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"  Report and Remarks
^
FOURTH AND A FIFTH HUNDRED ,\
°1
J
ATTRACT EXTR
im"
r~\
-L 1U X
ACCORDING TO VON GRAEFE'S METHOD.
/
V
By H. KNAPP. M.D.
OF NEW YORK.
GEN?
Repris'jkd from the Archives of Ophthalmology and Otology, Vol. VI., Nos. I. and II.
       NEW YORK:
WILLIAM WOOD & COMPANY, PUBLISHERS,
      27 Grkat Jones Street.
         1S77. 
-<4k
/$7J 
 REPORT AND  REMARKS ON A FOURTH  AND A

   FIFTH HUNDRED CATARACT  EXTRACTIONS,
      ACCORDING TO  VON GRAEFE'S METHOD.


                 By H. KNAPP, of  Xeyv York.


   When  I published,  seven years  ago, the  report of a third
 hundred  cataract extractions by the peripheric linear section,
 that  method enjoyed an almost uncontested  favor on the part
 of eye surgeons.  But  as soon as its great originator closed his
 eyes, a recurrent—not  to  say reactionary—wave arose in dif-
 erent places.   The  adherents of the classical  flap  extraction,
 held  their field, and gained  ground.  Others made greater or
 smaller allowances  to the  flap method,  using Graefe's narrow
 knife,  making puncture and counterpuncture  in the  corneo-
 scleral juncture, but lower than Von Graefe did, thus forming a
 flap  of small  elevation. This variety I  saw  very extensivelv
 practised when I traveled in Europe in  1871.   A. Pagenstechcr
 continued to extract the lens together with the capsule.  Alfred
 Graefe followed the  method of his illustrious cousin, but with a
 lower section.  Adolph  Weber was verv sanguine of his method.
 Licbrcich performed  a more or less linear section, in the lower
segment of the cornea, sometimes with,  mostly without iridec-
tomv, the centre of the section  lying about  midway  between
the centre of  the cornea and its lower  margin.  Lc Brun  did
         1 
4
H. Knapp:  Cataract Extractions.
the same in the upper segment.   Two years ago, L. dc Wccker
published his " new method of cataract extraction—extraction
with  a peripheric  flap—"  (Paris, Gauthier-Villars,  1875, see
these Arch. IV. p.  465),  and his assistant,  Masselon, communi-
cated  the  results  of  179  operations done according  to  this
method.  (See these Archives, vol.  V. p.  239).   Wccker s peri-
pheric flap is situated in  the limbus conjunctivas, and comprises
one-third of the circumference of the limbus.  No iridectomy
is  performed.   Prolapsed  iris is pushed   back  with a blunt
spatula, and kept in position by the instillation of the alcaloid of
calabar bean, called eserine.
  Besides  these, there are  many unimportant deviations from
Graefe's method which I need not mention.
  Does the method of a great practical genius deserve to be so
soon abandoned, or is  this recurrent movement only the natural
reaction after too enthusiastic expectations ?  The discussion of
this question  can be taken  up by theoretical  reasoning, or by
statistical deductions, or by both  combinedly.  The latter is the
best way.  In this sense I shall endeavor to analyze the last two
hundred cases of extraction, which 1 have made  according to
V. Graefe's method.   I shall  begin with the statistical part, and
thus deduct from facts the influence, favorable or prejudicial,
which each factor  of  our problem exercises on the immediate
and final results.  In order  to make the deductions as objective
as possible, and divest them from my personal  views,  I shall
present condensed  histories of the cases in a tabulated form, ex-
tracted from the extensive records kept by the resident assistant
surgeons of  the  N. Y. Ophthalmic and Aural Institute.  The
cases are not, in any way, selected ; but represent all that I have
operated on according to Graefe's method, from April, 1869, to
June, 1876, with the exception of a few cases in  which detach-
ment of the  retina was present  and diagnosticated before the
operation.   Detachment of the retina is commonly considered
a contra-indication to  any operation for cataract.  Yet, if there
is only one eye left, and this suffers frcm  cataract  and absence
of the upper half of the field of  vision, the operation, it seems
to me, is justifiable, and in some cases on which I have operated, 
H. Knapp: Cataract Extractions.
5
the patients were so  much benefited that  for some  years they
were enabled  to see  their way  in walking.  The 200 cases  of
extraction  here compiled  are not the only ones  which I  per-
formed in the  space of seven years.  Several times I  abandoned
Graefe's  method and tried another.  This was, however, not
done in such a way that the promising cases were given to the
new method,  and the unpromising to  Graefe's, but  when I de-
termined to test the  value of a new method,  I tried it on all
cases that came under my  care.   Though the results I obtained
by Graefe's method in America fall short of what I obtained by
it in Heidelberg, I still adhere to it as the method which yielded
me better results than any other I have tried. 
6
H. Knapp :  Cataract Extractions.
^
J. M.	70
Heb.	
N. Y.	
City.	
 De-
crepit
 and
 ner-
 vous
 man.
 G. M.
 Ger.
 Egg
H'rbor
 N. Y.
66
 D. B.
 Ger.
Pough-
 keep-
  sie,
 N. Y.
60
 Mrs.  154.
H.  Cr.
 Am.
 Heb-
 ron,
 N. Y.
 F. H.
 Ger.
Union
Sp'ngs
 Ala.
5°
Hard.
Ripe.
	*>i
Condition of Eye.	\\
	^
Hard.
Ripe.
Hard.
Ripe.
Hyper-
mature
Hyper-
mature
Execution

Optration.
Incidents of
 Operation.
April.
1869.
June,
i860.
 Peri-    No anaesthe-
 pheric  sia.    Escape
section, of vitreous by
        spasmodic
        closure of lids
        during  pres-
        sure  on  cor-
        nea. Lens ex-
        tracted  with
        large   spoon
        easily  and to-
        tally.
May,
  Cortex and
blood remain-
ed in anterior
chamber.
Sept.
 Anterior
 capsule
 removed
with cys-
totomy 
H. Knapp:  Cataract Extractions.
7
Course of Healing Process
 and After- Treatment.
                       DAYS
  Very painful hyalitis,\  35
cyclitis and iritis, with
closure of pupil.  From
the fifth  to  the  tenth
day -I- Ti.    After six
weeks eye quiet.  Ti.
Treatment    internal:
sedative ;  local :  atro-
pine and leeches.
After- Operations
s
REMARKS.
  The loss of  the
eye was caused by
the   introduction
of a  large  spoon.
A ncesthesia  might
have cbviated  the
loss  of   vitreous,
and saved the eye.
Patient  died  18
months after oper-
ation   of  general
debilitv.
  Hurt eye eleven days
after operation. Wound
reopened,   but  closed
again in two days.   Dis-
charged with  consider-
able cortex  in  anterior
chamber.   Free   from
irritation.
10
20 0
JUL.
100
20.
SO
  Wound spontaneous-
ly (?) reopened on  3d
day, but closed the fol-
lowing night.
M
20
70 
H. Knapp :
Cataract Extractions.
No. of Case. Name, ATativity, Residence.		60	General Condition.	Quality of Cataract.	Condition of Eye.	Time of Operation.	Execution °f. Operation.	Incidents of Operation.
6	Mrs. M. Am. B'klyn		Hard.					Section small. Con-siderable rub-bing to expel the remnants of tenacious corticalis.
7	A. M. 1581 Ner-Heb. ! vous, N. Y. timid City. ; man.			Hard.	Externally nothing unusual. Highly myopic.	Oct. 1869.		Blood after section, quickly coag-ulating, made other steps of operation dif-ficult. No ac-cident. Chlo-roform.
8	Mrs. .63 T. St. Heb. N. Y. City.			Hard.				
9	Mrs. M. C. Irish. N. Y. City.	62		Hard. Ripe.		Nov. 1869.	Usual Graefe's section ; apex touching corneal margin.	•
IO	Dr. W. Am. N. Ca.	67		Hard.	Eye deep-seated.	Nov. 1869.		
 
H. Knapp : Cataract Extractions.            .     9
Course of Healing Process
   and After- Treatment.
^*
^ .'

After- Operation.
                      |DAYS
  Ring-abscess.   Pan-  17
ophthalmitis.   Phthisis'
bulbi.
16
 20
T5 0"
REMARKS.
  The  loss is at-
tributed  to   the
bruising  of   the
small wound  dur-
ing  extrusion   of
lens  and cortex.
20
y3-^   Extensive scle-
    ro-choroiditis and
    rarefaction of chor-
    oid.   Other  eye
    had unsuccessfully
      been  operated
    on  two  years pre-
    viously.
  Died two  years
later.
   Suppuration  began
at  inner   corner  of
wound  in cornea  and
iris.     Unsuccessfully
treated  by warm appli-
cations   and  paracen-
tesis  of ant.  chamber
by    reopening    the
wound.   Flat leucoma.
14
^Vo    The  centerj ^/V I   The optical con-
    of a thin sec-!     ditions  being  ex-
ondary   cata-,
ract torn with
a sickle needle
20 days  after
cellent, atrophy of
opt. disc was  dis-
covered   ophthal-
|moscopically    as 
5 S
SO

s  i

H. Knapp: Cata'n%ct Extractions
5^3
-~s		
		e
«	K	w
		
'OJ		
Condition of
   Eye.
I 5
Execution

Operation.
Incidents of
 Operation.
11	Mrs.	S8	Hard.		Dec.	Both eyes	
B. S.			Ripe, j		1869.	at the	
12	Ger.		in both			same	
	New-		eyes.			time.	
	ark,						
	N.J.						
l3	A.F.S.61 Ger. N. Y. City		Hard. 1 Ripe. 1				
			1				W
14	Mrs. Z.	42	Imma-		Feb.		Capsule
Ger.			ture.		1870.		opened with
Ct.			Swol-len.				knife during its passage
							through ante-
							rior chamber.
15
 Mrs.
  I.
 Am.
New-
 ark,
 N.J.
76
Com-
 pli-
cated.
   High de-
gree of M.
 Synechige.
Post,   cap-
sule  thick-
ened.
March
 1870.
 Sec. down
& outward.
Iridectomy
 removing
all synech-'
ise.  Thick-
ened caps.
circumcis'd
with cysto-
tome,  and
ext.   with;
 forceps. 
H. Knapp : Cataract Extractions.
11
^1
Course of Healing Process
  and After- Tieatment.
\	
Vj	&o
	«
	^
	
	
<M	
^	^
Aftet- Operations
extract. Reac-
tion    slight.
Pupil   clear.
Discharged 5
 days   after
  secondary
operation.
REMARKS.
the cause  of low
V.----   Other eye
unsucessfully  op-
erated on  (by ex-
traction) previous-
ly.    Died a year
after  operation.
16
 2_0_
loo
20
To
  On third day hemor-  12
rhage in ant. chamber
from  patient  hurting
his   eye  during  ban-
daging.    Disappeared
in a few days.
20
To
2_0
2 0"
  Cystoid protrusion in
one  corner  of wound.
No  irritation  from  it
up  to this time,  May.
1877.
T T i  2 0_
11 ' "2"0 0
  Division of
sec.   cataract
with    sickle
needle 6 mos.
after   extrac-
tion.   No  re-
action.
f^ |    The other eye
    being  unaffected,
    the     extraction
    should have been
    delayed  until the
    swelling  by  imbi-
    bition of the cata-
    ract   had   disap-
    peared. 
12
H. Knapp :  Cataract Extractions.
	
"•3	
<3	
O	S
J[	^
8 >S
r s 8
^
OJ
 L. S.
 Ger.
Brook-
 lyn,
 N. Y.
57
F. Pf. 61
 Ger.
N. Y.
 City.
 Right
  eye
 hard,
left eye
hyper-
mature
 with
 thick-
 ened
 cap-
 sule.
Condition of
   Eye.
Hard.
Ripe.
<^S

Execution
   °f.
Operation.
May,
1870.
Incidents of
 Operation.
 Left: Dislo-
cation of  lens
while  tearing
the capsule.
Thickened
capsule   ex-
tracted.   On
pressure with
spoon,  vitre-
ous pres'nted.
Lens extract-
ed with large
spoon.    One
or two drops
of vitreous es-
caped.
M.R.
Ger.
N. Y.
City.
64
Hard.
Ripe.
			
C. B.	37		Soft.
Ger.			Ripe.
N. Y.			
City.			
Dislocation of
lens with cys-
totome. Lens
extracted with
sharp hook. A
few  drops of
vitreous   es-
caped.
  7  months
 previously
  a  small
 piece  of
iron pierced
the   cornea
& remained
in the  ant.
  cortex,
May,
1870.
 Piece 01
  iron
came out
with lens. 
H. Knapp : Cataract Extractions.                13
Course of Healing Process
 and After- Treatment.
^
^E>
^
^' I               ^

  After-Operations1,   2

                 I
:q
DAYS

 T 6   -2-0-
 1U   100
REMARKS.
  Left  tardy  union of
wound.
 20
ToTT
 2_Q_
Too
_2_Q_
100
  The third day spongy
exudation appeared  in
ant.   chamber,   fourth
day densest, filling the
whole chamber.  Pulse
72.  Chemosis, 5th day :
it   began  to   absorb
from   the   periphery,
showing sharp   edges. 
14
H. Knapp : Cataract Extractions.
	ity, nee.
^	l'%%
	.Q « ~
s	^
20	
8 "*3
^c3
v h
s
Condition of
   Eye.
where it was
seen during:
the  extrac-
tion  and re-
moved with
the lens.
^8

Execution
   °f.
Operation.
Incidents of
 Operation.
 S. L.
 Span.
Porto
  Rico.
46
S. K. j5J
 Ger. ;
N. Y.
Hard.
Ripe.
July,  j   Usual A small quan-
1870. peripher-itity of cortical
      ic  linear substance left.
      section.
Hard.   Coloboma
Ripe,  from   pre-
      jvious   irid-
       ectomy.
Aug.      Large
1870.  jsection
      'for large\
      lens.
23
24
G. S.
Ger.
New-
 ark,
N.J.
59
B. K. 50
 Ger.  i
 Bliss-
 ville,
 L. I.
25
J.A.D/36
Fren.
N. Y.
 City.
Hard.
Ripe.
Sept.
1870.
Hard.
Ripe.
Sept.
1870.
Center of
 anterior
 capsule
removed.
Half-
  soft.
Large.
 Capsule divi-
ded with knife
  in  passing
through   ant.
chamber. 
H. Knapp : Cataract Extractions.                15
Course of Healing Process
  and After- Treattnent.
V
8 ^
6th  day,  no chemosis.
Exudation  limited  to
pupillary  space.   Iris
clear.   10th day : pupil
free  and  clear,  iris
bright.

    The  2d day puru-
lent infiltration of the
wound  under the con-
junctival  flap.   Pain.
Chemosis.   Pulse, 60.
3d  day ant. chamber
filled with dark blood.
Slow iritis.   Closure  of
pupil.
^T
After- Operations
-2A-
1 oTF
REMARKS.
20
30
  The weather was
very hot.  He said
that in Porto Rico,
his  home,  he had
not  suffered   so
much  from   the
heat  as  in  New
York.
  No  reaction  what-
ever.
  Capsulitis   plastica.j  12  ^g-
Blood  in pupil.   Pupil)
large.                 '
  Patient left the
hospital   without
permission.   Pros-
spect of improve-
ment of  S.  favor-
able.
T T   20
11   To
20
TT5 
i6
H. Knapp: Cataract Extractions.
	Name, Nativity, Residence.	i ^	8 "^3	Quality of Cataract. --------	Condition of Eye.	*. 2 \Exsecution sS of ■ r~ £ Operation.		Incidents of Operation.
26	M. S. Ger. N.Y. City.	67		Hard. Ripe.	Corneal specks.	Oct. 1870.		
27	H. W. Ger. N.Y. City.	43		Half-soft.		Oct. T870.		
28	Mrs. E. W. Ger. N.Y. City.	63		Hard.		Oct. 1870.		Escape of some vitreous, when spoon pressed upon cornea. Lens expelled by cautious pres-sure, no in-strument en-tering the eye.
29	Miss J.L. Am. N.Y. City.	36		Hyper mature flat, disci-form. Centre of cap-sule thick-ened.		Oct. 1870.		
 
H. Knapp :  Cataract Extractions.
17
Course of Healing Process and After- Treatment.	^5	V. at time of Discharge.	After- Operation;	53	REMARKS.
	DAYS I I	20 Too			
Pupil clouded.	14	1 5 20 0	Division of pupillary membrane 9 days after ex-traction. No reaction. Dis-charged 5 days later.	20 TO	
	17			2 0 Jo	
Pupillary opacities.	8	1 3 20 0	Division 5 weeks after	20 3"0	Extraction in the other eye 7 years
 extraction.
No  reaction.
previously    had
been  followed  by
pupillary opacities
They were divided
at the same time
with the eye  before
mentioned. Severe
reaction   followed
for six weeks.  No
improvement. 
i8
H. Knapp : Cataract Extractions.
*.$•&

3i
^s v S  Condition of

^  £ I
Soft.
Ripe.
0 -2  i Execution
11  :    of
K "^   Operation.
 Oct.
1870.
Incidents of
 Operation.
Centre of
 capsule
removed.
72
Hard.
Ripe.
45
Half-
   soft.
 Oct.
1870.
 A good
 deal of
 rubbing
on   cor-
nea in re-
 moving
the corti-
calis.
61
Hard.
Ripe.
 Oct.
1870. 
H. Knapp : Cataract Extractions.                 19
Course of Healing Process and After- Treatment.	^1	ft ^0 3 § ^ ft	After- Operations	.8 1	REMARKS.
	DAYS 6	20 1 0		20 20	
On fourth day, blood in anterior chamber, absorbed in six days.	11	20 Jo	Six months after extract. S. T2oV Divi-sion of wrin-kled caps, with Graefe's knife. No reaction. Discharged in 5 days.	20 Jo"	
On 3d day pain. Lids and conjunctiva swollen. Centre 01 wound bulging and white. Ant. chamber turbid. Iris swollen. Pupil narrow. The bulging portion of wound incised, perpen-dicularly to section, pus removed. Leeches to temple. Atropine. The inflammation {keratitis suppurativa partialis et iritis) at once abated, and ended in 10 days.	12	20 200		20 TO	
The second day oedema of lids. Pulse 84. Chemosis. Iris discolored. Inner angle of wound white, raised. It was incised and pus liber-ated. Symptoms abated. 3d day : Purulent secretion. Inner angle healthy looking. Outer angle of wound white. swollen ; puriform exuda-	21	6 2 0 0	63 days after extraction iridec-tomy, connecting with pupil. In-cision with Beers' knife through pupillary mem-brane. Iris drawn out with Tyrell's hook.	20 40	The splendid re-covery in this case is attributed to the energetic after-treatment.
2 
20                  H. Knapp :  Cataract Extractio?is.
ft <-> « o	Name. Nativity, Residence.	% ^	^ 8 ft-is r s 8 ^3	Quality of Cataract.	Condition of Eye.	Time of Operation.	Execution °f. Operation.	Incidents of Operation.
33		61				Oct. 1870.		

								
34	A. L. Ger. N.Y. City.	5°		Very old trau-matic and par-tia 1 ly dislocat-ed cata-ract which had freed him from military service. Anterior capsule thicken-ed. (Com-plicat'd)		Nov. 1870.		Immediately after the section fluid vitreous es-caped. The pro-lapsed iris was cut off. Lens was brought out with capsule by spoon passed behind post. capsule. During extraction a hard rubber spoon was gently pressed on the cornea, following the course of the lens from below upward. Loss of vitreous inconsiderable. Wound closed nicely.
 
H. Knapp :  Cataract Extractions.
21
Course of Healing Process
   and After- Treatment.
*5

-3£
ft ?<
After- Operations
tion extending from it into
ant. chamber.  Ant.  cham
ber cloudy;  iris  swollen,
yellowish white. Pupil plug-
ged  with  a grayish-white
substance.    Outer   angle
deeply incised, pus liberat-
ed ; six leeches  to  temple.
\th day : Less pain at night.
Purulent discharge dimin
ished.  Edges of wound in
their whole length  white,
infiltrated.   Ant.  chamber
filled   with  whitish  flakes
Pulse 75. Wound vertically
incised  at  several  points,
anterior  chamber  tapped
and almost  all the pus in it
evacuated.    %th day  :  No
pain  during night.    Dis-
charge less ; anterior cham-
ber restored, clear.   Pupil
partially free.  The inflam-
matory  symptoms  steadily
abated.  Pupillary  mem-
brane.   Tn. F complete.
REMARKS.
  id day : ant. chamb. filled,
middle third of wound gap-
ing,  but  bridged  over by
raised conjunctiva. The con-
junctiva was incised several
times, but it  always  closed
again over night,  and the
union of the wound progres-
sed  but slowly from  the
sides.   From the 13th to
the  28th  day  the  gaping
wound  was  touched  five
times with nitrate of silver
in substance, which reduced
its size to about one-fourth.
Pat.  wanted  to leave the
Hospital.  At his  house I
touched the wound twice at
an interval of  seven days.
The  first touching  was fol-
lowed  by hardly  any re-
action, the second by suppu-
rative inflammation,  which
destroyed  the eye.
20  |  11
   It  is  likely  that
without the touch-
ing    the   wound
would slowly have
closed, and the eye
might have recov-
ered. 
22                 H.  Knapp :  Cataract Extractions.
ft <->	Name, Nativity, Residence. ]	ft	►^ 8 5-3 ft-~ r^ 8	Quality °f i Cataract.	Condition of Eye.	•S ft "2	Execution °f. Operation.	Incidents of Operation.
35	Mrs. S. G. Am. N.Y. City.	65		Hyper-mature ; thicken-ed cap-sule.		Nov. 1870.	Anterior capsule removed.	The section, too small for the lens, was ex-tended, after which the cata-ract readily slipped out. (Smooth.)
3^>	Mrs. A. F. Ger. N.Y. City.	57		Hard. Ripe.				
31	Mrs. C. Am. Heb-ron, N.Y.	5°		Ripe. Hard.		Nov. 1870.	A very smooth operation. Pat. told time at the watch to the minute.	
38	J.U.F. Ger. N.Y. City.	45		Half-soft. Ripe.		Nov. 1871.		
39 40 .. ..	J. G. Neg. N.Y. City.	7i	Fat & feeble.	Both hyper-mature		Dec. 1871.		
4i	J.G. Irish. N.Y. City.	61		Ripe. Hard.		Dec. 1871.		
42	J.W.K Ger. Van-cou-ver I.	61		Partial-ly dislo-cated ; capsule thicken-		Jan. 1872.		The thickened portion of cap-sule was circum-cised ; but could not be removed
 
PL Knapp .-  Cataract Extractions.
23
Course of Healing Process

  and After- Treatment.
V
 8  ;-
 ft r^
H»5 tN
^
ft zr
After- Operations
^
REMARKS.
After-bleeding in ant. chamb. four days after ex-traction. In the course of 18 months V diminished to ■£■£$ by vertically folded and striped secondary cataract (posterior capsule).	DAYS 10	20 TO	18 months af-ter operation division of sec. cataract by Graefe's knife. Reaction slight.	20 70	Three years after the second operation plas-tic cyclitis and opaci-ties of the vitreous set in, reducing V to tuh-No irritation of other eye.
	T3	2 0 To" 2 0 To	(4 months.) (5 years.)		
Suppuration, beginning at the edges of the wound, presenting the form of ring abscess the third day. Pan-ophthalmitis.	18	O		0	The other eye suc-cessfully operated on 15 months previously. Case 4 of this table.
	9	1 0 To		20 30	
Slow healing. Wounds' 2=5 7—— gaping and ectatic. Cystoid j cicatrices, synechia and pu- 15 pillary obstructions in both, i , 2TTF					
Swelling of lids and con-junctiva. Copious muco-serous discharge. Spongy exudation. Iritis. Slight synechias.	18	2 0 Too		20 To	
On the 7 th day, struck his eye, the re-covery of which had proceeded favorably.	14	20 100		2 0 1 0	
 
24
H. Knapp :  Cataract Extractions.
	Name, Nativity, Residence, j		General Condition.	Quality of Cataract.	Condition of Eye.	Si « 8 V. •<s> ft	Execution °f. Optration.	Incidents of Operation.
42		6l	ed(com-plicat-jed.)			Jan. 1872.		with forceps. After the expul-sion of the lens, it was extracted with forceps. Some cortex remaining.
43	M. R. Ger. N. Y. City.	48	Half-soft,' mature			Jan. 1872.	Knife split the capsules, but a more extensive laceration was made afterwards.	
44	F. 0. Ger. N. Y. City.	69		Hard. Ripe.		Feb. 1872.	A quad-rangular piece of an-terior cap-sule re-moved.	
45	Mrs. M. K. Ger. N. Y. City.	59		Hard. Ripe.		Feb. 1872.	Quadran-gular piece of capsule cut out.	
								
 
H. Knapp : Cataract Extractions.
25
Course of Healing Process and After- Treatment.	^1		After-Operations		REMARKS.
The wound burst and some vitreous escaped. No bad consequences.	DAYS				
	12	20 •x 0			
Capsulitis Suppurativa et hemorrhagica.—The upper edge of the remaining cap-sule first showed white patches, then became uni-formly white, thickened and pervaded with blood-vessels. While the upper portion was clearing up, the inner, then the lower, and at last the outer edge of the quadrang-ular opening in the capsule became successively white and thickened. Hypopyon and repeated abundant hemorrhages took place. When he left, the exudation in the pupil was diminished, the shape and tension of the globe being normal.	34	I ~oo F. com-plete.			
O 2 0 o To			20 30		
					
 
26
H. Knapp : Cataract Extractions.
	Name, Nativity, Residence.	ft	si 8 8^ ^3	"^ V S Condition of § *-S 1 Eye. ^ a 1		Time of Operation.	Execution of. Operation.	Incidents of Operation.
46	Mrs. B. M. Ger. New-ark, N.J.	55	Hard. Ripe.			March [Capsule 1872.: cutout		
47	C. S. Am. Or'nge N.J.	42		Hard. Ripe.		Mar., 1872.	Capsule cut out.	
48	S. L. Heb. N. Y. City	60		Hyper-mature		Feb. 1872.		
49	C. Bl. Ger. Adrian Mich.	56		Nucle-ar cat-aract. Cortex still semi-trans-parent in both eyes. (Imma ture.)		April, 1872.	Knife was blunt requiring a good deal of dragging and saw-ing.	After division of ant. capsule vitreous exuded without any pres-sure on the eye. Cataracts easily extracted with large spoon, a small quantity of vitreous follow-ed. Wound clos-ed well.
5o	Mrs. M. M. Irish, Hob-oken, N.J.	41		Disci-form, old, (hyp'r-ma-ture.)		April, 1872.		Great pressure had to be em-ployed to expel the lens, upon which a small quantity of vitre-ous escaped.
 
H. Knapp :  Cataract Extractions.
27
Course of Healing Process
  and After- Treatment.
<1S
 ft  ~c
.8  5
DAYS

  14
 20
Too
After- Operations
REMARKS.
20
40
M
 20  ,   gix months la-
 Yw0 jter V reduced by
 11'ths vertically  striat-
later. ed secondary cat-
     aract.  Division
     with  Graefe's
     knife,   a  year
     after  extraction
     resulted in
 V.
 20
 To
per-]
m  a -
nent.
20
J~o
  Cyclitis.—4th day, yellow-
ish  reflex from well dilated
pupil.   10th day :  synechia;
and  pupillary membrane.
16:  Hemorrhage  in  ant.
cham.   19:   more hemor-
rhage : iris bulging forward.
39th : Eye  shrunken.   Iris
bulging. Perception of light
faint, pain,  which had been
acute, disappeared.
39
20
30 
28                H. Knapp :  Cataract Extractions.
ft «■> a j	Name, Nativity, Residence.	ft a/;	-s. 8 p .ft 8 S3 r^ 8 ^s3	Quality of Cataract.	Condition of Eye.	Time of Operation.	Execution °f. Operation.	Incidents of Operation.
51	M. L. Am. N. Y. City.	32		Soft.		April, 1872.		
52	C. B. Am. Strat-ford.	76		Hard. Ripe.		April, 1872.		
53	Mrs. F. M. Am. B'klyn N.Y.	58		Hard.	Inner lower quadrant of F. absent; nothing to account for it.	May, 1872.		Some blood and cortical sub-stance left.
54 55	Mrs. U Am. N.Y. City.	78	Decrep-it and childish.	Hard. Ripe. Both.		May, 1872.		Left eye : inner border of iris pushed out of wound by pass-ing lens.
56	Mrs. CA. Am. N.Y. City.	54		Hyper-mature		May, 1872.		
57	K. V. Ger. Jersey City, N.J.	42		Hard.		May, 1872.		
58	Mrs. M. W. Irish, N.Y. City.	56		Hard. Ripe.		May, 1872.		
 
H. Knapp :  Cataract Extractions.
29
Course of Healing Process and Afte?-- 7"reatment.	Length of Treatment.		After- Operations	^ ! | , REMARKS. 0	
	DAYS 6	20 Too		20 30	
	11	20 "2"o 0		-||t Other eye unsuccess-fully operated on 4 years previously.	
From the fifth to the twelfth day conjunctiva in-jected and swollen. Opacity in centre and upper part of cornea, deepseated as if pro-duced by scraping with the cystotome.	26	20 "2T7o		2 0 1 0	
L. Violent iritis: plug in pupil, hypopyon. After absorption dense pupillary opacity.	21	20 10 0 I 00		SJL ^0 5 20 0	
	r3	2 0 5 0"		TO	
15
 20
10 0
20
To
   Iritis.    Dense
pillary membrane.
pu-
 Iridectomy ^q-q
downward,  not
very  successful:
pseud o-mem-
brane extending
downward  also.
Division of mem-
      Other eye  had
    been  operated  on
    before.    Closure
Pf-! of pupil. V. ^oby
    artificial pupil.
_2_0_
100
brane  at first of.
m a -
nent.
(May
1876) 
3°
H. Knapp: Cataract Extractions.
ft <s sj	Name, Nativity, Residence. Age. General Condition. Quality of Cataract.	Condition of Eye.	8 ^	Execution °f. Operation.	Incidents of Operation.
58|       !56|                          | May,
                                      j 1872.
								
59	J. w. Ger. New-ark, N.J.	62		Hard. Ripe.	1 June, 1872. ,			
60	T. G. Ger. N.Y. City.	72		Hard. Ripe.		fune, 1872.		
61	J. D. Am. N.Y.	60		Hard. Ripe.	Left eye. Chronic Iritis.	June, 1872.		
62	S. M. Am. N.Y. City.	5°		Hard. Ripe.		June, 1872.		
63	Mr. M. D. Ger. N.Y. City.	65		Hard. Ripe.		June, 1872.		Some vitreous escaped.
64	J. Ch. Heb. N.Y. City.	78		Hard. Ripe.		Oct. 1872.		
 
H. Knapp :  Cataract Extractions.
3i
Course of Healing Process
 and After- Treatment.
little   benefit ;
improvement
later.   Floating
opacities in vit-
reous.
 Iritis ; pupillary mem-
brane.   Prospects  by
16
 Other eye opera-
ted on previously
after-operation very favorable.					phthisis bulbi.
Iritis. Pupillary mem-brane.	29	2 100	Discission with Beer's knife. Pu-pil perfectly clear.	20 To	
Iritis and keratitis suppurativa in both corners of wound. These corners incised. Pupillary membrane.	26	1 200	Division with Beer's knife 18 months later.	20 100	Had a good deal of irritation in both eyes, for months after his discharge. Left irido-cyclitis absolute.
	11	20 100		20 To	
Iritis. Pupillary mem-brane. Iris drawn up-ward toward wound.	21	5 200	4 months after extr. triangular iridotomy with scissors,followed by panophthal-mitis.	0	
	16	20 200		20 100	
 
32                 H. Knapp : Cataract Extractions.
ft	ATame, Nativity, Residence.	£ ^	K^ 8 ft ;~ 8^3 ^c3	Quality of Cataract.	Condition of Eye.	Time of Operation.	Execution °f. Operation.	Incidents of Operation.
65	J. K. Am. N.Y. City.	56		Hard. Ripe.		Oct. 1872.		
66	Mrs.V. Fr. N.Y. City.	70		Hy-perma-ture.	Old poste-rior syne-chia?.	Oct. 1872.		
67	Mrs. B. Am. Buff'lo, N.Y.	77		Hy-perma-ture.		Oct. 1872.		
68	N. K. Ger. N.Y.	49		Hard. Ripe.		Oct. 1872.		
69	Mrs.C. Am. Sussex Co. N.Y.	49		Hard. Ripe.		Oct. 1872.	Capsule removed.	
70	A. W. Ger. Hobo-ken, N.J.	28		Soft. Ripe.		Nov. 1872.		
7i	Mrs. M. D. Irish, Hobo-ken, N.J.	40		Half-soft.		Nov. 1872.		
 
H. Knapp : Cataract Extractions-
Course of Healing Process and After- Treatment.	^8 ^ ft ^	W ft ,~o "^ ft	After- Operations	Ultimate I'.	REMARKS.
	DAYS 9	20 4 0		20 30	
	!3			20 70	
	II	20 "2~0"0"		20 10 0	
	TI	20 10		20 "3~0"	
Plastic capsulitis, begin-ning at upper border of capsule which became white and thickened. The inflam-mation travelled around, produced.some synechise, but left centre of pupil free.	i7	20 800		20 To six vve'ks To (four years later.]	
	IO	20 loo		20 TO	
	18	20 TO		20 TO	
 
34
H. Knapp : Cataract Extractions.
ft3	Name, Nativity, Residence.	4 ^	5:1 ft *~ 8 ft rft 8 sic3	Quality of Cataract.	Condition of Eye.	ft\g 8 8 ;~ ft	Execution °f. Operation.	Incidents of Operation.
72	A. L. Heb. Mont-gomery Ala.	55		Hard. Ripe.		Nov. 1872.		
73 74	L. C. Am. N. Y. City.	44		Hard. Ripe, (both).		Nov. 1872.		
75	Dr. D. Ger. N. Y. City.	62		Hard. Ripe.		Dec. 1872.		
76	C. M. Am. N. Y. City.	69		Hard. Ripe.				
77	J. S. Ger. N. Y. City.	72		Hard. Ripe.		Jan. 1873.		
78	Mrs. C D. Irish. N. Y. City.	^3		Hard. Ripe.		Feb. 1873.		
79	H. K. Am. N. Y. City.	59		Hard. Ripe.		April, 1873.		
 
H. Knapp : Cataract Extractions.
35
Course of Healing Process and After- Treatment.	^5 S Si		After- Operations	•Si 8	REMARKS.
	DAYS 16	20 40		20 TO	
R. eye. Spongy exuda-tion, taking a favorable course. Some capsular opacities. L. eye. Plastic iritis. Closure of pupil.	L3	20 "2"0 0 1 8 F, c. Tn.		20 10 0	Returned 3 weeks after his discharge, having a relaspe of capsulitis with hypo-pyon in his right eye. Under antiphlogistic treatment recovered slowly. V <?,$,, and 2 months later V ^oV
	9	20 To"		20 20	
	14	20 20		20 40	
	13	20 10 0		20 40	
	11	20 100		20 30	
	12	20 10		10. 30	
3 
36
H. Knapp :  Cataract Extractions.
ft	
	
ftl	ft-.-gs -
*	Nan Nativ Reside
s	
80
J. H.
Ger.
N. Y.
City.
^ ^	General Condition.	-Ss ^ ^g Hard. Ripe.	Condition of Eye.	V 8 § g •« ft April, i873-	Execution °f. Operation.
59					
Incidents of
 Operation.
M.  C;62
Irish.
N. Y.
City.
Hard.
Rip'e.
May,
1873-
Mrs.F.j8o
 Am.
B'dge-i
 port,  '
  Ct.
   Hy
perma-
 ture.
May,
1873-
Inner border of
iris  pushed  into
the  wound  and
bruised by pass-
ing  lens.
83
84
85
86
F. M.
 Ger.
 Carl-
stadt,
 N.J.
6r
Mrs.
L. R.
 Am.
N. Y.
City.
157
 S. S.
Heb.
N. Y.
City.
43
  D.
 C.  G.
 Am.
B'klyn
 N.  Y.
61
  Mor-
gagnian
 Hyper-
mature.
May,
1873-
 Com-
 ph-
cated.
Leucoma   May,
adhaerens   1873.
 corneas
centrale.
Zonular
congenit
(Imma-
 ture.)
May,
1873.
Hard.
Ripe.
 Centre of
 anterior
  capsule
thickened.
May,
1873-
 Centre of
ant.  caps.
 circum-
cised came
 out  with
 cataract.
 Pupil appeared
clear, but show-
ed cortical  sub-
stance  and  a
strip  of  capsule
the next day. 
H. Knapp : Cataract Extractions.                 37
Course of Healing Process and After- Treatment.	^1	'-2 -8	After- Operations		REMARKS.
Purulent Iritis. Pan-ophthalmitis.	DAYS 14	0		0	
	12	20 "20 0		20 4 0	
Purulent iritis, start-ing from inner border of coloboma. Panoph-thalmitis.	21	O		O	Other eye had been unsuccessfully operat-ed on four years pre-viously.
	l8	20 Too		20 40	
Iritis. Pupillary mem- n brane.		1 5 TOJ	Division four 4-P-, r : 5 0 weeks alter ex traction. No re-action.		
Recurrent capsulitis and irido-cyclitis, leav-ing dense secondary cataract.	fc	1 2 0 0	Iridectomy.	2 2 0 0	Eye remained irrita-ble (irido-cyclitis) for two years, but never affected the other.
	12	20 10		20 30	
 
38                 H. Knapp : Cataract Extractions.
ft 5'	Name, Nativity, Residence.	ft	-^ 8 8-* ft -13 8>s ^ 8 ^<3	Quality of Cataract.	Condition of Eye.	ft'ft 8 £ ;» ft	Execution °f . Operation.	Incidents of Operation.
87	Mrs. E. K. Am. Hobo-ken, N.J.	79	Exces-s i v el y decrepit Skin like pa-per.	Hy-perma-ture.		Mav. 1873-	Section strictly peripheric.	
88	G. 0. Ger. Savan-.nah, Ga.	60		Hard. Ripe.		June, 1873-i		
89	H. H. Am. Atlan-ta, Ga.	58		Hy-perma-ture.		June, 1873-		
90	M. B. Ger. Phila-del-phia, Pa.	72		Hy-perma-ture.		June, 1873-		
91	V. W. Am. N. Y. City.	72		Mor-gagnian. Hyper-mature cum bursa.		June, 1873-		After the soft cortical sub-stance and the hard nucleus had come out, a white bag showed itself in the pupillary space. It was pressed out with some effort b y means of two spoons, a silver spoon keeping the lips of the wound apart, and a rubber spoon pressing on the
 
H. Knapp : Cataract Extractions.
39
Course of Healing Process and After- Treatment.	^1 5 8 ft £	ft ft	After- Operations	^ 1 -Si <3 si	REMARKS.
2d day: Wound open and slightly gaping. $d day: Suppuration in corners of wound. Pan-ophthalmitis.	DAYS 14	O		O	
	l8	20 10 0		20 40	
	14	2 0 1 0		20 30	
	20	20 Too		20 TO"	
	12	20 100		20 1 0	
 
4°
H. Knapp.- Cataract Extractions.
ft	Name. Nativity, Residence.	ft	"vi 8 ft v3 ?*^ ^c3	Quality of Cataract.	Condition of Eye.	i Time of j Operation. '	Execution of. Operation.	Incidents of Operation.
91		72				June, I873-		cornea and push-ing the bag to-ward the sec-tion. The bag, apparently a re-cess of the cap-s u 1 e, burst, a milky fluid es-caped, and the wrinkled bag re-mained at the upper border of t h e coloboma, leaving the cen-tre of the pupil perfectly free (no accident)
92	Mrs. B. A. Ger. Rye, N. Y.	52		Hard. Ripe.		June, 1873-		
93 94	Mrs. B. F. Irish. N. Y. City.	60		R. Hy-perma-ture. L. Hard. Ripe.		June, 1873-		
95	Mrs. M. K. Ger. N. Y. City.	60		Hard. Ripe.		June, 1873-		
96	J.B.-Am. B'klyn N. Y.	60		Hard. Ripe.		June, 1873-		
 
H. Knapp:  Cataract Extractions.
4i
Course of Healing Process
 and After- Treatment.
	"£>
	^
Jp"^	■*■> "-8 ^ ft
	« •-
s^	^
After- Operations
DAYS
 12
 2_p
Too"
REMARKS.
l3
20
To
20
fo
   Incarcerated iris  in
both eyes;  causing  no
annoyance.
2.0
10
  Jan.  1877  S
sunken  to gT$
from pupillary
membranes. Di-
vision by needle
gave in 9 days
20
To
20
4 0
  The prolapse of iris
in right eye  became
red on 4th day, was
excised.  Recovery
perfect.
20
To
 20
Too
20
To 
42                 EI. Knapp .- Cataract Extractions.
ft	Name, Nativity, Residence.		-*, 8 ft Iji 8 ^3 ^3	Quality of Cataract.	Condition of Eye.	<v.ft ft -K .8 8 r'* ft	Execution °f. Operation.	Incidents of Operation.
97	M. Span. N. Y. City.	37		Half-soft. Ripe.		July, 1873.		
98	C.P.S. Am. Spring field, Mass.	41	Excel-lent.	Ripe.		Sept. 1873-	Apex oi section 1 mm. in cor-nea.	
99	A. B. Heb. Chi-cago, 111.	69	Ple-thori-cal. Excit-able.	Hard. Ripe.	Pupil mod-erately di-1 a t e d by atropine. Eye myo-pic.	Sept. 1873-	Ap. of sect. touching transpar-ent cornea. Wound enlarged with scis-sors.	A small quan-tity of cortex left.
100	L. N. Am. N. Y. City.	55	Fee-ble.	Imma-ture. Swol-len.		Sept. 1873-		Some lens and tough capsule remained in the pupil.
101	B. E. Ger. Maine.	54	Good.	Half-soft. Ripe.	Arc. seni-lis pro-nounced.	Oct. 1873-	Remnants of corticalis removed by con-siderable rubbing. Conjunc-tival flap.	A small piece of iris, caught in the inner corner of the wound, was cut off". (Accident.)
 
H. Knapp : Cataract Extractions.
43
Course of Healing Process and After- Treatment.	OS Sfft-SEN	ft r-9 .8 e >S -8	After- Operations	1\	REMARKS.
	DAYS 12			20 4~0	
	14	20 To		20 2"0	
Some irritation at cor-ners of section where iris was adherent.	20	20 To"	9 weeks after extraction divi-sion of sec. cata-ract with needle. No reaction.	20 40	A year later had hem-orrhage into the vitre-ous, which left floating bodies and, at the time of discharge, V f %.
Marked spongy exuda-tion. Absorption on the fifth day. The gela-tinous exudation look-ed like a dislocated lens, with a sharp some-what ragged edge. Pu-pillary membrane.	20	1 0 100	6 weeks after extraction a cru-cial division of the pupillary membrane, pro-ducing a very clear pupil, and no reaction.	20 7 °, S'v'n we'ks aft er ex tr. S i x d ays aft er d i vi-sion.	
Pain and mucous secretion. Conjunctiva raised. Inner corner oi section whitish. From it white exudation (pus' descending tongue-like into ant. chamb. Iris discolored ; aqueous turbid. This condition lasted a week, during	35	1 2 200	30 days after the extraction, when the irrita-tion had almost disappeared, but a tendency 10 closure of the pu-pil and stretch-ing of the iris was still manifest, a Beer's knife was thrust through	20 70 Thr'e we'ks aft e r sec'n d ary oper-ation	
 
44
H. Knapp : Cataract Extractions.
ft	Name, Nativity, Residence.	ft	■^ 8 (3 .ft 8^	Quality of Cataract.	Condition of Eye.	Time of Operation. __------	Execution °f. Operation.	hicidents of Operation.
IOI		54				Oct. 1873-		
102	N. H. Ger. New-ark, N.J.	57	Good.	Hard. Ripe (nine years).	Myopic.	Oct. 1873-	Apex of sec. 1 mm. be-low mar-gin of cornea.	
IO3	N. B. Am. De-troit, Mich.	54		Hy-perma-ture. Chole-sterin-ic and chalky depos-its.		Oct. 1873.	Apex of sec. 1 mm. be-low mar. S ection large.	Tough capsule torn, but lens would not move on pressure. Ex-tracted with large spoon. Thickened cap-sule removed with forceps.
 
H.  Knapp :  Cataract Extractions.
45
>s"
Course of Healing Process
  and After- Treatment.
After- Operations'
.q
which time the  wound
was incised and  the an-
terior chamber emptied
every day.   Then the
inflammation gradually
disappeared,  leaving  a
dense pupillary  mem-
brane.
   No reaction until the
fifth day;  then circum-
corneal  injection,  hy-
peremia of  iris,  hazi-
ness of  pupil and vit-
reous. Eye tender.  Ir-
ritation  {hyalitis) grad-
ually subsided.
14
40
the lower part of
the cornea and
upper part  of the
iris.  The  lower
lip of the iridoto-
my wound was
seized   with  a
blunt hook, and
drawn toward
the  wound,  in
order to be  cut
off, but  it slipped
off the hook.  As
a large  opening
appeared in  the
iris,    through
which   vitreous
passed  into  the
ant. chamb., and
even out of  the
corneal  wound,
n o  further  a t-
tempt at iridec-
tomy was made.
Little   reaction
followed and  pa-
tient was  d i s-
charged six days
later with a clear
pupil.
 20
100
REMARKS. 
46                 H. Knapp :  Cataract Extractions.
ft	Name, Nativity, Residence.		5-2 ft."s 8 ^3 .ft s* *5	■£r> ft	Condition of Eye.	ft "^	Execution °f. Operation.	Incidents of Operation.
104	Mrs. C. Am. N. Y. City.	78	Good.	Hard. Ripe.	Large arc. senilis.	Oct. 1873-		
!°5	Mrs. C. B. Ger. N. Y. City.	38	Phthisis pulmon.	Soft. Ripe.		Nov. i873-		
106	J. w. H. Am. Bos-ton, Mass.	39		Ripe.		Nov. 1873-		
IO7	L. R. Am. Syra-cuse, N. Y.	55		Ripe.			Quad-rangular piece of capsule excised.	
108	J. W. Ger. Syra-cuse, N. Y.	66		Hy-perma-ture.	Myopic.	Nov. 1873-	Apex of sec. 1 mm. be low cor-neal mar-gin.	In cutting the iris, a small piece of the ant. Lip of the section was cut.
IO9	Dr. J. M. Am. Ober-lin, Ohio.	7i		Hy-perma-ture.	Myopic.	Dec. 1873-	Capsule resisted Weber's double hook, there-fore	Cataract e x -tracted together with capsule by large spoon. Es-cape of vitreous.
 
H. Knapp : Cataract Extractions.
47
Course of Healing Process 1 and After- Treatment.	I5!	ft f-o ft	After- Operations	.8 1	REMARKS.
	DAYS 14	20 TO		20 40 2i y's later.	
On fourth day, spongy exudation, lasting five days. Portion of anterior capsule in pupil. Remainder of pupil clear.	13	20 Too			
	17	20 TO		20 20	
	15	20 To			
Slow closure of wound. Chemosis. Circumscribed purulent infiltration of wound ; irritation gradually disappearing, leaving inte-rior clear, but a part of the pupil filled with capsule.	3^	20 TO			
Recovery, without notable irritation.	21	20 TO		20 TO 3 m'ths	
 
H. Knapp :  Cataract Extractions.
ft			
a	?r ft „~ -O ft S; > 8		
s	^"•s^	bo	ft 8
s'		'<,	.ft
no	N. A. P.	65	
-^  "S
Condition of
    Eye.
%	8 ft
	
	p
	
	ft
IN	>
	O
Execution
   °f.
Operation.
Incidents of
 Operation.
Hard.
Ripe
 Am.
N. Y.
City.
Dr. Br. 73
 Ger.  ;
B'klyn
Jan.
1874.
  De-
 crepit.
Cough.
Prosta-
  titis.
Hard.
Ripe.
  Pupil di-
lated    but
  little  by
   atropia.
Jan.
1874.
  Apex of
sec.  i\
mm.  be-
low  mar
sin.
 Apex of
sec.  2
mm.  be-
low  mar-
gin.
J. M.
Irish,
N. Y
City.
49
Cata-
racta
accret.
H3
G. K.
 Ger.
N. Y.
 City.
61
Asth-
 ma.
Ripe.
 Leucoma
 adhaerens
from burns.
Iridectomy
 had been
   made.
Jan.
1874.
Sectio n
inward.
Feb.,
1874.
114
G. B.
Irish,
N.Y.
City.
52
 Cata-
racta
 accre-
  ta.
"5
Kerato-iritis,
with  closure
of pupil 5 yrs.
previously.
  Iridectomy
r^ years  pre-
viously,  Tra-
choma    and
pannus   one
year.
Feb.,
1874.
Section in-
  ward.
The  rotten  iris
was drawn out by
pieces and cut off
 Miss
J. W.
 Am.
N. Y.
 City.
25
 An-
aemic.
Halt-
   soft.
Ripe.
Maculse  Cor-
 nese.  Eye
greatly sun-
ken.
Feb.,
1874.
Ap. of sec
 I2 below
marg. Vit-
reous pre-
sented.
 Lens extracted
with the capsule.
  Considerable
loss of vitreous.
Eye collapsed. 
H Knapp : Cataract Extractions-
49
Course of Healing Process and After-- Treatment.	^'1 ft ~8 ^	ft fo ft	After- Operations	Ultimate V.	REMARKS.
Hemorrhage into anterior chamber o n fourth day ; absorbed in three days.	DAYS *5	20 Too		20 TO 6 we'ks	
Slow healing of wound. Some capsu-lar obstruction in pupil.	14	20 100			Five months after operation patient had a severe general disease, subacute irido-cyclitis. He died soon after.
	l8	1 0 200		l 0 200	Result excellent con-sidering the complica-tions, especially the opacity of the cornea.
Violent fits of cough-ing. Inner corner of wound bulging. Slow closure.	I I	20 ^0 0			
	23	5 Too			Result all that could be expected. Vision improved by treatment of trachoma.
No reaction. Wound closed 3d day ; reopened by injury the 4th, closed again the sixth. Pat. left with floating opacities in vitreous.	16	20 Too			
 
50                H. Knapp : Cataract Extractions.
ft =1	Name, Nativity, Residence.	fee	*£■! ft l~ 8>3	Quality of Cataract.	Condition of Eye.	\8 <V, ft ft -52 .8 § r~ ft	Execution °f. Operation.	Incidents of Operation.
116	CD. Ger. Hobo-ken, N.J.	56		Hard. Ripe.		Feb., 1874.		Wound had to be enlarged with scissors. (No accident.)
117 118	E. W. Neg-ress, N. Y. City.	90		Hyper-mature, chalky, thick-ened capsule. (Both.)	Chronic Conjunctivitis	Mch., 1874.	Sect, a lit-tle below transpar-ent margin.	
119	A. H. M. He-brew, Mil-wau-kee, Wis.	26		Soft Trau-matic (3 years)	Good.	Mch., 1874.	Apex of sec. 3 mm below cor-neal mar-gin.	Capsule resisted cystotome, therefore extrac-tion with cap-sule. No intro-duction of instru-ments. No pro-lapse of vitreous.
120	Dr. St. Am-. Staten Island, N.Y.	79	De-crepit.	Hyper-mature.		Mch., 1874.	Ant. Cap-sule freely lacerated and lens easily re-moved.	The op a que centre of post. capsule was torn with sharp hook, but could not be extracted on ac-count of protrud-ing vitreous.
121	Mrs. M.R. Am. N. Y. City.	45		Ma-ture.		April, 1874.	Centre of capsule cut out.	
 
H. Knapp :  Cataract Extractions.
51
Course of Healing Process
  and After- Treatment.
^ri
s-n
~.^
                 ft
After-Operations   S

              !  I
REMARKS.
  Iritis  and  capsulitis
plastica, leaving  pupil-
lary obstructions.
DAYS
 35
   Iritis  leaving  pupil-
lary   obstruction    in
both.
26
 Division by sic-
 kle-needle 13
weeks after ex-
traction.  No re-
action.   5 days.
20
lo"
  5_
 2" 0 0
 1_5_
 Joo
  6
we'ks
   Diffuse   opacity   of
vitreous  with  circum-
corneal  injection from
3d to 15th  day.   One
small synechia at inner
angle of wound.
*9
 Ex-
 cel-
lent.
 Plastic capsulitis, pro-:  37
ducing a pupillary mem-
brane.
  3 months later
iridectomy  fol-
lowed  by hem-
 orrhage.   Dis-
charged 6th day
with
later

TOO
14 
52
H. Knapp .- Cataract Extractions.
i	1 Name, Nativity, Residence.	ft &o	•^ 8 ft-tt 8^3	Quality of Cataract.	Condition of Eye.	ft' ft ft -hS S3,	Execution of. Operation.	Incidents of Operation.
122	J. w. Am. N.Y. City.	70	Feeble	Cata-racta accre-ta.	Recurrent iri-tis for years 20 years ago. Pupils closed. Vi both for twenty years. Tn. Fc.	April, 1874.	Extraction R . Eye smooth. Counted fingers.	Some cortex left.
123	Mrs. E. P. Am. West-field, Mass.	70		Hard. Ripe.		April, 1874.		
124 *25	S. V. Ne-gress, N. Y. City.	63	Bron-chitis.	R. eye Hyper-mature L. eye Synch-ysis. (Com-plica-ted.)		April, 1874.	Extraction with cap-sule. No introdu c-tion of in-struments.	Escape of fluid vitreous. Small section enlarged with scissors. Fluid vitreous escaped. Iridectomy made with great diffi-culty. Cataract extracted with hook. Some cor-tex left. About one-third of vit-reous escaped. Eye collapsed.
 
H. Knapp -.  Cataract Extractions.
53
Course of Healing Process and After- Treatment.	"*- 8 ft9* r- ft	& . 8 S° ■v. <-	After- Operations	§	REMARKS.
Reaction inconsider-able. Coloboma ob-structed by remnants of capsule and lens.	DAYS 20	TVG	6 months later irid'ctomy, yield-ing.................. but revealing sec-ondary cataract, which 3 weeks later was divided and depressed with Beer's knife. Recover-ed in 6 days		
	3° ! W		10 months later division of wrinkled cap-sule. No reac-tion.	20 TO 2 y'rs later.	
Some floating opaci-ties.	2	2 0 2"0 0			
32   o
  3d  day  suppuration
in the vitreous.  Pan-
ophthalmitis ;  atrophy
of globe. 
54                  H- Knapp : Cataract Extractions.
Name, Nativity, Residence.		■^ 8 ■a -^ 8^	Quality of Cataract.
Condition of Eye.	.3 5
	^
Execution
   °f.
Operation.
 Mrs.
A. M.
  K.
 Am.
N.  Y.
 City.
50 Bron-
  l chitis.
   20 yrs.
Hard.
 Ripe.
E.  F.
Heb.
Baton
Rouge
  La.
Mrs.
J. B.
Ger.
N. Y.
City.
5°
64
Half-
   soft
 Ripe.
Cata-
 racta
sublu-
 nata.
 (Com-
 plica-
 ted).
May,
1874.
May,
1874.
May,
1874.
I?icidents of
 Operation.
  Copious hem-
orrhage after iri-
dectomy.
 The ant. chamb.
emptied  several
times. A  sponge
was held  on the
wound for some
time.
   (Accident.)
  After the sec-
tion  it was  at-
tempted  to  ex-
tract the lens by
pressing  it  out
with  a  curette
applied  to  the
outer surface of
the cornea while
keeping  the
wound open by
depressing  the
posterior  lip  of
the wound.  The
lens  did  not
move.  A sharp
hook  was  then
introduced,  its
point inserted
into  the  lens
from the posteri-
o r  pole   The
cataract was
readily   drawn
out, and the cap-
s u 1 e  followed
with only  one
bead of vitreous. 
H. Knapp : Cataract Extractions.
55
Course of Healing Process and After- Treatment.	^ ft ■S5	ft ^ .8 « •C -8 ». ft	After- Operations	« .8 0	REMARKS.
Obstruction of pupil by pseudo-membrane.	DAYS I 1	1 0 ?0()	30 days after extraction, divi-sion of seconda-ry cataract with falciform needle. Recovered in 5 days with	20 100	
	15	2 0 7 0		20 TO 2^y'r	
No reaction.	IO	2 0 loo			
 
56
H. Knapp : Cataract Extractions.
ft a	Name, Nativity, Residence.		General Condition.	Quality of Cataract.	Condition Eye.
129	Mrs. M. M. Am. Brook-lyn, N. Y.	36		Morg-agnian (Hy-perma-ture.)	
130	P. T. Am. N. Y. City.	56		Hard. Ripe.	
131	D.S.H. Am. N.Y. City.	80	| De-crepit.	Catarac-ta cys-tica, oi 40 years' stand-ing. (Hyper-perma-ture.)	
132	M. B. Ger. N.Y. Citv.	5*		Mor-gagnian (Hyper-mature)	Very opic.
of	Time of Operation.	Execution of. Operation.	Incidents of Oper'alion.
	June, 1874.	After the rupture of the capsule the milky cortic ali s escaped in-to the ant. chamb. It was re-moved, as cleanly as p 0 s s i ble, with the nucleus.	
	June, 1874.		
	June, 1874.	Extraction with cap-sule with-out intro-duction of instru-ments, fol-lowed by the escape of a smal' quantity oi vitreous.	
my-	Oct. 1874.		
 
H. Knapp : Cataract Extractions-
N^' ^ ft "^ § ; ft ?o Course of Healing Process ; ■§ 5 .3 js and After-Treatment. ~&\ : ^ *bj | 1 h\			After- Operations	ft 3	REMARKS.
Mild iritis. Some synechiae, and capsular opacities.	DAYS 16	20 70			
On the sixth day, hurt his eye violently. Wound ruptured. An. cham. filled with blood. Gradual absorption. Synechias and opacities of pupil.	28	8 20 0	5 months after extraction, divi-sion of sec. cat. with sickle nee-dle. No reac-tion. 5 days.	20 Too	
Suppuration and hyalitis, and iritis. Ant. chamb. and iris cleared up, but pupil re-mained occluded.	*3	I OO F. c.			
	x9	20 100			
 
e.S                H. Knapp :  Cataract Extractions.
ft	Name, Nativity, Residence.	^ ^	.ft 8	Quality of Cataract.	Condition of Eye.		Execution °f. Optration.	Incidents of Operation.
133	M. B. Heb. N.Y. City.	51		Hyper-ma-ture. Cap-sule thick-ened.	Always highly my-opic.	Oct. 1874.		
134	J.O'N. Am. N.Y. City.	44		Hard. Ripe.		Oct. 1874.		
135	H.D. Am. N.Y. City.	63		Hard. Ripe.		Nov. 1874.		
136 137	J.M'C Am. S.Sing N.Y.	64		R. Hy-perma-ture. L.Hard Ripe.		Nov. 1874.	R. ex-traction with cap-sule.	R. A single drop of vitre-ous.
 
H. Knapp :  Cataract Extractions.
59
Course of Healing Process
  and After- Treatment.
*5
■-8  §
  Bulging  incarceration of
iris in outer corner of wound
abscinded,  without empty-
ing ant. chamber.  No reac-
tion.
DAYS
 23
   Small prolapse of iris
at outer angle of wound.
V.
20
70
After - Operations
14
  I^ years after-
ward, acute pur-
ulent iritis, (in-
tense pain, peri-
corneal injection
and  impairment
of S the first day ;
purulent  disch.
oedema of  lids,
chemosis,  hypo-
pyon, iris  green-
ish,  pupil plug-
ged,  Vi the sec-
ond  day.    The
prolapse was
swollen,   white,
covered with ad-
herent mucus.  Il
was  incised, the
iris  drawn  out
extensively  and
abscinded. Ant.
chamb. emptied.
From  that mo-
ment,  improve-
ment ending  in
complete  recov-
ery.   V=j{}.
REMARKS.
20
To
20
10
.2 0.
70
20
TO
 (12-
year.) 
6o
H. Knapp: Cataract Extractions.
ft	--Name, Nativity, Residence.	£ ^	General Condition.	Quality of Cataract.	Condition of Eye.	V 8 ;~ ft	Execution °f. Operation.	Incidents of Operation.
138	E. E. Am. N.Y. City.	70		Hard. Ripe.		Nov. 1874.		
139 140	Mrs. W. S. Heb. Wm's-burg, N.Y.	60		Hard. Ripe, both.		Nov. 1874.		
141	L. C. Ger. Hobo-ken, N.J.	52	Nerv-ous. Ple-thoric.	Hard. Ripe.	Eye very deep-set.	Nov. 1874.	Capsule cut out.	A few drops of vitreous after ex-it of lens by ex-cessive pressure of patient.
142	J- P. Am. B'ling-ton, N.J.	69		Hyper-mature		Nov. 1874. Nov. 1874.		Some rem-nants of cor-tex left.
M3	H. P. Ger. Flat-bush, N. Y.	64	Stout. Ple-thoric from drink-ing.	Hard. Ripe.				
 
H. Knapp :  Cataract  Extractions.
61
Course of Healing Process
  and After- Treatment.
	"s
>>-	
5=1 ft	ft ?0
-8 8	
"^a"*"	•c ^
8* ft	•^ %
	
SK,	^
                         iDAYS
   Iritis with complete  42
closure of  pupil.  Iris'
drawn upward.
  After-hemorrhage in ant.
chamber in both eyes, leav-
ing in the right some pupil-
lary opacity.
After- Operations
  14 weeks after
first   operation,
artificial   pupil
with   Beer's
knife and  Tyr-
ell's hook.  Cen-
tral,  sharply de-
fined  pupil yiel-
ding S -#0.   A
thin   membrane
which    spread
across the pupil
was divided four
weeks   later,
yielding
 and
 20
 To

 Hi
year.)
16   R.
L.
 20
 100
 2 0
 40
 (4
mo.)
REMARKS.
Mild iritis.
28
*9
  (3
!mo.)
			(2	
			mo.)	
	13	2 0 100	2 0 '20' yrs.)	
 
62                H.  Knapp : Cataract Extractions.
ft	Name, Nativity, Residence.	8j>	ft ;~ 8 ^s ^3	* A , <S >. g Condition of s * -2 Eye.		Time of Operation.	Execution °f. Operation.	Incidents of Operation.
144	L. S. Ger. Eliza-beth, N.J.	64		Hard. Ripe.		Dec. 1874.		
J45 146	Mrs. J. Heb. N. Y. City.	80	Stout. |Hyper- Deep-set. Deere-; mature pit. both.			Dec. 1874.		Section small in both. Expul-s i 0 n difficult. Some cortex left in both.
i47	Mrs. P. Heb. N. Y. City.	60		Hard. Ripe.		Dec. 1874.		
148	R. V. Am. B'klyn, N. Y.	5° 65	Had had ar-ticular rheu-matism several times. (Com-plicat-ed.)	Poste-rior sy-nechia?		Dec. 1874.	Extrac-tion with capsule. No in-strument introduc-ed.	
149	Mrs. E. P. Am. West-field, Mass.			Hard. Ripe.		Jan. 1875.		
 
H. Knapp : Cataract Extractions.
63
Course of Healing Process | ^
 and After- Treatment.
REMARKS.
    Purulent   keratitis
and panophthalmitis in
both.
    Plastic  iritis  withj 36
closure of pupil.
   Hyalitis  on  fifth  day.
Iritis.   Pupil obstructed ;
clearing up.  In the third
week attacked with  acute
articular   rheumatism,  on
account of which  he desired
to be discharged.    His eye
was  improving and showed
 I
^o
Too
25
20
To
   Five  months
later, iridectomy
with Beer's knife
and  Tyrell's
hook.    Central
pupil  yielding
  Patient died six
weeks after his dis-
charge.
 20
 To

yrs.)
  Other  eye oper-
ated on before.
(See case 123). 
64                 H. Knapp :  Cataract Extractions.

150  Mrs.  45
    M.  M.!
     Am.
   JB'klyn,'
     N. Y.
151
 Mrs. l59|
C. M.
 Am.
Eliza-
 beth,
 N.J.
a -^
.ft s
^3. ft
^;
oj
G
Condition of
    Eye.
Half-
 soft.
 Ripe.
Hard.
 Ma-
 ture.
^1	Execution
s 8	of
r~ ft	Operation.
Lncidents of
 Operation.
| March
  1875.
April,
 1875-
[521  Mrs.  70
   hM.A.S.-
     Am.
     S. I.
    N. Y.
*53
  Hy-
perma-
 ture.
Hard
 Ripe.
May,
1875-
r54i
Mrs.
C. S.
 Am.
N.Y.
City.
5°
Ripe.
Large,
May,  Large sec-
j-g7c.  ,tion wholly
  '^' in the limb.
      conjtv.
  A small por-
tion  of   iris
  near peri-
phery fell  be-
fore knife and
was cut. 
H. Knapp : Cataract  Extractions.
65
	VH^			^	
	* ? ! s ?o				
Paling Process r- Treatment.	nq K	v. <; ft	After- Operations	1	REMARKS.
	DAYS				
itis.	25	20 70			
l3
2 0
To
2.0
7 0"
,o.)
 20
 70
 (5
mo.)
 UL
 3 0
 (5
mo.)
   Purulent  iritis  from
the second day.  Wound
opened.   Ant.  chamb.
evacuated   several
times.   Complete clo-
sure of pupil.
16
  7 months later, cor-
nea flat, indrawn scar,
painful  irido-cyclitis.
Vision of other eye im-
paired, without physi-
cal changes, indicating
sympathy.  Antiphlo-
gistic  treatment.  In-
flammation soon ceas-
ed. Other eye healthy
S|i   No  irritation 
66
H. Knapp: Cataract Extractions.
	.- O ft S. L. Am. Bridge port, Ct.	5°	General Conditio/	Quality of Cataract.	Condition of Eye.	8 P ^| May, 1875-	Execution °f. Operation.	Incidents of Operation.
155				Hard. Ripe.				
156	L. C. Ger. N.Y. City.	52		Hy-perma-ture. Cap-sule thick-ened.	Myopic.	May, 1875.	Apex of section 1 mm. be-low cor-neal mar-gin.	Lens extracted with capsule by means of a hook. Capsule burst, but the greater part of it was re-moved. A few drops of liquid vitreous escaped.
J57	Mrs. M.M. Am. Brook-lyn, N. Y.	55		Hard. Ripe.		May, 1875-		
158	J. F. Am. Fort W ayne Ind.	65		Imma-ture. (Dark nucleus, cortical-is semi-transpa-r e n t, capsule opaque.		May, i875-	Large section, centre of ant. cap-sule re-moved.	
 
H. Knapp : Cataract Extractions.
67
Course of Healing Process
  and After- Treatment.
,	""h> - !
>s	
	
	
	•J3 "8
#>?	ft
s£	^
14
After- Operations
REMARKS.
 (10
mo.)
 Tn

 with
  Reads 6 to 7 hours
a day without any an-
noyance.   Other eye
blind.
  Reaction very  mod-
erate.
_2 0_
1 0 0
			
Mild but very obsti-nate irido-hyalitis.	34	20 100	20 30 (6 mo.)
Mild iritis.	36	20 7 0	
5 
6 b"                 H. Knapp: Cataract  Extractions.

  ^r ft
,- o ft
^ ■ ~ 8
8 .R •£
P -2
ft -"^3
: >0 m
OJ
i59
 Mrs.
C. G.
 Ger.
Hob-
oken,
N.J.
64
Condition of
    Eye.
 Hy-
perma-
 ture.

June,
1875-
Execution
   °f.
Operation.
Incidents of
 Operation.
i6o;  F.  D.
     Ger.
     N.Y.
     City.
39
Half-
 soft.
 Ma-
ture.
 Both eyes
prominent,
 somewhat
 hydroph-
 thalmic.
June,
1875-
  An  extraordi-
nary amount of
liquid   escaped
after the comple-
tion of the  sec-
tion.
161I  W. B. 60
     Ger.
    Brook-
     lvn,
     N. Y.
Hyper-!
 ma-
 ture.
June,
i875-
  A drop of vit-
reous escaped on
removal of corti-
cal remnants.
162 W. B. 76
163  Am.
   1 N. Y.
     City.
   Hy-
perma-
 ture
 with
thick.
 cap-
 sule,
 both.
June.
 1875
cut out.
Capsule #■• A drop of vi-
        treous while  last
        portion of cortex
        was removed.
         L. Vitreous pre-
        sented while cor-
        tex was removed,
        It  receded   as
        soon  as  pres-
        sure of the globe
        was   discontin-
        ued.
1641  Mrs.
    A. Mc
      G.
      Am.
     N. Y.
     City.
60
Imma-
 ture.
Corti-
 calis
 semi-
 trans-
parent
Sept.
1875.
Exit
  Section
large  The tardy
tough cap-
 sule was
 ruptured
with diffi-
culty.
       of lens
        Visual
test  negative.
Cortex left. 
H.  Knapp .■  Cataract Extractions.
69
Course of Healing Process and After- Treatment.	^8' ft ~8 ^ r- ft		After- Operations	ft 1	REMARKS.
	DAYS 19 1*1			2 0 50 (2 mo )	
	14	2 0 7 0			
Intense iritis.	46	2 0 70			
	M	R. 15 100 L. 15 70		2 0 "5 0 2 0 To (1 y'r).	
Purulent iritis. 
70
H. Knapp : Cataract Extractions.
G
"5  ^'
G
£>	
Q ft	3
O	e
	o
	ft ft
Condition of	ft -*2
Eye.	:~ ft
	Ni -Sl O*
Execution
   °f.
Operation.
Incidents of
 Operation.
City.
  en.
 Cap-
sule ir-
regular
 LHy-
perma-
ture.]
165 Dr. LJ54! Stout. Ma-					. j Highly my- Sept.		Capsule	
Ger. 1 , ture.					opic. 1875.		cut out.	
N. Y. ■								
City. ;								
166	M. A. 60			Mor	Sept.			
	C.			gagm-	1875-			
	Am.			an.				
	N. Y.			THy-				
City.				perma-				
				ture.]				
167	Mr. A.	80	Hard.			Oct. |		
	Am.		Ripe.			1875-:		
	Green-							
	pomt,							
	N. Y.							
168	Mrs.	60	S Hard. ! Oct.					
	A. R.	Ripe.				1875-		
Am.								
N. Y.								
City.								
169 F. P. 54			Hard,			Oct. 1 Lens re-		Escape of
	Ger. N. Y.			and shrunk		I875-	movea in capsule by large spoon	some vitreous.
depressing
 posterior
lip, and
 rubber
  spoon
  pushing
lens out by
pressing on
cornea. 
H. Knapp :  Cataract Extractions.
7i
Course of Healing Process
  and After- Treatment.
V
^.-
-O^	v,	
^£	^'	^
After- Opera tions
REMARKS.
DAYS
 24
  Irido-cyclitis.   Clo-' 25
sure of pupil.  Indrawn
scar.
^
 (4
mo.)
  Ciliary  region  re-
mained tender to the
touch  for ten weeks.
No irritation of other
eye.
  Lardy    closure  o f
wound.   No irritation.
16
 12
mo.
Slight iritis.
16
20
"ST
No reaction.
15
 20
 To

 {\
mo.)
 411

mo. 
72                H. Knapp :  Cataract Extractions.
Condition of Eye.	<u "~ .8 S Ol ^
—_ ^ _ —	
Hard. \    Dacryo-  Oct.
Ripe. |   cystitis  j 1875.
       chronica.
Execution
   °f.
Operation.
 Extrac.
 ith cap-
ule-
Incidents of
 Operation.
Nov.
I875-
172!  A. S.  65 Feeble)  Cata-   Function-
     Heb.  ;           racta  al examin-
    N. Y.  j         j accreta ation satis-
     City,  j         I  For-  satisfactory
                     mer ir-
                      ido
                     choroi-
                     ditis.
Nov.
1875.
 Capsule
cut out.
  Lens slight-
ly  dislocated
by cystotome.
Escape of vit-
reous.
173  Mrs.  60
   |M. M.
     Am.
    N. Y.
     City.
174
S. W.
Am.
N. Y.
City.
72
175  Mrs.  66
    H. M.
     Am.
    N. Y.
     City.
 Ex-
ceed-
ingly
 fat.'
 Hard. Posterior syn-
 RiDe  echiffi-  Func-
 ,, ^   tional exami-
 ^    • nation  n o r-
accret.      mai.
Nov.
i875-
 Bleeding in ant.
chamb.  Escape
of vitreous.
Hard.
Ripe,
Catar.
accret.
Nov.
1875-
Nov.
1875.
  Extrac-
tion with
capsule.
 Bleeding.  Es-
cape of vitreous. 
H. Knapp : Cataract Extractions.
73
Course of Healing Process and After- Treatment.	Lentgth of Treatment. V. at time of Discharge.		-Si After-Operations !~	REMARKS.
	DAYS 16	20 7 0		The dacryo-cystitis was tr< ated 5 days be-fore the extraction with injections of sulph. zinci in the sac, which improved the condition greatly.
Mild iritis.	J5	**-^0 0	i 2 0 1 Jo 1 (3 jmo.)	
Suppuration in vitre ous. Great pain. In-drawn scar.	" 7 * 00			I "OO	
Suppuration in vitreous. Anterior chamber opened once daily for five days. Pupil closed.	22	1 60 ;		O	
	J3	20 7 0			
Suppuration of vitreous. Pupil closed by yellow sub-stance.	29	0		O	
 
74
H. Knapp : Cataract Extractions.

1^
8 "*3
.ft 8
^3rft
ft
O
^S
176I  Gen.
      U.
177
 Am.
 Long
Island,
 N. Y.
72
Condition of
   Eye.
 R.
Mor-
gag-
nian.
 L.
Hard.
Ripe.
^s

Execution
   °f.
Operation.
Jan.
1876.
Incidents of
 Operation.
178  J. s.
    Germ.
     N. Y.
     City.
44
179  Mrs.
    G. W.
    Germ.
    N. Y.
     City.
65
Ripe.
Hard.
Ripe.
Feb.
1876.
Mar.
1876.
Escape of a few
drops of vitreous
after  expulsion
of  lens  by  an
awkward  move-
ment of patient.
180
Mrs.
S. N.
Am.
N. Y.
City.
 M. T.
 Am.
 Long
Island,
 N. Y.
67
56
Ib2
M.W.
 Am.
N. Y.
 City.
66
Hard
Ripe.
Hard.
Ripe.
Hard.
Ripe.
Mar.
1876.
Mar.
1876.
Mar.
1876. 
H.  Knapp : Cataract Extractions.
75
Course of Healing Process

  and After- Treatment.
^
^
| After-Operations
s^  L-q
 2 0
 4 0


 III

 (6

w'ks.)
REMARKS.
					
Some floating opacities in vitreous, when discharged.	16	20 "^0			
	8	20 To			
Mild iritis, leaving a few filiform synechire and a thin pupillary membrane.	23	2 0 TO	Ten weeks la-ter S -2s0flo, the thin wrinkled capsule was split with Beer's knife,	2 0 TTT¥	Sight changed con-siderably, and on ex-amination retinitis al-buminurica was dis-covered.
yielding
Asma	11 part of incarcerated		iq	20 To	20 To
ins in	one corner	ot the			(6
wound	is removed,	though			w'ks.
showing no irritation.					9
				1	mos.)
					
14
20
"Sir
 so
 40

 (4
w'ks.) 
76
H. Knapp : Cataract Extractions.
ft 4	Name, Nativity, Residence.	^ ^	r^e 8 ^3	0 ft <. s. s! 0 3	Condition of Eye.	\8 ft'.ft ft -5 .8 S [*» ft	Execution °f. Operation.	Incidents of Operation.
i83| 0. N. Am. N. Y. City.		46		Hard Ripe. 1		Apr. 1876.		
184 I. S. Germ. N. Y. City.		48		Hard Ripe.		Apr. 1876.		
185 S. S. Heb. N.J.		48,		Trau-matic. (Com-plicat-ed.)	Synechiae Funct. exam. normal.	Apr. 1876.		
186 C. M. Am. N. Y.		60		Hard Pipe. (Com-plicat-ed.)	Myopia. Apr. Extensive jg^g choroidal at- ' rophies, seen after recovery.		Section very large.	
187 Mr. G. Germ. N.Y. City.		641		Hard Ripe.		Apr. 1876.		
188	Mr. S. Ger. Phil. Pa.	76	Nephri-tis and Bron-chitis chron.	Hard. Ripe.		April, 1876.		
 
H. Knapp .- Cataract Extractions.
77
V
Course of Healing Process
  and After- Treatment.

After-Operations
REMARKS.
   Irido-cyclitis, mild,  but
obstinate, with partial bulg-
ing of iris.  Centre of pupil
kept clear.  Recovery, bulg-
ing disappeared.
Iritis.
27
_2i>_
10 0
	DAYS	1	
	20	20 i 30 ! 1	20 "2~0 (6 w'ks.)
	14	20 30	
 
78
H.  Knapp :
Cataract  Extractions.
ft • ~ s?
* 8 fc
   >3
s.?-a
^
190
Mrs.
  E.
(xer.
N.Y.
City.
  D.
 Ger.
Union
 Hill,
 N.J.
48
70
[91
Mrs.
  S.
 Am.
N.Y.
City.
65
192
Mrs.
  H.
Ger.
N.Y.
City.
76
G
8 ft1 Q
s   "S
oj  c3
Condition of
    Eye.
       Execution
          °f .
\r h?    Operation.
Hard.
 Ripe.
 Hard.
 Ripe.
(Compli
cated.)
Hard.
Ripe.
Myopic.
April,
 1876.
Incidents of
 Operation.
Highly myop-
ic,  hydroph-
thalmic  eye.
Other eye suc-
cessfully oper-
ated on before
showing  ex-
tensive  atro-
phic patches
of choroid.
April, ;  In cap-     Considera-
 1876. 'sule.      [ble   loss   of
                 ivitreous.
   Lens
partially
disloca-
ted  in
anterior
chamber
(Com-
plic't'd.)
Consecutive
    glaucoma
acut.
May,
1876.
May,
1876.
   Lower
 section
 through
 cornea.
 No iri-
dectomy.
 Exit of
lens easy. 
H. Knapp : Cataract Extractions.
79
Course of Healing Process
 and After- Treatment.
I	S
^8	
	
-8 ^	8 ~
ft £	e • ~
^
After-- Operations
REMARKS.
  Iritis a week after opera-
tion.
zl   7 0
20
7 0
  2 months after  IjQ.
operation,   divi-1
sion  of  false j   3
membrane  withlm0s
Beer's knife/,  tg;
Yielding
                70
  Very  tardy  closure  of
wound on  account of vitre-
ous keeping a small portion
of it gaping.   The protrud-
ing little  bead was  cut off'
a lew  times.  At last  the
wound closed.
32  ' tf
 2_0_
 "0 0
with-
out a
glass.
 -f-jv  1   Many   atrophic
^j^8 patches of choroid.
_l- i|Opacities in vitre-
  ^  ous.
mos.
Jo
Central, round pupil.
20
To
   Patient knew no
cause of  the dislo-
cation.  Stated that
she had been blind
2 years.    Of late
the eye became in-
flamed. 
80                H. Knapp :  Cataract  Extractions.
Name. Nativity, Residence.	H°'	General Condition.	Quality of Cataract.	Condition of Eye.	Time of Operation.	Execution °f. Operation.	Incidents of Operation.
Mrs. A. B. Ger. N.Y. City.	48		Hard. Ripe.		May, 1876.		
Dr. L. Ger. N-Y. City.	5°	i Hard. Ripe.		Myopic. Floating opa-cities of vitre-a year before operation.	May, 1876.		
Mr. ,78 T. Ger. B'klyn N.Y.			Mor-gagnian (Hyper-mature.)		May, 1876.		
Mrs. [55 J-Am. N.Y. City. '		Hard. Ripe. I			June, 1876.		
E. R. Ger. N.Y. City.	68		Hard. Ripe.		June, 1876.	Section small. Ex-pulsion slow, but complete.	
 
H. Knapp: Cataract Extractions.
81
Course of Healing Process
  and After- Treatment.
	>
ft1 « — ft "8 ~	. ft 8 h ■v. ^
r- ft	
^K	^
After-Operations]   2
REMARKS.
On the third day iritis set in, 5th day pus in pupil and ant. chamber. 6th day infiltration of part of flap. Flap incised, anter. chamb. emptied. 7th, reopened, chamb. filled with blood. Then gradual absorption and clearing of pupil.	DAYS 25	1 ~00		20 0 2 mos. 20 2~0 0 3 mos.	
	J5	20 "Fo"		20 TO 5 we'ks	
	18 -r° 2 0 0			20 To 4 we'ks	
	7	20 To			
	9	20 "ST			
 
82
H. Knapp:  Cataract Extractions-
8*^
ft 8
^ ft  S3
	ft1.^
Condition of	
Eye.	r~ ft
	^
Execution


    °f.
Opei'ation.
Incidents of

 Operation.
198' Mrs.		49		Hard.		June,	
	S.			Ripe.		1876.	
	Ger.						
	N.Y.						
	City.						
199	L. L.	68	Hard.			June,	
	Ger.		Ripe.			1876.	
	N.Y.						
	City.	; !					
200 Mr.		48! Hyper- j j June,					
A. •		mature. l8y6_					
	Ger. N.Y.						•
 
H. Knapp :  Cataract Extractions.                   83
Course of Healing Process
   and After- Treatment.
>8'	V:
	
~8 5	5: ft
	
	
	
s s	|^|
After- Opera tions
REMARKS.
  Capsulo-iritis.     Hypo-
pyon.   Afterward   whole
ant. chamber filled with yel-
lowish  bloody  exudation,
stationary  for  nine  days,
then  gradually  absorbing,
leaving   dense   pupillary
membrane.
32
20
7 0
20
"Fo"
  4 months later -AJL.
artificial  pupili
withBeer's knife.I   6
The  corneal we'ks
wound was small J
and  it required!
some   effort  to
 withdraw Ty- 1
rell's hook. Arti-|
fie.  pupil small,
clear;  corneal
wound  irritated
for two weeks.
 (4
w'ks. 
84
H. Knapp : Cataract Extractions.
  From  the  foregoing tabular statement, the influence which
different factors  have on the result of the  operations may be
more or less conclusively derived.   I shall successively consider
these factors as follows.
                       I. NATIONALITY.
TABULAR  STATEMENT.
Nationality.	Number of Operations.	Results.*				
		Good.		Moderate.	Failures.	
Americans,	88	73	; 83^	4 ; 4-5#	II	12.5$
Germans,	69	62	; 89.8$	2 ; 3^	5	7.2$
Hebrews,	20	i5	; 75^	1; 5$	4	20<fc
Irish,	J3	10	; 77I0	2; 15-3^	1	7-7fo
French and	4	3	; 75$		1	2 5$
Spanish,						
Negroes,	6	:'	16.2^	4 ; 66.6$	.	l6.2r/o
	200	164	; 82^	13; 7-5#	23	ll.Sfo
  This table shows a markedly reduced rate of success in the
Hebrew  and Negro nationalities, while in the others the differ-
ences of success are  hardly marked enough to  demonstrate
more favorable conditions in the one than in the  other national-
ity.   The number  of  operations performed  on  Hebrews and
Negroes was, however, too small to assume that  cataract opera-
tions in these races  offer a worse chance than in others.   The
four cases of failure in the Hebrew patients are accounted for
by special causes: in the first, the operation was laborious, the
lens was extracted  with  a spoon, and vitreous escaped;  the
second and the third referred to hypermature cataracts in a fat

         * As good results are reckoned cases of S = \% to -/P,j.
          As moderate results are reckoned cases of S = $*0 to -jffoj.
          As failures results are reckoned cases of S < -g^. 
H. Knapp :  Cataract Extractions.
85
and feeble woman of eighty years, who was fidgety and unman-
ageable.  The expulsion of the lenses was difficult.  The fourth
case was a cataracta accreta in an eye which had suffered from
irido-choroiditis.
  In regard to the negroes I am not prepared to state that they,
as a race, offer the same ratio of success as the whites.   Opera-
tions in the negro, other circumstances being equal, seem to be
followed by more irritative processes than in the white man.
                           II. AGE.
  The influence  which the age of the patients had on the final
results is shown in the following table.
Age in   \  Number of                 Results:
Years.     Operations.  \    n  ,        ir  ,         ~7T,
           r             Good.        Moderate.   ,   Failures.
20	to	29	3	3	IOO'b				
3°	to	39	10	10	IOO',' !				
4°	to	49	27	23	85^	2 ;	7-5#	2 ;	7-5f«'
5°	to	59	53	45	85:^	3;	5H	5;	9-4f«
60	to	69	64	52	81$	2 ;	3-4?	10 ;	15.6$
70	to	79	36	3°	83-3^	4 ;	1 i.i#	2 ;	5.6^
■ 80	to	90	7	1	14-3.^	2;	28.6$	4;	57-i#
  This table shows that up to the age of 40 years, all operations
were followed by complete success.  From 40 to 80 years, the
percentage of good results remained almost the same, varying be-
tween 85 per cent and 81 per cent, whereas after 80 it abruptly
sank  to  14.3 per cent.   If we disregard the  column  of the
moderate results, and examine that of  the failures, the age of
the patients seems to have a decided influence on the results, so
that the ratio of losses increases with advancing years, being 0%
until  the age of 39 years, y.yf between 40 and 49 years, 9.4;/
between 50 and  59 years, 15.6$ between 60 and  69 years, 5.6;/ 
86
H. Knapp :  Cataract Extractions.
 between 70 and  79 years, and $7.1% between  80 and 90 years.
 The table shows a steady increase of the failures from 40 to 69
 vears of age, but then there is a marked—evidently accidental
 — diminution during the years from 70 to 79,  and again an ex-
 traordinary rise after 80 years.   Half of the cases (5 out of 10)
 of failure in the years  from 60 to 69 referred to complicated
 cataracts and impure operations.  Each of the  four cases of loss
 in patients from  80 to 90 years  showed some accident  in the
 operation ; the first, introduction of a large spoon, and escape of
 vitreous ; the second, escape of vitreous ; the third and fourth,
 difficult exit of lens with remaining rests of cortex.
   The two cases of moderate success referred to the two eyes
 of a negress (case 117 of  the table), whose  age could only ap-
 proximately be ascertained.  She was led to the clinique by an
 old man who showed  her  the greatest kindness.   When we
 asked him how old his wife was, he answered: " She is not my
 wife,  but my mother, and I am 70 or 71."  Both operations were
 smooth, yet followed by adhesive iritis.
   It  seems  not  surprising  that  the chances  of a  successful
 cataract operation should diminish with advancing years.  The
 older the person, the more the structure and function of his eyes
 must  fall short of their standard  in  youth and vigorous man-
 hood,  since  a multitude of unfavorable conditions surround
 even  the most felicitously situated among us.   In  general, we
 may expect that the older the patients the more complications
 accompany the cataract, the  more difficult and impure are the
 operations, the less speedy  and complete is the recovery, the
 more  unfavorable  are  the  results.  That  this,  as a  general
 proposition, is true, I have little doubt,  though the numbers in
 this and former reports are not large enough  conclusively to
show the deleterious influence of advancing years.  We all have
seen old people make easy and perfect recoveries from cataract
extractions, but in what  percentage of the cases does this occur ?
If we speak of the prognosis of cataract operations  in old age,
we should count all the cases as  they come before us,  and  not
exclude the complicated cases, since many of the complications
are qualities inherent to old age ; for instance, a relaxed condition 
H. Knapp :  Cataract Extractions.
87
 of the  conjunctiva and  probably  of  other coats of the  eve.
 Senile involution, which  is so conspicuous in many parts of the
 eye,  is  certainly  an  unfavorable  factor in the  prognosis  of
 cataract operations.

                   III.  QUALITY OF  CATARACT.
    I shall distinguish, as in former reports, four kinds of cataract:
 mature,  immature,  hypermature, and complicated.   I have called
 mature  all cataracts  in which  the opacification was complete,
 either soft cataracts  or  hard,  or—which is very frequent—a
 hard nucleus surrounded  by soft corticalis, the so-called cataracta
 semi-mollis, which word, in the table, I have literally translated
 with half-soft.   The  period of complete opacification  is not
 always the most favorable to operate in, since the lens  may be
 considerably swollen by imbibition.  On account of the shallow-
 ness of the anterior chamber in this condition, the knife encoun-
 ters two obstacles on its way : the bulging iris—and the anterior
 capsule.   It is difficult to avoid the iris  immediately after the
 puncture,  and still more difficult  before the  counterpuncture
 is effected.  Moreover, in the avoidance  of these obstacles, we
 are apt to make  the counterpuncture too far in front, in which
 case  the section becomes irregular and  too short.  Arlt very
 justly remarks that this period of swelling by imbibition should
 have passed before the extraction is undertaken.
    As immature cataracts  are  entered those in which the cortical
 substance  was  still more  or less  transparent.  Such cataracts
 can  seldom be  cleanly  removed, and only for  very forcible
 reasons should their extraction be attempted.  I have, like many
 others, been frequently punished for violating this rule.
    Hypermature cataracts  are those which  show symptoms of dis-
 integration, such as thickening  of the capsule, white, fatty or
. milkv-looking, chalky or  crystalline patches.  The majority of
 Morgagnian cataracts, and also the cystic cataract, are classified
 under this head, though many of them, especially  the cystic
 variety,  are complicated  with diseases of the inner membranes.
    As complicated cataracts I  have entered only those in which
 some ocular disease of importance existed in conjunction with 
H. Knapp : Cataract Extractions.
the cataract; for instance, atrophic conditions of the iris, choroid,
retina and optic  nerve,  synchisis, adherent leucoma,  and so
forth ; whereas ordinary cases of myopia are  not included, since
they give no worse prognosis than the common cataract.  One
case of large zonular cataract (No. 85), in a man  of 43  years of
age,  is entered as an immature cataract.  The extraction had a
poor result, and the long-continued iritis made me fear sympa-
thetic ophthalmia, which, however, did not occur.
  The following tabular statement shows  the  influence of the
quality of the cataract on the course of the operation and on  the
final results.
		Operation :	Result:		
Cataract. Number.		With Ac-Smooth, j cidentSt	Good. Moderate.		Failure.
Mature,	128; 64^'	112; 87.5^ 16 ; 12.5^	114; 89^ 4; 3.2$		10; 7.8^
Immature, | 7; 3.5;^		1; 14.3^ 6; 85.7;;	4; 57# 1; I4P: 2; 29$		
Hyp'rmat'e 48; 24^;. 30; 62.5^ 18; 37.5;,'			40; 83.2^4; 8.3^1 6; 12.5$		
Complica'd 17; 8.5^		7; 41.2^10; 58.8;;	' 8; 47^	4;23-5r;' 5; 29-5$	
Total, j2oo; 100^		15°; 75^50; 25^	;i64 582.5^	13; 7-5^	23; n-5^
  The first row shows a  rather low  figure  for  the simple,
mature,  uncomplicated cataract, namely,  64^', whereas  the
hypermature cataracts were relatively frequent, viz., 24^'.  The
influence which the quality of cataract exerted on the course
of the operation is clearly  exhibited in the second  and third
rows.  The operations  for mature cataracts were accompanied
with accidents in 12.5^  of  the cases, for hypermature cataracts
in 37.5;/, for complicated  cataracts in 58.8^', and for immature
cataracts with 85.7^.   The  final  results of the operations show
a similar proportion:  89;; perfect results in mature cataracts,
83.2;; in hypermature, 57^ in immature, and 47;; in  complicated
cataracts.   The  imperfect results  and failures are  the  least
frequent in  mature cataracts; then follow,  in  the  order of fre- 
H. Knapp :  Cataract Extractions.
89
quency, the hypermature, immature, and complicated cataracts.
The table  shows  that the  immature  cataracts yielded  surpris-
ingly unfavorable results, nearly  as unfavorable  as  the  compli-
cated  cataracts.   This shows the great responsibility the oper-
ator  takes  on  himself  when,  by  inattention,  indifference,
weakness,  or  professional jealousy,  he  is  led  to  extract an
immature  cataract.   I make  it a  rule not to operate as  long as,
on ophthalmoscopic examination, the fundus yields a red reflex,
however faint it may be;  furthermore,  as long as the patient is
able to count  fingers, after dilatation of  the pupil, and as long
as,  by  oblique illumination,  in combination with a magnifying
glass of great aperture,  it can be ascertained that a  part of the
corticalis is still  transparent.   In such cataracts the semitrans-
parent portions of the cortex adhere  so tenaciously  to the cap-
sule that the most judicious and  persevering  efforts may fail to
remove them.  It is sometimes  exceedingly difficult to  with-
stand the entreaties of patients who have travelled hundreds and
thousands  of miles.  They see hardly  enough to  walk about
alone, and the operator,  instead of telling  them  to go  home
again and  wait till  their cataracts are  fully mature, is apt  to
listen  and  yield  to their entreaties   to  operate   at least on
one eye.   The result of such a proceeding is seen in the second
horizontal  column of the foregoing table.  There  were, it is
true, only  3.5$ of immature cataracts,  but in 85.7^' of them the
operation  was accompanied  by  unfavorable accidents, at the
head of which was the leaving of a greater  or less quantity of
cortical substance in the eye.   Only 57^' of these eyes obtained
good vision, lAff moderately  good vision, and the failures have
reached the high number of 29^.   That I, however,  am not the
only one who, in this matter,  yielded to  temptation and fell, may
be seen from the following example.
  Some years ago, a German, about 55 years old, residing in Boston,
wanted  me  to operate on  one of his eyes.  This eye  suffered from a
cataract the nucleus of which was completely opaque, but the outer
layers of the cortex were translucent.  A faint red reflex was gained
from the fundus, and the patient could with this eye count fingers at a
distance of  three feet, while the vision of the  other was  still tolerably 
9o
H. Knapp: Cataract Extractions.
good.  I told him his cataract was not ripe,  and he should wait.   He
did not wait, but sailed for Europe.  Six months later, he came back
to me  with a letter  from  an excellent German oculist, exemplifying
anew the old story.   The patient had travelled over 3000 miles to have
his cataract removed, and did not want to return to America with the
cataract in his eye.   The  oculist yielded, the  expulsion  of the lens
was laborious and incomplete ;  severe and prolonged iritis with closure
of the pupil followed. When I saw the patient again, the eye operated
on was collapsed and hopelessly blind.
   While  a student in  London,  I  saw  an  excellent operator
extract many an  immature cataract.   I expressed my astonish-
ment,  and he  answered: "These people will be operated  on.
There is a keen competition in the city.  If I send them  away,
telling  them  to wait,  somebody else will  operate on  them."
Such principles can, without  damage to their  reputation,  be
practised  only by  surgeons  of hospitals, the old popularity of
which covers, with the  kind mantle  of charity, many a  sin of
those " whose  gratuitous services to the poor are inestimable,"
as the usual phraseology runs.

                 IV. CONDITION OF THE EYE.
   Under  this  head there  are some  interesting observations
noted.  They  do not easily  admit of  a statistical arrangement,
but  their nature and consequences can be conveniently studied
by going  over the general table.
               V. THE TIME  OF THE OPERATION
does not give rise to any remarks of importance.  I have been
taught that the hot  season is unfavorable for cataract extractions.
To this rule  I have always adhered, and  if I  cannot demon-
strate that the heat in  itself is an unfavorable agent  as to the
healing of wounds  of the eye,  I can appreciate how unpleasant
it must be, during  the " heated term," to lie quiet, with bandag-
ed eyes, from 4 to  7 days.  Some of the patients who had been
operated  on in June, July, or August, were uncomfortable and
restless from the  heat,  which, no  doubt,  had a bad influence on
their cure. 
H. Knapp :  Cataract Extractions.
91
             VI.  EXECUTION OF THE  OPERATION.
                       A. Instruments.
  The knife which I prefer is shaped  like that of Liier, but its
surfaces are slightly concave,  like those of  a razor.  I recom-
mended these knives four years ago.   They  are unsurpassed in
convenience, and  their edge can be made sharper than that of
the knives  with flat  surfaces  (Liier  and others), and  much
more than those with convex  surfaces (V. Graefe).   They are
perfectly  reliable as concerns strength, and do not  favor the
escape of aqueous, as  has, by  theoretical  reasoning,  been  pre-
tended.  I have given these knives a  fair trial, and can repeat
my recommendation.
  Several forms of iris-forceps are in use.   I have no preference
for any one of them.   The iris, which almost always protrudes,
can be conveniently  seized  and  secured  with  any kind  of
forceps, and it is a matter of practice with each operator to find
out that form which will render him the best services.
  I am very careful to have  the iris scissors perfectly  sharp and
move evenly to the very point, so as to avoid the least bruising
of the iris while cutting it.
  I use Yon Graefe's  cystotomc for the division of the capsule,
and am very particular that its point and small cutting edge be
of the utmost sharpness.  An imperfectly sharp cystotome is apt
to  dislocate the cataract, and divide  the capsule more in the
way of tearing than of cutting.  From numerous  reactive pro-
cesses of the capsule which I have  closely watched and studied,
I conclude that the capsule, like the iris, bears clean cutting'
well enough, but reacts unpleasantly  on being  torn with  a
blunt instrument.
  For the expulsion  of the lens I use a hard-rubber  spoon, the
blunt  edges of which are pressed on  the lower  part of the
cornea.  (All my  remarks refer to an  upper section, unless a
section in  another direction  be specially  mentioned.)   The
edges  of  the spoon should be rounded and perfectly smooth ;
its  form is indifferent. In the  great  majority of cases I press,
during the passage of the lens, the posterior lip of the wound
gently backward with  a broad silver spoon.  If the cataract cannot 
92
H. Knapp :  Cataract Extractions.
be expelled in the usual way, and I am sure that the section of
the cornea and the division of the capsule are sufficiently large,
especially  if the  vitreous  escapes, I introduce  the same spoon
slowly behind the cataract and  extract it.  A spoon almost as
broad as the lens is the most reliable instrument in the so-called
" accouchement force " of the cataract.   If the cataract is hard,
and cannot be removed by external pressure, a sharp hook, mod-
erately curved and not too short, may be introduced behind the
lens, implanted into the nucleus, and the lens thus drawn out.
                    B. Mode of Operating.
  As regards the
                    locality  of the Section,
the experience gained by these  last two  hundred  extractions
tends to show that the advantages of a peripheric section, that
is, one implicating the corneal  tissue as little  as possible, are
more  than counterbalanced  by  its dangers.   Among these
dangers I  will mention the following:  i. It facilitates prolapse
of vitreous, with  all its injurious consequences ;  2. It is more
apt to produce incarceration of  the iris and capsule of the lens
than a corneal section ; 3.  Its reactive processes readily extend
to the ciliary body, thus producing prolonged irido-cyclitis, and
sometimes even  sympathetic ophthalmia.    My notes are not
detailed enough to furnish numerical evidence of these proposi-
tions, but I have  observed the  facts, and  they are deeply im-
pressed on my mind.   There was no  instance of sympathetic
ophthalmia in  these two  hundred cases, but such an  example
came recently  under my observation, and  the  experience was
terrible.
  The main advantage of the peripheric section, as  has always
been asserted, consists in the  greater immunity of the flap from
sloughing.  It was Jacobson, of Konigsberg, who transferred the
section from the cornea into the sclero-corneal juncture, because
the tissue of the sclerotic has less tendency to suppuration than
the cornea.  He supported his recommendation by the results
of 100 peripheric  operations,  of which he had lost only  one eye.
Jacobson's argument  and practice  have  not  been   corrobo-
rated by more extensive experience.   In  the two  hundred 
H. Knapp :  Cataract Extractions.
93
extractions  here under consideration, six cases of failure from
primary suppuration of the flap were noted.  In three of them—
Xos. 9, 21, and 37—the section was strictly in the sclero-corneal
juncture, being a regular Graefe's peripheric linear section, free
from pathological complications and operative accidents.  In the
fourth—No. 6—the operation was smooth, the section  peripheric,
butsmall. In the fifth and sixth—Nos. 145 and 146—thesection was
peripheric, but small, and some cortex was left behind.   We see
that all the instances of primary suppuration of the flap occurred
in cases where the section was peripheric.   On the other hand,
special notice is made of cases—Nos.  98, 102, 103, 108, no, in,
115, 119—in which the section encroached considerably, one to
three  millimetres, upon the transparent cornea,  and in all of
them  there  was no suppuration in the flap, and the results were
good.   If we consider these contrasting conditions as proof and
counterproof, and attach no more value to them than the small-
ness of the numbers warrants, we may safely draw  from them
at least this inference : Suppuration of the flaps  occurs as well
after a peripheric as after a corneal section.   Yon Graefe also,
in his later  publications, lays less stress upon the periphericity
of the wound than upon its linear direction.  Upon the same
principle  are  based the methods of Licbrcich  and Lcbrun-War-
lomont.
                      The Size of the Flap
is of  the greatest  importance.   It  is self-evident  that  the
larsrer  a  wound, the  greater is  the reaction  from  it, other
things  being  equal.  We should, therefore,  make  no section
larger than  the easy expulsion of the cataract in a  given case
requires.  The mathematical rule  that a distance of 9.5  millimetres
between the internal  points of puncture  and counterpuncture
is  sufficient for the  ready  exit of  the  largest cataract,  has
led to an  operative  technique which is minutely described
in text-books and pamphlets, and need not here be repeated.
But since,  in shaping a  section,  we cannot measure it  with
mathematical accuracy, it will happen that the section becomes
either too large or too small, and of these two errors the latter
is infinitely the worse.   All authors  who write  from personal 
94
H. Knapp : Cataract Extractions.
experience dwell on the numerous dangers of an insufficiently
large section, and though I have always fully appreciated these
dangers, there is in these last  two  hundred cases a certain
number (4)  where  the  section was noted as being too small,
and the loss of the eye was attributed to this defect.
                   The Excision of the Iris,
the second step of  the  operation,  was always  made large and
with particular care to avoid incarceration of the iris in the cor-
ners of the wound.  And yet, when, after the completion of the
operation, no  iris could be detected in the wound, and even
when the sphincter edges were  clearly visible in the anterior
chamber, it has happened that some days later a small prolapse
of iris made its appearance.   The unpleasant consequences of
these angular incarcerations have been pointed out by many
operators.   My experience on the course which these prolapses
may take is  as follows.
   1.  A  great number of them have  no marked effect on  the
healing of the  wound, nor on the result of the operation, and
remain permanently quiet.
   2.  Man)- others cause irritation : injection and swelling of the
tissue around the corner of the wound, turbidity of the aqueous,
plastic iritis, pupillary membranes.  Sometimes a  cystoid scar
forms around them, and remains, for a long time,  subject to re-
lapses of acute inflammation, lasting between 4 days and a week.
I have not seen that glaucoma develops from this condition.
To avoid any injurious consequences arising from  these small
incarcerations of iris, I  have of late always removed them as
soon as they showed any inflammatory irritation.  This I did as
early as three days  after the extraction,  and at any period
afterward,  whenever they  became troublesome.  The little
operation is easy, and I  have never seen any bad results from it.
With a Graefe's knife I freely split the conjunctiva which covers
the prolapse, seize the iris with a pair forceps, draw it out as far
as possible,  and cut  it  close to  the  sclerotic.  The aqueous
humor always escapes.   When the imprisoned iris is markedly
raised, it may be better to cut it away as any other small sta-
phyloma, but it will be  necessary to remove, with a forceps, all 
H. Knapp : Cataract Extractions.
95
the iris  that is  left in the wound.   Incarcerated  iris  of  many
years' standing need not detain us  from performing operations
for secondary cataract, should any such become advisable.  On
a case of that kind I operated only a few weeks ago.   The two
eyes of an old lady, Mrs. B.  Fife—Nos. 93 and 94 of the table—
had been operated on three years and a half previously with good
result.   Two months ago she returned, complaining  that, of
late, she could not see so clearly as at first.  Thin, irregularly
dense membranes spread across both pupils, and the vision was
reduced to pp^.  In each eye there was a  small prolapse  of
iris in one corner of  the wound.  That of the  right was  about
as large as a pin-head,  that of the  left was  smaller.  Through
both  pupillary  membranes a crucial incision was  made with a
broad sharp needle.  No reaction in the eyes; pupils splendid.
On the third day, the prolapse of the right eye and its surround-
ings began to be red and a little raised.  This  condition  was a
little more pronounced on the fourth day.  I, therefore, removed
the protruding iris in the manner above described, and in 4 days
all irritation was over,  S. was f-g- in the right and  f-g- in the left
eye.
  3. In some cases purulent iritis occurs a long time after  the
operation.  Dr. Steffan  described such a case.  (Report  of his
Ophthalmic Institution,  1873 to 1874.)  A woman of 63 years of
age had  been operated on for cataract by Von Graefe's method
with excellent result, but iris was inclosed in one corner of  the
wound.   Two  years  and four months  later the  eye was  de-
stroyed  by spontaneous purulent  irido-cyclitis, the cause  of
which, as Dr. Steffan alleges, was the incarceration of the iris.
  A similar case  came  under  my care last year, in which  the
impending destruction  of the  eye  was  averted by immediate
removal  of the prolapse.  As the case  seems to be of great im-
portance, both as to the pathology and therapeutics of the con-
ditions under consideration,  I will report it in detail.
  James O'Neil, of  New York, ret.  44, in Oct., 1874, had been operated
on his right eye for cataract, according to Von Graefe's method (Case
134).  A  small prolapse of  iris at the outer corner remained, causing no
disturbance.  The vision at the  time of his discharge from the Hospital 
96
H. Knapp :  Cataract Extractions.
was -f-g-, and soon increased to \%.   Several times, after an exposure, his
eye was a little red and sensitive, but always became well again in a day
or two.   On Jan. 26th, 1876, however, he took a severe cold by wetting
his feet.  In the night he  felt intense pain in his eye, which continued
during the next  day, with rapid diminution  of sight.  I  saw him at
8 p.m. on Jan. 27th, that is, 30 hours after the exposure.   His eyelids
were red and greatly swollen, the  conjunctiva  chemotic, and there was
copious,  hot, sero-purulent discharge.   The prolapse  of iris  and the
surrounding tissues were  swollen and  yellowish-white.   The  iris was
greenish, the pupil narrowed  and completely plugged by a yellowish
dull  substance ;  the  aqueous was turbid;  there was  hypopyon of two
millimetres in  height.  The tension  was  increased, and the vision re-
duced  to mere perception of light.   I was  convinced  that the incar-
cerated  iris, acting  like a foreign body, was the starting point  of the
purulent iritis.   The inflammation, I imagined, produced  in the pro-
lapse similar conditions as we witness in strangulated hernia.   Believ-
ing that  only the immediate removal of the imprisoned and inflamed
part could save the organ, I at once went home, called my assistant, Dr.
A. Alt, and with him performed the operation, half an hour later.  The
swollen prolapse was freely incised, seized with the forceps, drawn for-
ward, and cut away.  The anterior  chamber was emptied.  I  applied
the  ordinary  flannel-charpie  bandage, and  ordered  instillations of
atropia.  The  patient felt  at once relieved.   His pain had disappeared.
He passed a good night.   When I saw him the next morning, the swell-
ing of the  lids had  diminished,  the hypopyon had disappeared, the
chemosis and  the plugging of the  pupil were as  the day  before ; the
wound was whitish infiltrated; the tension of the globe  had become
normal;  sight  no better.   During  the  next two  days the symptoms
somewhat abated.   I ordered five leeches to the temple, and a thorough
aperient.  The fourth  day no  oedema of lids, pupil still  cloudy, Tn,
S ^ ; wound bulging; but patient felt  comfortable,  and the discharge
was purely serous.  From that time the improvement progressed stead-
ily ;  the  wround  collapsed, and  the pupil gradually cleared  up from
the sides.  On  the  7th  of February, the prolapse had disappeared, the
wound was closed, the anterior chamber had  its  natural depth.   The
patient could count  fingers at the distance of half a foot.   There was
still  intense circumcorneal injection, and the iris still  looked dull and
discolored.  I again ordered  the application of leeches to the temple.
From the 9th, there was a steady subsidence of all the symptoms.   The 
H. Knapp :  Cataract Extractions.
97
pupil  became black, the sclerotic  white again.   On  February  19th,
twenty-three days after the operation, he could count fingers at the
distance of three feet;  on March the 2d, at twenty feet; on March the
23d. S was yVg- and f %.  Four weeks  later, that is, three months after
the operation, it was f-g, and his eye  was  free from all irritation.  A
slight  pupillary opacity was left. The cataract in his other eye was then
removed  (case 183), resulting in S=-|-g- after two weeks, and f|- after
six weeks.  He has had no annoyance from either eye since.
   The case is certainly one of the most suggestive of the whole
series.
                   The Division  of the Capsule
was always done with  a  cystotome,  the point of which was
passed  first along one  side of the remainder of  the  natural
pupil and its  extension, then  along  the  other side,  and  the
periphery of the capsule behind the coloboma.  The cystotome
was then pushed again to the lower edge  of the pupil, slightly
turned, so as to grasp  the  circumcised  quadrangular piece of
capsule  and extract  it.  Sometimes the little piece of capsule
was on  the  point of the instrument, and  could, by  the  micro-
scope, be identified.  When the centre  of the  capsule  was
thickened, and, after its circumcision, did  not come  out on the
point of the cystotome, it was extracted with a pair of delicate
forceps.   In the  majority of cases the circumcised  piece  of
capsule  came out together with the cataract.  Even if we did
not find it, its  absence  from the eye  could be  demonstrated
afterward by oblique light,  which rendered the edges  of the
capsular defect quite conspicuous.
   The reactive  processes on  the part  of  the lacerated  capsule,
to which I have always paid a good deal of  attention, are quite
frequent, and in some cases very serious.  They shall be spoken
of hereafter.
                   The Expulsion of the Lens
was effected by pressing with a  rubber spoon on the lower edge
of the cornea, at first directly toward the centre of  the globe,
then following the passing cataract so as  to evacuate, if possible,
nucleus and cortex together.  During this time I facilitated the
opening of the wound by  gently pressing the  posterior  lip
backward, while an assistant steadied  the  globe with a pair of 
98
H. Knapp :  Cataract Extractions.
fixing forceps.  When I  found  that the  capsule was  freely
divided and the exit of the cataract retarded by an insufficient
section, I enlarged the wound at one  corner with a strong and
sharp  pair of  strabismus scissors.*   Sometimes the conjunc-
tival flap is an obstacle to the ready slipping out of the lens, and
should, in such cases, be incised with scissors.
         The Removal of Remnants of Cortical Substance
was always effected by rubbing with the lids in the well-known
manner; never was a Daviel's spoon or any other instrument
introduced into the eye for that purpose.  I prefer leaving some
cortex in the eye to attacking it with a  spoon.   My experience
from the days when I  used a Daviel's spoon has been that those
remnants which  I was not able  to remove by rubbing,  could
also not be removed with the spoon.   I  dread scraping the
interior of an eye, however gently people tell you they can do
it.  Sometimes a piece  of thickened capsule, with  some lens
matter adherent to it, was, after the exit of the cataract, removed
with a pair of Mathieu's forceps.
  In eleven cases  the
    Cataract zvas removed together with the Unbroken Capsule.
  This procedure, I  think, is indicated when the suspensory
ligament is torn or frail,  as in tremulous and certain hyperma-
ture cataracts,  which  may be recognized by  a hydrophthalmic
condition of the globe, abnormal depth of the anterior chamber,
slight dislocation  of the lens.  In some  cases the  former con-
dition of the eye, if known by previous examination, for instance
high  degrees  of  sclero-choroiditis,  synchisis  corporis  vitrei,
furthermore the comparison with the other eye, and so forth, will
aid the diagnosis.  In such cases I make the section very large and
less peripheric than usual, in order to avoid or restrict, as  much
as possible, the prolapse  of vitreous.  In one case the lens was
removed with a large spoon; in the ten others, the crystalline
body  was removed without the introduction of a traction  in-
strument.  After  the section had been  completed and  the

    * There are more bad strabismus scissors in the world than good ones, and it is
not quite easy to find such as will  answer the requirements of enlarging a cataract sec-
tion without bruising. 
H. Knapp :  Cataract Extractions.
99
iridectomy made, the eye being steadied with  fixing forceps by
an  assistant, I held the posterior  lip of the wound  backward
with a large spoon, and expelled  the lens in the usual manner,
by  pressure upon the cornea from below  upward.   The results
of these operations, considering the unfavorable conditions of
the cases, were rather satisfactory.   One eye was lost, in another
the vision obtained  was moderate (-giro),  in the nine others it was
good.  The following  synopsis will afford an easy  review of
these rather difficult cases.

  No. 109. Pat. 71 years.  Capsule resisted Weber's double hook.  Lens
with capsule extracted by large spoon.  Escape of vitreous.   Reaction
slight.  S f £.
  No. 115.  Pat. 25  years.   Cataract half-soft.   Vitreous presented
after  iridectomy.  Lens with  capsule extracted,  considerable loss of
vitreous.  No reaction.  S -fifo.
  No. 119.  Pat. set. 26.  Extr. with capsule.  No prolapse of vitreous.
No reaction.  S. f$ after  19 days.
  No. 124.  Negress,  aet.  60.   Escape  of vitreous  after exit of lens.
Healing without disturbance. Floating opacities  in vitreous.  S -g2^ in
32 days.
  No. 131.  Decrepit  person,  set. 80.    Cystic  cataract of  40  years'
standing.   Prolapse of a moderate  quantity  of vitreous.   Suppurative
iritis and hyalitis. Occlusion of pupil. Perception of light only preserved.
Failure.
  No. 136.  Patient 64 years  of age.  Cataract hypermature.  Escape
of a single drop  of vitreous.   No reaction.  Vision f-g-, 18 days after
operation.
  No. 148.  Pat.  aged  50, of  Brooklyn.   Subject  to articular rheuma-
tism.   No accident during operation.   Iritis and hyalitis set it on fifth
day ;  improving in third week.   A new attack of articular rheumatism
in third week.  Discharged on  21st day with S T^.  Result moderate.
Patient died of rheumatism six weeks afterward.
  No. 169.  Pat.  aged  54.  Cataract hard and shrunken;  capsule irreg-
ular.  Slight prolapse of vitreous.   No reaction.  S  yVV  at time of  dis-
charge, 15 days after operation; fg- two months later.
  No. 170.  Pat.  aged 58; chronic dacryo-cystitis.   No accident.  No
reaction.  S fg at  discharge.
         7 
ioo             H. Knapp : Cataract Extractions.
   No. 174. Pat. set. 72.  Cataract hard, ripe.   No accident, no reac-
 tion.   S -f-g- at discharge.
   No. 190. Pat. aged 90.  Hydrophthalmic eye.  Considerable loss of
 vitreous.   Very tardy closure of wound, S -gfa without a glass, 32 days
 after extraction ; f-g two months later.   Reading glass  + y.   Extensive
 atrophic patches of choroid, and floating opacities in both eyes.

     INCIDENTS DURING THE OPERATION,  AND THEIR CON-
                         SEQUENCES.

   Among the 200 operations 150, that  is 75^,  were  perfectly
 smooth and without any unusual features.   In 97, that is in 65$,
 of these  150 smooth operations, recovery took place without any
 inflammatory or other disturbance.
   The primary results  of the 150 smooth  operations  were 127
 good  results,  15  moderate  results, and 8 failures.   Of the 15
 moderate results 8 were, by  after-operations,  converted into
 good results, and one into a failure.   Of the 8 failures ii. e., S ~)
 two were converted, by after-operations, into good results, so that
 the final statement of the 150 smooth operations was as follows:
       Good results: 136 eyes, i. e., 90.6^.
       Moderate results: 7 eyes, i. e., 4.7$.
       Failures: 7 eyes,  i. e., 4.7/0.
 Of the 200 extractions 50,  that  is  25$, were anomalous, i. e.,
 accompanied with accidents.   In  12 of them, that is in 24^, the
 recovery was undisturbed by inflammation or irritative reaction
 of any kind.
   The primary results  of the 50  anomalous operations were:
 good 23, moderate  10,  failures 17.   After-operations converted
 1 failure into a moderate, and 5  moderate into good results, so
 that the  final statement  of the complicated operations was:
       Good results: 28 eyes, i. e., 58$.
       Moderate results: 6 eyes, i. e., 10$.
       Failures:  16 eyes, i. c, 32^.
   If we  put  these numbers  together in  a table,  a comparison
 will show, at a glance, how much the rate of success is lowered
by accidents during the operation. 
H. Knapp :  Cataract Extractions.
101
Operations.		Recovery :		j Good.	Results :	
		Smooth. Disturbed.			Moderate.	Failures.
Smooth,	!5° ; 75$	j 97; ^	53 ; 35^|II36; 9°-6<y		7; 4-7$	7; 4-7$
With acci-dents,	50 ; 25^1 12 ; 24$		38 ; 76$ 9i; 45-5$	28556$	6; i2f*	16; 32$
Total,	200; 100$	,io9; 54-5		164; 82$	13; 7-5$	23; ii-5£
  This statement of 4.7^ of failures after smooth operations, and
32^  after  operations  accompanied by  accidents, would be a
severe verdict against the operator, were all the accidents his
fault.  Some of  the accidents are  unavoidable, or almost un-
avoidable ; for instance, hemorrhage  from the iris, or- into the
vitreous (no example in our present series of cases), the numer-
ous more or  less prejudicial incidents and manoeuvres intrinsi-
cally connected with the removal of hypermature and complicated
cataracts, as the introduction of  traction instruments with all
their bad consequences.  The extraction  with the capsule,  for
certain cataracts the least hazardous operation, is almost always
accompanied by loss of vitreous.   In the preceding tables are
counted  even the slightest  incidents during the  operation that
could possibly have any influence on the cure.  That they may
be compared with other publications  the basis  of  which  is
different, I will put them together in  groups, and  add such re-
marks as appear of interest and importance.
           Synopis of Incidents during the Operation.
  1.  In   case  154,  a part of  iris  near the periphery fell before
the knife and was cut off.  Lens large.  Purulent iritis.   S I..—
Cutting  of a  central part of the iris is commonly done without
much harm ;  cutting of a peripheric part may be more dangerous,
since the iris is pressed against the hard  sclerotic and into the
wound.   1 would,  in such cases,  try  to extend  the iridectomy
beyond the bruised part of the iris. 
io2              H. Knapp : Cataract Extractions.
  2.  In case 126, unusually copious hemorrhage  followed the iri-
dectomy.  It  was finally  arrested  by emptying  the  anterior
chamber, in pressing  upon the cornea with a blunt instrument,
while a sponge was held on the wound.  Pupillary membrane.
S s-^.   Discission.   S y^-.  I am particular in removing blood
from the anterior chamber.  It makes the subsequent steps of
the operation uncertain, thus giving rise to accidents.
  3.  In 3 cases the capsule zvas opened by the knife on its passage
through the anterior chamber.   All did well.—As this opening
is commonly insufficient, it should  be enlarged with the cysto-
tome after the iridectomy.
  4.  In case 108, a small part of the anterior lip of the wound was
cut away in cutting  the iris.  The wound united slowly, and
there was partial infiltration of the cornea.  Though the result
was  good, the reaction showed that the  accident was not in-
different, and that we should be careful to avoid it.
  5.  In case 32,  a good deal of rubbing of' 1Pie lids over the cornea,
in order to remove remaining cortex, led to purulent infiltration
of  the edge of  the flap.  A  moderate degree of rubbing is
commonly done without bad consequences, and is certainly less
injurious than to try to remove the remnants with a Daviel's
spoon.—Result good.
  6.  Case  114.  Degenerated iris drawn out piecemeal and cut off.
Cataracta accreta.  Trachomatous pannus.   S -g^.  Operative
result  excellent.—It  is known  that a cornea suffering  from
pannus has little tendency to slough.
  7.  In 3 cases—55, 82, 101—a part of the iris, bordering on the
coloboma, was pushed out of the  wound by the passing lens, and evi-
dently bruised.  Violent iritis followed in each case.   In one (82),
S=o;  in the other (55) S A, later ^;  in the third  S ^, raised
by an early iridectomy to -f-g-.—I make it a rule in such cases to
extend the iridectomy, after the  exit of the lens, so as to remove
the bruised part of iris.
  8.  In 4 cases—19,  120, 128,  158—the lens was extracted  with
a sharp hook.  In all of them prolapse of vitreous occurred.  In 
H. Knapp : Cataract Extractions.
103
two  there was no reaction, in  the other two the reaction was
moderate.   S good in 3 cases;  moderate in 1.
  9.  In 6  cases—1, 17, 34, 49, 103, 109—the lens  was extracted
with a large spoon.  In one—103—it was done without loss of
vitreous, in the other five vitreous escaped.   In one—109—there
was only slight irritation ;  S f-g-.  In the second—17—the union
of the  wound was  tardy ;  S f-g-.  In the third—103—hyalitis set
in on the  5th day,  getting well, with  S -^w.  In the fourth and
fifth—1, 49—destructive irido-cyclitis ensued ; S I, S o.   In the
sixth—34—the union of the wound  was very slow,  a  bead of
vitreous held  the wound  gaping for 6 weeks.  It was touched
with nitrate of silver 6 times without much reaction.  On  the
seventh touching,  purulent hyalitis set in, followed by phthisis
bulbi.  Occasional clipping of the prolapsed vitreous with the
the scissors, and persistent bandaging seem to  be the proper
treatment of such  cases.
   Half the cases, in which a large spoon  was used,  were lost.
In former years I made similar experience.   I, therefore, employ
the spoon only as  a last resort.
   10. In 4 cases—6, 125,  145, 146—the section  was too small,
making the further steps of the operation  difficult and impure.
In No. 6  considerable rubbing had  to be done to remove  the
tenacious cortex.   Ring-abscess and panophthalmitis followed.
In  Nos. 145  and  146, the smallness of the section made  the
expulsion of  the  lenses difficult and unclean, cortical matter
remaining behind.   Panophthalmitis in both. In case 125 fluid
vitreous escaped immediately  after  the small section;  the lens
was drawn out with a sharp hook, some cortex remaining.
Panophthalmitis.   These  four cases exemplify  the injurious
effect  of an insufficient section in its worst light, but there are
many  cases in which comparatively  little  and even no damage
is done to an eye  by a small section.  A  healthy eye bears an
incredible amount of injury, witness the great number of trau-
matic  cataracts, where  small, irregular,  and often  lacerated
wounds of the cornea with prolapsed iris lead to  absorption of
the  lens  with astonishingly slight  reaction. But cataractous
eyes are not healthy eyes, they bear less injury, and, therefore, 
104
H. Knapp :  Cataract Extractions.
the surgeon's constant  endeavor should  be to extract the lens
with as  little injury as possible, and since  experience shows
that an insufficient section entails a multitude of dangerous con-
ditions, it  is one  of the greatest, if not  the  greatest, fault an
operator for cataract could commit.
   n.  9 cases (3, 21, 24, 42, 53, 85, 99,  100, 150, 164)  were  noted
in which more or less cortical substance remained in the eye.  Two
of them (164 and 21) were lost  by purulent iritis and keratitis.
The others showed more or less intense reaction, but recovered
good  sight, except a case of zonular cataract (85), in which
irido-capsulitis produced dense false membranes which,  after an
iridectomy, yielded only S ^hr-
   12.  Prolapse of vitreous was the only or gravest accident in  16
cases (28,50,63, 115, 124, 131,136, 141,  161, 162, 169, 172, 173, 175,
178, 190).  In 7 there was  no reaction, and sight  was excellent.
In 3 cases floating opacities, with good vision, were noted.   In
1 case iritis and a  pupillary membrane gave vision only g-g-g ; in
another, intense  iritis  was well cured with S -^w.   In  the
remaining 4 cases suppuration  in the  vitreous ensued with loss
of sight.   Besides these  16 cases, there was  loss of vitreous in
10 others where it was accessory to accidents mentioned before,
such  as  extraction of the  lens with a hook  or spoon.  There
were,  on the whole, 13% of  the  operations  complicated with
escape of vitreous.  This, however, should not be mentioned as
a  drawback to Graefe's operation, nor does  it argue personal
carelessness or lack of skill, since prolapsus vitrei  is almost an
inherent incident to certain operative procedures, for instance,
the extraction together with the  capsule.   If we  deduct  the
cases (9 in number) in  which the extraction  with  the  capsule
was originally decided upon  and performed accordingly, only
8.5^ should be mentioned  as complicating Graefe's  operation.
   For the  sake of a comprehensive review of the  incidents of
the operation and their consequences,  I  will put them in a
tabular statement. 
H. Knapp : Cataract Extractions.
105
Nature of Accident.
H
*

S
Recovery
Result :
 1. Peripheric part of iris fell before knife
    and was cut off,......
 2. Copious hemorrhage after iridectomy
 3. Capsule opened by knife,   .  .   .
 4. Part of anterior lip of wound cut away
    with iris scissors,......
 5. Unusual degree of rubbing to expel
    cortex,.........
 6. Degenerated iris drawn out in pieces
    and cut off, ........
 7. Iris bruised by passing lens,  .   .
 8. Lens extracted with sharp hook (pro-
    lapse of vitreous in all), ....
 9. Lens extracted with large spoon  (loss
    of vitreous in  5),......
ro. Sec. too small  (loss of vitreous in 1),
11. Cortical substance left in eye, •  .
12. Escape  of vitreous  (not mentioned
    previously), ........
 6
 4
 9

16
Total,
5°
_3»
15
  The study of the
                 REACTIVE  PROCESSES
which follow the extraction of cataract are of particular impor-
tance, and I may, therefore,  be allowed to describe them more
in detail than 1 did  in  my  former  reports.  In  the  following
tabular  statement I have put together, in sixteen groups, all
the anomalous features  in the  course of healing  that had been
noted in the cataract journal.   I  have not mentioned  such as
are of normal or almost normal occurrence, and  do not influence
the result, such as the ordinary  striped keratitis,  slight circum-
corneal injection from hyperemia of  the iris leaving  no syn-
echia, nor the non-inflammatory thin obstructions of  the  pupil
dependent  on imperfect removal and wrinkling of the capsule,
nor injection  and swelling of the conjunctiva, if it occurred in
an eye otherwise recovering without disturbance. 
106              H. Knapp :  Cataract Extractions.
  The  anomalous  reactive processes, their  relative frequency,  and
the visual results which they yielded, may be seen in the following
table.
Nature of Reactive Processes.	Frequency.	Results :		
		Good.	Moderate, failure. 1	
I. Tardy closure of wound,	7	6		1
II. Reopening of wound,	4	4		
III. After-hemorrhage into the anterior chamber,	6	6		
IV. Cystoid scar,	3 !| *		2	
V. Incarceration of iris,	4 i! 4			
VI. Deep-seated keratitis,	i	1 j		
VII. Simple iritis,	21	17	2	2
VIII. Spongy iritis,	5	5		
IX. Simple capsulitis,	5	4	r	
X. Simple hyalitis,	6	5	1	
XI Cyclitis and irido-cyclitis,	5	1	1	3
XII. Partial suppurative keratitis	6	5		1
XIII. Total suppurative keratitis	4			4
XIV. Purulent iritis,	8	1	1	6
XV. Purulent capsulitis and capsulo-iritis,	2	1		1
XVI. Suppurative hyalitis,	5			5
Total,	92	61	8	23
 
H. Knapp :  Cataract Extractions.             107
  The sum total shows  that almost  half the cases  (46$), were
followed by some  reactive process  or other.  Many of them
were insignificant, and did not materially interfere with a good
recovery.   I have arranged the different groups in such a way
that the  severer forms follow the milder,  the severest—the sup-
purative inflammation—occupying the last place.  The table
may give some estimate of the relative danger connected with
the different reactive processes, and  on that account  be of use
to the practitioner in framing the prognosis, and directing the
treatment of the reactive processes here described.  The visual
result does not, however, solely depend on the nature of the re-
active processes, but on the quality of the cataract, the incidents
of the primary  and  the success of  the after-operations.  The
dependence  of  these conditions  upon  one  another,  and  a
short description  of the disturbances of  the healing process in
each case, arranged  according to the groups in the preceding
table, will be found in the following tabular statement, which is
intended to afford easy reference and  facilitate the study of
the reactive processes following Graefe's extraction, for which
reason some repetition will, I trust, be  pardoned.  The  num-
bers  in  the second column  refer to the general table, where
more information may be found, if desired. 
io8
H. Knapp: Cataract  Extractions.

^
Nature of Reactive
     Processes.
Quality	Incidents	Primary
of	of Oper-	Result.
Cataract.	ation.	S.
  After-
Operations.
 Final
Result.
   S.
17
34
"3
H5
167
7   190
1     3
I.  Tardy Closure of
       Wound.
 No irritation.
  Part of wound held open
by a small bead of clear
vitreous.  From 12th  to
36th day 7 times touched
with nitrate of silver ; six
times it produced no irri-
tation, the seventh was fol-
lowed by  suppurative hy-
alitis.

  No irritation.
  Inner corner of wound
bulging after violent fit of
coughing.

  Wound  closed on  3d
day,  reopened  on  4th,
closed on  6th.   Floating;
opacities in vitreous.
No irritation.
  Very tardy closure, by
intrusion into the wound
of  transparent  vitreous
which was repeatedly cut.

   II. Reopening of
       Wound.
  Hurt eye on  nth day,
wound  ruptured,  closed
again in 2 days without
irritation.
Hyper-mat ure.	Extrac-tion with	Too"
Thick-e n e d capsule.	spoon. 1 or 2 drops of vitre-ous.	
Com-plicated.	Escape of fluid vitreous. Spoon.	n
Hard,		m
ripe.		
Ripe.		n
Half-soft	Extr. with cap-sule. Es-cape of vitreous.	rVo"
Hard,		' f»
ripe.		
Com-plicated.	Escape of vitre-ous.	200
Hard, ripe.	Cor-tex and blood re-mained.	*>&
n 
H. Knapp: Cataract  Extractions.
109
^5
Nature  of Reactive
     Processes.
 5   Spontaneous reopening
   011 3d  day,  closed again
   the following night.

42,   Traumatic rupture of
   wound  on 7th day, follow-
   ed by escape of vitreous
   but no  bad consequences
130
13
31
35
139
140
14
  Hurt  eye  violently  on
6th day, rupture of wound ;
hemorrhage into anterior
chamber, gradually  ab-
sorbed.   Synechiae and
pupillary membrane.
III. After-Hemorrhage
   into the Anterior
       Chamber.
  Pat. hurt his eye, on 3d
day, while  bandage was
changed, hemorrhage into
anterior  chamber, disap-
peared in a few days.

  Hem.  on 4th day ;  ab'
sorbed in six days.

  Hem. on 5th day.  Ab-
sorption. Irido-cyclitis 4^
years later.

  Hem.  on 4th day,  ab-
sorbed in 3 days.

  Hem. in both eyes ; fol-
lowed in right by thin pu-
pillary membrane.

  IV. Cystoid Scar
Cystoid  scar  in  innner
corner of wound, causing
no irritation.

  Slow  healing, cystoid
protrusion  of scar, syn-
echice, pupillary obstruc-
ts™  in  both eyes of an
   negress.
tion
old
Quality
   of
Cataract
  Hyper
mature.
  Com
plicated.
   Hard
ripe.
   Hard
ripe.
   Hard
 ipe.

  Hyper
mature.
   Hard
ripe.

  Hard,
  ripe,
  both.
  Imma-
ture.
  Hyper-
mat u r e
(both).
Incidents
of  Oper-
  ation.
Primary
 Result.
   S.
  After-
Operations.
 Final
Result.
  S.
	n		
Some	TOO		n
cortex			
left.			
	A	Discission.	f¥o
	n		
	*#		
	n	Division of wrinkled capsule, 18 months.	
	n		
			T015
Capsule	TiPo	Discission.	S*
opened			
with			
knife.	TOT Mo		
 
no
H. Knapp :  Cataract Extractions.
3^
Nature  of Reactive
     Processes.
 Quality
   of
Cataract.
Incidents
of Oper-
  ation.
Priviary
 Result.
   S.
  After-
Operations.
 Final
Results.
   S.
133
134
 V. Incarceration of
          Iris.
  Iris imprisoned in one
corner of wound, causing
no annoyance.
53
58
59
60
63
  Imprisoned prolapse of
iris  in one  corner  of
wound, causing irritation
of iris, was cut off on 5th
day.  Rapid recovery.

  Small  incarceration,
causing acute suppurative
   is   18   months  after
operation.   Eye saved by
immediate  removal  of
imprisoned iris.

VI. Deep-seated Kera
          titis.
  The posterior layers of
the  urjper  and  centra-
parts were opaque.   Pos-
sible cause scraping with
cystotome.
 R.  Hy-
p e r m a-
ture.  L.
Hard,
ripe.

  Hyper-
mature.
   Hard
ripe.
Hard.
VII.
Simple (plastic)
  Iritis.
  Leaving dense pupillary
membrane.

  Pupillary   membrane.
(Prospects  of  secondary
operation very good).

  Dense pupillary mem-
brane.

  Pupillary membrane.
   Hard,
ripe.

   Hard,
ripe.


   Hard,
ripe.

   Hard,
ripe.
n
   Blood
and  cor-
tex left.
  Escape
of vitre
ous.
t<?o~
wty
   Division
of sec. cat-
a r a ct  3 ^
years  later.
  Removal
of prolapse
Iridecto-
my.
Division.
  Triangu
lar  iridoto-
my  with
scissors.
Panoph-
thalmitis. 
H. Knapp:  Cataract  Extractions.
in
•S^


^>
■v>



^
Nature of Reactive   \    0 +
                      Cataract.
Processes.
Incidents
op  Oper-
  ation
Primary
 Result.
   S.
  After-
Operations.
 Final
Result.
  S.
74
84
99
117
118
r3


M

15


16


17

18


19
Closure of pupil.



Pupillary membrane.


Some synechiae.
  Pupillary  obstructions
in both.
129


134


141



M7


150

158


161


168

171


180
Mild iritis. No sequels


Closure of pupil.


Mild.



Closure of pupil.


Mild  iritis.

Mild  iritis.


Intense iritis.


Mild.

Mild.
   Hard,
ripe.


  Com-
plicated,

   Hard,
ripe.

  Hyper
ma ture
(both).

   Mor-
gagnian.

    Hard,
 ripe.

    Hard
 ripe.
   Hard,
ripe.

Half-soft

  Imma-
ture.

  Hyper-
mature.

   Hard
ripe.
  Hyper
mature.
F. -f com-
plete.

  Ms
  Som e
cortex
left.
  A few
drops  of
vitreous
  Mild.   Thin  pupillary
membrane.

  Mild.
  Iritis.   Set in a  week
after extraction.
   Hard,
ripe.

   Hard,
ripe.
Hard,
ripe.
 2 a
 oO

JUL
Division.
   Division
(both).
Iridecto-
my.
Iridecto
my.
Division.
i-S
1%

T0%
n 
ii2                  H. Knapp : Cataract Extractions.

Nature of Reactive
    Processes.
Quality	Incidents	Primary
of	of Oper-	Result.
Cataract.	ation.	S.
  After-
Operations.
 Final
Result.
  S. ■
41
73
105
23
116
126
 VIII.  Spongy Iritis.
  Spongy exudation on 3d
day, absorbed in 10 days.

  Spongy exudation ;  Iri-
tis ; slight synechiae.

  Spongy exuda'.ion. Ab-
sorption leaving some cap-
sular  opacities.    Three
weeks after his discharge
capsulitis with hypopyon.
Recovery.

  Marked  spongy exuda-
tion.  Absorption began
on the 5th day ; pupillary
membrane.

  Spongy ex. on 4th day,
lasting 5 days.

IX- Simple and Plastic
       Capsulitis.
  Plastic capsulitis. Blood
in pupil.   Pupil large.

  Plastic capsulitis, travel-
ling around edges of colo-
boma, leaving  centre of
pupil free.

  Plastic irido-capsulitis ;
pupillary membrane.

  Plastic capsulitis ;  pu-
pillary membrane.
  Irido-capsulitis
lary membrane.
pupi
Soft, ripe.		1UV
Hard, ripe.		3fV
Hard, ripe.		m
Imma-ture.	Cortex & tough capsule remain'd	1 Q-too
Half-soft		^0%
Hard, ripe.		-#0-
Hard, ripe.		"sroHr
Hard, ripe.		m
Hyper-mature.	Remo-val of part of anterior, lacera-tion of posterior capsule.	TtW
Hard, ripe.	Unusu-al hemor-rhage af-t e r i r i-dectomy.	.10. zoo
 Crucial
incision.
Pros-
pect
good.
Division.
Iridecto-
my.
Division 
H.  Knapp : Cataract Extractions.               113
	8 "•si						
	"^8	Nature of Reactive Processes.	Quality of Cataract.	Incidents of Oper-ation.	Primary Result. S.	After Operations.	Final Result. S.
e^							
		1	-. -,..-_:=-				
		X. Simple Hyalitis.					
I	105	Opacity of vitreous, first visible on 5th day ; slow, but good recovery.	Hyper-mature.	Extrac-tion with large spoon; no escape of vitre-ous.	m		
2	119	Diffuse opacity of vitre-ous. Perfect recovery.	Soft.	Extrac-tion with capsule.	n		
3	124	Diffuse and formed (floating) opacities in vit-	Hyper-mature.	Extr. with cap-	2Q TOO		
		reous. Recovery from in-		sule.			
		flammatory symptoms in					
		30 days.					
4	148	Opacities in vitreous distinct on 5th day. Iritis subsequently. Pupillary obstruction.	Com-plicated.	Extr. with cap-sule. No instru-ment in-troduc'd. No es-cape of vitreous.	"zthi		
5	157	Mild, but very obsti-nate (34 days) irido-hya-litis.	Hard, ripe.		'ro%		38
6	178	Floating opacities in	Ripe.	Escape	!»		
	vitreous when discharged.			Of a few drops of			
	XI. Cyclitis and Irido-			vitreous.			
	cyclitis.						
1	1 Very painful hyalitis		Hard,	Escape	1		1
	and irido-cyclitis. From		ripe.	of vitre-	00"		oo
	l^th to 10th day +Ti ;			ous. Ex-			
		after six weeks eye quiet.		traction			
		-Ti.		with large spoon.			
2	49 Cyclitis. 4thday:yel-		Imma-	Knife	1		0
	llowish reflex from well-		ture.	blunt	"00		
		dilated pupil. 10th day ■		escape oi		!	I
 
ii4
H. Knapp :  Cataract Extractions.
c2^
Nature of Reactive
     Processes.
Quality	Incidents	Primary
of	of Oper-	Result.
Cataract.	ation.	S.
  After-
Operations.
 Final
Result.
  S.
		synechiae. 16th day hem-		vitreous.			
		orrhage i n t 0 anterior		Ext r ac.			
		chamber ; 19th day : hem-		with			
		orrhage repeated, iris		large			
		bulging. 39th day: eye		spoon.			
		shrunken.					
3	85	Recurrent capsulitis and	Zonu-	Trans-	2T)"0~	Iridecto-	"Z"§TT
		irido-cyclitis. Iris un-	lar cata-	p aren t		my.	
		even. Dense secondary	ract in	c ortex			
		cataract.	person 43 yrs. old.	left.			
4	166	Irido-cyclitis. Closure of pupil. Indrawn scar.	Mor-gagnian.		I 00"		
5	187	Irido-cyclitis. Iris in one place considerably bulging. Centre of pu-pil remained clear. Bulg-ing disappeared. XII. Partial Suppura-tive Keratitis.	Hard, ripe.		M		H
i	21	Purulent infiltration of	Hard,	Cortex	I		
		corneal edge of wound.	ripe.	left.	oo"		
		Slow iritis. Closure of					
		pupil.					
2	32	Partial suppurative ke-	Hard,	A good	2TJ0		n
		ratitis. Iritis.	ripe. deal of				
				rubbing.			
3	33	Severe partial suppura-tive keratitis. Absorp-tion. Iritis. Dense pu-pillary membrane.	Hard, ripe.		wo"	Iridecto-my.	n
4	61	Purulent infiltration of cornea in both corners of wound. Iritis. Pupillary membrane.	Hard, ripe.		?ita	Division.	m
5	101	Partial kerato-iritis. Tongue-like plug of pus descended from inner cor-ner of wound into ante-rior chamber. Inflamma-tion 35 days. Dense pu-pillary membrane.	Half-soft	A small piece of iris, caught in inner cor-n e r of wound, cut off.	*"&	Iridoto-my (on 30th day).	w
 
H. Kfiapp : Cataract  Extractions.
"5
8	
	
	
	£
*o	
^	<3
	
	
	
>	kb
Nature of Reactive
     Processes.
108
37
 Quality
   of
Cataract.
Incidents
of  Oper-
  ation.
Primary
 Result.
   S.
  After-
Operations.
 Final
Result.
  S.
  Part,  suppur. keratitis, Half-soft
mild.   Slow  closure  of
wound.
XIII. Total Suppura-
    tive Keratitis.
  Ring-abscess.  Panoph-
thalmitis.   Phthisis bulb.
  Suppuration  of cornea
beginning at inner corner
of wound.   Flat leucoma
(phthisis anterior).

  Suppuration  began  at
edges of wound 2d day ;
ting-abscessed day; pan
ophthalmitis.  (The other
eye operated on 15 months
previously.  Recovery
and vision good.)
87   Suppuration of cornea
   beginning in  corners  ol
   wound.  Panophthalmitis
XIV- Purulent Iritis.
55   Violent  iritis ; plug in
   pupil; hypopyon.   Dense
   pupillary membrane.
80
  Purulent iritis.
ophthalmitis.
Pan-
   Hard,
ripe.
  Part of
edge of
flap  cut
with scis-
sors.
  Section
small.
 Consid-
e r a b le
 rubbing
to  expel
cortex.
   Hard
ripe.
   Hard,
 ripe
(General
health
good).
  Hyper-
 mature.
 (Patient
 set. 79,
decrepit)
   Hard
ripe.
Hard
ripe.
  (A very
smooth
 Graefe's
opera-
tion. Im-
 mediate
visual re-
s u 11  ex-
cellent.

 (Periph
eric reg
ular sec
tion).
  Inner
border of
iris push
ed ouc by
 passing
lens.
5TO 
n6
H. Knapp: Cataract Extractions.
8 £
r<3 S

V.8
Nature of Reactive
     Processes.
Quality	Incidents
of	of Oper-
Cataract.	ations.
Primary
 Result.
   S.
 After-
aerations.
 Final
Result.
  S.
82
145
146
154
164
T93
44
  Purulent iritis, starting   Hyper
from inner border of colo- mature
boma.  Panophthalmitis.
  Purulent irido-keratitis
and  panophthalmitis
both.
  Purulent iritis.  Com-
plete closure of pupil.
Purulent iritis.
  On 3d day : iritis ;  5th
day :  pus in pupil and an-
terior chamber ;  6th day :
infiltration of part of flap.
Gradual  absorption.

 XV. Purulent  Capsuli-
 tis and Capsulo-iritis.

  Suppurative   and   he-
morrhagic  capsulitis,  be-
ginning at  upper edge of
capsule  travelling  all
around.   Repeated hem-
orrhages. Hypopyon.
Closure of pupil.  Tn.   |
  Hyper-
mature
(both).
   Ripe
large.
  Imma-
ture.
  Hard:
ipe.
ripe.
  Inner
border of
iris push-
ed into
wound &
 bruised
b y pass-
ing lens

  Section
small, ex
 pulsion
difficult.
Cortex
left be
hind,  ir
both eyes

   Small
 periph
ric  part
of  iris
 bruised
and cut
by  cata-
ract knife

  Expul
sion dif-
 ficult
Cortex
left.
Hard,  A quad-
      rangular
      piece of
       capsule
      cut   out,
      as usual.
0		
0		
0		
I		I
CO		co
I		
CO		
1 CO		2Q 2~0 0
I		
co		
 
H. Knapp :  Cataract  Extractions.
T17
c3^
198
A'ature of Heactive
     Processes.
 Quality
   of
Cataract.
Incidents
of  Oper-
 ations.
Primary
 Result.
   S.
125
131
172
173
175
  Capsulo-iritis, purulent
and hemorrhagic. Gradual
absorption.  Dense pupil-
lary membrane.

  XVI. Suppurative
       Hyalitis.
  On 3d day suppuration
in vitreous.   Panophthal-
mitis.  Atrophy of globe.
 Suppurative hyalitis and
iritis.   Pupil  closed.  F
complete.
  Suppuration in vitreous.
Great pain.   Indrawn
scar.

  Suppuration in vitreous.
Pupil closed.
 Suppuration in vitreous.
Pupil  closed by yellow
substance.
Hard,		1
ripe.		CO
Com-	Extrac-	0
plicated.	tion with hook. Consid-e r a b 1 e loss of vitreous.	
Cystic,	Extrac-	I
of 40 y'rs	tion with	CO
duration.	capsule, without introduc-t i 0 n of instru-ments.	
Com-plicated.	Escape of vitre ous.	I CO
Com-plicated,	Escape of vitre-ous.	I CO
Cora-	Escape	0
plicated.	of vitre-ous.	
  After-
Operations.
Iridecto
 Final
Result.
  S. 
n8
H. Knapp : Cataract Extractions.
  The foregoing table may suggest many reflections, but as  it
speaks for itself, I shall content myself with the following:
  I.  Of the seven cases in which a slow union of the wound  is
noted, four were distinguished by escape of vitreous during the
operation.  The best mode of treatment  seems to be  to keep
the eye  closed by a compressive  bandage until  the union  is
effected.  In case conjunctival irritation forbids the permanent
closure of the lids, the bandage may be removed for several
hours  during the  day, or during the night,  and  reapplied in
the morning.
  If  vitreous protrudes  through the wound, either  as a trans-
parent or a whitish mucoid substance, it seems best to cut it off
with a pair of scissors, in order  to remove from the wound the
foreign substance which  keeps it gaping, and  when protruding
exerts, during the movements of the eye, a certain  degree of
injurious traction.  Touching the  prolapse of  vitreous  or the
ununited part of the wound  with caustics seems  highly  objec-
tionable, a fact emphatically illustrated by case 34.
  All the cases,  except the  one  just mentioned, recovered.
That in many cases of slow closure of the wound—three to six
or more days—no reaction follows is well known, yet  I con-
sider such a condition not only  as anomalous, but  as decidedly
less favorable than the closure in the first or second  night, and
cannot in this point agree with Prof. O. Becker* who  thinks
" that the delayed  restoration of  the anterior chamber  is al-
most a favorable condition as to the final result."  If thesection
closes soon after the operation, the wounded internal parts are
protected from all external prejudicial influences, and the re-
covery under  such conditions seems to me 2.  great deal  easier
than with an open wound, just as an uncomplicated  fracture
presents  a better prognosis  than  one   that is  complicated.
Though I think that the  dangers from the infectious qualities of
the atmosphere and the conjunctival secretion have of late been
very much exaggerated, I believe that  foreign  substances  of
any kind act injuriously  on all wounds of the eyeball, since  in
 * Pathologie u. Therapie des Linsensystems, in Graefe-Saemisch's Cyclopedia. Vol.
v., p. 361. 
H. Knapp :  Cataract Extractions.
119
the eye, healing by first intention is almost indispensable for a
good recovery.
  According  to these views  I  conduct  the after-treatment.
The patient is kept as quiet as possible, until the wound  is per-
manently closed.   During the first day or two no visitors,  no
conversations, no reading  to  him, no  physical  exertion are
allowed.  If he  is  restless, anodynes are  administered.  If I
discover a  low tendency of  the wound  to unite,  by finding
either  the  lint wetted or a stream of "tears" (aqueous humor)
running  from the eye when the bandage is changed and the
eye  cleansed, I  do not open the lids—unless in addition there
be  pain or  oedema  and  discharge.   I  sometimes  keep the
bandage unchanged  for 24,  36 or 48 hours.  Under  these
circumstances, I think that a  limited rehabilitation  of the old
custom of a permanent  bandage after  the operation  is good
practice.
  II. The  reopening of the wound was notoriously the result of
a hurt in three cases  out of the four which are  noted in  the
book.  I have always been of opinion that the sudden and  un-
expected evacuation of the anterior chamber after the third day,
in a regular  course  of  healing, was mostly the  result  of  an
injury.   The  patient strikes his eye against a pillow,  or  un-
consciously rubs it in his sleep.  To prevent such an accident, I,
in common with others, take the precaution of loosely tying the
hands of the patient during the night, whenever he is restless, or
complains of itching in his eye.  The rupture of the wound, in
an otherwise favorable case, is not a serious complication.
  III.  After-hemorrhage  into the anterior chamber was noted in
six cases (3$), all of which did well.  I do  not know what, in
some cases, produces this after-hemorrhage, nor does the same
occurrence after operations on other parts of the body throw
any  light on the subject.  If we speak of a peculiar predisposi-
tion, it  should be defined, and, if possible, pointed  out before
the operation.  I would then make the "section less peripheric, to
avoid vascularized tissue. We all consider a perfect dilatability
of the  pupil by atropine as a  favorable condition.   If  the  di-
latation is effected by the contraction of the muscular coats of the 
120
H. Knapp :  Cataract Extractions.
blood-vessels,  an eye  whose  pupil is imperfectly dilated  by
atropine suffers from atrophy or paralysis of this muscular coat;
and  a certain degree  of passive  congestion must be present.
That such eyes  are more  than others predisposed to inflam-
matory reaction, in particular to purulent iritis,  seems generally
admitted, and I have seen it illustrated by many examples  in my
own experience.  But I shall,  in future, direct my attention
particularly to the question whether  such eyes are or are  not
more predisposed than others to primary (during the operation)
and secondary hemorrhages.
  IV.  Cystoid scar was noted in  3  cases (1^%)  only-  The  one
was an immature (swollen)  cataract, in a woman of 42 years of
age, the other two were hypermature cataracts in an old negress.
I know nothing about  the conditions that lead to the formation
of a cystoid scar.  There was no  symptom ol glaucoma in  any
one of the three eyes so affected.
  V.  Incarceration of iris in the scar is mentioned in four cases
(2%), but occurred more frequently.  In two cases only it caused
irritation, in the one soon after the extraction, in the other 18
months later.   I  think it is good practice to  remove  the  im-
prisoned  iris  whenever symptoms  of irritation manifest  them-
selves, as in case 133.   The other case (134) in which  purulent
iritis set in has been above fully discussed.
  VI.  Plastic iritis—21 cases, io£$—is the most  frequent morbid
process  after  extraction.   It  led  in  two  cases  to complete
closure of the pupil with preservation  of the shape and tension
of the  globe, and  good perception of light.   In the one case
(147) iridectomy yielded a perfect result (S ff), in the other (74)
iridectomy offered the same chances, but the patient did not re-
appear.   In the great  majority of these cases a judicious after-
operation will not fail  to convert moderate into good results.
In one of our cases (63), the eye which had S ^|¥, was destroyed
by  an  iridotomy.  The treatment  oT iritis was the  ordinary
antiphlogistic treatment of non-traumatic iritis, and proved, in
general, very satisfactory.  In  these cases,  careful observation
of the eye soon after the operation, leading to the early discovery
of iritis, saves many an eye. 
H. Knapp : Cataract Extractions.
121
   VII. A peculiar form of iritis which, some time before the
 first cases were described, I demonstrated to my class, under
 the name  of spongy iritis or spongy exudation, was noted in 5
 cases (2\<f).   This form is not peculiar to eyes operated on for
 cataract.  I have seen it after operations for glaucoma, and in
 spontaneous, either syphilitic or non-syphilitic, iritis.   O. Becker
 gives  a—rather insufficient—description of it.*  It is identical
 with the lens-like exudation of H. Schmidt \ and the gelatinous
 exudation of Dr. Gunning.\
   Commonly on the third or fourth day after the operation cede-
 matous swelling of the edge  of the  upper  lid and lachrymal
 region with more or less chemosis sets in.   There is moderate,
 sometimes intense pain.  The secretion is watery, or sero-mucous,
 never purulent.   The  episcleral injection is marked.   In the
 pupillary space appears a spongy-looking, semi-transparent sub-
 stance  of exceedingly fine, irregularly interlaced filaments, of
 grayish color, sometimes with a yellowish tinge.  It increases
 during one  or three  days and may fill  the  anterior  chamber
 either partially or totally.  If  it occupies the whole  anterior
 chamber, it greatly diminishes the vision,  sometimes  to mere
 perception of light, the pupil is clouded and the iris very dull—
 apparently  infiltrated, in reality, however, only  covered—and
 this dullness may be mistaken for diffuse  opacity  of the cornea.
 On the third, fourth, or fifth  day,  the irritative symptoms
 suddenly disappear, the pain  ceases, the swollen  conjunctiva
 collapses, and a process of contraction seems to take place in
 the exudation.  The  grayish substance  shows  sharp  edges,
 around which the periphery of the  iris  is seen  in its normal
 lustre, and the mass itself looks  like  a compact, grayish, semi-
 transparent body,  resembling a  crystalline lens, dislocated into
 the anterior chamber, and for such it has, in cases of spontaneous
spongy iritis, been mistaken.  From day  to day  the grayish
   * L. c, p. 358, lines 4 to 22.
   f Zeh. Klin. Monatsbl. f. Augenhl. 1871, p. 96.
   \ Zeh. Klin.  Mon, 1872, p. 7.  See also: E. Griming: Spongy Exudation.
These Arch. III. p. 20.  C. f. Kipp :  Syphilitic Iril is with Gelatinous Exudation.
These Arch. III. p. 71- 
122             H. Knapp : Cataract Extractions.
 compact  mass becomes smaller, a part of the pupil, and at  last
 the whole pupil, becomes free, and clear.   This process of ab-
 sorption may last from three to ten days.
   The cases where the exudation fills only a part of the anterior
 chamber  are  more frequent, but less characteristic.  The area
 of the pupil and its immediate surroundings are occupied  by a
 grayish substance,  which in  the first day or two has  a spongy
 appearance, then becomes compact, and shows the same sharp
 edges as the larger masses.   By its contraction and absorption,
 first a part of  the pupil becomes free and black, and  gradually
 the whole pupil is disengaged and clear.  The irritative symp-
 toms are  less  severe than in the forms in which the  whole an-
 terior chamber is filled.
   In  spontaneous spongy iritis the exudation  may  also fill  the
 anterior chamber either  partially or totally.  The  exudation
 begins commonly at the lower part of the iris, and may, when
 the pupil is dilated with  atropine, be characteristic  from  the
 outset.  The lower part of the anterior chamber is hazy, gray,
 frequently with a yellowish tinge, and the  lower part of  the
 pupil is occupied by an irregular  network of coarser filaments
 which by oblique light and a large lens may be distinctly seen
 through the diffuse, semi-transparent, not yet contracted exu-
 dation in the anterior chamber.  The  haziness  increases  in
 extent and density, and in two or three days, may fill the whole
 anterior chamber.   Then contraction takes place, the edges
 become sharp, withdraw  from the periphery of the  chamber,
 and the globular, gelatinous mass is very characteristic.  If ab-
 sorption begins before the whole anterior chamber  is  filled, the
 edges of the exudation are mostly less sharp, yet the disease
 may be diagnosticated  by  the  comparative  clearness of the
 upper part  of the chamber. The  upper  part of the pupil
 appears like a black crescent, while the remainder is occupied
 by the grayish substance.  Total  absorption took  place in all
 cases that came  under my observation.
  I have notes of about  18  cases  of spongy exudation, which
 might serve to draw a sufficiently clear clinical picture of this
peculiar form of iritis.  There are, of course, transitional forms 
H. Knapp .-  Cataract Extractions.
123
 in which the differential diagnosis offers some difficulty.  They
 border,  on the  one side, on the ordinary plastic iritis, on the
 other, on the purulent iritis.  The pure forms of spongy exuda-
 tion are distinguished by  the absence both of plastic pupillary
 excrescences and of pus (hypopyon).   Immediately after the ab-
 sorption of the  hyaline, grayish substance, the pupil  is widely
 dilated,  free from adhesions, and the iris shows no structural
 changes. The recovery is rapid and complete.   The transitional
 forms are, however, complicated with synechias and  pupillary
 obstructions.  The spongy exudation, in such cases, may  be
 considered  as an  additional though  peculiar feature  of plastic
 iritis or irido-capsulitis.   In some intense cases of spongy iritis,
 I have for a day or two been in doubt whether purulent iritis
 would  develop or  not.   Though  the yellowish tinge of the
 lowest part of the  exudation  looked suspicious of pus, yet  it
 could be distinguished from  hypopyon by its diffuse nature ;
 the border-lines were  always gradually fading  away, and never
 assumed the sharp outlines, nor had its centre the uniform  satu-
 rated white color by which hypopyon is so distinguished.
   I have seen spongy iritis, traumatic and  spontaneous, compli-
 cated with  venous hyperaemia of the retina, diffuse  opacity ol
 the  vitreous, and  grayish circumscribed exudations  in the
 fundus, the form of which was oval with a longest  diameter
 reaching two P DD. in length.  They occupied the bottom of
 the  vitreous chamber and covered the  details of the fundus.
 This condition leads me to believe that they are compact exu-
 dations at the bottom  of the vitreous, like  those in the anterior
 chamber, though they  greatly resemble circumscribed choroidal
 exudations, so much the more because the  choroidal exudations
 in the initial stage are also surrounded  by diffuse opacity of
 the vitreous.  The complication with choroiditis and cyclitis is
 mentioned also by Schmidt and Gunning.
  The anatomical nature of spongy exudation is a fibrinous
deposit.   Dr. A. Alt* has examined and described one specimen
taken from  my collection, and  in another  case  I extracted the
exudation from  a living eye, and placed it immediately under
* Anatomical Contributions, No. XII. These Archives.  Next number. 
124
H. Knapp : Cataract Extractions.
the microscope.  It consisted of a dense network of very deli-
cate fibrils, enclosing white and red blood corpuscles, and of a
finely granular substance.  The case  was that of a woman, on
whose eye I had performed  an iridectomy for glaucoma.  The
day after the operation the greater part of the  anterior cham-
ber  was  filled with a grayish, compact substance  with sharp
edges.  This substance protruded through the  wound,  which
was imperfectly closed.   I  seized the protruding part  with a
pair of iris forceps, and extracted it, together with a portion of
the  exudation  which  occupied  the  anterior  chamber. This
fibrinous  nature explains the clinical  features of the  spongy
exudation.  In traumatic cases it is probably poured out from
the cut edges of the coloboma, and when its quantity is  limited
it  adheres to these  edges and to the  anterior capsule.   After
cataract extractions the shreds of the capsule may, perhaps, also
furnish this kind of exudation.  I have seen it in cases where the
iris remained fairly normal and the pupil moderately  dilated,
whereas in the  pupillary space the shreds of capsule were thick-
ened, opaque,  beset with whitish  dots, and soon afterward a
thicker, grayish, compact substance filled the pupillary space,
projected into  the  anterior chamber, and overlapped the adja-
cent iris.  During  its  contraction  it assumed sharp edges,  a
small crescent of black pupil became visible, and at last, in from
three to  ten  days,  the whole mass was absorbed.  It was im-
possible to mistake  these grayish plugs for remnants of lens,
since, one or several days after the  removal  of  the cataract,
the pupil was seen  black, containing nothing but  thin pieces of
transparent capsule.  The gradual development  and increase
of  the spongy  exudation could be watched,  and offered  the
same features as in spontaneous spongy iritis.  Its disappearance
followed  the same course.
  From the different aspects which the spongy exudation pre-
sents, some conclusions as to its constituent parts may be derived.
When the substance is uniformly semi-transparent (hyaline,
gelatinous, like  a dislocated lens), it probably consists exclusive-
ly, or almost exclusively, of coagulated fibrine ; if it has a gray-
ish or whitish-gray color, the fibrine seems to contain a certain 
H. Knapp .- Cataract Extractions.
i25
 amount of  white blood corpuscles, which, when accumulated in
 clusters, will appear like whitish dots.  The yellowish or yellow-
 greenish tinge indicates, in my opinion, the presence of red blood
 corpuscles.   This argument, I  think, is  strengthened by  the
 fact that I saw only the lowest part of  the exudation greenish-
 yellow, which, it seems to me, is due  to the gravitation  of  the
 red blood corpuscles.
   The  prognosis  of  spongy exudation,  as far as my  present
 experience goes, is favorable.
   Its treatment is simple, and need not here be dwelt upon.
   IX. Simple or plastic capsulitis figures in the table with 5 eases
 {2Y/0), and—XV.—purulent capsulitis with-2 cases {1%).
   The  inflammatory processes which  originate in the capsule,
 and either remain confined to it, or extend to the neighboring
 parts, if attentively watched, offer such distinctive features that
 the term capsulitis, as the inflammation of a special organ, is as
 applicable as that of iritis or keratitis.   I have, in my former
 reports, dwelt more or less extensively on the clinical picture
 of  this  disease.
   The history of the two hundred extractions  now  under con-
 sideration  has added  new material  to complete the picture.
 The  irritative processes, due to the incarceration of  the cap-
 sule in the wound, have of late years been more closely studied,
 both clinically and microscopically (A.  Pagenstecher, O. Becker,
 Iwanofif, Von Wecker, and others).   The pupillary opacities which
 result from remnants of cataract, iritis, and chronic  thickening
 of the capsule have, under  the name of secondary cataract, been
 described over and over again, but the  clinical picture of pri-
 mary acute traumatic capsulitis  seems not to  have received the
 attention it deserves.   The method of  exsecting a quadrangular
 piece of the anterior capsule, which I  have practised for  many
 years, rendered  observations on pure  capsulitis  particularly
 fruitful.
  In  typical cases the picture is the  following.  In a ripe, un-
complicated cataract, a square-shaped piece  of capsule is cir-
cumcised with a sharp sickle-shaped cystotome, and removed
either with the cystotome, or a delicate pair of  forceps. In many 
126
H. Knapp : Cataract Extractions.
cases it comes out with the cataract.  Repeatedly have I been
able to find  this piece of  capsule, and  identify it  under the
microscope.  When  I did not find  it, I could, in many cases,
demonstrate  its excision by focal illumination.  Since, in  most
instances, I was scrupulously careful in removing the remnants
of lens, a perfectly free pupillary space, bordered by sharp edges
of a grayish,  translucent membrane, like the frame of a picture,
could  with oblique light and a large magnifying glass be dis-
tinctly seen,  sometimes immediately after  the  operation, but
always one or several days later, leaving  no doubt that the
quadrangular free space was not the result of a retraction, but of
a removal of so much  capsule.   One or several days after the
extraction, when  the  pupil was dilated with atropine, and free
from iritic adhesions and remnants of the lens, the edges of the
capsule were evenly stretched across the eye, at an appreciable
distance behind the iris. The upper edge presented a narrow
strip which was neither applied to the cornea nor adherent to
the  closed wound.   The majority  of these  cases showed  no
reaction and  yielded excellent results.
  In some, however,  peculiar changes took place in the cap-
sule, and  in the capsule only.  Accompanied by moderate cir-
cumcorneal hyperasmia, one point of the edge (the frame) of the
capsular  window, commonly the inner-upper or outer-upper
corner, grew opaque, gray or whitish. This opacity, in from two
to four days, spread over the whole superior strip of capsule,
cleared up at the corner from which it started, became more
saturated and lingered for a few days at the opposite corner, then
the whole superior strip cleared up, but the adjacent part of the
vertical column of the capsule coloboma became opaque, and the
opacity spread over the lateral edge in the same way as  it had
gone over the superior.  While it cleared up, it extended over
the lower edge, left this, and ascending, invaded the other lateral
edge, which, in some days, also cleared up.  While in this way
the infiltration travelled all around  the  border of the capsule
coloboma, the  centre of the  pupil,  the  aqueous  and vitreous
remained clear, the  iris free from adhesion, and S  continued 
H. Knapp :  Cataract Extractions.
127
 good.  The duration of this process was  from ten to fourteen
 days.
   This picture of a simple, pure, uncomplicated capsulitis offers
 numerous variations.  As has been said above, a kind of spongy
 exudation may be connected with it, obscuring the pupil for a
 while, then  disappearing.  The exudation, however, may also
 be diffuse, plastic, or purulent.  Diffuse exudation renders the
 pupillary area and the whole anterior chamber turbid.  The iris
 is hyperasmic, but the  pupil is fully dilated, the circumcorneal
 injection and  the pain are very  moderate;  absorption is fol-
 lowed  by good sight.  Plastic capsulitis is complicated  with
 iritis.  After a few days of irritation, the anatomical cause of
 which remains undetermined, a striated and irregularly opaque
 substance  extends from  the wound through the pupil, unites
 with the pupillary edge of the iris, contracts it, and  draws the
 iris  upward.  I am speaking here  of such cases in  which the
 reaction originates in the capsule,  and only secondarily involves
 the  iris.  The  capsule,  in such cases, is fastened in the  wound,
 as may be demonstrated a day after the operation or  later, and
 for a few days, this part of the capsule is the only one that be-
 comes  opaque  and  swollen.   After a somewhat  protracted
 course of from three to six weeks, the irritative symptoms disap-
 pear ; a pupillary membrane is  left; the vision is moderate, but
 becomes good by a simple horizontal or j_ shaped splitting  of
 the membrane.   Some  degree of cyclitis seems to be connected
 with this kind of plastic capsulitis, for in a recent case in which
 I divided the pupillary membrane, about four weeks after the
 extraction, shreds of tissue could  be  seen behind it.   Encour-
 aged by Wccker s recent publications, I made this operation with
 a very sharp,  broad needle, to prevent  the iris from being
 drawn upward  by the  contracting pupillary membrane.   The
 reaction was moderate  and the result satisfactory.
  Cases of purulent capsulitis I have seen frequently enough to
 distinguish its peculiar features.  There is at first moderate cir-
 cumcorneal injection, hyperaemia of the iris with a pupil dilat-
able  by atropine.  The pupil becomes hazy, and the capsule
thickened and opaque.   In cases where a  part of the capsule 
128
H. Knapp :  Cataract Extractions.
was removed, commonly one of the  upper corners of the  cap-
sular  coloboma first grows white,  and then yellowish-white,
bearing the greatest resemblance to  a pustule.   The  surround-
ing capsule becomes opaque, and one or several other places,
frequently the other upper corner, are the seat of other pustules.
The centre of the pupil may remain tolerably clear, but hypo-
pyon soon appears.   If the capsule was irregularly divided, the
pustules may appear in the centre  or near the centre of the
pupil, give rise to hypopyon, while the periphery of  the pupil
remains comparatively clear.  It is by such cases (see my former
reports), that I became  convinced, I had  to deal  with a  sup-
purative process of  the  capsule.  There  were  no  appreciable
remnants of  cataract, no visible changes  in the vitreous, the
iris was only moderately  implicated—scant filiform  adhesions
—and  the corneal section was perfectly closed and  free from
irritation.  There was in these cases moderate pain, chemosis,
cedema of the lids, and sero-mucous discharge.  The suppura-
tion may set in a  week after  the  extraction or later, and  1
remember one instance where the patient had been discharged,
at his urgent solicitation, though not fully cured, and returned a
week later with a pustule in the centre of the pupil  and hypo-
pyon, pupil dilated,  iris hyperasmic, and in some places adherent
to the capsule; in less than a week the pustule and  hypopyon
had disappeared.  The issue of  these cases is mostly  favorable ;
they  require careful after-treatment (leeches, atropine, rest in
bed, closure  of the eyelids, darkness), but since severer compli-
cations on the part of the iris, ciliary  body, and vitreous are
absent, a more or less simple  pupillary membrane is  the only
obstacle to good sight, and this obstacle can be easily removed.
   X. Simple Hyalitis is mentioned in 6 cases  (3$).   Opacities
of the vitreous are of very frequent occurrence after cataract
operations, as we may convince ourselves by examining the eye
with the ophthalmoscope during the  first week after the  ex-
traction.  They never  fail, as  far as my experience  goes, after
extractions  with the capsule,  whether these  extractions are
performed with or without the introduction of traction instru-
ments ; they are always present if the extraction is complicated 
H. Knapp .-  Cataract Extractions.
129
with prolapse of vitreous.  The exudation  in  hyalitis  may  be
diffuse, plastic (cords, flakes, and membranes), and purulent.  In
a majority of cases, especially after extractions with the  capsule,
they seem to be the result of hyperaemia and  inflammation of
the ciliary body.   If  the exudation  remains diffuse  (simple
hyalitis), the issue is always  good; if it is plastic, the recovery
may linger and be imperfect, resulting in  permanent  floating
opacities  of the vitreous, with  their prejudicial  influences  on
the ciliary body, the substance  of  the vitreous,  the  hyaloid
membrane—which  may  be  detached—and  the  retina.  They
may, however, clear up  after a duration of many months.   I
need hardly mention that hyalitis is frequently only a secondary
affection,  resulting from  the lesions  of  the  parts directly con-
cerned in cataract operations.
  All  the  cases of  simple and plastic hyalitis noted in the table
did well,  one  only (148)  yielded a moderate  visual  result (-^f),
offering, however, good prospects for an after-operation.
  All  the cases of XVI.  Suppurative Hyalitis (5, or 2^f), led  to
the loss of the  eye.  In  every one  of them the cataract was
complicated, and the extraction followed by  loss of vitreous.
The suppuration began  in the  vitreous itself, the  cornea and
iris being only secondarily involved.   Enough  has been said  on
this subject by Arlt, Becker, and others.
  XI.  Cyclitis and  Irido-cyclitis  are  mentioned  in 5 cases (2-|-^),
one of  which  only was a success, and  this  case (No. 187) was
very remarkable.   After a smooth operation of a hard ripe
cataract in a middle-aged man, with clear and dilated pupil, there
was very  marked circumcorneal injection,  and gradually the
inner-upper part of  the iris became bulging, as we see it in the
so-called crater-shaped pupil.  The centre of the pupil  remain-
ing clear, vision good, and the bulging limited to the inner part
of the  iris, I  abstained  from operative interference, and saw
that the protrusion, in the third week of its  existence, began to
diminish, and  finally disappeared altogether, leaving Vf|.   This
was evidently a case of partial  cyclitis, that  is, in one  place
there was  a sacculated cyclitic  exudation behind the iris ; the
pronounced general circumcorneal injection and the discolora- 
13°
H. Knapp :  Cataract Extractions.
tion  of the whole iris indicated that the whole ciliary body
participated in the inflammation.
  The cases mentioned  in the table show  that cyclitis, after
cataract  operations,  as   cyclitis in  general, is commonly a
secondary affection, engendered by extension of the irritation
to neighboring parts.   It may, in its course and  consequences,
become more important than the primary disease.  In its graver
forms, the chronic, frequently  relapsing cases of irido-cyclitis,
it represents one of the most deleterious eye diseases, since it not
only is the  terminal  affection  in one eye, but endangers  the
other by sympathy.   I would  longer dwell on this subject,  but
the  remarks which O. Becker makes on  it in  his repeatedly
quoted treatise, and the references to his own original investiga-
tions, and those of A. Pagenstecher, Iwanoff, and others, are so
instructive that I am afraid of making too  many repetitions.
  XII.  Partial  Suppurative Keratitis, observed  in  6 cases (3%),
has,  it seems to me, mostly local causes—bruising of the edges
of the wound by the turning of the knife,  or the passage of a
hard cataract, impaction in the section of iris, capsule and rem-
nants of lens, a good deal  of rubbing to remove  the cortex,  cut-
ting the edge of the flap,  etc.   In some cases it is difficult to
determine whether the suppuration originates in the cornea or
the adjacent part of the iris.  Partial  suppurative  keratitis has
often been described,  and  many modes of treatment for it have
been highly praised as having the effect of preventing the sup-
puration from becoming total.  I have, for  years, and especially
in cases making part of those now under consideration, treated
partial suppurative keratitis as a pustule, which I opened more
or less freely, evacuating the anterior chamber at the same time.
The results have been highly  satisfactory.  This treatment, I
think, is rational and  should  not be abandoned.   Yet it  has
failed me in cases  which,  for a while, looked as  if the suppura-
tion would  remain limited, and in other  similar cases I have
seen equally good results from  expectant treatment.   In  the
virtues of the compressive bandage (Schntirverband) which  Von
Graefe so highly recommended,  I never have  had great faith,
and if I am well informed, this faith, without any refutation, is 
H. Knapp .-  Cataract Extractions.
l3*
 gradually weakening.  The explanation of the success of all
 methods of  treatment in certain cases of keratitis suppurativa,
 and of the failure of all in others, seems to me that certain local
 causes, as mentioned above, exert only a limited injurious in-
 fluence, whereas in other cases the causes or conditions that lead
 to suppuration are so powerful that no medication can avert the
 disastrous termination.   It is only in the cases touching on the
 borderline of these two groups, that treatment may save an eve,
 or if injudicious, help to destroy it.
   XIII. There were four cases  (2p) of total suppurative keratitis
 among the two hundred ; two of them showed the typical form
 of Graefe's "ring-abscess."  The one case of "ring-abscess"
 (37) referred to a perfectly regular operation of a ripe  cataract
 in a healthy person.   Who can account for it ? In the other case
 (6),  smallness of the section and considerable rubbing  to expel
 the  cortex  are noted.  The next  case (9) was  again unexcep-
 tionable  as  to the  conditions  of patient  and the  operation,
 whereas  in the fourth case (87), hypermaturity of the cataract,
 old  age and decrepitude  of the patient may be mentioned as
 predisposing causes.  In opposition  to  Becker's statement*
 that  " ring-abscess  "  does not  seem  to occur after Graefe's
 operation, the above cases convince me—and I am sure that in
 time every operator will share my conviction—that  pure total
 suppurative keratitis is  one of the disastrous issues  of Graefe's
 operation, as well as of any  other mode of  extraction.  The
 differences  are only differences of frequency,  not of kind, yet
 with regard  to sloughing of the cornea, the linear methods have
 the advantage over the flaps.
   XIV. Purulent Iritis was observed in 8 cases (4 ft).   With the
 exception of one case (193), there was a direct cause  of the sup-
 puration mentioned; bruising  of the border of the iris with the
 knife or lens, expulsion difficult, considerable cortex left.  Since
 all these incidents are well borne  by  the majority of cases, to
 understand the inordinate reaction in  certain cases we  have to
inquire into the degree of bruising, the condition of the iris, and
the quality of the remnants of cortex.  If, on examining an eye
              * Treatise in Graefe-Saemisch, p. 367, line 11.
        0 
132
H. Knapp :  Cataract Extractions.
before the operation, we are led to assume a greater vulnerability
of the iris, we  should be very  particular in making a large
corneal section and a very large coloboma.   I mention this with
special reference to eyes  the pupils of which dilate only insuf-
ficiently by atropine, for I think such irides are more vulnerable
than others.
  The eighth case (No. 193) was very remarkable for the spon-
taneous recovery,  by  absorption,  of severe suppurative  iritis
and keratitis.  Such cases, though rare, are important in showing
how careful we must be in  framing a hopeless  prognosis, or in
ascribing a saving influence to a certain mode of  treatment
which may not deserve it.
  The average stay of a patient at the  hospital was 18 days, which
is more than it was in Heidelberg (14 to 15 days).  The greater
number of complicated cataracts, and severe reactive processes
I had to deal with in New York, may account  for the differ-
ence.  The shortest stay  of any  patient at the hospital was five
days, the longest forty-six.
  The following table on the
                       VISUAL RESULTS
speaks for itself.  It differs from my former reports in so far as
this time the final results, taken  from the last examinations ob-
tainable, were noted, while formerly I noted the results obtained
by the examination at the time the patients left the hospital.  At
the time of discharge the reactive processes have  commonly not
yet entirely diappeared, the scar is not completely consolidated,
opacities in the refractive  media have not sufficiently cleared
up, etc., to show final  visual results.   This is the  reason why in
my former reports V  |4}  was never,  and V |-g- only rarely men-
tioned.  The primary results are noted in a proper  column of
the  general table  which may be  consulted as a proof of  the
above  assertion.   While in this  report  the  acuity of  sight
obtained ranks higher than in my former reports, there is  this
time a certain, though small, number entered as  failures which
in the former reports were entered  as successes, namely such
cases in which a  later disease—for instance, detachment of the
retina,  irido-cyclitis, etc., or an after-operation—destroyed  that 
H. Knapp :  Cataract Extractions.
133
amount of sight  which the patient enjoyed when leaving the
hospital.  Remarkable, in this  series, is the small number of
moderate results (7.$%), and this is certainly owing to the par-
ticular care that was taken during the operation to  clear the
area of the pupil  as much as possible from the capsule and rem-
nants of cataract.  To clear the  pupil I have never introduced a
Daviel's or other spoon, since at the beginning of my career I
received the impression that such instruments were commonly
not more, but mostly less, efficient than the rubbing manoeuvre,
and  were rather dangerous.  Tough capsules were  removed
with forceps, which method I consider comparatively uninjuri-
ous.  The rubbing procedure, however,  while  clearing  the
centre of the  pupil, is apt to  push shreds of capsule  and rem-
nants of cataract between the lips of the wound, where, as for-
eign bodies, in a certain number of cases, they awaken an inflam-
mation which may jeopardize many an eye that otherwise would
have been saved.   I remember  that Von Graefe, after the expul-
sion of the cataract, took less pains to clear the  pupillary space
than I have done.  To clear the area of the pupil is certainly a
good thing, but  in doing it we  should avoid pushing capsule,
lens matter, and  perhaps iris into the corneal  section.  I  have
of late, as the terminal step of the operation, tried, with delicate
forceps, to grasp and exsect shreds of capsule which I  supposed
lying in the  corneal  wound, and  have  succeeded in this  at-
tempt.   After the excision I passed a blunt spatula through the
corneal wound with a view of shifting the capsule back into the
eye, even if I could not see it.  The results of this procedure,
thus far, have been encouraging.
                     Final \risual Results.
                 S f$ in  21 cases  or  11. *f<
                 S f£ in  25 cases  or  12.5%
                 S f-g- in  28 cases  or  14  %
                 S |4} in  28 cases  or  14  %
                 S f % in  31 cases  or  15.5;/
                 Sy2,,^ in 24 cases  or  12  r/(
                 S.,-,,1^ in   7 cases  or   3.5^

           Good result in 164 cases or  82  c/r 
134
H. Knapp :  Cataract Extractions.
S ^g-  in 4 cases  or  2 %
S ^o  in 3 cases  or  1.5^
S ^-f^  in 1 case   or  0.5$
S -jf^  in 4 cases  or
^  70
                 S -g-fpo  in  1 case   or 0.5^

        Moderate result in 13 cases  or 7.$%

S £ (perception of light with preservation  of  the  shape of the
    globe) in  9 cases or 4.5$
       S o in 14 cases or 7  %
    Failure in 23 cases or 11.$%.

   In order not to extend  this paper too far,  I shall here give
only a brief account of the
                      AFTER-OPERATIONS
done on cases belonging to this series, so much the more because
I intend at another time to discuss in  detail this important sub-
ject, which of late has received  so much attention by De Wecker
and other authors.  At  the time  when the  general tabular
statement was compiled, I had performed, on these 200 cases of
extraction, thirty-three after-operations by  methods and with
results as follows :
               I. Division of secondary cataracts :
    a) with sickle needle  14; improved 13,  unimproved 1 ;
    b) with Graefe's knife 3 ; improved  2,  unimproved 1 ;
    c) with Beer's knife   4; improved  4,  unimproved o;

                    total  21 ; improved 19,  unimproved 2.
   II.  Iridotomy with Beer s knife and TyrelVs hook 9, all improved.
   III. Iridotomy, with fine  scissors (not Wecker's, and previous
to Wecker's publications)  1 case ;  eye lost.
   IV. Removal of old prolapse of iris, 2 cases,  result good.

  Recapitulation :  After-operations  33 ;  impmved  30,   unim-
proved 2, lost 1.
 
■$
t¥

        3 o i "6 -S
Report and Remarks
'-/«
FOURTH AND A FIFTH HUNDRED
CATARACT EXTRACTIONS,
ACCORDING TO VON GRAEFE'S METHOD.
By H. KNAPP, M.D.,.
    OF NEW YORK. /V*
Reprinted from the Archives of Ophthalmology and Otology, Vol. VI., Nos. I. and II.
       NEW YORK:
WILLIAM WOOD & COMPANY, PUBLISHERS,
     27 Great Jones Street.
         1877. 
 
 
 
 
 
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