in, 517, 527, 528, 
 
 . .53. 538 
 iridocyclitis after, 519 
 
 Extraction of cataract, iritis after, 
 
 519 
 irrigation of anterior chamber 
 
 after, 494, 535 
 keratitis after, 523 
 keratome in, 537 
 kianopsia after, 526 
 lavage after, 494, 535 
 linear, 536 
 
 mydriasis in, 483, 516 
 of adherant cataract, De 
 
 Wenzel's, 540 
 position of patient, 486 
 preliminary iridectomy in, 
 
 5 2 9 
 
 preparation of eye for, 483 
 of patient, 482 
 
 prolapse of iris after, 512, 515 
 of vitreous after, 511 
 
 puncture and counter-punc- 
 ture, 488 
 
 red vision after, 527 
 
 relative merits of methods, 
 
 5 2 7 
 
 retro version of iris after, 518 
 rigidity of pupil in, 508 
 rupture of capsule, 551 
 
 of zonule, 511 
 senile entropion after, ^526 
 simple, 486 
 * technic of, 486 
 sinking of lens into vitreous, 
 
 S 10 
 
 slow closure of wound, 522 
 splitting cornea in, 505, 594 
 spongy exudate into anterior 
 
 chamber after, 506 
 striped keratitis after, 523 
 subconjunctival, 531, .532 
 suppuration after, 520 
 suture of conjunctiva in, 532 
 tearing out capsule in, 534 
 technic, 486, 530, 552, 590 
 toilet of wound after, 498, 
 
 552 
 
 vitreous escape in, 511, 551 
 with iridectomy, 527 
 with preliminary iridectomy, 
 
 529 
 
 without capsulotomy, 545 
 without iridectomy, 486 
 wound in, 488, 508, 590 
 Eye, deviating, i 59 
 
 extraction of foreign bodies 
 
 from interior of, 616 
 foreign bodies in, 616 
 preparation of, 483 
 shades, 26 
 shields, 24 
 speculum, 107, 112 
 squinting, i 59 
 Eyeball, enucleation of, 457
 
 INDEX. 
 
 66 5 
 
 Eyeball, enucleation of, accidents 
 
 in - 47 1 - 473 
 implantation of artificial 
 
 globe, 465 
 
 perforation of sclera in, 471 
 evisceration of. (See Exenter- 
 
 ation.) 
 foreign bodies in, 616 
 
 Rtintgen rays in, 629, 647 
 massage of, 48, 385 
 Mules' operation on, 416 
 operations on, 371 
 steel in, 616 
 
 Eyelashes, epilation of, 209, 211 
 Eyelids, elephantiasis of, 228 
 e version of, 206 
 operations upon, 206 
 plastic operations on, Dieffen- 
 bach's, 284, 289, 293, 2i;4 
 ptosis of, 228 
 spasm of, 2 50 
 Eye-muscles, operations on, 158 
 
 Failure to open lens capsule, 507 
 False passage in probing lachry- 
 
 mo- nasal duct, 127, 132 
 Fergus' operation for ptosis, 236 
 Filtration scar, 404, 457 
 Fisher's lid retractor, 530 
 Fistula of lacrimal sac, 152 
 Fixation forceps, 89, 93 
 Fixing eye, 89-93, 487, 53O-53 1 . 
 542-543. 57 
 
 suture in Fuchs' method of 
 
 tarsorrhaphy, 221 
 Flap, conjunctival, 489, 506 
 Flaps, pedicled, 296 
 
 dressing, 308 
 
 preparation of, 306 
 
 selection of, 302 
 
 Flarer's operation for trichiasis, 276 
 Fluoroscope for locating foreign 
 
 bodies in eyeball, 63 1 
 Forceps, 89-107 
 
 advancement, 98 
 
 capsule, 97 
 
 cilium, 98, 209 
 
 dressing, 94-95 
 
 entropion, 9899 
 
 fixing, 89-93 
 
 hemostatic, 99 
 
 iris, 95-96, 446-447 
 
 Knapp's roller, 358-359 
 
 lid, 98 
 
 needle, 103 
 
 rotary, 97 
 
 trachoma, 98 
 
 toilet, 97 
 
 Forceps-scissors, 88 
 Foreign bodies in anterior chamber, 
 617 
 
 Foreign bodies in cornea, 371 
 in eyeball, 616 
 in iris, 618-619 
 in lens, 621 
 in orbit, 598 
 
 in posterior chamber, 620 
 in vitreous, 621 
 
 loosening with magnet, 65 s 
 drawing into anterior cham- 
 ber, 654 
 
 Riintgen rays for, 629, 647 
 Forster's method of ripening cata- 
 ract, 572 
 
 Fox's operation of peridectomy, 354 
 French method of blepharoplasty, 
 
 289 
 Fricke's method of blepharoplasty, 
 
 297 
 
 Frost-Lang operation of implan- 
 tation, 465 
 Fuchs' lattice bandage, 25 
 
 tarsorrhaphy, 221 
 Fukala's suture for ectropion, 280 
 
 Gaillard's suture for entropion, 252 
 Galezowski's operation for ptosis, 
 
 238 
 
 crucial anterior sclerotomy, 403 
 excision of retro-tarsal "folds, 
 
 363 
 Galvano-cautery. (See Actual 
 
 Cautery.) 
 
 Galvano-puncture for conical cor- 
 nea, 388 
 
 for detachment, 410 
 for paracentesis, 386 
 Gama Pinto's operation, 568 
 Gaping of wound in cataract ex- 
 traction, 515 
 Gauze, 14 
 Gayet's operation for entropion, 259 
 
 iridectomy, 445 
 General anesthesia in ophthalmic 
 
 operations, 12 
 
 Giant magnet, technic for, 652 
 Gifford's evisceration, 413 
 Gifford on recurrent pterygium, 351 
 Gland, extirpation of orbital lacri- 
 mal, i 56 
 
 palpebral lacrimal, 1 56 
 Glass ball in eye, introduction of, 
 
 416 
 
 Glass in the eyeball, 616, 620 
 Glasses, protective, 27 
 Glaucoma, absolute, anterior 
 
 sclerotomy for, 400 
 posterior sclerotomy for, 403 
 acute, iridectomy for, 433-434 
 after cataract operations, 524, 
 
 544 
 arrachement of iris in, 449
 
 666 
 
 INDEX. 
 
 Glaucoma, chronic, 434 
 
 coloboma in iridectomy for, 
 
 448-449 
 
 cyclodialysis in, 406 
 filtration scar in, 404, 457 
 paracentesis for, 380 
 hemorrhage, expulsive after 
 
 iridectomy for, 453, 513 
 incision for, 437, 444-445, 450 
 iridectomy in, 404, 434 
 
 technic of, 437-450 
 massage of eyeball in, 385 
 posterior sclerotomy for, 403 
 relapsing, 401, 403 
 scleral puncture in, 403 
 scleriritomy for, 402 
 sclerotomy for, 400, 403 
 secondary, 524, 544 
 simple, 434 
 tardy closure of wound in 
 
 operations for, 457 
 wounding lens in iridectomy 
 
 for, 455 
 
 Globe. (See Eyeball.) 
 Gloves, operating, 2 
 Goggles, 2728 
 Grafts, cutaneous, in operation for 
 
 ectropion, 309 
 Graefe. (See von Graefe.) 
 Grandemont's operation for ptosis, 
 
 238 
 Granules, trachoma, expression of, 
 
 358 
 
 Grattage, 357 
 Gruening's operation for ptosis, 238 
 
 H 
 
 Haab's large magnet, 624 
 Hansel-Sweet, enucleation, 464 
 Harlan's operation for symbleph- 
 
 aron, 328 
 
 blepharoplasty, 294 
 Hasner's blepharoplastic operation, 
 
 299 
 Heembold's operation for ectropion, 
 
 282 
 
 Heat, 44 
 
 Heine's cyclodialysis, 406 
 Hemorrhage in enucleation of eye- 
 ball, 471 
 
 in iridectomy for cataract ex- 
 traction, 513 
 expulsive, after iridectomy for 
 
 glaucoma, 453, 513 
 in cataract extraction, 513 
 Hemostasis in lacrimal operations, 
 
 *'S* 
 
 Hess's operation for ptosis, 231 
 Heurteloup's artificial leech, 53 
 Hirschberg's electromagnet, 623 
 History of extraction, 574 
 Holocain, 10-11 
 
 Hook, blunt, 69, 447 
 sharp, 68-69, 447 
 squint, 73 
 
 its many uses, 74 
 Hooks, Beard's, for closing wounds, 
 
 278 
 Hotz operation, 258 
 
 method of skin grafting, 316 
 Hotz-Anagnostakis operation for 
 
 entropion, 258 
 Hotz operation for ectropion, 316 
 
 3i7 
 
 symblepharon, 331-333 
 Hunt-Tansley operation for ptosis, 
 
 2 35 
 
 Hydrochlorate of cocain, 10 
 Hydrophthalmos, 403, 433-434 
 Hyphema, 456, 506, 526 
 Hypopyon, 384 
 keratitis, 384 
 
 I 
 
 Illumination for operations, 8 10 
 Implantation of artificial globe, 465 
 
 vitreous, 416 
 Incision of anterior lens capsule, 562 
 
 wall of lacrimal sac, 138 
 in anterior sclerotomy (De 
 
 Wecker's), 406 
 
 in cyclodialysis (Heine's), 406 
 for extirpation of lacrimal sac, 
 
 147 
 
 in extraction of cataract, 488, 
 
 5 8 , S3' 1 . 5 8 , 59 
 
 Earth's, 581 
 
 Beer's, 581 
 
 Bowman's, 581 
 
 Critchett's, 582 
 
 De Wecker's, 586-587. 
 
 De Wenzel's, 580 
 
 Jaeger's, 588 
 
 Kiichler's, 587 
 
 Lebrun's, 589 
 
 Liebreich's, 588 
 
 Pamard's, 580 
 
 Pellucci's, 581 
 
 Richter's, 581 
 
 Santerelli's, 582 
 
 Travers', 582 
 
 Von Graefe's, 583-586 
 
 Weber's, 587 
 in iridectomy for glaucoma, 
 
 444-500 
 
 for iridotomy, 422 
 with lancet in iridectomy for 
 
 glaucoma, 444 
 in optical iridectomy, 429 
 in paracentesis cornea, 380-3 
 in posterior sclerotomy, 406 
 in simple extraction, 488, 508, 
 
 S3 1 - 58o, 590 
 Incisions of the orbit, 610
 
 INDEX. 
 
 667 
 
 Indian method of blepharoplasty, 
 296 
 
 operation for cataract, 547 
 Infection of cornea following cat- 
 aract extraction, 520 
 Infiltration anesthesia, 1 1 
 Inhalers, 13 
 Injections, hypodermic, 49 
 
 intracapsular, 50, 573 
 
 subconjunctival, 49 
 
 paraffin, 145, 146 
 
 tissue, 48 
 Injuries of lens during iridectomy 
 
 for glaucoma, 455 
 Ink, India, in tattooing, 397 
 Insanity after cataract extraction, 
 
 5 2 5 
 
 Inspection of eye, after extraction, 
 
 502 
 for contained foreign body, 627 
 
 Instruments, care of, 117-122 
 management of, 55, 113 
 manipulation of, 113117 
 testing edges and points of, 
 
 12 i i 22 
 preparation of, 2, 4, 120 
 
 Interior of eye, extraction of foreign 
 bodies from, 616 
 
 Ir.termarginal incision, 264 
 
 Internal tarsorrhaphy, 222 
 
 Intracapsular injections, 573 
 
 Intratenonian injections, 50 
 prothesis, 465 
 
 Introduction of glass or gold balls 
 into the eye, 416 
 
 Iridectomy, 426 
 
 accidents in, 450 
 anesthesia in, 436 
 antiphlogistic, 434 
 blood in anterior chamber, 456 
 cataract following, 455 , 
 I choice of knife for, 442 
 coloboma in, 448 
 
 "key-hole," 449 
 complications following, 451 
 consecutive accidents, 457 
 expulsive hemorrhage, 453, 513 
 general considerations, 43 5 
 Graefe knife in, 443-445 
 grasping the iris, 446 
 historical, 426-428 
 in cataract extraction, 517, 
 
 S 2 7-53 , S3 8 
 in glaucoma, 433-450 
 incision for, 437, 444, 450 
 in hemorrhagic glaucoma, 434 
 in hydrophthalmus, 403, 433- 
 
 434 
 
 in magnet operations, 619 
 intraocular hemorrhage after, 
 
 453, 5 J 3 
 kind of knife for, 428, 442 
 
 Iridectomy, Kuhnt's forceps in, 447 
 Liebreich's forceps in, 447 
 modifications of, 441 
 
 Burnett's, 446 
 
 Carter's, 445 
 
 Dianoux's, 446 
 
 Gayet's, 445 
 
 mydriatics and myotics in, 43 5 
 optic, 429 
 
 Pope's, 431 
 point of entrance of keratome, 
 
 , 437, 444 _t 
 
 position of new pupil, 429 
 preliminary, in cataract extrac- 
 tion, 428 
 
 ' preparatory, 428 
 prolapse of vitreous in, 456 
 pupillary bridge in, 431, 454 
 size and shape of coloboma, 448 
 technic of, 436, 448-449 
 therapeutic, 432-435 
 toilet of eye after, 440-441 
 value of, in extraction, 517 
 withdrawing the iris in, 446 
 Iridencleisis, 430 
 Iridesis, 430 
 Iridochoroiditis, suppurative, enu- 
 
 cleation in, 475 
 
 Iridocyclitis after cataract extrac- 
 tion, 519 
 Iridodesis, 430 
 Iridodialysis, 427 
 Iridolysis, 425 
 Iridorrhexis, 427 
 Iridotomy, 418 
 
 De Wecker's, 420 
 in secondary cataract, 565 
 modifications of, 422 
 technic of, 422 
 Iris, arrachement of, 449 
 bombe, 433 
 
 bridge coloboma of, 431, 454 
 coloboma of, 448 
 excision of, 426 
 forceps, 95, 96, 447 
 foreign bodies in, 618-619 
 hooks, 68, 69, 447 
 implantation cyst of, after 
 
 cyclodialysis, 408 
 operations on, 418 
 prolapse of, after cataract ex- 
 traction, 512, 515 
 treatment of, 512, 515 
 reposition of, 512 
 scissors, 87 
 
 Iritis after cataract extraction, 519 
 iridectomy in, 432-435 
 in chronic, 432-435 
 in recurrent, 432-435 
 operative treatment of, 432-43 5 
 Irito-ectomy, 419, 420 
 Abadie's, 424
 
 668 
 
 INDEX. 
 
 Irito-ectomy, Agnew's, 423 
 
 modifications of, 423 
 Irito-dialysis, 419, 420, 421 
 Irotomy, 418 
 Irrigation, 39 
 
 of anterior chamber after ex- 
 traction, 494, 535 
 Irrigators, 38, 495 
 
 J 
 
 Jackson's tendon displacement, 197 
 Jacobson's extraction, 386 
 Jager's cataract knives, 588 
 incision, 588 
 
 lid spatula, 112 
 
 operation for ectropion, 291 
 Jasche-Arlt operation for trichiasis, 
 
 2 57 
 
 Jones (Wharton-) operation for 
 ectropion, 290 
 
 K 
 
 Kalt's corneal suture, 532 
 Keratitis after cataract operation, 
 
 523 
 
 striped, 523 
 
 Keratoconus, operations for, 386 
 Keratoglobus. (See Hydrophthal- 
 
 mus.) 
 
 Keratome, 65, 537 
 Keratonyxis, 557, 559 
 Keratoplasty, 393 
 
 partial, 395 
 
 total, 394 
 
 Key-hole coloboma, 449 
 Knapp's blepharoplasty, 295 
 
 knife needle, 67 
 
 lid clamp, 99 
 
 needle forceps, 103 
 
 operation for pterygium, 343 
 for squint, 184 
 
 peripheral capsulotomy, -533 
 
 trachoma forceps, 358-359 
 Knies' irido-sclerotomy, 402 
 Knife, cataract, forms of, 64, 580- 
 
 584 
 
 Graefe, 64 
 needle, Knapp's, 67 
 needles, 67 
 
 Kronlein's operation, 601-606 
 Kiichler's incision for anterior 
 
 staphyloma, 391 
 for cataract, 587 
 
 Kuhnt's expression methods, 3 59 
 operations for trachoma, 362 
 Kuhnt-Miiller operation for ectro- 
 pion, 282 
 Kyanopsia, 526 
 
 Lacrimal canal, hemostasis of, 151 
 operations on, 123 
 slitting of, 134-135 
 
 Lacrimal canal, threading, 129 
 punctum, dilating, 123 
 dilator, Landolt's, 123 
 electrolysis, 140 
 glands, excision of, 155-156 
 extirpation of orbital, i 56 
 
 of palpebral, 155 
 probes, introduction of, 127 
 Bowman's, 124, 125 
 Weber's, 112 
 Theobald's, 125 
 probing, 127 
 
 punctum, ligation of, 139 
 sealing of, 139 
 dilating of, 123 
 sac, excision of, 141 
 extirpation of, 141 
 fistula of, i 53 
 incision of, 138 
 obliteration of, i 53 
 sounds, Beard's, 125 
 
 Weber's, 112 
 stenosis of infants, 132 
 stricture, incision of, 136 
 syringe, Wilder- Beard, 129-130 
 syringing, 132 
 Lacrimonasal stenosis in new-born, 
 
 J 3 2 
 
 Lance keratomes, 65 
 Landolt's operation for restoration 
 
 of lid, 300 
 Landolt's method of advancement, 
 
 172 
 
 tendon lengthening, 196 
 Lagrange's implantation in Tenon's 
 
 capsule, 467 
 Lang's operation for dividing 
 
 synechia, 426 
 Latent squint, i 59 
 Lavage after extraction, 494, 535 
 Lebrun's method for ectropion, 589 
 Leeches, 52 
 
 natural, 52 
 artificial, 53 
 
 Le Fort- Wolfe transplantation oper- 
 ation for entropion, 310 
 Leiter's tubes, 46 
 
 coils, 46 
 Lens, foreign bodies in, 621 
 
 removal of. (See Extraction.) 
 Leukoma of cornea, tattooage for, 
 
 396 
 
 trephining for, 395 
 Lid clamp, Knapp's, 99 
 elevator, 77 
 e version of, 206 
 forceps, 98 
 operations upon, 206 
 Liebreich's method of extraction, 
 
 588 
 
 Ligation of canaliculi, 139 
 of pterygium, 348
 
 INDEX. 
 
 66 9 
 
 Linear extraction of cataract, 536 
 Local anesthesia in ophthalmic 
 
 operations, 10 
 Localization of foreign bodies in 
 
 eye, 626 
 
 Davidson's method, 643 
 Guilloz's method, 643 
 Sweet's method, 63 1 
 comparison of methods of, 1 649 
 control of the eye in, 646 
 Localizer, Sweet's new, 636 
 Loops, wire, 76, 77 
 
 M 
 
 Magnet of Haab, 624 
 of Hirschberg, 623 
 relative merits of small and 
 
 large, 656 
 operations, 623 
 Magnet operation, causes of insuc- 
 
 cess in, 658 
 history of, 623 
 
 small, in foreign bodies in eye- 
 ball, 623 
 
 operations, technic of, 650 
 Masks, operating, 6-8 
 protective, 24-25 
 Manipulation of instruments, 113 
 
 117 
 Massage, 48 
 
 of cornea after paracentesis, 
 
 385 
 
 of eyeball, 385 
 in embolism, 385 
 in glaucoma, 385 
 vibratory, 48 
 McKeown's irrigator, 495 
 McReynold's operation for pter- 
 
 ygium, 345 
 
 Median tarsorrhaphy, 222 
 Meibomian cyst (see also Chala- 
 
 zion), 216-222 
 Mellinger's speculum, 107 
 Membrane, Descemet's, detachment 
 
 of, in cyclodialysis, 408 
 Mercury cyanid injections, 50 
 Metallic foreign bodies, removal of, 
 
 616 
 
 Meyer's method of enucleation, 463 
 Mooren's iridectomy, 428 
 Motais' operation for ptosis, 239, 
 
 244-247 
 Mules' operation for artificial 
 
 vitreous, 416 
 ptosis, 231 
 repositor, 108 
 Mueller's myectomy, 189 
 
 sclerectomy, 410 
 Muller-Kuhnt operation for ectro- 
 
 pion, 282 
 
 Mydriasis in extraction, 516 
 in iridectomy, 43 
 
 N 
 
 Narcosis, 1 2 
 
 Needle knife, Knapp's, 67 
 
 stop, Bowman's, 68 
 
 sewing, 112 
 
 tattooage, 68, 397 
 
 Nerve, optic, resection of, in enu- 
 cleation, 470 
 
 New-born children, probing in, 132 
 Nicati's operation of anterior scle- 
 
 rotomy, 402 
 Nitrate of silver, 44 
 Noyes' shortening operation, 187 
 
 O 
 Oblique illumination for foreign 
 
 body in cornea, 371 
 Ocular mask, Ring's, 24 
 Ocular muscles, operation upon, i 58 
 Ointments, 41 
 Oliver's restoration of cul-de-sac, 
 
 333 
 
 Operating room, 8 
 gloves, 2 
 masks, 6-8 
 
 Ophthalmoscope for locating for- 
 eign body in eyeball, 628 
 Optic nerve, resection of, in enu- 
 cleation, 470 
 Orbit, cellulitis of, 610 
 cysts of, 608 
 exenteration of, 611 
 partial, 614 
 total, 612 
 
 exostoses of, operations for, 605 
 foreign bodies in, 598 
 diagnosis of, 599 
 technic of removal, 600 
 hemorrhage in, 613 
 incisions of, 610 
 Kronlein's operation upon, 
 
 601606 
 
 indications for, 605 
 modifications of, 604 
 operations upon, 598 
 tumors of, 606 
 
 technic of removal, 608 
 Ouletomy of Panas, 401 
 
 Pagenstecher's intracapsular ex- 
 traction, 546 
 knife-needle, 67 
 operation for entropion, 261 
 
 ptosis, 230 
 Panas' operation for artificial pupil, 
 
 43 
 
 for anterior sclerotomy, 401 
 for entropion, 260 
 
 lower lid, 275 
 for ptosis, 233
 
 670 INDEX. 
 
 Panas' operation for restoration of Pterygium, Desmarres' transplanta- 
 
 lid, 300 tion for, 347 
 
 for symblepharon, 329 electrolysis of, 348 
 
 Pannus, operations for, 369-370 false, 349 
 
 Panophthalrnitis, enucleation in, 475 Galezowski's operation for, 347 
 
 Paracentesis of cornea, 380 historical, 339 
 
 in conical cornea, 386 Knapp's operation for, 343 
 
 in embolism and thrombosis, ligation of, 347 
 
 382 'McReynold's operation for, 345 
 
 in iritis and iridocyclitis, 381 recurrent, 350 
 
 in ulceration of cornea, 382 Gifford on, 351 
 
 Paraffin in Tenon's capsule, 467 Ptosis, or blepharoptosis, 228 
 
 for artificial vitreous, 416 Beard's method, 241 
 
 Parinaud's operation for ptosis, 239 Bishop's method, 232 
 
 Patches, 23 Bowman's method, 238 
 
 Patient, preparation of, 4-6 Darier's method, 229 
 
 Pediceled flaps in plastic operations, De Grandemont's method, 238 
 
 328 Denonvilliers' method, 229 
 
 dressing for, 308 De Wecker's method, 231 
 
 preparation of, 306 Dransart's method, 230 
 
 selection of, 302 Eversbusch's method, 236 
 
 Peridectomy, 352 Fergus' method, 236 
 
 Peritomy, 352 Gosselin's method, 229 
 
 Phlebotomy, 51 Graefe's method, 229 
 
 Pince-ciseaux of De Wecker, 88 Gruening's method, 238 
 
 Pope's optic iridectomy, 431 Hess' method, 231 
 
 Posterior chamber, foreign bodies historical, 228-229 
 
 in, 617 Hunt-Tansley method, 235 
 
 sclerotomy for removal of Mules' method, 231 
 
 foreign bodies, 651 Motais' method, 239-245 
 
 indications for, 405 Pagenstecher's method, 230 
 
 in glaucoma, 403 Parinaud's method, 239 
 
 Masselon's method, 405 principles involved, 229 
 
 modifications of, 404 Snellen's method, 237 
 
 technic of, 404 summary, 243 
 
 Post-chorioidal hemorrhage, 492, Vautrin's. method, 229 
 
 5 X 3 535 varieties of, 228 
 
 Postoperative astigmatism, 553 Wilder's method, 232 
 
 dementia, 525 Puncta lacrimalia, sealing of, 139 
 Precorneal iridotomy, 427 stenosis of, in infants, 132 
 Preliminary iridectomy, 428 Puncture of cornea. See Para- 
 Preparation of hands, 2 centesis.) 
 
 of instruments, 2-4 Function of sclera. (See Posterior 
 
 of patient, 4-6 sclerotomy.) 
 
 Preparatory iridectomy, 428 Pupil in cataract extraction, 479, 
 
 Pressure bandage, 14 483 
 
 Priestly Smith's balance for testing position of artificial, 429 
 
 knives, 122 rigidity of, in extraction, 508 
 
 Prince's method of advancement, Pupillary bridge, 431, 454 
 
 i?5 
 
 advancement forceps, 98 
 
 Primrose's operation for pannus, 369 Rabbit's conjunctiva, transplan- 
 
 Probe, lacrimal, 125-127 tation of, 325, 327 
 
 Beard's, 125 cornea, transplantation of, 395 
 
 Bowman's, 124-125 eye, transplantation of, 467 
 
 Theobald's, 125 Raclage for trachoma, 357 
 
 introduction of, 127129 Radiography for locating foreign 
 
 Prolapse of iris, 453, 512, 515 bodies in eyeball, 629 
 
 of vitreous, 511, 551 positions of head and tube, 
 
 Provisional tarsorrhaphy, 304 647 
 
 Pterygium, Arlt's excision for, 340 Rays, Rontgen, in foreign bodies in 
 
 cautery of, 348 eyeball, 647
 
 INDEX. 
 
 671 
 
 for cataract. ; . 
 
 - ' .:'-. 7 r -.-:.-. -.1 .-.: ' - : - 
 Redressing the eye, 29, 501 
 
 > -- :':'-. . -. - . :-...,-:-- ' 
 
 extract*o>m without iridec- 
 " ~" - ' 
 
 '.'.'-'-- : : 
 
 Resection off tarsus for ptosis. 238 
 
 -' . - - : : :i 
 
 Retraction o caruncle foDowimg 
 tenotomy, 167 
 
 -- - -.."-.I: i. - - : : 
 - . 
 
 - " ; : : 
 
 ': - -------.-...-.: : 
 
 Ring's ocular mask, 24 
 
 Roosa"s extraction in capsule, 546 
 
 Sac, excision of lacrimal, 141 
 
 - - - : _ 
 
 Savage's method for shortening 
 
 -__ : 
 
 Scalpels, 62 
 
 _ _ " " ----- 
 
 Scissors, canthotomy, 88 
 
 : - - 
 
 ' -.:'.'.' ' - 
 
 forceps of De Wecker, 88 
 
 7* 
 MIS, 87 
 
 Strabismus, 79 
 
 Stevens, 83, 163 
 Terson's, 87 
 
 Wartamont's hemostatic, 470 
 Sdeia, eatenteration of, 411 
 operations on, 400 
 perforation of, in enocleatjon, 
 
 47 
 
 in tenotom y, 166 
 smtores of, 410 
 t rephina tkm of, 408 
 
 - - - : 
 
 Scleral incision for magnet oper- 
 ation. 651 
 sutures, 410 
 Sclerectomy, 408 
 
 for detached retina. 409 
 for magnet opejrataomt, 651 
 L. MnDer*s method, 410 
 Sderintomy. 4<>>_ 
 Sderoticopiincture, 557 
 Sclerotomy, anterior. 400 
 De Wecker's, 400 
 combined, 402 
 for retinal detachment. 409 
 Galezowski's crncia], 4<>3 
 indications for, 403 
 in glaucoma, 400, 403 
 
 5'. ' T - : - ' - - : - - . : - 
 
 posterior. 403 
 
 indications for. 405 
 in glaucoma. 405 
 Sa*g the lacrimal pnncta, 139 
 Secondary cataract (see After-cat- 
 aract). 563 :.._. 
 
 -'..:- :*j. 
 
 Senile cataract. (See Extraction.) 
 Serpiginons nicer of cornea. Sae- 
 misch section in. 384 
 
 --..- . ;-.--.- - : -- : >: 
 
 Severance of optic nerve m enn- 
 
 cleation. 469 
 -._-- ; 
 Shields. 24 
 Shortening of Hd for senile ectropion, 
 
 - - r .-.- '-- - :-.---:- .'-'.'---- : - -" - 
 
 tor. 539-540 
 Sideroscope. 628 
 
 in foreign bodies in eyebaD, 
 
 628 
 
 Simple extraction, 486 
 Skin-grafts in operations for cica 
 
 tricial ectropion. 309 
 Skin grafting. 309 
 
 Thiersch's method, 315 
 Wotf-Le Forte method, 310 
 without pedicle. 309 
 Slitting up of the canalicultis, 134 
 Small magnet in foreign bodies in 
 
 eyeball, 623 
 Smith's methods of extraction in 
 
 capsule. 
 
 SneOen's operations for ptosis. 237 
 suture for ectropion. 278 
 
 for entropion, 253 
 tenotomy. 163 
 wire loop. 77 
 Sounds, lacrimal, 125 
 Spastic ectropkm. operation for, 2 50 
 
 SneOen's suture for. 278 
 entropion after extraction, 526 
 
 operation for. 255 
 Spatula, iris, - - 
 
 lid. Jaeger's. 112 
 knife. Beard's. 76 
 Speculum, eye. 107 
 
 Hd, 107 
 
 Spencer- Watson's operation for en- 
 tropion. 258 
 Sphincterectomy. 43* 
 Sphincerolyse. 
 Splitting of cornea, 505. 594 
 Sponges. 32-33 
 Spoons. 70. 75 
 metal. 70. 75 
 Pagenstecher's. 70. 546 
 Spratt on intratenoman implanta- 
 tion. 466
 
 672 
 
 INDEX. 
 
 Spud, foreign body, 70, 372 
 Squint (see also Strabismus), 158 
 advancement for, 169-189, 
 
 200-205 
 hooks, 73 
 
 secondary, 159, 198 
 tenotomy for, 160 
 varieties of, 1 58 
 Staphyloma, anterior, operations, 
 
 for, 389 
 of cornea, 389 
 partial, 392 
 total, 390 
 
 pellucidum, operations for, 386 
 Stellwag's suture, 254 
 Stenosis of lacrimal punctum, 123 
 Stereoscopic localization of foreign 
 
 bodies in eyeball, 63 1 
 Sterilization of dressings, 6 
 
 instruments, 2-4 
 Stevens' tenotomy instruments, 
 
 !63, i?9 
 
 Stop needle, Bowman's, 68 
 Strabismus, 1 58 
 
 advancement for, 169-189, 200- 
 
 205 
 
 secondary, 159, 198 
 tenotomy for, 160 
 hooks, 73 
 
 Streatfield's tarsoplasty, 260 
 Strabotomy, 160 
 
 Stricture, incision for lacrimal, 136 
 Stricturotome, Stilling's, 136 
 Subconjunctival injections, 49, 522 
 Subcutaneous injection of cocain, 
 
 11,12 
 Subtenonian injection of mercuric 
 
 cyanid, 522 
 Sutures for ectropion, 278 
 
 for entropion, 2 53 
 Swelling of lens, corneal puncture 
 
 in, 544 
 
 Sweet's Rontgen ray methods for 
 locating foreign bodies, 63 1 
 Sweet- Hansel enucleation, 464 
 Swabs, 34 
 Symblepharon, 321 
 anterius, 322 
 posterius, 322 
 totalis, 322 
 
 operations for, method by 
 mucous or cutaneous 
 grafts, 326, 330-337 
 pediceled flaps of conjunc- 
 tiva or skin, 326-329 
 sliding flaps of conjunctiva, 
 
 322 
 Sympathetic inflammation after 
 
 cataract, 585 
 enucleation, 465 
 exenteration, 465 
 Frost's operation, 464 
 
 Synechia, anterior, 425 
 
 Agnew's method for, 426 
 
 posterior (corelysis), 424 
 Synechiotomy, 424 
 
 Wenzel's, 424 
 Syringe, Anel's, 129 
 Syringing lacrimal canal, 129132 
 Szymanowski's operation for ectro- 
 pion, 285 
 
 blepharoplasty, 294 
 
 Tagliacotian method of autoplasty, 
 
 3i8 
 Tansley-Hunt operation for ptosis, 
 
 235 
 
 canula for Anel's syringe, 130 
 Tarso-chiloplastic operation, 259 
 Tarsorrhaphy, 220 
 
 Arlt's internal, 222 
 external, 220 
 Fuchs' method, 221 
 median, 222 
 provisional, 304 
 
 Tarsus, excision of, Kuhnt's com- 
 bined, 364 
 extirpation, 367 
 simple, 363 
 for ptosis, 229, 238 
 Tattooing, influence on vision, 400, 
 
 43 
 
 needle, 68 
 of cornea, 396 
 operation of, 397 
 remarks on, 399 
 Wecker's, 396 
 Teal's operation for symblepharon, 
 
 3 2 4 
 
 Tear sac speculum, 148 
 Tearing of iris in iridectomy, 449 
 Tendon advancement, i 6 9-1 8 9 , 
 200205 
 
 lengthening, 193 
 
 recession, 191 
 
 resection, 187 
 
 shortening, 185 
 
 tucking, 185 
 Tenon's capsule, advancement of, 
 
 183 
 
 artificial globe in, after enu- 
 cleation, 465 
 Tenotomy, 160-169 
 
 complete, 168, 169 
 complications after, 165 
 graduated, 168, 196 
 open, i 68 
 partial, 168 
 subconjunctival, 168 
 Therapeutic iridectomy, 432 
 Thermocautery in serpiginous ulcers, 
 378
 
 INDEX. 
 
 Thiersch's skin-grafting method, 
 
 3i5 
 
 graft, 315 
 
 Thread operation, subcutaneous, for 
 ptosis, 230 
 
 for lacrimal obstruction, 129 
 
 Graefe's, 170 
 
 Tillaux method of enucleation, 463 
 Tobacco-pouch suture, 412, 521 
 Todd's tendon tucker, 186 
 Toilet of wound after extraction, 
 
 498, 55 2 
 
 after iridectomy, 440 
 Trachoma, cautery for, 361 
 
 chemical treatment of, 361 
 
 combined excision for, 364 
 
 curettage for, 362 
 
 excision for, 362363 
 
 expression of follicles in, 3 58 
 
 forceps, Knapp's, 358-359 
 
 granules, expression for, 3 58 
 
 grattage in, 357 
 
 isolated excision for, 367 
 
 massage for, 357 
 
 mechanical treatment of, 356 
 
 operations for, 362 
 
 radiation for, 361 
 
 simple excision for, 363 
 Transplantation, corneal, 393-396 
 
 for pterygium, 342 
 
 of rabbit's conjunctiva, 325, 
 
 3 2 7 
 
 eye, 467 
 
 operations, double, for pter- 
 ygium, 343 
 Trephining of cornea, 395 
 
 of sclera, 408 
 Trichiasis, 256 
 
 double transplantation for, 259 
 electrolysis for, 212 
 operations for, 256 
 Flarer's, 276 
 Hotz-Anagnostakis, 2 58 
 Jaesche-Arlt, 257 
 Panas', 260 
 Spencer- Watson, 258 
 Tripier's operation for ectropion 
 from bone lesions of orbit, 
 309 
 
 Trousseau's folding operation, 187 
 extraction, 534 
 
 U 
 Urine in cataract, 478 
 
 Van Milligen's tarsochiloplasty, 259 
 Verhoeff's advancement operation, 
 
 176 
 
 lengthening operation, 196 
 Vibration massage, 48 
 
 43 
 
 Vicenti's anterior sclerotomy, 402 
 Vienna enucleation operation, 459 
 Vitreous, foreign bodies in, extrac- 
 tion of, 621 
 
 prolapse of, in extraction, 511 
 during discission, 456 
 in iridectomy for glaucoma, 
 
 453-455 
 
 sequelae of, 511, 551 
 Von Ammon's operation for ectro- 
 pion, 281, 289 
 Von Arlt's enucleation, 459 
 
 internal tarsorrhaphy, 222 
 operation for pterygium, 340 
 
 for symblepharon, 323 
 scalpel, 62 
 suture, 252 
 tenotomy, 162 
 Von Graefe's ectropion, lower lid, 
 
 290 
 
 entropion, lower lid, 275 
 extraction, 584 
 Faden-operation, 170 
 iridectomy for glaucoma, 427, 
 
 443-445 
 operation for ptosis, 229 
 
 for spastic entropion, 254 
 tenotomy, 161 
 knife, 64, 583-584 
 
 in iridectomy, 427, 443-445, 
 
 584 
 operation for senile entropion, 
 
 2 75 
 
 Von Hippie's corneal transplanta- 
 tion, 395 
 trephine, 395 
 
 W 
 
 Waldhauer's operation for entro- 
 pion, ^ 51) 
 Walther's operation for entropion, 
 
 259 
 Warlomont's lid clamp, 99 
 
 enucleation scissors, 470 
 Weber's advancement, 68 
 
 canaliculus knife, 64 
 
 cataract knife, 587 
 
 incision for extraction, 587 
 
 wire loop, 77 
 
 \\Vcker. (See De Wccker.) 
 Weeks' operation for total sym- 
 blepharon, 334-335 
 Wliarton-Jones operation for ectro- 
 pion, 290 
 Wilder's chalazion clamp, 99 
 
 double knife, 267 
 
 operation for ptosis, 232 
 
 paraffined plates, 335 
 Wire loop, 76 
 
 \\Vhfr 's, 77 
 
 Snellen's, 77
 
 674 INDEX. 
 
 Withdrawing iris in iridectomy, Wound of lens capsule, in excision of 
 
 446 iris, 455 
 
 Wolfe graft in ectropion, 305, 310 scleral, treatment of, 410 
 
 preparation of, 312 
 
 Worth's method of advancement, 
 
 177 Z 
 
 Wound, gaping of, in cataract ex- Zirm's keratoplasty, 396 
 
 traction, 515 Zonule, rupture of, 455
 
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