RESUME 
Cataract Operations. 
A. W. CALHOUN, M.D., 
ATLANTA. GA., 
PIIOFESBOB OP DISEASES OF THE E\E AND EAB IN THE AXIASTA MKDICAI. Cor.EEGE. 
Extracted from the Atlanta Mescal and Surgical Jonmal. 
ATLANTA, GEORGIA: 
DUNLOP, WYNNE & CO., PRINTERS, 11 NORTH BROAD STREET. 
1874. . 
i i With the -compliments of the Author. 
REPORT 
OF 
TWENTY-SEVEN OPERATIONS FOR CATARACT, 
"With Remarks upon Some of the Modes of Operating. 
Bx A. W. CALHOUN, M.D., Atlanta, Ga., 
Professor of Diseases of the Eye and Ear in the Atlanta Medical College.- 
That something is needed to perfect the various operations 
for the relief of cataract, is evidenced by the multitude of sugges- 
tions coming from ophthalmologists in every country. Such a 
variety of opinions, arising in every direction and from the best 
of sources, indicates a restlessness amongst this class of surgeons, 
brought about, doubtless, by a need of some positive plan upon 
which we can always base a mode of operating. As a conse- 
quence of this, new operations are being constantly developed, 
exist but a brief period, and then cease to be heard of, except as 
mere matter of history. 
But from all this, some good is being derived; for, while many 
of the suggested operations, as a whole, may be discarded, some 
single ideas are often retained and adopted as modifications in 
the more general modes of operating, and are thus gradually ad- 
vancing us to that end we so much desire, viz: an operation which 
is complete in all its details, and affording the best possible 
chances to the patient. 
The operation known as Graefe’s is, by common consent, ac- 
knowledged to be the one best suited to certain forms of cataract; 
in other words, to the large majority of cases; but in reading the 
reports of cases, and in hearing surgeons speak of their opera- 
tions, we are struck with the fact that few, if any, adhere to 
Graefe’s original idea in full, but that very nearly all hold to it 
simply as a ground work, each deducting certain minutiae, and 
adding modifications peculiar to himself. 
Of the twenty-seven operations I have comparatively recently 
made, the extractions were not all performed after Graefe’s plan; 2 
but keeping the main principles in view, I have also added to or 
deducted certain things which appeared to me to be of use in the 
completion of the operation, and which in the main have served 
me quite well. 
Of the above number, six extractions were performed with 
Beer’s knife, and by making a large flap upwards; the other 
steps in the operation being just the same as in the linear ex- 
traction. The only difference, then, between the latter, or 
Graefe’s mode, and that practiced in the above cases, is that the 
broad knife was used, enabling me to make a larger wound for 
the exit of the lens, and also, at that time, being more readily 
used by myself than the long narrow knife used at present in 
performing the linear extraction. 
A few years ago, some of the most prominent oculists in this 
country, and even now several of the English surgeons, particu- 
larly at Moorefield’s Ophthalmic Hospital in Loudon, make use 
of this kind of a knife (Beer’s or Sichel’s) in preference to any 
other, it being more easily handled than the long knife of Graefe, 
and the extent of the wound being more accurately regulated. 
Oritchett, one of the most celebrated of London oculists, brings 
it into constant use. 
The recoveries of these six cases thus operated upon were 
perfect in every particular; the vision being, in each case, 
brought up to as near a normal standard as is usually the case 
after such an operation. The ages of five of them ranged from 
sixty to eighty-two years, but in each instance the recovery was 
not in the least hindered, although one or two of them were in 
feeble health. The sixth case was twenty-six years old, and had 
congenital lamellar cataract. Upon her the same plan of operat- 
ing was followed, she not being able or willing to undergo the 
more tedious operation of discission or laceration; and the result 
was that she now superintends her own business—that of farm- 
ing—and for a time even taught successfully a small school. 
In addition to this, there were twelve cases upon whom the 
linear extraction was performed, as near as practicable, in entire 
conformity with the idea of Graefe, using the narrow and slender 
knife now almost altogether used in making this operation. Of 
these, eight made rapid and good recoveries; vision being also 
restored to more than half the normal degree in each instance, 
and in several, to as near a natural state as could be hoped for. 
Amongst the remaining four, two had severe iritis to follow the 
CATARACT OPERATIONS. CATARACT OPERATIONS. 
operation, interfering materially for the time being with the com- 
plete success that was promised for several days, by the forma- 
tion of secondary cataract, an exudative membrane produced by 
the inflammatory process, and filling up the pupil to greater or 
less extent. One of these two has since regained tolerable vision, 
by the almost complete absorption of this membrane. The other 
requires only a simple needle operation to rupture the membrane, 
and thus permit of good vision here also. In one case, upon 
which twro other operations were performed, the double cataract 
was the result of severe irido-cyclitis in each eye, which existed 
in a chronic state at the time of the operation. It was necessary 
to make extensive iridectomies to relieve the complete posterior 
synechise, which were the causes of the violent pain and the con- 
tinuation of the inflammation, and at the same time both lenses 
were extracted. Although comparative success was promised 
(the patient being able to count fingers immediately after the 
operation), the old disease (irido-cyclitis) sprang up acutely after 
a few days, and continued, notwithstanding the most active treat- 
ment, till the pupils became totally occluded by a thick mem- 
brane, completely cutting off all entrance of light into the inte- 
rior of the eye. The prognosis of this case was so unfavorable 
that it was not deemed advisable to interfere further. 
So, then, to sum up the results of the twelve linear extrac- 
tions, eight came through with no undue inflammation and good 
vision; one had iritis, and as a consequence, a membrane, filling’ 
the pupillary space, but it ultimately disappeared by absorption, 
leaving still fair sight; another suffered similarly (from iritis), 
and the thickness of the membrane will require the use of the 
needle to break it up, when, in all probability, the vision will be 
as perfect as though no secondary inflammation had arisen to 
even temporarily obstruct it. The other case, upon whom the 
two operations were made, had an acute attack of the chronic 
affection (irido-cyclitis), destroying the slight vision that was 
gained immediately after the operation. 
It is well to remark, just here, that in this last ease the oper- 
ations were made not so much for the relief of the cataract 
(though at the time it was hoped that the extraction w’ould re- 
sult in some good), but more especially to relieve the synechia 
posterior and the chronically inflamed condition of the iris, and 
the consequent pain. The last, I hope and believe, I have suc- 
ceeded in fully overcoming. 4 
CATARACT OPERATIONS. 
Upon children, nine operations were made, and, as usual in 
young persons, the character of the cataract was soft, requiring 
the operation known as discission. In a few of the cases it was 
necessary to repeat the operation several times before complete 
absorption had taken place; while in others a few strokes of the 
needle seemed to dissipate the opacity, the lens substance having- 
become quite fluid (morgagnian cataract), needing only a rup- 
ture of the anterior capsule to allow it to flow out and become 
mixed with the aqueous humour. In each case the cataract was 
congenital; and their ages, at the time of the operation, were 
from five to thirteen years. As is well known, operations for 
complete congenital cataract are rarely markedly successful, from 
the simple fact that the sensibility of the retina is nearly always 
obtunded; that is, amblyopia to a greater or less degree exists, 
and increases more and more, the longer the cataract is allowed 
to remain. On this account it is advisable to operate upon chil- 
dren with congenital cataract as soon as their age and condition 
will allow it, so that the retina may be brought into early exer- 
cise, whereby alone it can be restored to its natural function. 
With the exception of one case, operated upon some time 
since, and still another now under treatment, all were materially 
benefited, and a few restored to a remarkable and unexpected 
degree of vision. Not a single case suffered from undue inflam- 
mation, but each grew rapidly well, being usually ready, when 
necessary, to have the operation repeated after two or three 
weeks. 
There are three, aged respectively five, nine and thirteen 
years, who, up to the time of their discharge, had so far improved 
as to bo able to go about, even in strange places, unaided and 
unattended—an impossibility prior to the operation. The flat- 
tering results, in two of these cases, I think I can in great meas- 
ure, attribute to the use of strychnine, beginning with the forti- 
eth of a grain (hypodermically) daily, and increasing the dose 
gradually to the fourth or fifth of a grain. The good effect of 
this medicine in atrophic conditions of the optic nerve has long 
since been well established, and the results of its iise in these 
two, as well as other cases, have been very satisfactory indeed. 
To recapitulate, of eighteen extractions, all were successful 
except two cases. One of these now needs only a rupture of the 
pupillary membrane, by means of the needle, to be restored to 
good vision. The other was originally a most unfavorable case CATARACT OPERATIONS. 
5 
(chronic irido-cyclitis, with secondary cataract), and it was at 
first only intended to make an iridectomy for the relief of pa n 
and other troublesome symptoms; but it was afterwards deter- 
mined to remove the diseased lens at the same time. The pain 
was relieved, but the extraction was of only temporary benefit. 
Of the nine discissions in children, with one exception all 
were restored to more or less vision. The one mentioned as an 
exception was benefited, but »ot to any great degree. It was a 
little girl of thirteen years, with ill-developed and constantly 
moving (nystagmus) balls and congenital cataract in both eyes. 
Another, upon whom I recently operated, is still under treat- 
ment, and wall probably need a repetition of the operation once 
or twice more before complete absorption takes place. 
The fact that a child with congenital cataract has tolerable 
perception of light, or can distinguish between the principal col- 
ors when held before it, is not always an evidence that success 
will follow an operation and vision be perfected. I have often 
seen just such cases, and have myself had one or two, where one 
unaccustomed to making these operations would naturally imag- 
ine that a simple removal of the lens would be productive of 
good sight. < Often, however, is vision not one particle benefited, 
the little patient seeing just as much, but not a whit more, after 
the absorption of the lens as before. The amblyopia, or impair- 
ment of the more sensitive elements of the retina, perhaps from 
non-use, has existed so long that the removal of the probably 
original trouble (the opacity of the lens) does not increase the 
vision. It is barely possible that in such cases, long continued 
active exercise of the retina, and the use of some powerful nerv- 
ous stimulant, as strychnine, will ultimately restore more or less 
vision. 
Amongst oculists, one of the greatest fears in all operations 
having the extraction of the lens in view, is the loss of vitreous 
humour, and in every, so-called, improved operation that is pa- 
raded before the profession, the promise to more effectually pre- 
vent such an escape of vitreous, is indulged in as an evidence of 
superiority in the new mode. 
My experience in witnessing and following up an immense 
number of extractions in most of the large hospitals of Europe, 
and in this country, and my own personal experience, lead 
me to believe that this fear is greatly exaggerated. Indeed, Has- 
ner, Professor of Ophthalmology in the University of Prague, 6 
CATARACT OPERATIONS. 
makes it a point after each extraction to rupture the posterior 
lenticular capsule, and allow the vitreous humour to flow into the 
anterior chamber, whereby more or less is invariably lost by be- 
ing washed out through the corneo-sclerotic wound at the mo- 
ment of rupture. His object is, by the bulging forward of the 
vitreous, to make a rent through the posterior capsule, and what- 
ever remnant of cortical substance of the lens may be remaining 
behind, thereby pi’eserving a clea* opening, even though second- 
ary cataract should supervene. 
Pagenstecher, Professor in Wiesbaden, makes a very success- 
ful operation for extraction of cataract, peculiar to himself, in 
which, in a very large majority of cases, a large quantity of the 
vitreous escapes. Nothing is done to prevent it, more than that 
ordinary caution is exercised. Not the least harm ever results 
from such an accident (as it is usually so considered), and the 
various steps of the operation are proceeded with in the usual 
manner, as though nothing had gone wrong. 
It is true that an escape of vitreous humour during an opera- 
tion is. not desired, for it interferes very much with the progress 
of the operation, unless it has already been brought nearly to an 
end, as is the case most frequently. 
Oftentimes have I seen the fourth or fifth, or even more, of 
all the vitreous escape without hindering, in the least, the perfect 
healing of the wound, and with as good vision as could possibly 
have otherwise been obtained. Loss of vitreous previous to the 
exit of the lens is indeed a serious complication; for each suc- 
cessive attempt to deliver the lens only tends to increase the out- 
flowing of vitreous humour. Such an accident is, however, of 
but rare occurrence. ’• Most frequently, the vitreous begins to 
rush out after the removal of the lens, it being then deprived of 
its support from the front, when a large quantity can be lost not 
only without any hinderance to the healing process and good 
vision, but I am inclined to the belief that it is an actual benefit, 
inasmuch as the tendency to serious inflammatisn is apparently 
much reduced after such an escape, provided the iris may have 
been freed from any pressure or traction, from being caught in 
the corneo-sclerotic wound as the vitreous flowed out, and 
washed the iris along with it. 
The operation of iridotomy, as performed by De Wecker, of 
Paris, mostly for the relief of secondary membranous cataract, 
can not unfrequently also be put to good use in certain cases as CATARACT OPERATIONS. 
7 
an auxiliary to the ordinary mode of extraction. For example, 
in those cases where cataract is secondary—that is, more partic- 
ularly the result of a chronic inflammation existing in the iris or 
iris and ciliary bodies—the iridectomy, or this, with the bruising 
of the iris incident to the passage of the lens, has a tendency to 
start the chronic inflammation afresh; as a consequence of which 
the iris substance swells and the edges of the iridectomy approach 
each other, oftentimes meeting and adhering, causing complete 
obliteration of the pupil, and the iris to appear as if no pupil 
had ever existed. Under such circumstances, the occlusion is 
not altogether caused by a membrane simply filling up the pupil- 
lary space, but by the edges both of the natural and artificial 
pupils being drawn together and thus uniting. Now, it has oc- 
curred to me to be of benefit, and I have put it into execution 
with success in a few cases, to combine the iridotomy in the lowTer 
portion of the iris, with the iridectomy in the upper portion, in 
those cases of extraction where, from long continued iritis or 
irido-cyclitis, the tendency is for the pupil to become entirely 
obliterated by the approach and union of the cut edges. By 
such a procedure, the iris is divided more or less into two halves, 
and the circular muscular fibres (the sphincter) are severed at 
two opposite points, thereby giving complete rest to each por- 
tion. Even though acute inflammation should then spring up 
out of the chronic, the contraction of the iris tissue would be 
inclined rather to draw the two halves away from each other; so 
that, notwithstanding the exudative deposit, enough clear space 
might be left between the cut edges of the iris to allow of tolera- 
ble vision. 
Of course, in ordinary uncomplicated cataract—in short, in 
any except such cases as just mentioned—an iridotomy is not to 
be thought of, as it would not only be unnecessary, but might be 
of injury; at all events, of great disadvantage. In simple cata- 
ract, the least done to the iris the better. 
Note.—Since the publication of the above Report of Cases in the Journal, 
I have made three additional operations, increasing the entire number to 
thirty. Each cataract was mature and in elderly persons. Graefe’s linear 
extraction was made in these cases, as being best suited to the nature and 
variety of the disease. Success has followed in each instance, but little in- 
flammation taking place as a consequence of the operation. The patients 
are able to come up to the requirements necessary in deciding the acuteness 
of vision and the success of an operation.