the junction of the sclera and cornea, and the handle elevated a little, so as to start the cut without any sawing motion, such as is usually advised, but which we wholly disapprove of. If, now, too much tension be not given CATARACT. 123 the muscles of the hand, an easy and middling rapid sweep, combined with a slight elevation and circular movement in withdrawing the hand, will carry the blade through the tissues and out at the desired point. In this way the jagged edges of the wound, almost inevitably connected with any sawing movement, are obviated; there is less escape of aqueous, less gaping of the wound for entrance of septic material, and, lastly, the edges of the wound are more regularly apposite for perfection of subsequent healing. If the novice find that he is about to make a sclerotomy in this way, he must not stop and "saw," but carry out the sweep, as the bridge of unsevered tissue can be better separated by the iris scissors afterward than by the knife at the time. The iridectomy forceps are now entered, closed, and advanced till their points are opposite the pupillary edge of the iris, when the forceps are allowed to open and enclose a portion of the iris, no larger than is required to secure a firm hold upon a fold grasped at the pupillary margin. This is drawn out of the lips of the wound and slightly advanced till it is rendered taut; the lower blade of the iris scissors is now gently slipped into the lips of the wound, below the iris fold, and held horizontally and firmly in place, while the upper blade is made to descend and sever the iris fold close to its ciliary attachment. The cystotome, having been bent to suit the conformation of the parts, is now inserted and the capsule thoroughly ruptured by several incisions upon each side of a quadrilateral whose corners reach the extreme point of the iris retraction producible by atropia. A rubber spatula or spoon is now pressed against the lower edge of the cornea in such a manner as to tilt the upper edge of the lens forward, and a gentle upward teasing force is exerted, slowly and patiently, till the edge of the lens appears. At this point pressure must be slightly lessened, to avoid any loss of vitreous, and the lens coaxed out with delicate manipulation and the least force possible. We must now clear the edges of the wound, make a sharp scrutiny for cortical and capsular shreds and remains, either in the wound or in the anterior chamber. Blood in the anterior chamber is not, as a rule, productive of bad results, being generally absorbed within 24 hours. It is, however, well to clear out what hemorrhage we can by gentle stroking and pressure from below upward upon the cornea. The greatest care is now required to replace the iris and see that none of its filaments are caught in the wound. Instillations of atropia are made and the dressings applied. These consist of oval pieces of patent lint, 11⁄2 inches in long diameter, lightly covered with simple vaseline and laid on both lids. Over these a large piece of the dry lint is laid, extending on to the forehead and cheeks, with a central vertical slit in it, to leave the nose free. The hollows of the eyes are filled, to a level with the nose, with loose al sorbent cotton, and a black knit bandage, with two tapes at each end (those at one end much longer than the others), is lightly tied over the whole. The patient may be kept in a dark room,* and not be allowed to rise or exert himself in any way for 24 hours. To insure rest, one grain of powdered opium may be given upon the evening following the operation. The preliminary treatment should be continued during convalescence till a very faint mercurial odor is detected in the breath. Atropine may be suspended the third day, if no iritis has followed the operation. In 24 hours after the operation the patient may sit up for a time, the room being moderately lighted. The bandage must not be permanently removed for from 7 to 10 days, and the eyes accustomed to the light only gradually. The first dressing after the operation is to be made in 24 hours; the old dressings having been carefully removed, the lids and surrounding parts are gently sponged and washed with warm water and F. 1. New dressings, just like the first, are prepared, atropine dropped into the eye, and both eyes bandaged as before. This should be repeated till the bandage is left off entirely, its place being supplied by colored spectacles. In about 20 days the patient may be fitted with proper spectacles. Contingencies and Accidents. If the vitreous should break forth before the delivery of the lens, the latter will not be delivered by pressure. A Critchett scoop must at once be deftly inserted behind the lens, which is drawn out by its aid. If there be a small escape of vitreous after the lens, it should be seized by the iris forceps and cut off with the scissors. No serious result follows the loss of a small portion of vitreous. It may happen that the lens is unusually large, or the wound have been made too small, so that the moderate pressure which is alone admissible will only bring the lens to the edge of the wound. In such a case the wound must be enlarged by a slight cut with the scissors, made in continuance of its general direction. Should the eye, instead of healing, be found to suppurate, mercurial inunctions of the temples are to be freely and thoroughly made, 4 to 8 leeches applied, and hot fomentations frequently given the eye and surrounding parts. If these measures do not arrest the suppurative process, the only * Dr. Michel, of St. Louis, and Dr. Chisolm, of Baltimore, have dispensed with all bandages, compresses and dark rooms in the after-treatment of cataract and iridectomy operations, and express themselves highly pleased with the results. A strip of isinglass plaster is placed over the lids, the patient, from the first, being kept in an ordinarily lighted room. (See Am. Journ. Med. Sci., Jan., 1887). This, the so-called, “rational treatment," certainly deserves careful consideration at the hands of the profession. CATARACT. hopeful treatment is of a heroic nature. 125 The wound should be com pletely opened, the anterior chamber thoroughly syringed and washed with F. 1, and the conjunctival folds treated in the same way. This is to be repeated several times, or till the suppuration cease. If the process continue persistently, the galvano-cautery of the whole of the corneal wound is the only remaining hope of saving the eye from panophthalmitis. If iritis supervene during the otherwise normal recovery of the eye, it must be treated as an ordinary attack. The Linear Extraction, which v. Graefe modified into the now most generally accepted "Modified Linear," is suitable only for soft cataracts, for those below the age of 30. It was a small keratome incision within the corneal margin, through which the lens pulp was squeezed. It has been supplanted by the more commendable Suction Operation.—An incision is made through the cornea with a broad-pointed needle, at about the same location as in discission. The lens capsule is freely lacerated with the broad needle, and the nozzle of a Teale or Bowman syringe passed through the opening and slightly dipped into the lens matter. The suction should be gentle and slow, care being taken not to rupture the posterior capsule or injure the iris. Modifications, etc.-The Flap Extraction was the usual one until v. Graefe introduced the Modified Linear. The Flap Extraction was made by a Beer knife, either above or below, generally the latter, the puncture being in this case at the corneal margin and slightly below the centre. The counter-puncture was directly opposite. This large flap of cornea which, even not severed, is nourished with great difficulty, led to such frequent suppuration that von Graefe was led to devise the operation above described. Various modifications in the details have not led to any widelyaccepted deviation from the principal, which was that of a straight or linear wound instead of a flap, and its location in the sclerotic, with an iridectomy. Critchett made the puncture and counter-puncture 1 mm. from the corneal edge and 3 mm, below its upper tangent, the knife emerging still in the sclerotic but yet close to the corneo-scleral junction. De Wecker's cut was at the junction and 3 mm. deep. Others have proposed or practiced a corneal section in the v. Graefe manner, either upward or downward, with and without an iridectomy. The advantage of not performing an iridectomy is the resultant normality of the pupil and iris; the disadvantage is, that the iris is often so wounded by the passage of the lens that iritis follows, or that the iris becomes incarcerated in the wound and leads to irido-cyclitis, etc. Pagenstecher extracts the lens in its capsule, thus obviating the possibility of the extremely troublesome sequel of recurrent capsular cataract. He accomplishes this by means of a large incision in the sclerotic, I mm. from the cornea, and after an iridectomy a scoop is introduced behind the lens, drawing out the lens and capsule en masse. Macnamara extracts the lens in its capsule, without an iridectomy, through a corneal keratome incision and by the use of a scoop. Though this is the ideal of all operations—i.e., the safe extraction of lens and capsule without iridectomy-no other surgeons have adopted Macnamara's method, either from the extreme delicacy it requires or from the even extremer danger attending it. Recurrent Capsular Cataract.-No operation should be undertaken until long after all signs of irritation from the previous one have disappeared. An incision is made with a keratome at the corneal margin, and a delicate hook is inserted, with which the capsule shreds are extracted. The aid of long, fragile iris forceps may be required. If it is desired only to displace shreds or break away a clear space, a discission needle may effect this, entered as in the discission operation. A second needle, entering from the opposite side, is found very effectual for this purpose. Sometimes with the hook the capsule easily gives way at its peripheral attachment, and with deft manipulation may all be brought away in a mass, without any injury to the ciliary body or iris. But the extremest care and lightness of touch are necessary. Enucleation of the Eyeball.—The patient is under the influence of ether, the eyelids held widely apart by the speculum, and a fold of conjunctiva is seized by strong fixation forceps in the left hand, and opened by a snip of the strabismus scissors. The conjunctiva is then cut close to the cornea and completely around the same, after which the tendon (if of the right eye, the internal rectus; if of the left, the external) is seized by the fixation forceps and close to its insertion. A stroke of the scissors severs the tendon to the right of the forceps, which continue their hold and steady the globe, while the other tendons of the eye are divided close to the globe. The superior oblique and superior rectus are severed at one clip, next the two inferior muscles, likewise at one stroke; the globe is then rotated toward the nose, so as to bow the optic nerve outward, and for severing this last a strong grip of the hand upon the scissors is required. (It will be remembered that this division should be made as far back toward the orbital apex as possible in cases of glioma of the retina.) The forceps are now dropped, the globe itself seized with the fingers, and, having forced the same out of the socket, the remaining tendon is quickly cut, |