COCAINE 
IN 
OPHTHALMIC MEDICINE AND SURGERY. 
BY 
HENRY W. WILLIAMS; A. M., M. D„ 
PROFESSOR OF OPHTHALMOLOGY IN HARVARD UNIVERSITY; EX-PRESI- 
DENT OF THE AMERICAN OPHTHALMOLOG1CAL SOCIETY; VICE- 
PRESIDENT OF THE INTERNATIONAL OPHTHALMOLOGICAL 
CONGRESS, LONDON, 1872; MEMBER OF THE HEIOELBER- 
GER OPHTHALMOLOGISCHE GESELLSCHAFT; 
FOREIGN HONORARY FELLOW OF THE 
EDINBURGH MEDICO-CHIRURGICAL 
SOCIETY; EX-PRESIDENT OF 
THE MASSACHUSETTS 
MEDICAL SOCIETY. 
BOSTON 
CUPPLES, UPHAM & CO 
©lb donut bookstore 
283 Washington Street 
1887 COCAINE 
IN 
OPHTHALMIC MEDICINE AND SURGERY. 
SIMPLE CATARACT EXTRACTION. 
EXENTERATION OF THE EYEBALL 
THESE PAPERS HAVE LATELY APPEARED IN AN APPENDIX TO THE 
SECOND EDITION OF THE AUTHOR’S WORK ON THE DIAG- 
NOSIS AND TREATMENT OF THE DISEASES OF THE 
EYE; WHICPI EXPLAINS THE REFERENCE 
NOW AND THEN MADE IN THIS REPRINT 
TO CERTAIN PAGES OF THAT WORK. WORKS BY H. W. WILLIAMS, M.D. 
Recent Advances in Ophthalmic Science. One 
vol. i2mo. Paper $0.50 
Cloth . . . . 1.00 
The Diagnosis and Treatment of Diseases of 
the Eye. With illustrations and Ophthal- 
moscopic Plates. Second edition, 1887. One 
vol. 8vo 4.00 
A Practical Guide to the Study of the Diseases 
of the Eye: Their Medical and Surgi- 
cal Treatment. With Illustrations and 
Plates. One vol. i2mo. Cloth 3.00 
CUPPLES, UPHAM & COMPANY, 
PUBLISHERS, 
BOSTON. APPENDIX. 
COCAINE IN OPHTHALMIC MEDICINE AND SURGERY. 
On the 15th of September, 1884, at the annual con- 
gress of the Ileidelberger Ophthalmologische Gesellschaft, 
and on the 17th of October of that year, at the meeting of 
the Medical Society of Vienna, Dr. K. Koller, of Vienna, 
announced that, knowing the fact, observed by Schroff in 
1862, that the application of cocaine, prepared from the 
leaves of Erythroxylon Coca, a Peruvian plant, caused 
insensibility of the tip of the tongue and of the throat, he 
had been led to inquire as to the effects of this substance 
on other mucous membranes, and to experiment with it 
upon the eyes of animals, and afterwards upon those of 
himself and his friends. The result of these researches 
had been the discovery that a drop or two of a 2 per 
■cent, solution of the chlorhydrate of cocaine, applied 
inside the lids or upon the eyeball, caused complete and 
nearly instantaneous anaesthesia of the conjunctiva and 
the cornea; so that either of these could be touched or 
incised without exciting consciousness of pain in the animal 
or person experimented on. These assertions were made 
good by operations done in presence of the assembly. 
It is needless to say that the medical profession of the 
civilized world were soon actively engaged in testing for 
themselves the merits of the analgesic agent, for which so 
much was claimed; and they were not disappointed. 
Dr. Roller’s own account of this inestimable discovery, 
only second in importance to the demonstration of the 
455 456 
APPENDIX. 
general anaesthetic powers of sulphuric ether, first made- 
in this city in 1846, affords a brilliant example of wise 
conception, patient and careful investigation, and judicious 
estimation of the value of observed phenomena. I give a 
brief translation, as follows: — 
“ After a drop or two of the 2 per cent, cocaine solution 
had been introduced within the eyelids, the animal closed 
the lids for an instant, evidently feeling slight irritation. 
In from half a minute to a minute the lids were re-openedy 
and the eye had a fixed expression. If the cornea was then 
touched, without touching the eyelashes, the lids did not 
close, the globe remained unmoved, and the animal did not 
shrink. The strongest irritation of the cornea, by scratch- 
ing or pricking with pins, or by cauterization of its surface, 
evidently caused no sensation whatever. Where previous 
inflammation of the cornea had been induced, the anaesthe- 
sia produced by the solution was as complete as in a 
healthy cornea. This lack of sensation continued, on the 
average, ten minutes. 
“ In experimenting on myself and friends, the following 
phenomena have been observed. After instillation of the 
solution upon the cornea, or in the conjunctival fold, there 
was a sensation of warmth, accompanied by a copious 
secretion of tears, succeeded in half a minute by a feeling 
of dryness. The lids were more than usually open, giving 
a slightly staring expression to the eye. There was an 
absolute absence of sensation or of reflex action when the 
cornea was touched ; the same was the case with the con- 
junctiva, which, moreover, could no longer note differences 
of temperature. This complete insensitiveness continued, 
from seven to ten minutes; with a gradual return after 
this time to the normal condition. Fifteen or twenty 
minutes after the instillation, the pupil began to dilate, 
the greatest size being reached within an hour, and the en- 
largement entirely disappearing a few hours later. This 
dilatation was never ad maximum; and the pupil con- APPENDIX. 
457 
tinued to react to the influence of light and to efforts of 
convergence of the eyes; so that there was at no time the 
dimness of vision for small objects which attends mydriasis 
resulting from the use of atropia; but merely a paresis of 
the accommodation. I furthermore observed a marked 
anaemia of the conjunctiva, especially in its palpebral 
portion. In no case did the cocaine give rise to other 
symptoms of irritation. The wide opening of the lids, 
supervening at the same time with the anaesthesia of the 
cornea and conjunctiva, I attribute to the absence of that 
sensitiveness which, in the normal state, determines the 
closing of the lids to a certain point. If, after the disap- 
pearance of this first anaesthesia, the instillations of cocaine 
are repeated, a cumulative effect is to some extent gained, 
and the duration of complete insensibility may be doubled. 
There is no doubt of the penetration of the cocaine, by 
slow absorption, to the interior parts of the eye ; as after 
instilling a 5 per cent, solution once in five minutes for 
half an hour, I found the sensitiveness of these parts to 
strong pressure greatly diminished.” 
“I have used a 2 per cent, solution upon a large 
number of patients affected with conjunctivitis, and with 
eruptions and ulcers of the cornea. Within a few minutes 
they have invariably experienced a notable amelioration of 
their subjective symptoms, the pains were relieved, and the 
photophobia had greatly lessened. This improvement 
continued for two or three hours. There is every reason 
to believe, though as yet I have not had opportunity to 
verify this, that a repeated application of the remedy at 
the proper intervals would permanently relieve, or, at least, 
greatly diminish, the symptoms. I have had the same 
success in painful erosion of the limbus cornese. Even in 
the extreme pain accompanying inflammation of the iris, I 
think the efficacy of cocaine can be relied on; for the 
extension of its effect to the iris and the ciliary body 
appears to me to be demonstrated. Its contractile action 458 
APPENDIX. 
upon the blood-vessels may well have a favorable influence 
on morbid processes in the iris. Perhaps in combination 
with atropia it may have a great effect in this disease.” 
“If cocaine is applied previous to the use of stimulating 
or caustic remedies upon the inner surface of the eyelids, 
the severe pain otherwise caused is either unfelt or is 
rendered very slight; — although in some patients the pain 
declares itself at such time afterwards as the analgesic 
influence begins to subside; but this pain quickly ceases if 
renewed instillations of the cocaine are made.” 
As regards its efficiency as a local anaesthetic in ophthal- 
mic surgery, the observations of Dr Roller, necessarily 
limited in number at the time of his announcement, are no 
less accurate and satisfactory. He says: “ Cocaine finds a 
special adaptation in the extraction of foreign bodies from 
the surface or the substance of the cornea. After one or 
two applications of a 2 per cent, solution, the patient is no 
longer conscious of the presence of a foreign body; and 
while this is being removed he is able to hold the eyeball 
perfectly still; declaring that he feels nothing. Operations 
for the removal of staphyloma upon two children, and 
operations for cataract with iridectomy were done nearly 
painlessly after the use of a 5 per cent, solution of cocaine 
every five minutes for half an hour.” 
Thus had the problem been definitely solved by Dr. 
Roller; — and his results are amply confirmed by the 
researches of others. There is yet discussion among au- 
thorities as to some matters of detail; and still further 
observation is needed as to the extent of application and 
the safety of this new agent. Though this, like most other 
usually harmless therapeutic means, may possibly be harm- 
ful if ignorantly applied; the alleged critical symptoms 
which have been imputed to its use, in a few instances 
among many thousands of cases in which cocaine has been 
employed, may be explained by the still imperfect knowl- 
edge of the qualities of this tranquillizing means so recently APPENDIX. 
459 
bestowed upon us : and, while they should teach us caution, 
they by no means forbid its free but prudent use. The 
local or general accidents which have been attributed to 
cocaine have been: superficial cloudiness or desquamation 
of the cornea; vertigo or other cerebral symptoms, occur- 
ring in aged or enfeebled persons ; and panophthalmitis. In 
nearly if not all of the reported cases, solutions of 4 or 
5 per cent, have been used. It is quite possible that the 
high price and scarcity of cocaine preparations soon after 
the first sudden and enormous demand for them, may have 
led to accidental or intentional adulterations having irritat- 
ing qualities; or the lack of freshness of some solutions, or 
their needlessly repeated application, may have affected the 
cornea in a few instances. 
Vertigo or other temporary cerebral disturbances were 
by no means unknown in timid, aged, or feeble persons, 
during the performance of cataract extraction, with or with- 
out etherization; before the advent of cocaine. Acting as 
this apparently does only on the terminal nervous fibres, it 
seems unlikely that it should give rise to ophthalmitis; the 
origin of which it would be perhaps more rational to refer 
either to an epidemic ophthalmitis after operation, such as 
had frequently been observed before the introduction of 
cocaine ; or, possibly, in one hospital where a number of 
cases occurred whilst other institutions in the same city 
were exempt, to the use of hygroscopic gelatine discs con- 
taining cocaine, — which might have been a nidus of germs ; 
or, in the case of another practitioner, to staleness of the 
solution employed, — this gentleman experiencing no fur- 
ther mishaps after he substituted fresh solutions, although 
he used those of 8 per cent. I have many times made use 
of 4 per cent, or sometimes stronger solutions of cocaine; 
yet, neither in my own practice nor within my personal 
knowledge, have I ever known harm to result from so 
doing; although, as a rule, I now prefer a 2 per cent, 
solution, as being sufficiently effective. We know, how- 460 
APPENDIX. 
ever, that solutions of 20 or 25 or more per cent, are 
made use of by laryngologists and dentists; and sub- 
cutaneously, sometimes in considerable quantity, by sur- 
geons ; and we may feel reasonably safe in applying a 
very weak solution to the eye ; knowing as we do how very 
many times this has been done without detriment. It is a 
boon for ophthalmic surgery that general anaesthesia may 
now be nearly always dispensed with for those operations 
which require the most delicacy of manipulation; — except, 
of course, in children or very nervous persons, who would 
be intractable even if they felt no pain. Warlomont says : 
“ With rare exceptions, general anaesthesia is destined to be 
disused for operations on the globe of the eye; — and 
scarcely any operation should be done without cocaine.” 
Klein, of Vienna, in his work published in 1886, says: “ Nar- 
cosis is now become unnecessary in cataract operations; 
as with cocaine they are done almost painlessly.” It is 
indeed a great thing that a patient can now submit himself 
to an operation without trembling with fear. 
The absolute tranquillity of the eye, and of the patient, 
obtained by the use of cocaine, adds greatly to the safety 
of operations for extraction of cataract; as there is no 
reflex muscular contraction, and no subsequent nausea and 
vomiting, to extrude the iris or expel a portion of the 
vitreous; and none of the involuntary movements of the 
globe and the lids during the period of recovery from un- 
consciousness, to cause loss of vitreous, hernia iridis, or 
displacement of the edges of the corneal wound. 
It seems to be now generally conceded that for simple 
cataract extraction, where iridectomy is not done, one or 
two or three instillations upon the cornea, at intervals of 
three minutes, of a 2 per cent, solution of chlorhydrate 
of cocaine, are enough to induce sufficient anaesthesia. 
The eye and lids have become unconscious of the use of 
the elevator for the lids, of the corneal incision, and of the 
exit of the lens. After the operation, before applying the APPENDIX. 
461 
•dressings, it is well to instil another drop or two of the so- 
lution ; so as to keep up for a while the anaesthetic influ- 
ence, and thus lessen the disposition to move the eye or the 
lids. 
For the painless performance of iridectomy, or for the 
-extraction of foreign bodies from the interior of the eye, by 
the magnet or otherwise, repeated applications of the solu- 
tion of cocaine should be made for some time before opera- 
ting, or a little should be instilled into the eye after the 
.section of the cornea has been made. In the removal of 
pterygium or other external growths, it may be requisite to 
repeat the cocaine as the operation is proceeded with. 
For strabismus operations, instillations should not only 
be made on the conjunctiva previous to its incision, but the 
solution should be injected beneath the conjunctiva, over 
the situation of the tendon, before cutting the latter. A 
similar course is advisable in the removal of chalazion or 
•other growths from the eyelids. Cysts of any size of the 
lid or orbit may call for subcutaneous injection. Staphy- 
lomata may be painlessly excised, with or without eviscera- 
tion of the contents of the globe, and sutures inserted to 
unite the edges of the wound, after several instillations of 
cocaine. Neurotomy or enucleation may be advanced 
through the first stages of the operation by applications of 
•the cocaine while the conjunctiva and tendons are divided; 
but, to prevent pain upon section of the optic and ciliary 
nerves, orbital injections of the solution would be needed; 
and as regards the absolute safety of these there appears to 
be some question. The subsequent suture of the divided 
conjunctiva can be made painlessly. Paracentesis of the 
•cornea, for the evacuation of hypopion or for other reasons, 
as well as excision of a prolapsus of the iris through a 
corneal perforation, call for the aid of cocaine, to secure 
immobility and abolish reflex action. 
Although the advantages obtained by the use of cocaine 
in eye operations are so many and so marked, it has a yet 462 
APPENDIX. 
broader field for its usefulness in the vastly larger number 
of persons who daily and hourly derive benefit from its use 
as a remedial agent in the numerous inflammatory affec- 
tions of the eye. In eyes which are suffering from extreme 
photophobia, or are irritated by the presence of a foreign 
body, or have received a severe traumatic injury, it facili- 
tates the necessary inspection of their condition. It may 
also be used, in a few cases, for opthalmoscopic inspection,, 
to effect a sufficient but transient dilatation of the pupil, 
without causing the continued annoyance following the use 
of atropia for this purpose. 
In the Annales d' Oculistiqiie, Avril, 1885, the Editor-in- 
chief, M. Warlomont, writes as follows: “Till now, en- 
deavors seem to have been made only to abolish pain and 
the reflex acts which depend upon it, by cocaine ; such, for 
instance, as the photophobia in cases of ulceration of the 
cornea. In our judgment, its ischsemic properties have been 
too much ignored. After the transient sensation of slight 
smarting, caused by the immediate action of the cocaine,, 
the eye feels a sensation of coolness, and the conjunctiva 
becomes paler than previously. This double action of the 
remedy might apparently be utilized in treatment of the 
congestive affections of the ocular membranes, the conjunc- 
tiva, iris, sclera, etc. 
“ The slightly mydriatic effects of the cocaine may be 
neutralized by combining eserine with it, in the proportion 
of one part eserine to twenty-five of cocaine. Morphia may 
be employed to increase or prolong its anaesthetic influ- 
ence.” 
In the number for January, 1886, referring to the above 
statement of opinion, he adds : “ To-day we have no longer 
any doubt on this subject. For months we have used on a 
large scale, with the greatest success, collyria containing 
equal parts of cocaine and morphine (five centigrammes of 
each) ; sometimes combining them, according to the cases, 
with eserine or atropine, in all affections of the eye accompa- APPENDIX. 
463 
nied by pain and hypermmia; keratitis, scleritis, iritis, cor- 
neal ulcer, injuries from foreign bodies, accidents consecu- 
tive to operations, etc., etc.; and, very important to men- 
tion, without having ever met with a single case where the 
cocaine has given rise to general symptoms, although we 
rarely inspect a sensitive eye without previously applying 
it. This, it must be admitted, is reassuring.” 
The keeping an injured or inflamed eye as free as possi- 
ble from movement is sometimes essential to its recovery. 
This is accomplished by the aid of cocaine, in allaying the 
irritation which excites spasmodic friction of the lids upon 
the affected surfaces. In abrasions of the cornea, often the 
source of agonizing pain, the symptoms are at once relieved 
by its use; and rapid healing of the excoriation is promoted 
by now and then instilling a drop of the solution. A 
foreign body implanted in the cornea or hidden beneath the 
lid can be removed with surprising facility from the utterly 
unconscious eye after a single instillation. Where gun- 
powder has been blown into the eye in large amount, its 
immediate removal is important; but this was formerly 
almost impossible without etherization. Recently, I saw a 
case where the entire epithelial layer of the cornea in one 
eye, and a large part of it in the other, was completely rid- 
dled by implanted grains of powder from a premature blast. 
Vision was abolished. This disorganized, totally black sur- 
face was painlessly removed by patient work, cocaine being 
instilled from time to time without a resort to general anaes- 
thesia. Good sight was recovered. 
Eserine or pilocarpine may be combined with the cocaine 
with much benefit in many cases of corneal ulceration, with 
photophobia; and such collyria are advantageous substitutes 
for the solutions of atropia so long indiscriminately used 
in these and other eye affections. The complete reparation 
of a deep corneal ulcer is not to be always immediately 
accomplished; but the urgent symptoms of pain and intol- 
erance of light are usually at once mitigated, and the heal- 464 
APPENDIX. 
ing process is hastened by these calmative applications, 
used more or less frequently, as required. 
Phlyctenular papulae, whether situated on the conjunc- 
tiva, or in a flattened herpetic form on the cornea, create 
much irritation, though rarely inducing serious results. 
Here, also, immediate mitigation and speedier cure can be 
attained by instillations of cocaine ; and although, where 
the raised and vascular spot is situated in the corneal 
epithelium, complete recovery may be delayed, no such 
anxiety need be felt as is caused by the existence of ulcera- 
tion. Klein regards cocaine useful, in these cases, not 
only in quieting pain and photophobia, but as exercising a 
contractile influence on the blood-vessels which have 
become developed on the cornea. 
In the various forms of conjunctivitis, catarrhal, phlyc- 
tenular, trachomatous, etc., cocaine lessens the vascularity, 
diminishes the morbid secretions, and relieves the photopho- 
bia and blepharospasm; thus mitigating the discomfort of 
the patient, reducing the risk of implication of the cornea, 
and shortening the disease. Of course, its use in all these 
inflammatory conditions is to be associated with suitable 
astringent or other remedies, in the form of collyria, used 
at home by the patient, or of various auxiliary mean?: 
applied by the physician himself. Where, as in the chronic 
forms of granular and trachomatous conjunctivitis, fre- 
quently repeated applications to the roughened lids of 
a crayon of copper sulphate or some other active astringent 
is requisite, cocaine not only assuages the pain following 
their use, but, by its quieting effect, lessens the flushing of 
the surfaces and the copious lachrymation; which symp- 
toms may persist for a considerable time where this is not 
used. The relief to the feelings of the surgeon, in knowing 
that he is no longer, as formerly, causing much pain in 
making these indispensable applications, is scarcely less 
than that of the patient. A drop or more of the 2 per cent, 
solution may be spirted upon the lids or the globe from a APPENDIX. 
465 
drop-tube; then, after waiting a minute or so, the upper 
lid may be everted much more readily after the' use of the 
sedative solution, and the crayon applied to its surface 
more or less lightly or extensively, according to the indica- 
tions from day to day in each case, and not in too routine a 
manner. It is well to make a second application of the 
cocaine after the touch with the crayon. In some in- 
stances, at the end of the period of usual duration of the 
anaesthetic action of the cocaine, or afterward, pain begins 
to be felt; but this is generally only moderate in degree. 
If needed, however, the patient or his friends should renew 
the instillations of cocaine from a dropper or a teaspoon, 
continuing these till relief is gained. So far as one can 
judge, in affections of so chronic a character and variable 
duration, I am satisfied that recoveries are more rapid than 
when no such mitigating appliances were at our com- 
mand. In treatment of obstructions of the lachrymal pas- 
sages, the pain caused by the passage of probes is obviously 
reduced by the previous injection of a few drops of cocaine 
solution through the punctum into the lachrymal sac. 
My experience in the application of cocaine to the 
treatment of iritis has been considerable and satisfactory. 
The intense pain accompanying attacks of this disease, 
aggravated at night, and often extending to the supra- 
orbital and temporal regions, is most disquieting to the 
sufferer, and frequently requires large and sometimes 
repeated doses of opiates to control the severity of its 
paroxysms. I have found instillations upon the eye of a 
2 per cent, solution of cocaine, once in five minutes, gener- 
ally sufficient for relief in from fifteen to thirty minutes. 
In a few cases, a 4 per cent, solution has been used, in order 
to obtain prompter action. As a rule, the suffering has 
been alleviated, and the patient could enjoy good sleep 
during the night; but sometimes a renewed access of pain 
required a repetition of the lethal applications. If, in some 
instances, the relief at once obtained, or gained by a second 466 
APPENDIX. 
resort to the instillations, is not sufficiently prompt or com- 
plete, opium or morphia may he employed as an adjuvant. 
Some of the cases I refer to have been persons of rheumatic 
diathesis, subject to frequently recurring attacks, of which 
I had often watched the course; and the judgment of these 
individuals, accustomed to note all the varying phases in 
the attacks of their disease, has coincided with my own 
observation as to the great relief obtained by the new plan 
of treatment, and the marked abbreviation of the attacks. 
Atropia should be applied, pro re nata, to maintain large 
dilatation of the pupil; its efficiency being seemingly in- 
creased, as is also that of opium or morphia, by the combi- 
nation with cocaine. Where sufficient solace can be 
obtained by the aid of cocaine alone without other narcot- 
ics, the patient escapes the disagreeable sequelae ensuing 
upon the administration of large opiates, which become so 
troublesome where their help is needed for several nights 
in succession. If even partial relief is obtained by its 
means, the patient is in so far a gainer in the lessening of 
the amount of anodynes which would otherwise be re- 
quired. 
Numerous other conditions will suggest themselves in 
which cocaine may fulfil its peaceful mission. One instance, 
in particular, seems most promising: its use as a local appli- 
cation for the relief of the agonizing pains occurring in 
herpes zoster frontalis; but, as this affection is rare, I have 
not, as yet, seen an instance of it since the addition of 
cocaine to our resources. APPENDIX. 
46T 
SIMPLE CATARACT EXTRACTION. 
An important matter, in respect to which a strong revul- 
sion of opinion has taken place within a short time, is the 
question as to the most advantageous procedure in oper- 
ating for senile cataract. 
From the time when Yon Grafe, in 1865, promulgated 
the linear peripheral scleral section, combined always with 
iridectomy, as being the most desirable method for extrac- 
tion of cataract, this plan continued to be accepted and fol- 
lowed, on his authority, until very recently almost unques- 
tioned by the great majority of operators. Some, however, 
including names of the highest distinction, — Sichel, Bow- 
man, Hasner, Desmarres, and others, — never adopted Yon 
Grafe’s idea; and, gradually, nearly all the most noted 
and experienced among his adherents adopted each his own 
modification of the method inculcated by him, either alter- 
ing the form or the extent of the incision, placing the sec- 
tion more or less in the cornea instead of wholly within the 
sclera, varying the amount of excision of the iris, etc., etc. 
Already, in 1879, Warlomont, in his Annales d'Oculis- 
tique, had predicted a return to the French method of ex- 
traction, as introduced by Daviel. “ There will soon be 
nothing remaining of the revolutionary linear method 
except the special form of the knife used in it; no more 
linear incisions; no more iridectomies.” My own opinion 
was expressed in this work in 1882, p. 278. In November, 
1882, Chavernac read a paper before the Societe de Chirur- 
gie de Paris, entitled Retour a la methode de Daviel pour 
Vextraction de la Cataracte, in which he gives an account of 
his experience, first, of four years with Daviel’s process, 
then of eight years with Von Grafe’s peripheral linear sec- 
tion with iridectomy, and, lastly, of another four years of 
practice, with much greater success, in resuming Daviel’s 
plan. In February, 1883, Galezowski published, in the 468 
APPENDIX. 
Fecueil d' Ophthalmologies a paper on Extraction de la Cata- 
racte sans excision de Viris, in which he gives his conclu- 
sions, based on an experience of 1022 cases: “1. Excision 
of the iris by no means prevents phlegmonous accidents; 2. 
It is often the cause of secondary cataract; 3. Scleral or 
sclero- corneal wounds are more perilous to the result of the 
operation than are wounds of the cornea.” He therefore 
returns to the method of Daviel, modifying this by making 
the flap extend only from 3 millimetres above the hori- 
zontal diameter of the cornea to 2 millimetres from the 
superior scleral border. He records seventy-four opera- 
tions thus performed without serious accident, and with 
a visual acuteness greater than in eyes where iridec- 
tomy had been done. Two years later, at the Congress of 
the SociSte Frangaise d' Ophthalmologies he reiterates the 
.same opinions, and says further that prolapsus of the iris or 
loss of vitreous during the operation was very rare ; and 
that astigmatism after recovery, if existing at all, was so 
slight as to be practically nil, instead of being frequent and 
considerable as when Yon Grafe’s operation was done. 
Panas, at the same meeting, and afterward, declared himself 
a strong partisan of extraction without iridectomy. In the 
Annales d? Oculistique, December, 1884, and August and 
December, 1885, De Wecker describes at length the advan- 
tages of his “ Simple Extraction,” done without iridectomy; 
the section including the upper third of the cornea, and 
conforming exactly to the limit of its transparent border. 
He refers to the frequency of sympathetic ophthalmia after 
Grafe’s peripheral scleral section, as a consequence of 
implication of the ciliary body in the cicatrix of the 
wound; as well as of destructive irido-choroiditis of the 
operated eye; — results wholly unknown previous to 
the introduction of Yon Grafe’s method. He regards 
excision of even a small portion of the iris as objectionable, 
since it involves danger of iridal or capsular adhesions to 
the inner face of the corneal wound, which is unlikely to APPENDIX. 
469 
occur where the sphinctar iriclis has been left intact. He 
considers a combination of eserine with cocaine as a 
security against prolapsus of the iris or capsular entangle- 
ment, and lays great stress upon antiseptic precautions 
against infection of the wound. 
Sir William Bowman, in a letter to De Wecker, July, 
1885, writes: “ I do not remember that I ever made a great 
point of the section for extraction of cataract being exactly 
one-third of the corneal margin, neither more nor less; 
but certainly that was what it amounted to in a large 
number of cases. The extent of the incision varied 
according to one’s conception of what the size and bulk, 
hardness or softness of the lens was likely to prove in the 
particular case, the principle being to make the incision 
quite large enough, but not needlessly large, to admit of the 
lens emerging without undue dragging, or the risk of 
having fragments of its margin broken off in its passage. 
I speak of extraction without iridectomy and without 
scoop. I myself generally preferred to have the incision 
run in near the corneal margin, but I was in the habit for 
many years of trying various methods, from extreme 
marginal to more or less far intra-corneal ones.” 
The importance of the questions involved justifies the 
details I have given of the recent change of opinion which 
has so suddenly, and as if by general consent, taken place 
with regard to cataract extraction. It was my privilege, a 
short time previous to the promulgation of Von Grafe’s 
method, to witness, and to amply appreciate, the operative 
dexterity of its illustrious author; but after a fair trial of 
his plan, it did not commend itself to my judgment. 
But as una voce poco fa, I have here cited the opinions of 
some, from among many unquestioned authorities, in 
favor of a mode of operation comprised in a section of the 
cornea of moderate extent, not conforming too rigorously to 
exact limits, but varied, as advised by Bowman, to suit the 
requirements of each case; — and done without mutilation 470 
APPENDIX. 
of the iris. It will be seen that there is substantial agree- 
ment among the authorities cited, as to the situation and 
the form of the corneal flap. The method of Lebrun,, 
described in this work, pp. 278-281, differs slightly from 
this in being rather more intra-corneal. The only criticism 
I have seen of it, however, is that there is a tendency to 
prolapsus of the iris or to the formation of adhesions between 
the pupillary margin of the iris and the scar of the corneal 
section. But adhesions of the outer marginal portions of 
the iris to the scar of Grafe’s peripheral linear section, are 
by no means rare. These marginal synechise, so near to 
the iridal angle and the ciliary region, are liable to induce 
subsequent dangerous symptoms, involving one or some- 
times both eyes; as proven by the numbers of cases of 
sympathetic ophthalmia cited by De Wecker, Nettleship, 
and other authorities. On the contrary, where there is 
anterior synechia of the pupillary margin of the iris, this is 
usually but slight, affects vision little if at all, and gives 
rise to no irritation of the eye. De Wecker says, on this 
point, Annales d’ Oculistique, August, 1885 : “ There is no 
comparison to be made between an inclusion of a peri- 
pheral portion of the iris in a section near its border, and 
an inclusion or adhesion to the scar of a section in the 
cornea proper and situated near the sphincter at the 
pupillary margin. Whilst in the first case we see extreme 
sensitiveness of the eye and especially of the ciliary region, 
followed by iritis or irido-clioroiditis which often results 
unfavorably; we observe, in cases of synechia of parts 
of the iris near the margin of the pupil in a corneal wound, 
only an absolutely tolerant state of the eye.” 
As an offset to the possible formation of anterior 
synechia, the median flap of Lebrun offers this advantage 
over a less intra-corneal section; of being so placed as to 
allow of easy exit of the lens, with little friction upon the 
iris during its escape, and with therefore less chance of 
separation of cortical portions from the mass of the lens, APPENDIX. 
471 
or of a loss of vitreous. But it is not to be forgotten that 
with the present means at our command in employing 
eserine and cocaine, the chance of the occurrence of prolap- 
sus, or the formation of synechise, is reduced to a minimum ; 
the sedative, cocaine, preventing reflex spasm of the ocular 
muscles, and the myotic, eserine, or pilocarpine, causing 
subsequent contraction of the pupil, and drawing the iris 
away from contact with the corneal wound. 
At a meeting of the Ophthalmological Society of Great 
Britain and Ireland, 15 October, 1885, Dr. McKeown of Bel- 
fast, read an account of a novel modus operandi deserving 
of mention; which consisted in the very gentle injection of 
a few drops of distilled water, at about the temperature of 
the body, by means of a small syringe, within the capsule 
of the crystalline, after the expulsion of the lens; to 
remove any transparent or opaque portions of cortical 
substance which may remain within the capsule, instead of 
removing these by massage of the cornea. Thirty-nine 
cases were reported with good results. Other experi- 
mentors seem to favor the procedure. As yet I have not 
found opportunity to make trial of this plan; but the 
removal of these sometimes tenacious, sticky masses, with- 
out prolonged friction manipulations upon the eyeball is a 
great desideratum, since they are a not infrequent cause of 
accident during efforts for their expulsion, or may give rise 
to troublesome symptoms if left in situ. 472 
APPENDIX. 
EXENTERATION OF THE EYEBALL. 
At the International Ophthalmological Congress, held at 
London, in 1872, a vote was proposed for adoption recom- 
mending the immediate enucleation of every which had 
been evidently hopelessly injured by an accident; as a safe- 
guard against sympathetic ophthalmia. This was not 
accepted by the congress; but the discussion served ta 
show that a certain number of its members favored the 
proposition, as they did also the ablation of eyeballs which 
had become disorganized by irido-choroiditis, separation of 
the retina, etc., provided morbid sensitiveness or injection 
of the ciliary region continued or occurred. As a result of 
this prevailing sentiment, diseased eyeballs were freely sac- 
rificed during the ensuing ten years; many of them by 
practitioners who dared not risk the responsibilities possi- 
bly involved in delay and an expectant treatment. In 
1876, Boucheron proposed division of the optic and ciliary 
nerves behind the eyeball as a substitute in many instances 
for removal of the globe. This procedure proved advanta- 
geous in numerous cases; and many reasonably sightly* 
although sightless eyeballs were thus preserved, to the 
great advantage of their wearers. On my last European 
visit, two years since, I soon perceived a change of practice 
in regard to the frequency of a resort to enucleation, which 
accorded with my own judgment, always rather conserva- 
tive in this matter. Two of the most distinguished opera- 
tors whose cliniques I visited, before knowing my own 
views, spoke of the comparative rarity with which they 
nowadays resorted to enucleation ; -one of the gentlemen 
saying that he did not now remove one eye where he for- 
merly would have removed six. 
In my first published work on Diseases of the Ejrn, in 
1862, I recommended laying open the globe, in cases of 
purulent ophthalmitis, and evacuation of its more solid con- 
tents, so as to permit its collapse, in hydrophthalmia and 
large staphyloma, as already advocated as a means of pre- APPENDIX. 
473 
venting sympathetic ophthalmia by Mackenzie, in 1854* 
Diseases of the Eye, p. 621. This practice of exenteration 
I have ever since followed, as described in the present vol- 
ume, pp. 71, 121, 179, 273, 295, 405; removing the ocular 
contents by means of a scoop, or a lid-elevator, or a sponge,, 
when these contents had become sloughy, and retaining a 
portion of these where it was only necessary to remedy 
abnormal enlargement, but where no great disorganization 
had taken place in the internal transparent media. With 
or without evisceration, the edges of the retained portion 
of the tunics of the eyeball were brought together by 
sutures. In cases where there was already inflammatory 
action, this gradually subsided; in other instances, almost 
immediate healing took place, and, even where the globe 
had been entirely evacuated, the scleral cavity seemed 
sometimes to refill, so that no very marked contraction took 
place, and artificial eyes were worn with more comfort and 
advantage than after enucleation. In no instance have any 
serious results followed; and the patients, whilst perfectly 
secured against sympathetic disease, have been spared the 
more serious mutilation, as well as the dangers, attending 
enucleation. 
In September, 1884, in a paper presented at the meeting 
of German Naturalists at Magdebourg, Prof. Alfred Grafe, 
after referring to the great number of fatalities from menin- 
gitis occurring as a consequence of enucleation of the globe, 
advised exenteration of the eye as a substitute in all cases, 
for the more serious operation; as offering an equally 
certain guaranty against sympathetic ophthalmia; whilst 
being a less important cosmetic loss to the patient, and 
creating a wound of less extent, separated by the interposed 
sclera from communication with the orbit and the cranial 
cavity; thus averting the dangers of fatal consequences 
which attend enucleation. These suggestions, in favor of 
the general adoption of a far milder substitute instead of a 
really grave operation, have met with general acceptance 
by the profession. THE BOSTON 
Medical & Surgical Journal 
A First-class Weekly Medical Newspaper. 
This Journal has now nearly reached its sixtieth year as a 
weekly Journal under its present title. 
Such a record makes superfluous the elaborate prospectus 
and profuse advertisements as to enormous circulation, etc., etc., 
required by younger aspirants for professional and public con- 
fidence. 
It is, however, no less incumbent upon this Journal than 
upon others to assure its patrons from time to time, as the oc- 
casion arises, of its desire, its ability, and its determination to 
meet all the requirements of the most active medical journalism 
of the day, without sacrificing any of that enviable reputation 
which is an inheritance from the past. 
It is under the editorial management of Dr. George B. Shat- 
tuck assisted by a large staff of competent coadjutors. 
Communications from all quarters of the country are accepta- 
ble. Liberal arrangements are made for reprints of original 
articles, and for such illustrations as serve to increase their 
value or interest. 
The word “Boston ” is retained in the title, as it was in the 
original name, but every occurrence of professional importance 
whether within or without the borders of New England, will re- 
ceive prompt and impartial notice. 
The circulation is large, and steadily increasing ; the sub- 
scription-list covering almost every nook and corner of the 
United States and Canada, and extending to foreign countries. 
All communications for the Editor, and all books for review, 
should be addressed to the Editor. 
Subscriptions and advertisements received by the undersigned, 
to whom remittances by mail should be sent by money-order, 
draft, or registered letter. 
Terms $5.00 a year, or $3.50 a half year, In advance. 
GUPPLES, UPHAM & CO., Publishers, 
283 Washington St., BOSTON.