Ophthalmic Notes. 
1. TREPHINING THE CORNEA TO REMOVE A FOR 
EIGN BODY DEEPLY EMBEDDED IN ITS SUB 
STANCE. 
2. A CASE OF DOUBLE, EXTREMELY MINUTE AND 
APPARENTLY CONGENITAL LACHRYMAL FIS- 
TULA. 
3. A CONTRIBUTION TO THE STATISTICS OF CAT A- 
RACT EXTRACTION OF ONE HUNDRED AND 
EIGHTEEN RECENT CASES. 
HY 
DR. C. R. AG NEW, 
NEW YORK. 
NEW YORK: 
WILLIAM WOOD & CO., 37 GREAT JONES STREET 
1874. Ophthalmic Notes. 
1. TREPHINING THE CORNEA TO REMOVE A FOR- 
EIGN BODY DEEPLY EMBEDDED IN ITS SUB- 
STANCE. 
2. A CASE OF DOUBLE, EXTREMELY MINUTE AND 
APPARENTLY CONGENITAL LACHRYMAL FIS- 
TULA. 
3. A CONTRIBUTION TO THE STATISTICS OF CATA- 
RACT EXTRACTION OF ONE HUNDRED AND 
EIGHTEEN RECENT CASES. 
DR. 0. R. AGNEW, 
BY 
NEW YORK. 
NEW YORK 
WILLIAM WOOD & CO., 27 GREAT JONES STREET 
1874. TREPHINING THE CORNEA TO REMOTE A FOR- 
EIGN BODY DEEPLY EMBEDDED IN ITS SUB- 
STANCE. By C. R. Agnew, M.D., New York. 
M. C., set. 30, a fireman in gas-works, consulted me on Sep- 
tember 10th, 1873, for kerato-iritis of five months’ duration, 
produced by the deep lodgement of an extremely small foreign 
body in the cornea. 
Scattered over the area of the cornea were numerous cloud- 
like opacities, some deep and some superficial; there was 
marked ciliary injection, discolored, mossy-looking iris, with 
sluggish, irregular pupil, restrained but not fixed by three or 
four very small adhesions of synechia posterior. 
The ciliary neurosis was very annoying, and, combined with 
some sympathetic irritation in the fellow eye, had for some 
months kept the subject from work. 
Opposite the infero-nasal margin of the pupil in the cornea 
there was a very minute ulcer surrounded by a circular opacity. 
This opening led obliquely to a sinus, in the bottom of which, 
apparently as deep as the membrane of Descemet, was an ex- 
tremely minute black foreign body. To this unremoved for- 
eign body I attributed the kerato-iritic inflammation, as the sub- 
ject remembered the fact of his having got a bit of coke or coal 
in his eye, and of the immediate inflammatory consequences. 
I attempted to remove the foreign body from the bottom of 
the sinus, using delicately, for the purpose, various forms of 
spuds and needles, but without avail. I could easily explore 
the sinus in the corneal tissue down to the bed of the for- 
eign body on the membrane of Descemet, but without being 
able to dislodge the foreign body except at the risk of pushing 
it into the anterior chamber. Drs. Pomeroy and Webster 4 
examined the case by means of oblique illumination and the 
ophthalmoscope, and agreed with me as to its nature, and 
that the very minute black speck in the bottom of the sinus 
was not a pigmentary product in the inflamed cornea. It 
was evident that enucleation was inevitable unless the foreign 
body could be removed. It occurred to me, as I could not re- 
move the foreign body alone, that I might remove, by means 
of the trephine, the disc of corneal tissue which included it, and 
thus remove the cause of the kerato-iritis and of the sympathetic 
trouble in the fellow eye. We placed the patient under ether, 
held the eye under fixation forceps, and without difficulty re- 
moved a disc of corneal tissue, the exact centre of which was 
the opening of the sinus holding the foreign body. Although 
we applied the trephine perpendicularly to the corneal surface, 
we did not cut through into the anterior chamber so as to com- 
plete the circle at once, but so as to leave a small segment of 
the deep surface of the disc to be cut by the scissors. Removing 
the disc and examining the sinus in its centre, no foreign body 
could be found, as the black speck had disappeared. This 
speck had not dropped through the sinus into the anterior 
chamber, as there was no opening in that direction ; it could not 
be found floating on the surface of the eyeball, or in the infe- 
rior conjunctival cul-de-sac, and it is not probable that it got 
into the anterior chamber through the wound made by the 
trephine, as the kerato-iritis soon subsided and the eye regained 
a healthy state, and all sympathetic trouble in the fellow eye 
disappeared. The question remains, what became of the ex- 
reme ly minute black speck which was seen in the cornea before 
the operation, and could not be found in the disc of corneal 
tissue removed. In using the corneal trephine it is observed 
that the disc of tissue which it cuts out is more or less crumpled 
by the rotatory motion, and reasoning upon this fact, we were 
led to believe that the foreign body was worked out from the 
depth of the sinus, and washed away unseen by the free escape 
of aqueous humor and tears. No prolapse of iris followed the 
trephining, and under simple dressing, with a light bandage, 
the eye soon recovered without synechia anterior. 
The symptoms of kerato-iritis rapidly vanished, the cornea be- 
came much clearer except where the scar was left by the trephine. 5 
This scar, when mature, was only about half the diameter 
of the calibre of the instrument. I did not feel justified, in 
this case, in attempting to remove the foreign body by any of 
the methods previously recorded, and the history of the case, 
followed for many months subsequent to the operation, seems to 
ensure a beneficent result. Although the existence of slight 
synechia posterior guarded this subject against the occurrence 
of prolapse of the iris through the wound made by the trephine, 
we would not hesitate to resort to the use of the trephine for 
the removal of a deeply embedded and immovable corneal for- 
eign body, even though a synechia anterior might result, the 
danger resulting from a synechia anterior being less than that 
from a foreign body remaining permanently embedded in the 
cornea. A CASE OF DOUBLE, EXTREMELY MINUTE, AND 
APPARENTLY" CONGENITAL LACHRYMAL FIS- 
TULA. By C. E. Agnew, M.D., New York. 
The case was that of a girl three years of age, in excellent 
health and of healthy parentage. 
A year previously to the date of my examination, December 
9th, 1873, a minute drop of clear fluid was observed exuding 
from the region of the left lachrymal sac at a point immedi- 
ately below the tendon of Horner’s muscle. Six months after- 
wards a similar drop of fluid was observed over the right sac. 
In neither case was there, or had there been, the faintest trace 
of inflammatory action about the eyes, or any tendency to ble- 
pharitis or catarrh. I first saw the child on December 5th, 
1873, and observed its good health and entire freedom from 
any trace of eye disease or want of full facial development. 
The parts about the internal canthi were well formed, and 
might have been taken as models of anatomical perfection. 
Immediately beneath the horizontal elevation made by the 
tendon of Horner’s muscle, and over the centre of the correspond- 
ing portion of the lachrymal sac of each might be seen, on 
careful scrutiny, an extremely minute capillary opening, from 
which the merest drop of pellucid fluid would exude on pres- 
sure, or spontaneously. The margins of the fistulas were not 
raised in the least above or depressed below the surface of the 
surrounding skin, nor were they in the slightest degree inflamed 
or otherwise changed in color. The little fistulas were so ex- 
tremely minute that they were scarcely to be distinguished, ex- 
cept when a little dew-like moisture exuded. The 
seemed to be well formed and patulous. The parents stated that sometimes after crying, the fistulse would discharge tears 
in small quantity, but entirely unaccompanied by any local in- 
flammatory action. I did not feel justified in resorting to any 
form of surgical interference, contenting myself with asking to 
see the case, should any change occur. A CONTRIBUTION TO THE STATISTICS OF CATA- 
RACT EXTRACTION OF ONE HUNDRED AND 
EIGHTEEN RECENT CASES. By C. R. Agnew, lv{.D. 
The cases in the tables that follow are given as they occurred, 
and without selection or exclusion. 
They include several in which the most unfavorable prog- 
nosis was declared, and in which the bare chance of a good 
result was accepted by the subject. 
Some of the desperate cases did well, and some in which a 
favorable prognosis had been declared did badly, thus showing 
that however carefully we may weigh probabilities we are lia- 
ble to error, and that those who are blind with even seriously 
complicated cataract are entitled to a the chances of a good 
method of operating. 
The methods of operating used were those known as Graefe’s, 
Liebreich’s, Lebrun’s, and the “ old flap.” My opinion has at 
times been much unsettled as to the method which offers the 
best prospect for useful vision in the greatest number of cases. 
I have, however, about come to the conclusion that the Graefe 
operation is the best, provided the middle of the cut is not 
made far from the junction of the sclerotic and clear cornea. 
An insufficient wound is the most dangerous complication of 
a cataract extraction. Some of the so-called membranes in the 
pupil were so delicate as to be detected only by careful scrutiny 
with the ophthalmoscope or oblique illumination. 
1 have great pleasure in saying that most of the work of 
watching and recording the cases has been done by my 
assistant, Dr. David Webster, whose accuracy and carefulness 
are proverbial. 10 
No. of Case. 11 
1 
O 
be 
General 
Condition. 
Character of 
Cataract. 
Complications. 
Anaesthetic. 
Section 
Upwards. 
Section 
Downwards. 
Accidents in 
Operation. 
Complications during 
Recovery. 
Secondary 
Operations. 
Resulting 
Vision. 
1 
F. 
69 
Hard 
None 
1 
Y. — i 
2 
M. 
65 
Hard 
None 
1 
Y. — 
3 
M. 
65 
Hard 
( Ether ) 
< and >- 
1 
Spoon used. 
Membrane in pupil 
Membrane in pupil 
Membrane in pupil 
Membrane in pupil 
1 needling. 
4 needlings 
1 needling. 
1 needling. 
Y. = -pjj 
4 
F. 
F. 
M 
(?) 
68 
Hard 
( Chlor. ) 
Ether.... 
1 
Y. = 
5 
Hard... | 
Staph, post. } 
touching macula- ) 
Ether.... 
1 
V. = 
6 
7 
65 
Chlor 
1 
y — _2J) 
M 
58 
Insane.... 
Ether.... 
1 
v. = 6uT 
8 
9 
10 
11 
12 
13 
14 
F 
62 
Chlor.... 
1 
Y. = M 
F 
62 
Chlor 
1 
Membrane in pupil 
1 needling. 
V. = f 
M. 
76 
Feeble.... 
Corpulent. 
Ether.... 
1 
Y. =i 
Y. — 0 
M. 
M 
48 
75 
Ether.... 
1 
i Some ) 
•) vitreous V 
j Iritis with clos- ) 
1 ure of pupil. [ 
f 1 iridec-1 
J tom7) I 
j 1 kera- j 
[tonyxis. J 
Hard 
Ether 
1 
( lost. ) 
v. - 
M. 
M. 
49 
Ether.... 
j Iritis with clos-) 
| ure of pupil. ) 
f 1 iridot-1 
J omy, 1 
j1 need- j 
I ling- J 
j 
y-:= t8A 
‘; Heads ordi- 
nary print.” 
48 
j Diabetic 
} 
Ether. . . . 
( Cataract. 
f 
, 
EXTRACTIONS BY YON GRAEFE’S METHOD. 11 
15 
M. 
7G 
Hard 1 
Ether 
V — ®o 
v • — 4 0 
V — 
1G 
M. 
76 
Hard 
Ether... 
1 
17 
M. 
43 
Good 
Hard 
None... 
1 
( Iritis; closure } 
Iridotomy.. 
1 ‘ 70 
Y — 14 
' • — SV 
V — 
18 
M. 
49 
Hard.... 
None ... 
\ of pupils. J 
19 
M. 
43 
Hard 
Ether.... 
v • 8 XT 
Y — 1 
30 
M. 
73 
Hard 
None .... 
1 
v • T2 
( v. = 
4 Counts 
(fingers. 
V — 80 
— Tff 
V — 80 
v- — 80ff 
V — 80 
v • — rv 
V — 80 
v- — 
j Y.=Percep- 
21 
F. 
68 
( Gouty; ) 
■< enlarged V 
( joints. ) 
Corpulent. 
Hard 
None .... 
1 
( Iritis and clos- ) 
Iridotomy.. 
23 
F. 
45 
Hard 
Ether..., 
1 
| ure of pupil, j 
Membrane in pupil 
28 
M. 
61 
( Athero- ) 
4 matous >• 
Hard 
Ether. . . . 
1 
24 
F. 
65 
( arteries' ) 
Good 
Hard 
Ether... 
1 
25 
F. 
71 
1 Gouty; i 
•j enlarged > 
( knuckles ) 
Hard 
Ether... 
1 
j Iritis with clos-} 
Iridotomy.. 
( ure of pupil, j 
(tion of light. 
26 
M. 
60 
Hard 
Ether 
and 
1 
V — 80 
v • — tv 
( V. = Sees 
- to go about 
( alone. 
v. = n 
v. — 0 
27 
F. 
63 
Poor 
Hard 
Chlor. 
Ether 
and 
1 
( Iritis; mem- ) 
38 
M. 
54 
Fair 
Hard 
Chlor. 
Ether 
» 
1 
( brane in pupil. ) 
Membrane in pupil 
1 Hemorrhage ) 
Keratonyxis 
29 
M. 
75 
( Ex- ) 
•< tremely s- 
j Black 
( Cataract. 
\ 
Chlor. 
Ether 
and 
1 
( feeble. ) 
) 
Chlor. 
( vessels. ) 12 
No. of Case. 1 
M 
m 
tc 
< 
General 
Condition.} 
Character of 
Cataract. 
Complications. 
Anesthetic. 
Section 
{Upwards. 
Section 
Downwards. 
Accidents'in 
! Operation.; ' 
Complications' during 
; Recovery. 
Secondary 
Operations. 
Resulting 
Vision. 
30 
31 
33 
33 
34 
35 
36 
37 
M. 
F. 
F. 
M. 
F. 
F. 
M. 
M. 
48 
35 
70 
60 
73 
63 
57 
48 
Corpulent. 
Semifluid. 
Semifluid. 
( Detachment ) 
J of retina of > 
None .... 
1 
f Hyaline 
ruptured 
before sec- 
tion was 
complete; 
spoonused; 
some vitre- 
ous lost. 
1 
j Thick mem- ) 
I brane formed } 
a 
Membrane in pupil 
f Para- 1 
J cente- 1 
| sis; iri- j 
dotomy J 
Keratonyxis 
V — 20 
*• — sxr 
V — 20 
y • ~ SA 
V — 20 
V- — '2T5TT 
j Y. = Counts 
I fingers. 
V — so 
*• — tv 
v. =M 
y. = u 
y. = m 
fellow eye ) 
( Ether ) 
■< and > 
( Chlor. ) 
j Ether j 
-< and > 
( Chlor. ) 
None .... 
None 
Ether ... 
None .... 
1 
1 
1 
1 
1 
Membrane in pupil 
( Gouty; j 
< enlarged > 
(knuckles; 
Good .•... 
j Paralysis 
( Agitans. 
Poor . .. ■ 
Membrane in pupil 
Keratonyxis 
TTard 
L 
Myopia with } 
staph, post. ) 
1 
1 
Black cata- 
ract ; fluid 
vitreous, 
and tough 
capsule. 
Congenital 
i atrophy of 
fellow_eye. 
None .... 
Coniunctivitis 
♦ 13 
38 
89 
40 
41 
43 
ivr 47 
None .... 
1 
1 
V. = 
M. 
M. 
M. 
F. 
57 
Hard 
None .... 
1 
j Iritis; mem- ) 
| brane in pupil, f 
Iridotomy. 
v. =n 
81 
58 
76 
None .... 
1 
y — 20 
Hard 
Chlor. ... 
1 
V — 1° 
i 
"Visual field ) 
doubtful on 
nasal side. ) 
Ether.... 
1 
1 Cornea col- 
-j lapsed and 
( wrinkled. 
i 
V — 2 0 
] 
) 
43 
44 
45 
46 
F. 
F. 
F. 
F. 
75 
57 
57 
56 
\ 
General 
senile 
atrophy 
f Hard 
j nucleus; 
-] 
Ether.... 
1 
j Pupil filled with 
V 20 
1 
1 soft 
[ cortex. 
Opacity of cornea. 
Ona.nitv of cornea. 
Ether.... 
1 
( soft lens matter j 
V. = 
V. = As 
Ether.... 
1 
f Had ' 
general 
dropsy 
. 
Semifluid. 
Ether.... 
1 
j Iritis; mem- } 
( brane in pupil. [ 
Iridotomy. 
( Y=Un- 
| known. 
twice; 
47 
F. 
58 
very 
weak.^ 
Dyspeptic 
f Small 
| nucleus ; 
' 
Ether 
1 
v. = 
soft 
48 
F. 
74 
Feeble.. 
cortex. 
Ether.... 
1 
I 
Lens shaky, 
showing rup- 
ture of hya- 
line before 
( Iritis; mem- ) 
- -! brane in !- 
V — 20 
section com- 
pleted ; cor- 
nea wrinkled. 
( pupil. ) 14 
s' 
03 
D 
K 
O 
General 
Character of 
Complications. 
An ecs- 
|| 
PJ 
_o 
■d 
- 
c3 
k 
Accidents in 
Complications during 
Secondary 
Resulting 
■5) 
Condition. 
Cataract. 
thetic. 
O k 
o 
o 
m 
a 
£ 
Operation. 
Recovery. 
Operations. 
Vision. 
£ 
1 
P 
( Dyspeptic 
■< and half 
r 
Hemorrhage from 
v j Membrane in ) 
49 
M. 
74 
> Hard ... 
Ether.. 
1 
limbus into ant. 
V — 20 
( starved. 
chamber; cornea 
I pupil. J 
wrinkled. 
( Rheumat- 
) 
50 
F. 
00 
•< ic and 
>■ Hard .., 
Ether.. 
1 
V — 20 
V* — 
( dyspeptic. 
51 
M. 
61 
f 
Good . ..J 
Calcareous 
degenera- 
tion of 
capsule. 
1 
Ether., 
1 
Extracted capsule 
with forceps after 
ext. of lens. 
V — 20 
V- — TITO 
I 
J 
1 
f 
Old cho-'| 
( Fellow lost by ) 
< Extr. (pan- > 
( ophthalmitis). ) 
r 
Lens in capsule 
TV. = Sees 
53 
M. 
55 
\ 
roiditis; 1 
fluid vit- j 
reous. J 
None .. 
1 
extruded with vit- 
HyahtlS 
J to go 
1 
reous by spasm of 
orbicularis. 
j 
j about 
alone. 
53 
B. 
67 
( Goitre; 
I catarrh. 
| Hard . .. 
None.. 
1 
Iris fell before 
j Delicate mem- 
1 
V — 20 
knife and was cut. 
| brane in pupil. 
f 
f Mother 1 
f Hard 
Bleeding into ant. 
' 
54 
F. 
58 
J of 14 [ 
1 Chil- [ 
1 
y 7.. 
1 
chamb. from lim- 
( Iritis ; mem- ) 
Ether,, 
. J 
bus; small frag- 
ment of cortex left 
V •< brane in >■ 
V — 1 6 
V • — 5(J 
[ dren. J 
[ cortex. 
J 
( Pupil. ) 
in centre of pupil. 
Hyaline gave way 
5 
f Smokes 
1 
on completion of 
iridectomy ; re- 
55 
M. 
01 
J from 0 to 
j 10 pipes 
■! Hard ... 
None .. 
1 
. -< 
moved lens with 
\ Eye lost by | 
V. = 0 
1 
scoop; lost vitre- 
I Hyalitis. [ 
I a day. 
J 
ous and left some 
cortex in field of 
pupil. 15 
56 
57 
58 
59 
60 
61 
62 
68 
64 
65 
66 
67 
68 
69 
F. 
F. 
F. 
M. 
M. 
F. 
F. 
F. 
F. 
M. 
M. 
F. 
M. 
M. 
58 
41 
Dys- 'I 
peptic; 
- weak; V 
nerv- 
ous. J 
f Hard; 
develop- 
4 ed with 
■much 
pain. 
Hard.. . | 
Hard 
I 
u 
Ether.. 
I 
1 
1 
1 
1 
Slight serous iritis. 
V. =W 
V. = Wff 
v. = U 
v. 
v. = tt 
l-=* 
v- — 
V — so 
V- — ITT 
“ Has sharp 
vision. ” 
v. =K 
V. = “ Beads 
Jaeger No. 
Sat 7".”- 
v. = * 
j Y. = Not 
| recorded. 
V. = “Can 
read and 
write.” 
jxtracted after 14 
eedline-s: eve ex- 
Membrane in pupil 
tremefy myopic. 
) 
57 
50 
Hard 
Ether,. 
< 
Loss of vitreous 
with prolapse of Iris 
from vomiting 
while coming out of 
anaesthetic state. 
Cystoid cicatrix... 
V 
Hard 
1 
66 
36 
58 
40 
70 
55 
35 
54 
Ether., 
Ether.. 
T 
1 
Membrane in pupil 
Keratonyxis 
i 
Synech. post,... 
1 
I Hemor- 
•x rhage into 
( ant. chamb. 
1 Spoon used 
f 
4 
Synech. post, and 
Staph, post, with 
previous iridec- 
tomy 
1 
y 
1 
j 
1 
1 
None... 
( lens. ) 
j Spoon used to 
\ evacuate lens. 
I 
( 
1 
• 
Chlor.. 
j 
( 16 
cJ 
o 
o 
6 
M 
01 
tr. 
<i 
General 
Condition. 
Character of 
Cataract. 
Complications. 
Anres- 
thetic. 
Section 
Upwards. 
Section 
Downwards, 
Accidents in 
Operation. , - 
Complications during 
Recovery. 
Secondary 
Operations. 
Resulting 
Vision. 
70 
M. 
60 
( “ Reads 
< ordinary 
( print. ” 
V. - M 
71 
F. 
55 
1 
( Lens brought 
1 out with spoon. 
72 
F.| 
F. 
37 
Needling | 
V.= “Reads 
ordinary 
print.” 
V — 80 
v- — TAA 
V — 80 
v- — 
y. - o 
73 
47 
1 
Spoon used to } 
remove lens ) 
Capsular opacity.. 
74 
M. 
54 
Chlor.. 
1 
75 
F. 
67 
1 
76 
M. 
64 
None... 
1 
V — 80 
77 
F. 
63 
None... 
1 
Unknown. 
78 
F. 
70 
None... 
1 
( “ Reads 
-[ ordinary 
( print.” 
Y. — 0 
79 
M 
Chlor.. 
80 
F. 
65 
None... 
1 
Y. — U 
81 
F. 
69 
Rheu- 
matic 
and 
- 
Hard 
j Small cornea, } 
( 5" diameter. [ 
Ether.. 
1 
. 
Dialysis of iris 
produced by point 
of knife in mak- 
ing section which 
was enlarged 
with scissors. 
f Iritis without 1 
J pain—mem- ! 
y — 20 
82 
F. 
40 
dyspep- 
tic. j 
Nervous.. 
Hard 
Ether.. 
1 
- 
| brane in j 
I pupil- J 
V. =f# 17 
83 
F. 
38 
Hood 
' I Soft— 
Ether.. 
1 
11 
> 
84 
F. 
66 
- 
Subject' 
to at- 
tacks of 
traumatic. 
- Hard 
Ether.. 
1 
E ' 
v. = IS 
to 
85 
F. 
64 
erysip- 
elas. 
Corpulent 
. Hard 
Ether., 
1 
v. = n' 
1 
CD 
| 
u 
tl 
< 
General Condi- 
Character of 
Complications. 
Accidents in 
Condition of 
eye after opera- 
tion. 
Complications duri»g' | 
Secondary 
Resultingl 
O 
d 
525 
<D 
w. 
tion of Patient. 
Cataract. 
Operation. 
Recovery from Operation. 
Operations. 
, Vision, j 
( 
Pupil 1 f 
I 
[Catarrhal conjunctive 
) 
V — 20 
v • — ‘5TT 
1 
F. 
45 
J 
tis and immobility of 
lower segment of iris. 
y 
circular. ) ( 
s 
2 
M. 
40 
Fair 
Pasty .. | 
Atrophy of fellow 
i 
Pupil clear 
11 
3S 
eye from needling. 
I 
and circular 
f 11 needlings had 
J caused absorb- 
] tion of lens in 
[_ the other eye. 
fProlapse of] 
J iris sue- ! 
' j cessfully j’ 
[ reduced. J 
( Pupil ) 
1 Prolapse of iris ; ) 
iritis; closure of !- 
V — 20 
V • — T O TT 
3 
F. 
21. 
Fair 
Semifluid. 
•< clear and > 
Iridotomy.. 
( circular. ) 
( pupil. ) 
EXTRACTIONS BY LIEBEEICII’S METHOD. 18 
No. of Case. 1 ] 
1 
til 
< 
General Condi- 
tion of Patient. 
Character of 
Cataract. 
Complications. 
Accidents in 
Operation. 
Condition of 
Eye after 
Operation. 
Complications during 
Recovery from Operation. 
Secondary 
Operations. 
Resulting 
Vision. 
4 
M. 
F 
60 
63 
3s' 
40 
56 
50 
34 
Fair 
Hard 
( ) 
f Soft lens matter j 
J seen in pupil 48 [ 
j hours after ex- j 
traction. J 
I 
Keratonyxis. 
y — 20 
5 
Good 
Hard 
i 
( circular. ) 
Pupil clear 
V — 
6 
7 
F. 
Poor 
I 
1 
and circular. 
Pupil ) r 
) 
Soft lens matter "1 
seen in pupil a few I 
Paracentesis 
v — 20 
M. 
Poor 
Traumatic 
f Leucoma; 1 
J Synech. post. 1 
1 and ant. ; f 
[ fluid vitreous. J 
( 
fLoss of vitre-'| 
I ous ; collapse 1 
| of cornea; ( 
[ spoon used. J 
circular. ) j 
j Collapsed 
days after extrac- j 
tion; serous iritis. J 
Panophthalmitis. 
v. - $ 
8 
9 
10 
F. 
t Exces- ) 
•1 sively [• 
( nervous. ) 
j Weighs ) 
( 325 lbs. [ 
Very poor | 
j Thin and ) 
Hard 
( eyeball. 
Pupil ) f 
cl ear,mrl - 4 
Catarrhal conjunctiv- 
itis ; immobility of 
lower segment of iris ; 
membrane in pupil. 
Prolapse of iris ) ( 
24 hours after > < 
V. = 
v — 80 
M. 
Hard 
| 
circular. 
Pupil 
clear and 
Excision of) 
prolapsed >■ 
iris. ) 
Keratonyxis. 
Keratonyxis. 
F. 
In- ) 
flamma- >■ 
( Extreme myo- ) 
pia; atrophy 
( of choroid. ) 
j 
circular. 
Pupil 
clear and 
j 
extraction. ) ( 
Cortical matter in j 
pupil some days V 
later; membrane. ) 
f Catarrhal con- 'j 
! junctivitis; i 
j membrane in j 
I pupil. J 
Y. = 
11 
M. 
60 
tory ) 
Hard 
circular. ) ( 
( Pupil ) 
-J clear and - 
j p er I 
) cep. of j 
I light- J 
{ wiry. J 
( circular. ) 19 
- 
Pupil ) r 
Large prolapse of I 
f Excision I 
13 
M. 
35 
Fair 
■^Semifluid. 
iris 34 hours after 1 
J of pro- [ 
j Counts 
circular. ) 
extraction; iritis ; ( 
membrane in pupil. J 
1 lapsed | 
I fingers. 
[ iris. J 
f Hemi- 1 
I plegia I 
j from Ap- | 
I oplexy. J 
r 
Couching had been 
13 
M. 
70 
Hard... - 
done on the other 
eye; iris tremu- 
lous ; eye fre- 
quently red and 
painful. 
I Pupil ) 
-! clear and > 
i Prolapse of iris ) 
-• seen next day; > 
( slight iritis. ) 
V — 16 
*• — 3TT 
( circular. ) 
C Pupil ) 
i Serous iritis; ) 
f Paracen-1 
J tesis ) 
14 
M. 
65 
Fair 
Myopia' 
< clear and >- 
•< membrane 
( in pupil. ) 
v — 20 
Y * — 'SJS 
( circular. ) 
) done f 
[ twice. J 
15 
M. 
53 
Fair 
Hard. 
Pupil clear 
and circular. 
) ( Slight mem- ) 
[ ( brane in pupil. [ 
v — 20 
f Wound en- I 
1 Pupil j 
clear and J- 
16 
M. 
70 
Marasmatic. 
Hard 
j Totally } 
( inelastic iris, f 
larged with 
■ 
Panophthalmitis.... 
Y. — <> 
scissors; 
spoon used. 
( circular. ) 
17 
M. 
72 
Good 
Hard 
Pupil clear 
j- Membrane in pupil. 
Keratonyxis. 
v — 20 
v • — YTT 
and circular. 
18 
69 
Slight loss 
of vitreous. 
i Pupil ) 
( Synechia ante- J 
F. 
Good 
Hard 
< clear and >• 
rior of all the iris > 
V — 20 
v* — T U 
( circular. ) 
( below the cut. ) 
19 
M. 
63 
Good 
Hard 
Inelastic iris .... 
Wound en- 
larged with 
scissors at 
> 
( Cornea ) 
■j col- V 
f Synechia ante- I 
) rior of all below 1 
Keratonyxis. 
V — 20 
V • — fjj 
both ends; 
( lapsed. ) 
j cut; membrane j 
vitreous lost. 
[ in pupil. J 
20 
F. 
41 
Good 
Hard 
Membrane in pupil.. 
Keratonyxis. 
V — 20 
v* — 
M. 
64 
( Dyspep- ) 
1 Myopia with ) 
( Pupil ) 
21 
•< tic and >• 
Immature- 
-< staphyloma > 
( posticum. ) 
Slight iridectomy 
-< clear and >- 
Panophthalmitis.... 
V. = 0 
( nervous. ) 
( circular. ) 20 
-No. of Case. | 
M 
2 
c5 
be 
General Condi- 
tion of Patient. 
Character of 
Cataract. 
Complications. 
"Anaes- 
thetic. 
Accidents in Operation. 
Complications during 
llccovery. 
Second- 
ary Oper- 
tions. 
Resulting 
Vision. 
f Gouty; 1 
J rheumatic [ 
f Hard ] 
J nucleus ; 1 
j soft j 
[ cortex. J 
f Hard 1 
r 
Iridectomy of pupil- 'j 
' Membrane in 
1 
F. 
60 
None, x 
lary border of iris ; | 
soft lens matter V 
i milked out; cornea | 
flaccid. 
Soft lens matter I 
pupil absorbed 
without any 
secondary 
operation. 
- 
V — 80 
v • — VTT 
V. = “Reads 
j knuckles; | 
[_ neuralgia J 
f 
2 
F. 
70(?) 
i nucleus : 
j soft | 
cortex. J 
None, s 
i milked out and pupil I 
left clear; marginal | 
iridectomy. J 
I Slight serous 
1 iritis. 
ordinary 
1 
print 
easily.” 
3 
F. 
65 
Poor 
f Hard ] 
j nucleus ; ! 
] soft j 
[ cortex. J 
J 
Fellow eye 
lost by in- 
flammation 
> 
None... 
j Blood and corti- ) 
I cal left in pupil. ) 
No inflamma- 
tory reaction. 
Y — 80 
v • — ATT 
following 
extraction, j 
4 
F 
85 
44 
Feeble 
Soft 
Noneu 
V — 20 
5 
F. 
Marasmic .... 
Semifluid .. 
1 
Synecb. post. 
Previous 
None,.. 
No inflamma- ' 
tory reaction. 
i No inflam- 
( v.= 
-j Counts 
iridectomy. 
Lebrun’s section with 
iridectomy. The cap- 
sule was so tough that 
( fingers. 
( V- = 
6 
F. 
44 
Marasmic ... 
Semifluid .. 
Synecb. post. . 
None. i 
it bad to be extracted 
■< matory re- 
( action. 
< Counts 
by forceps before the 
( fingers. 
lens would move 
from its fossa. 
EXTRACTIONS BY LEBRUN’S METHOD. 21 
| No. of Case. 1 
M 
A 
<p 
to 
General Condition of 
Patient. 
Character 
of 
Cataract. 
Complica- 
tions. 
Anes- 
thetic. 
Flap. 
Upwards. 
Flap. 
Downwards. 
Accidents 
in Ex- 
traction. 
Complications during 
Recovery. 
Secondary Operations. 
Resulting 
Vision, j 
1 
M. 
55 
Good 
Hard... 
None... 
1 
V — 80 
v- — Tff 
Y 20 
2 
M. 
80 
Atrophy of old age.. 
Fair 
Hard.,. 
1 
3 
F. 
70 
Hard.., 
None... 
1 
Y. = || 
4 
F. 
05 
None... 
1 
1 Prolapse of iris J 
■s caused by fit of - 
( sneezing. ) 
X Hook operation ) 
for pupillary - 
( membrane. ) 
Y — .2 0 
5 
F. 
61 
Chlor. . 
1 
V — 80 
6 
M. 
53 
Ether.. 
1 
( Keratonyxis for } 
V — 20 
( membrane. J 
EXTRACTIONS BY THE OLD FLAP METHOD. 22 
STATEMENT OF RESULTS, 
Graefe’s - 
Liebreicb’s • 
Lebrun’s 
f Successes 661 
Partial Successes 9 
Failures, 7 
Unknown 3 
Successes 15 
Partial Successes 3 
Failures 4 
Successes 4 
Partial Successes 2 
- 85 
■ 81 
e 
6 
Total... 
118 
Successes 
91 — 77-J- per cent. 
Partial Successes. 
13 = 10i per cent. 
Failures 
11 = 9-j per cent. 
Unknown 
3 = 2i per cent. 
Total 
118 
In 11 cases V. = 
In 1 case Y. — 
In 13 cases Y. |$ 
In 1 case Y. = -fa 
In 1 case Y. = 
In 8 cases Y. = 
In 1 case V. = f 
In 1 case Y. = 
In 14 cases V. = f§ 
In 1 case Y. = A 
In 8 cases V. = f§ 
In 7 cases V. = Ability to get about 
In 5 cases V. = 
alone, count fin- 
In 1 case V. = 
gers, etc., etc. 
In 5 cases V. = 
— 
In 3 cases Y. = f £ 
13 cases reckoned as partial sue- 
In 9 cases V. = 
— cesses. 
In 8 case V. = i 
In 1 case Y. = £ 
In 9 cases Y. = 0. 
In 11 cases V. = Jv.Y 
In 8 cases Y. = Faint perception of 
In 8 cases Y. = Ability to read ordi- 
light 
nary print. 
— 
11 cases reckoned as losses. 
91 cases reckoned as successes. 
— 
In 3 cases the result is unknown. Remarks, 
Loss of vitreous occurred 3 times in the 21 Liebreichs, or 
in 14;- per cent.; 4 times in the 85 Graefes or in per cent.; 
and not at all in the Lebruns and old Flap. 
The lens was removed by the scoop in 5 Graefes, or about 
6 per cent.; in 2 Liebreichs, or about per cent., and not at 
all in Flap or Lebruns. 
Prolapse of iris occurred during recovery in the Liebreichs 
4 times, about 19 per cent.; in the Flap once, 16f per cent.; in 
the Graefes once, less than 14 per cent., and in the Lebruns 
not at all. 
Cystoid cicatrix occurred in one Graefe, and in none of the 
other methods. 
Synechia anterior occurred in 2 Liebreichs where there had 
been no prolapse of iris. 
Immobility of the portion of iris below the cut, either from 
synechia posterior, or from a localized iritis with interstitial 
thickening, was noted in two Liebreichs. 
Iritis with closure of pupil occurred in 5 Graefes and in 1 
Liebreich. 
Serous iritis occurred in 2 Liebreichs and in 1 Lebrun. 
Panophthalmitis occurred in 3 Liebreichs and in one 
Graefe. 
Hyalitis occurred in 2 Graefes. 
Pupillary Membranes formed in 20 Graefes and in 8 Lieb- 
reichs. 
Sympathetic Irido-choroiditis, destroying both eyes, occurred 
in one Graefe. 
Notes of cases in which loss occurred after operation by 
Graefds method. 
Case 7.—H. K., 58. Aothing peculiar observed in the 
physical condition of the patient, except that he was ex- 
tremely loquacious and had acne rosacea. Extraction done 
December 1st. A small portion of pupillary margin of 
iris was cut off in making the section. On lacerating 24 
the capsule fluid cortical substance flowed into and obscured 
the anterior chamber. The lens was easily extruded, but it 
seemed to be necessary to use a spoon to remove some small 
pieces of cortical from the anterior chamber. This patient took 
ether very quietly, and was left for a few moments by Ins at- 
tendant, after he had been informed of the safe removal of the 
cataract and replied that lie was very comfortable. In the course 
of half an hour the patient was found to have removed, during 
the temporary absence of his attendant, the black silk mask and 
strips of isinglass plaster with which his eye had been closed, 
and to have dressed himself for a walk. The patient was, after 
much difficulty, put to bed again and his clothes hidden and 
the dressings renewed. 
December 7th: Eye looks well; wound healed. Counts 
fingers readily. 
December 25th: Eloped from hospital, having found his 
clothes and borrowed a hat. 
January 5th: Returned again. Examined ophthalmoscop- 
ically and found to have retino-choroiditis with floating bodies 
in vitreous, and possibly a small retinal detachment. 
Case 11.—J. F., 43, muscular, and corpulent. Extraction 
attempted by Graefe’s method, December 15. It was impossi- 
ble to produce complete anaesthesia of the eye by means of 
chloroform. The patient straggled excessively against the 
anaesthetic, and would suddenly become stertorous and asphyxi- 
ated, compelling efforts to be made for his partial resuscitation. 
Under these circumstances there was a premature loss of 
aqueous in the attempt to make the section, and we were forced 
to desist. The wound healed kindly, and on January 1st an- 
other attempt was made to operate, under ether. The ether 
affected the patient as badly as the chloroform had, and at no 
time could anaesthesia of the eye be accomplished, although a 
pint of ether was used in a cone. There was so much muscular 
rigidity and straining, that two or three persons were engaged 
in holding the patient while the ether was being assiduously 
administered. The section was, however, completed. In cut- 
ting out, the iris came in front of the knife, and was so cut as 
to leave the margin of the pupil intact, forming an isthmus, as 
it were, between a large irregular perforation and the pupil. 25 
After lacerating the capsule, this isthmus-like segment of the 
pupillary margin was drawn out by means of forceps, and 
out with scissors in such a manner as to complete the colo- 
boma. While performing this manipulation, the vitreous 
prolapsed, and two or three minims of it escaped in a gushing 
manner. 
The eyes were closed with isinglass-plaster strips, and a 
black silk dressing. 
As there was little or no pain, it was deemed wise, in view of 
the large amount of vitreous humor lost, not to open or expose 
the eye, especially as the removal of the outer dressing showed 
that there -was neither swelling nor discoloration of the eyelids, 
nor any discharge. 
January 15th : At this date the eye was opened, the cornea 
found to be clear, anterior chamber restored, circum-corneal in- 
jection slight. A slow iritis now set in without pain or increase 
of tension. 
February 7th: Coloboma bridged over by a membrane. 
At this date the patient, having good perception of light, was 
allowed to go home. 
April 28th: We attempted to tear the membrane in the pupil 
by means of a stop-needle and sharp hook; patient under in- 
sufficient chloroform. Failed to secure an open pupil. 
July 11th: Did an iredectomy. Succeeded in removing a 
sufficient piece of iris from nasal side of the coloboma, but not 
in maintaining an open pupil. 
October 10th: Needled the membrane. After recovering 
from this operation, the patient had good vision, enabling him 
to read and write in his occupation—that of a lawyer. After 
a lapse of several months, however, vision began to fail, and 
then suddenly went, and the ophthalmoscope revealed almost 
total detachment of the retina. 
Case 25.—E. K. W., 71. Patient had marked senile atrophy. 
Eyelids and general skin flaxed and inelastic, and knuckles 
much enlarged by gouty deposits. 
Graefe’s operation done under ether and without accident or 
vomiting. Eye did badly from second day ; corneal wound did 
not heal until 15th day. Choroiditis with large lymphoid effu- 
sions in anterior chamber, reduced Y. to perception of light, and 26 
so matted iris as to make any operation for secondary cataract 
hopeless. 
This eye was enucleated some months afterwards by Prof. 
Bacon, of New Haven, who did a Liebreich upon fellow eye, 
resulting in useful vision. 
Case 29.—H,, set. 75. Lenses have both begun to undergo 
secondary degeneration, have dark chocolate-colored nuclei, 
especially the left with strise, and veins of a whitish calcific char- 
acter mottling or marbling them. Eight eye probably involved 
in an injury of that side of face in childhood, as there are exten- 
sive scars. Y.=counts fingers in one foot. Patient is an old 
rheumatic, has marked senile marasmus, and is very feeble. 
Y.= L. E. perception of light only. Ho limitation of visual 
field; phosphenes present. 
October 13, 1874: L. E. operated upon by Graefe’s method. 
Mixture of equal parts of ether and chloroform given. 
The cornea was very flaccid, wrinkling after escape of 
aqueous; lens large and 'very dark-colored nucleus. Ho ac- 
cident during the operation nor loss of vitreous. Isinglass plaster 
and black silk dressing applied. 
October 14th: Has had little or no pain since operation. 
Slept well without hypnotic. During the night blood issued 
from beneath the dressings. This morning eye examined; blood 
oozing from ciliary region through wound. Atropia instilled; 
bandage and charpie applied. Had some bloody oozing, until 
20th, when wound of cornea healed. On 30th October was 
discharged. Wound healed; coloboma still open and show- 
ing a dark, olive-colored reflex. Y.= faint perception of 
light. 
Case 55.—J. K., 61. Had right eye injured and vision im- 
paired, by wound from foreign body, eight or ten years ago, re- 
sulting after some years in a cataract. Has a central scotoma; 
circumference of visual field unaffected. 
Hovember 12,1873: Operated upon the right eye by Graefe’s 
method, without anaesthetic. Speculum and fixation forceps 
used, and section made easily. Iridectomy made in usual man- 
ner. This was immediately followed by gushing escape of vit- 
reous humor. Eemoved lens by means of a scoop, and was 
compelled by drainage of vitreous to leave some crumbs of cor- 27 
tex in field of coloboma. Had severe pain first night, requiring 
anodyne. ✓ 
November 13 : Removed bandage and charpie; considerable 
secretion from conjunctiva; eyelids swollen; chemosis marked; 
cornea clear, but aqueous turbid; field of coloboma grayish; ten- 
sion increased. 
Instilled atropia, applied iced cloths, and leeched temple. 
18th : Opened wound and evacuated anterior chamber. 
29th: Eye remained in condition of chronic iritis for sev- 
eral days, with small hemorrhages into anterior chamber. 
Discharged with good perception of light. 
Case 75.—E. C., 67. Marked premature senile marasmus. 
L. E. operated by Graefe’s method under ether, section 
downward, expecting in this way to obviate some of the difficul- 
ties of an operation. No accident attended operation, but 
cornea fell in a crumpled state into empty lenticular fossa. He 
had excessive, constantly recurring vomiting and retching for 
several days. 
May 17th : Cornea sloughing, and anterior chamber and len- 
ticular fossa suppurating. Soon sympathetic irido-choroiditis 
of a most painful character occurred in fellow eye, which was 
cataractons. Enucleation urged, bnt declined. Patient left 
Brooklyn Eye and Ear Hospital in a miserable state, and lost 
all perception of light, suffering exceedingly. 
Case 79.—W. J. D., 54, April 15th, 1871, Right eye operated 
upon, Graefe’s method, section upward. Chloroform given. 
Panophthalmitis set in on day following, sinking the eye. 
Notes of cases in which loss occurred after operation hy 
LiebreicJi’s method. 
Case 7.—M, II., set. 40. Blown up by gunpowder fourteen 
years previously. The accident had destroyed and sunk right 
eye, but leaving it free from irritability. It had produced a 
perforating ulcer of the fellow eye, which healed with an ex- 
tensive leucoma and synechia anterior, and slight synechia pos- 
terior, I had made an iridectomy upwards, at that time, restor- 
ing useful vision, which he had enjoyed until 1872, when, after 
receiving a blow upon the eye, cataract supervened, reducing 28 
vision to perception of light. Testing ms eye in 1873 for an 
operation, it was found that the lower portion of the visual 
field was blind, but whether from detachment of retina or 
choroido-retinal atrophy, we could not say. He was informed 
that the chances of a cataract extraction were all against him, 
but that it might possibly result in some vision. 
A Liebreich was attempted, March 12th, 1873. The lens 
proved to be pasty or waxy, and the vitreous and aqueous com- 
mingled, so that the eyeball began to empty itself as the cor- 
neal section was made. The lens was removed, however, 
partly by pressure, partly by the aid of a spoon, and the eyes 
closed by means of strips of isinglass plaster and a black silk 
dressing. 
March 13th: Some pain during night, but not so severe as to 
prevent natural sleep. Removed dressings ; instilled atropia 
anterior chamber full. 
March 13th, 5 p.m. Pain in forehead. Removed dressings; 
eyeball plump; cornea hazy; no perception of candle-light. 
Gave opium and repeated atropia. 
8 p.m, : Pain in forehead and eye increased. Gave hypoder- 
mic of Sol. Morph. M., m. x., with entire relief of pain. 
March 14th: Panophthalmitis, which ran its usual course 
spoiling eye. 
Case 11.—W., 60, A thin and wiry man with sclerosis of all ob- 
servable arteries. The operation (Liebreich) was without acci- 
dent, but the eye recovered with a membrane in the pupil, re- 
ducing Y. to -jY0. Some weeks later, as Y. lessened, the pupillary 
membrane was needled. This was followed by serous iritis, 
which yielded slowly to paracentisis, leeches, and atropia. 
After some weeks patient was allowed to go home. He re- 
turned in three weeks, with pupil closed, eyeball somewhat 
congested, tension minus, perception of light very uncertain. 
Case 16. (Liebreich’s).—H,, set. 70, farmer. Observable vessels 
sclerosed. Pupil sluggish. Ho anaesthetic used. Incision made 
easily. When the capsule was opened lens would not follow. 
Wound enlarged, but pupil would not stretch. I then tilted 
the lens by pressure on the upper part of the cornea, and deliv- 
ered it by means of a flat spoon. Ho vitreous lost, nor was there 
very much violence inflicted. Operation done June 4, 1873, 29 
June 5th : Removed flannel bandage and charpie; consider- 
able conjunctival secretion; cornea transparent; pupil black; 
incision scarcely discernible; little or no injection of circumcor- 
neal parts. Dropped in Sol. Atrop., and renewed bandage. 
June 6th, 6 a.m. : Had severe throbbing, supra-orbital pain 
during the night, but did not ask for relief. Removed ban- 
dage. Conjunctival secretion marked; eyeball red; cornea 
cloudy. Atropia and iced cloths, 
3 p.m. : Tension -j-. Opened wound and emptied anterior 
chamber. 
Evening; Edge of flap beginning to show necrosis. Applied 
hot fomentations; gave quinine and tincture of iron. 
June 10th : Eye gone by panophthalmitis. 
Case 21. (Liebreich) D. JB., set. 64. A very tall, thin gentle- 
man, who had had several severe attacks of bronchitis and been 
subject to syncopy. Marked sclerosis of radial arteries and 
other superficial vessels. Eyes known to he myopic and to have 
posterior staphylomata. Corneal diameter 5%"'. Pupil mobile. 
The incision was easily made. In finishing the latter the lower 
margin of the pupil fell in front of the knife and was cut. 
The lens came out easily, pushing through the wound one or 
two tags of the cut iris, which were easily removed by the scis- 
sors. Every vestige of cortex was carefully removed by gently 
stroking and pressing the cornea, and without using the spoon, 
until the pupil seemed under oblique illumination in the focus 
of a two-inch lens to be clean and black. No vitreous was lost, 
nor was there any remaining prolapse of iris. Patient counted 
fingers immediately after the operation on October 22d, 1873. 
A light flannel bandage and charpie were applied. The patient 
did perfectly well until the fourth day—26th inst., when at 
3.30 a.m. he was awakened by feeling as though he had struck 
his eye. This was followed by severe pain. 
At 10 a.m. the eyelids were swollen, tender to the touch, and 
there was much circumorbital pain. The eyeball was reddened; 
the iris pressed forward against the cornea, which was still 
transparent. The pupil was still clear and not contracted. 
Atropia was instilled, leeches applied, and after encouraging 
the bleeding by hot fomentations, iced cloths were placed upon 
the closed eye and frequently changed. Quinine was given, and 30 
such nutritious food as could be taken. In a comparatively 
few hours the interior of the eye seemed to be engaged in 
pyogenic action, and to furnish a free flow of pus, somewhat 
tinged with blood. Under this inflammatory action the cornea 
soon sloughed, the eye rapidly diminished in size, painlessly 
shrinking until it formed a bulb not more than four or five 
lines in diameter. We were impressed by the rapid diminution 
of the size of the eyeball. It seemed as though it quickly 
melted. There was very little pain after the pyogenic action 
was fairly set up, and at no time was much, if any, inflammatory 
action in the circumocular connective tissue. It occurred to 
me that the disaster might possibly be due to atheroma of one 
or more of the branches of the ophthalmic artery.