THE EXTRACTION OF CATARACT, 
AS INFUENCED BY 
MYCOLOGICAL DEVELOPMENT. 
BY A. E. PRINCE, M. I). JACKSONVILLE, ILL. 
While in general surgery the results of modern antiseptic treat- 
ment are brilliant beyond those in any former period of historic med- 
icine, no single capital operation has been placed on a base of 
greater certainty of success than that of cataract extraction. 
The origination of the operation of extraction by Jaque Daviel 
in 1750, though in a comparatively crude state, and attended by a 
large percentage of suppurations, was a great advance over the opera- 
tion of reclination practiced before that time. Modifications of the 
flap operation and improvement in the instruments used, still fur- 
ther increased the ratio of success to 90 per cent. 
No further advance was made until the immortal Graefe intro- 
duced the method of extraction through a small peripheral incission 
accompanied by an iridectomy. By this means the loss through sup- 
puration was reduced to 5 per cent. Graefe died before the era of 
applied anteseptics, and until its advent into surgery no further im- 
provement was made. Prompted by the still frequent occurrence 
of suppuration, numerous operators have varied the location of the 
line of corneal incission, but until it was shown by Lister and pro- 
ven by Koch that suppuration was invariably due to the admission 
of pyogenic organism into the wound area, no further advance was 
attained. 
The leading occulists of every civilized nation promptly antici- 
pated the salutary influence of the introduction of this new idea into 
surgery, and attempted at once, the application of anticeptic meth- 
ods to ophthalmic practice. 
Antiseptics applied to the operation as well as the preparation 
and subsequent management enabled Horner to realize the extreme 
of 98 per cent without suppuration. 
At first there was the respectable minority of so-called conser- 
vatives who laughed at the “bug-theory” but with the accumula- 
tion of statistics showing the increased ratio of successful results, 
the unimpeachable evidence of Koch, based upon inoculation and 
dry slide pure cultivation, and the unbiased and invaluable labors of 
Knapp, establishing the practice on a physiological base, by expe- 
riments made upon live rabbits, this class has finally acquiesced in 2 
the universal acknowledgement, that all septic or suppurating states 
are the result of mycologic life. 
Under the sway of this law many things have become unset- 
tled. Less importance is attached to the location of the incission, 
less emphasis is placed upon the confinement of the patient, and 
the bandaging of the eye. Even the time honored iridectomy 
which has been almost unmolested since the days of Graefe, bids 
fair to be abandoned. 
It would afford me pleasure to communicate my observation 
on the methods pursued by many able oculists in England, 
France, Germany and Switzerland, but the limit of this paper 
will only furnish the following detail of operation, in which attempt 
has been made to combine the points of various operators, which 
conduce to the certainty of success. 
OPERATION—Operating Room. Too little attention is paid to 
the question of an operating room in which the air is as nearly as 
possible free from germs. Prof. Michell of Wuertzburg, whose 
success approaches 100 per cent, lays great stress upon this point. 
He has, his room, which is especially constructed, sprayed before 
the time of operation, with carbolic acid, so that any floating parti- 
cles, may be caused to settle, thus avoiding the danger of there be- 
ing carried into the wound by natural or artificial currents of air or 
spray. In this connection I may be pardoned in this particular re- 
ference to the success of my father Dr. David Prince, who performes 
his major operations under a current of air which enters the room 
after having been sifted through cotton to remove every germ, 
moistened by steam to the point of saturation, and heated by gas 
to a temperature of 110 deg. Thus rendered absolutely free from 
germs, and it is innocuous and unirritating to ihe peritoncem. At 
frequent intervals its purity is tested by the exposure of sterilized 
broth for fifteen minutes, at the point of its admission into the room 
immediately over the operating table. Should any of the tubes 
fail to remain seril, the cotton through which it is sifted is changed. 
To this among other precautions is attributed the almost universal 
absence of suppuration following the ophthalmic operations as well 
as those of a general nature performed in this room. 
The operator should cleanse his hands and nostrils preparatory 
to an operation, and guard his breath from blowing directly into 
the patient’s face. 
Instruments should be sterilized in 3 to 5 per cent, car- 
bolic acid previous to operation, and used, dripping from a 2 3 
per cent, solution. The cutting instruments are placed in alcohol 
after being thoroughly cleansed and allowed to remain until the 
moment of their use. This method was originally advocated by 
Prof. Rothmund of Munich. 
The patient should have a preliminary bath, and immediately 
before the operation the face and hair are to be washed with sub- 
limate 1:5000—which is also used to cleanse the ciliary borders 
of the everted tarsi, as well as to irrigate the conjunctiva through- 
out its extent. Attention should be given to the roots of the lashes, 
about which organisms are prone to lurk. • If dachryocystic inhu- 
mation exist, the tract receives preliminary and immediate anti- 
ceptic- irrigation. Solution of atropine and cocain in sublimate 
1:5000, are especially prepared from boiled distilled water, and 
a separate system of applications is assigned to each patient. 
Cocainization is commenced fifteen minutes before the opera- 
tion and a 4 per cent, solution instilled every three minutes there- 
after, this length of time being allowed to effect the anaesthesia of 
the iris, the incission of which is sometimes painful when the co- 
cain is applied for a shorter period. 
The incission is made upward and placed in the line of the 
sclero corneal junction. 
Iridectomy.—The preference is still given to a small iridectomy, 
which will prevent the danger of incarceration in case of subse- 
quent escape of aqueous; the fate of too many modern attempts 
to attain the aesthetic circular pupil at the risk of subsequent sym' 
pathetic irritation. 
The Capsulotomy is made central by means’of a cystotome 
thus avoiding the complications attending the opening of the cap- 
sule with the knife while making the section, as practiced by 
Galezowski. 
The Extraction is affected by placing the curete an the oiled 
cutaneous surface of the lower lid, the speculum having been re- 
moved and the upper lid being elevated with a fenestrated spoon, 
with which, if required the upper lip of the incission may be de- 
pressed. Slight pressure from below upward causes the lense to 
enter the incission and escape. The pressure of the spoon on the 
lower lid is retained and by gentle manipulation, any remaining cor- 
ticle substance is removed. The irrigation of the anterior cham- 
ber is seldom found necessary except in traumatic or unripe catar- 
acts, in which case it is done as recommended by DeWecker, with 
a 1 per cent, solution of boric acid at 100 deg. F. 4 
The eye is again irrigated with sublimate warmed to the body 
temperature, and a portion of ointment of vaseleine and hydrarg. 
bichloride 1:2000 inserted under the lids. Some of the same is ap- 
plied outside and covered with a small portion of cotton to fill the 
depressions of the lids. Over this is placed a strip of adhesive plaster, 
reaching from temple to temple. This dressing in place of the old 
time bandage permits the patient to lie on either side, after the first 
day, which liberty would be unsafe should the bandage be applied, 
because of the danger of its being drawm too tightly over the eye 
by the motion of the head on the pillow. 
Inspection of the eye at an earlier period than forty-eight 
hours is liable to cause an escape of the aqueous, retard the heal- 
ing, and increase the danger of anterior senechiae. In practice 
the bandage is removed, once or twice a day and a drop of atropia 
sulph, 1 per cent, inserted at the inner cunthers without opening 
the lids, and the dressing reapplied, opening the for the first time 
at the end of four days. 
The Confinement of former times is discontinued. Until the 
discovery of the true origin of pus and putrefaction the phleg- 
monous inflamation and corneal suppuration, entailing total loss 
of sight, were attributed to some vice or indescretion. The cause 
was sought for in the blood, and preliminary systematic dieting 
and medication were thought necessary. Failing in this the source 
of trouble was thought to be mechanical, the evil consequences, be- 
ing presumed to follow the motion of the eye, or head, or body of 
the patient, or result from some injury or accident during sleep. In- 
fluenced by this conception the patient was placed in bed, on his 
back, and all motion interdicted for four days, during which he 
suffered physical pain or vital derangement from the confinement. 
The practice wras not uncommon of securing the hands, or elbow 
cuffs were fastened on the arms with tapes to prevent the approach 
of the fingers to the eyes during sleep. Light was excluded. 
Nowt since it is shown that suppuration is invariably the result 
of pyogenic microbs, the idea of the necessity of perfect quiet for 
several days is abandoned. The comfort of the patient is made a 
matter of study. He seldom has any pain. He sits up on the sec- 
ond or third day, and the increased comfort enables him to pass 
the wTeek until the bandage is removed, without being troubled 
with home sickness, and without knowing of the dorsal and lumbar 
torture which still haunts many a victim of the confinement prac- 
ticed in former times. 
A Charitable Cataract Fund has been established for the indigent. 
J. A. AYERS, Treas.