The After-Treatment of Cataract Cases,to the Exclusion of Com- presses, Bandages, Dark Rooms and Restraint. BY JULIAN J. CHISOLM, M.D., SURGEON IN CHARGE OF THE PRESBYTERIAN EYE AND EAR CHARITY HOSPITAL, BALTIMORE, MD. Read in the Section on Ophthalmology, Otology and Laryngol- ogy, at the Thirty-Eighth Annual Meeting of the Ameri- can Medical Association. Reprinted from the Journal of the American Medical Association, July g, 1887. CHICAGO: Printed at the Office of the American Medical Association. 1887 THE AFTER-TREATMENT OF CATARACT CASES, TO THE EXCLUSION OF COMPRESSES, BAND- AGES, DARK ROOMS AND RESTRAINT. At the last meeting of the American Medical As- sociation, May, 1886, in St. Louis, I reported to the Section on Ophthalmology that Dr. Charles Michel, of St. Louis, was treating cataract cases in light rooms with adhesive straps, instead of by compresses and bandages in dark rooms, and that he found it a desirable method of treatment. Although the dis- cussion which followed showed clearly that the mem- bers of the Section did not endorse the method, or think well of it, yet I was so impressed by it, that I told the Section that I would at once test this plan of treatment, and would report at the ensuing meet- ing in Chicago the results of my experiments. Hav- ing control of all the material at the Presbyterian Hospital of Baltimore City, to which last year were drawn, among its 6,125 cases, 342 cases of lens troubles, I had ample opportunity, immediately upon my return from St. Louis, to put the suggested method into practice. During the month of May, 1886, sixteen cataract extractions, beside iridectomies, were dressed with a strip of isinglass plaster as the sole dressing, and were kept in moderately lighted rooms. These plasters were put on each eye, and were removed on the fifth day. After removal the eyes, by contrast with those treated by bandages and in the dark, were found less red, with less lachrymation, and less photophobia. Moreover, convalescence seemed to be expedited to the extent that cataract patients, at the end of two weeks, could enjoy the freedom of the entire house without smoked glasses and without inconvenience. Upon further experimentation, I found that much of the restraint practised by Dr. Michel and by other 2 ophthalmic surgeons, such as keeping the patients on their backs in bed for a number of days, with both eyes closed, was unnecessary. As I eliminated them one after another, I found that they had not added to the per cent, of successes, and certainly not to the comfort of the patient. I now feel that I have settled down upon a method of treating cataract cases after operation which is far in advance of the accepted after-treatment in general use. My cataract extrac- tions since May 12, 1886, number ninety-eight, and my iridectomies sixty-seven; an experience amply large to test the efficacy of any one particular method. I now can say, without reserve, that I have abandoned absolutely compresses, bandages, dark rooms and restraints from the after-treatment of cat- aract cases, and that my per cent, of good results exceeds my former experience under the old method of compresses, bandages and dark rooms, still too general in use, to the annoyance of both surgeon and patient. My method of procedure is as follows: Patients are operated upon, as a rule, upon the day they pre- sent themselves for treatment, if they feel well and do not complain of fatigue from travel. They under- go no preparation whatever. My experience is that healthy patients, requiring operations on their eyes for the restoration of sight, do best when their sys- tems are not disturbed by medication, and are also better off when not kept in suspense by deferred operations. In cataract operations particularly, they cannot disassociate from this sensitive organ, the eye, a painful operative procedure. It is a great relief to all of them to have the trying ordeal over; and with it the cause for a very disturbing nervous excitement is removed. I have no superstitions concerning the necessity for daily evacuations of the bowels, which haunt the minds and guide the practice of so many physicians. Should complaint of constipation, and fulness of the head as a consequence, be made prior to the operation or during the course of treatment, 3 a purgative is given; but it is the exception, not the rule. All cases are operated upon in the operating-room of the hospital, on a table of suitable height and width, which stands in a projection containing three very large windows, so that I have ample light to operate on cloudy as well as on bright days. Con- sidering the operation itself as by far the most impor- tant part of the entire treatment for the restoration of good vision, in eye cases, and that, when the oper- ation is well done, nine-tenths of the battle is gained, I try to secure every convenience for both patient and surgeon during this very important crisis. After full trial I have abandoned operating upon patients in their beds. Too much inconvenience is occasioned from the awkward positions and body contortions of the surgeon during these bed manipulations. Unless the surgeon is perfectly at his ease, and has perfect control of the head of the patient, he cannot do the important manual work with satisfaction. I have never seen any trouble come from the move- ments of the body after the eye was properly dressed. I do contrast most favorably the quiet walking of a patient from the table to his room after a cocaine extraction as against the violent retching from the general anaesthetic of a few years since, in bed oper- ations ; and yet we know that these violent convulsive acts were not incompatible with the most perfect re- sults in restored vision to cataract patients. The table I use is narrow, facilitating manipulation from the head or from either side, and is just so high as to permit me to stand while operating, without un- comfortably bending. I have sixteen private rooms connected with the Presbyterian Eye and Ear Char- ity Hospital, and I succeed in inducing most of my private patients needing operations to use them, therefore I am never called upon to operate in hotels or private boarding-houses, and if I can help it, not in private dwellings, so that, in by far th 3 majority of my cataract cases, I can enjoy the comfort of my 4 hospital operating room and the operating table. In cataract cases I use invariably a 4 per cent, so- lution of the muriate of cocaine for local anaesthesia. I have used it now in nearly 300 cataract extractions, and have reason to extol its peculiar advantages for eye surgery. I have never seen harm come from its use, and have every confidence in its efficacy and safety. It is instilled into the eye when the patient reaches the operating-room, and most frequently when he is on the operating table. Usually, in five minutes the eye is fully anaesthetized, and is then ready for operation. After the speculum is inserted the eye is suffused with a biniodide of mercury solution, 1 part to 20,000. By elevating the speculum the antiseptic solution is brought into contact with every part of the mucous lining of the lids and eyeball, and is much more thoroughly applied than when the everted lids are mopped as I have seen done by others. If there be any virtue in the use of the germicide, it is all-important that no septic germs be left hid away in folds of membrane. The wiping of lids and cor- nea cannot make a complete application for thorough cleansing. Before using any of the instruments they are put under the hot water spout. They are also washed with very hot water as soon as they are used. In this way cleanliness is ensured. I make a wound in the clear cornea near the scle- ral border, large enough to allow of the free exit of the lens. I make a small iridectomy, taking care, however, that no portion of the iris remains caught in the angle of the wound. When the iris is drawn out by the forceps, one clip of the scissors removes all that is needful for the iridectomy. Blood in the anterior chamber from the section of the iris I see much less frequently than in former years, and this I attribute to the constringing effects of cocaine on the iritic vessels, as evinced before the corneal section by the dilatation of the pupil. I have made five ex- tractions recently without iridectomy, but have not succeeded in getting a perfect pupil in any of them. 5 All the cases had someiritic inflammation, enough to make the pupil dilate irregularly under atropia. In two cases there were small iritic herniae, although ese- rine had been freely used. Notwithstanding the fact that I lost none of these eyes, I have resumed iridec- tomy as the less hazardous method. The capsule is opened freely, usually by horizontal incision over the upper margin of the lens, although sometimes I make the capsulotomy boldly over the pupillary face of the lens. The lens, with all detri- tus, is removed by pressure of the rubber spoon upon the face of the cornea, making pressure with the edge of a second spoon upon the scleral border of the wound to dislodge particles of lens substance which may be caught under this ledge. Should any cloud- ing exist in the capsule, rendering it visible after the lens has escaped, I introduce the iris forceps and ex- tract the capsule entire. This always leaves a per- fectly black pupil, and ensures a perfect result. When the operation is finished and before the speculum is removed, the surface of the eye is again flooded with the antiseptic biniodide of mercury licpiid. When this runs away by tilting the head sideways, the spec- ulum is removed. After testing the vision in finger counting, the eyes are closed. The outer surface of the lids of the eye operated upon is wiped dry of the excess of the bin- iodide solution which had covered them. I now take a piece of very thin, diaphanous white silk isinglass plaster i% inch long and i inch wide, moisten this with the antiseptic solution, and lay it over the closed lids of the eye operated upon. It extends from just under the eyebrow to the cheek, and is wide enough to nearly cover the palpebral split, leaving the great angle beyond the puncta exposed for the escape of eye secretions, and also for the admission of atropia drops by capillary action, without disturbing the strap, should such drops be needed during the after- treatment. In its wet, softened and flaccid condi- tion, the adhesive strap can be stroked by the spoon 6 until every crease is effaced, and every eyelash, as seen through the strap, lies down smoothly upon the cheek. This pressure of the spoon is continued till the isinglass plaster adheres firmly at every point and becomes dry. I use the thin silk plaster in prefer- ence to the gold beater's skin, as suggested by Dr. Michel, because it has more body and wears better. Usually the one piece remains on for the five days needful for the firm corneal healing, and does not need replacing. When using the gold beater's skin I found that, on more than one occasion, the action of the lid muscles had ruptured the film. When this occurred on the third day it was not so objectionable, but when on the first day, before the corneal wound had healed, it was deemed an accident which could be prevented by using a stronger material. When the plaster is dry the two lids are made, as it were, one, with such perfect support of the eyeball that there is no fear whatever of disturbing the wound by any movement of the head or body. I now allow the patient to open his other eye, get down from the operating table and, if he has sight enough in the open eye to guide himself, walk to his room without assistance, often ascending two flights of stairs in doing so. Every window in the hospital, chambers, halls and water closets, has blue shades, which keep out the sun, leaving the house pleasantly lighted. When the patient reaches his chamber he may go to bed or not, as he pleases. Usually they prefer to lay on the bed dressed, and not take off their clothes till bedtime. My experience in the past year proves that patients do best who are least trammeled, therefore I give no orders about their movements, positions or diet, except to restrict them to their rooms for a few days, and prohibit the use of the opened eye for reading. They may remain in or out of bed, as they feel dis posed, dressing and undressing themselves. If both eyes are not cataractous, they can see to eat with the opened eye, and enjoy their meals. They are al- 7 lowed to see friends, and have the days of confine- ment to their rooms pass as pleasantly as possible. By means of this open eye they can take as good care of themselves as they did the day before the operation. The patient is restricted from using the eye in reading only, and finds it of immense comfort in dressing, walking, and eating. By this method of treatment very little nursing is required. Often the patient has no pain whatever during the operation or afterwards, the entire convalescence being absolutely a painless one. Some, on the con- trary, complain of pain in the eye during the first night after operation. Should this night pain be sharp and make the patient nervous, a drop of a i per cent, solution of atropia, put at the inner can- thus, is sucked in between the lids and usually soothes promptly. Rarely is it found necessary to administer morphine to allay this pain. If the patient is nervous at bedtime and fears a sleepless night, a dose of the bromides with chloral is administered. The use of this chloral mixture is the exception. When I visit the patients the day after the opera- tion, I usually find them dressed, sometimes lying on the bed, or reclining on a lounge, sitting in a rocking- chair or walking the room for exercise. They feel comfortable, have had their usual meals, and, if regu- lar in habits, the morning call of nature. By the light of the room (for no candles are needed for inspec- tion), the plaster strap on the closed eye is seen a little wrinkled, and shows evidence of having been moist at the lid split. The escaped secretions of the night have dried upon the strap, and were not in suf- ficient quantity to disturb the adjustment or detach the plaster from the lid surface. Through the trans- parent strap the lids are seen in their normal condi- tion; no redness, nor swelling, nor mattering along the visible row of lashes. The visit is designed for inspection only, for no dressing nor treatment of any kind is needed, and the isinglass strap is not dis- turbed. The second, third and fourth days are usu- 8 ally duplicates of the first. The patient has had no pain nor inconvenience. He has carried out pretty much his ordinary habits of life. After a good night's sleep he has risen at his usual hour, dressed himself, washed his face, avoiding wetting the plaster by using the wetted end of a towel, eats his three regular meals without restriction as to articles of diet, has received the visits of his friends, and has been read to between times to make time pass more agreeably, the light of the room being sufficient to allow this. The straps have been examined each day to observe their con- dition, but more especially to note the appearance of the lids and the condition of discharges which have dried upon the plaster. The strap may show more wrinkles, but usually has remained firmly adherent. If found at any time loose it is removed, and a second adjusted. Not once in ten cases is it necessary to renew the'Strap applied the day of operation. On the fifth day, the corneal wound having firmly healed and the strap having accomplished its work, it is removed by wetting it. The liberated lids sepa- rate, and the restored sight to the eye is recognized at once by the patient. The light of the room hav- ing been sufficient at any time to inspect the condi- tion of the lids, is also sufficient to allow of the inspection of the eye itself. To those accustomed to examine eyes successfully operated upon for cataract extraction by candle-light, five days after the operation has been performed, when treated by compresses and bandages in dark rooms, one is at once struck by the absence of redness,weeping and sensitiveness to light, which are the constant companions of the former treatment. The patient feels a little moisture as the eye is first opened, but the surgeon does not see the tears coursing down the cheek as when the thick compresses are first removed. With the removal of the isinglass strap no change is made in the daily life of the patient, nor in his surroundings. No smoked glasses nor eye screens are used, nor is the light of the room in any way diminished. For two or three 9 days longer he is restricted to the room, a little more light being daily admitted by drawing aside the win- dow shade. By the eighth day the patient is allowed the freedom of the house, and can go into any room from which the sunlight is excluded. By the tenth day I have often found them with raised curtain look- ing into the sunny street, but this was a liberty which they alone were responsible for. It was not advised, and yet no trouble came of it in any case. At this stage of the convalescence the ordinary light of a living room is not offensive to the eye recently oper- ated upon. By the fourteenth day the patient is ready for discharge from treatment, having a strong eye, and often so little injected as scarcely to be recognizable from the one not operated upon. For two weeks after dismissal I usually advise a smoked glass for the sunny street, but none for home use. I have often found this advice disregarded, patients finding no inconvenience from street exposure and without the protection of smoked glasses. Should they have them on, I find them looking over the rims, which means that the eye is standing all the exposure as if no glass was worn. In operating on patients at their own dwellings, they are never put to bed. With one eye open they are able to exercise themselves by walking about their chamber. By the seventh day they are down stairs in the shaded parlor, and are allowed to take their meals with the family, the dining-room window cur- tains being lowered. This method of treating cataract extractions has been under my close observation for twelve months. The method of leaving one eye open for guidance has been continuously used for four months, and in not a single case have I seen any harm whatever come of it. My cataract and iridectomy cases treated by the isinglass plaster dressing number 167. With me it is no longer a subject of experimentation. It has settled down with me as the regular method of treating such cases, and I now use no other. I can 10 truly say that bed operations, compresses and band- ages, dark rooms, bed treatment, diet and restraints of all kinds, are no longer in use by me in eye prac- tice. My greater per cent, of successes, to say noth- ing of the inestimable comfort to the patient, warrants me in the statement that I would be doing injury as well as injustice to my patients, should I go back to the old methods of after-treatment in constant use by me prior to May, 1886. This method of treating cataract and iridectomy cases, revolutionary as it seems, carries reasonable- ness on its very face. An eye accustomed to strong light is not inconvenienced by it, and a healthy eye kept for a short time in darkness may soon acquire a sensitiveness which makes strong light annoying. Everybody has had personal experience of this, when sitting at twilight in a room and the gas is suddenly lighted. Cataract patients, under the long continued darkness of compresses and bandages, experience this the more especially, hence, under the treatment of seclusion generally in vogue, congested, watery, and sensitive eyes, the one not operated upon as well as the one operated upon, had to be, and must ever be, for such is the law of nature. The reverse is equally the law of nature, and my everyday experience proves it. Do not exclude light from cataract eyes and they will not be annoyed by it. In other words, the congestion, photophobia and lachrymation so con- stantly found in eyes recently operated upon for cata- ract extraction, when the heavy, thick bandages are removed are caused by the dressing, and are not a natural sequence of the operation. Change the dress- ings to the light ones and the irritation of the eyes will diminish to a wonderful extent. As to the diaphanous adhesive strap, it is infinitely preferable to the compress and bandage on account of admitting light to the eye, and also in its more perfect adjustment. We will all acknowledge that after a cataract extraction, when we say to the patient, "the operation is now finished, close your eyes, " that 11 we believe that the lips of the corneal wound are ad- justed and in proper condition for quick union. All that any surgeon can wish for is to keep them so, and the closed lids are doing it. Keep the lids closed and the desirable effects are insured. Now, what is the best means of doing this? Is it by putting a piece of clean linen on the closed eyes, then a compress of cotton, well secured to the eye by a head band- age, or by using a light piece of isinglass plaster which really has no appreciable weight, and yet sticks to the skin as if it were a part of it, glueing the lashes to the cheek and making of the two lids one piece, to the perfect and permanent support of the front of the eyeball? Personal experience on the part of pa- tients endorses the latter method. I have patients who at intervals of two years have had cataract ex- tractions made. The first one was under compresses, in dark rooms and with restraint in bed; the second by an adhesive strip for one eye only, in a light room, and without any interference with their move- ments. As by both methods they secured good sight, they are loud in their praises of the adhesive strap method, and look back with dread to the eight days of continuous night to them. The front of the eye is the prominent part of an elastic ball. When pressure is made upon it, the prominence must be pressed in and the equator of the ball necessarily bulged out. When the eye has been cut open near the line of the equator, as in corneal section for cataract, any pressure upon the eyeball by a well secured compress must tend to displace the base line and disturb the nice adjustment of the lips of the corneal incision which the closed lids had effected. If the compresses are not snugly secured by the bandages surrounding the head, then they do not interfere with the lid support, and are simply a useless incumbrance, annoying the patient by their weight, and their presence. As the patient, under this dressing, is kept in bed, every movement of the head pulls more or less unequally upon the bandage, 12 and must cause irregular pressure upon the cut eye- ball, to its annoyance. To keep up by the bandage just such a degree of support as not to cause more or less pressure, is more difficult than at first glance would appear. The varied movements of the pa- tient's head upon the pillow, with irregular drawing upon the head band, can never be taken into ac- count, and yet they make an all-important factor during the early days of treatment. The removal daily of the bandages for eye inspec- tion, and the reapplication of a fresh dressing, is con- sidered very comfortable to the patient, and the reason for his gratitude is apparent. When a loose mass of elastic cotton is used as the compress-and it is by far the best-it is always found converted into a cake by the twenty-four hours' wearing, and its natural elasticity is gone. This is more especially the case when water applications are made. This matted condition of the cotton compress is an indi- cation of the extent that the eye has been squeezed by the head movements, for the cakey pad did not exist when the patient was put to bed. The daily inspection of the lids, making removal of the com- presses and their readjustment necessary, is agree- able to the patient for two reasons: first, in replacing the cotton cake by a fresh, elastic piece, the patient gets rid of some of the irregular pressure which his night movements had occasioned; and secondly, he gets a glimpse of the daylight and a ray of hope for future sight-an inestimable reassuring comfort to one who has been confined to utter darkness for twenty-four hours. With the light adhesive strap the pressure must ever be just what nature intended. The tarsal car- tilages, which during a long life had been moulded by nature for the very purpose of fitting, by their smooth concavity, every point of corneal convexity, and thereby give absolute and perfect support, are kept in position as in sleep without pressure, by the tonic contraction of the palpebral muscle. The ad- 13 hesive strap, when properly applied, keeps the lid closed, and by so doing keeps up a permanent tonic contraction of the palpebral muscle. It therefore becomes a perfect retaining and sustaining dressing. When this strap has dried on the lid, and had been properly adjusted, the eyeball is safe from accident. No ordinary movement imparted to the body can affect it, and therefore confinement to bed, with all kind of restraints, becomes needless. Under the general anaesthetics in former use in eye operations, with the retching and vomiting daily experienced, the light adhesive strap might have been deemed hazardous; and yet, when an eye dressed by the isinglass plaster is inspected, the thorough support given by the eyelid to the front of the eyeball would reassure any observer that it is a far better protec- tion than the compress and bandages, and that the corneal wound cannot be influenced by any move- ments of the jaws or legs. Hence it is that the ex- perience of the past year has taught me that restric- tions in eating, talking and walking do not influence the good results attained. Therefore, to keep pa- tients immovable in bed on their backs, fed on slops, and not allowed to converse, is an arbitrary exhibi- tion of professional authority. Extract from an article on the "After-Treatment of Cataract Operations," by Dr. C. Michel, in the September number of the Archives of Ophthalmology, 1886: "On the fourth or fifth day the patient is al- lowed to turn on the unoperated side, to relieve the aching produced by the dorsal decubitus, and from the sixth to the eighth day he is bolstered up in a sitting posture in bed, and the eye not operated upon left open. From the ninth or tenth day the operated eye is no longer closed, and the patient is dressed and permitted to leave the bed for a chair. " For the last six months I have not put patients to bed at all, and leave the choice of bed, chair or lounge to themselves. If they desire to go to bed, I do not object. If they prefer to go to a lounge from 14 the operating table and remain dressed until their usual bedtime, I equally do not object. So confident am I that the eye well strapped cannot be disturbed by any ordinary movements of the patients, I place no restrictions in their way. I can easily imagine the horror of the uninitiated, when they see my male patients pulling their day shirt over their heads the night after the operation, to replace it by the more easy fitting night shirt, and dressing again in the early morning. When, after watching this most unusual proceeding for five consecutive days, hearing no com- plaints of pain or uneasiness, nor evidence of lid red- ness, or eye mattering, the adhesive strip is removed by wetting it-for it still holds on as if it were a part of the skin itself-the eye opens widely, with no weeping and but little injection, and bearing the ex- posure to the moderate light of the room for inspec- tion without discomfort, his horror at first and subse- quent surprise give way to admiration at the beautiful results in the absence of restraint. I do not know who invented the theory that the movements of the jaw, as in chewing, will impart dangerous movements to the corneal wound, and therefore should not be indulged in by patients re- cently operated upon for cataract. Possibly move- ments of the temporal muscles may be transmitted to the head bandages and from them to the com- presses. The moment the bands encircling the head are omitted, the eyes are isolated from jaw move- ments. The starvation of patients during the early days of a cataract operation, under the isinglass dress- ing, becomes unnecessary. The use of the adhesive strap and treatment in light rooms, as suggested to me by Dr. Michel, was an immense improvement over the compress and dark rooms treatment. Another great advance was made by me when I was enabled to eliminate, step by step, the bed operation, the bed treatment, and the diet list. The crowning work of my past year's experiences 15 was when Ifreed the good eye from the bandage. This was a bold step, and was undertaken with a great deal of anxiety. I assumed that if iridectomies could be treated by bandaging only the eye operated upon, as my ample experience had already proved, cataract extractions might be similarly cared for. My first case was tried on February 18, 1887. The patient, a male, aged 50, in good health, had been myopic all his life. In the right eye he had been getting blind for five years with cataract, now fully ripe. In the left eye there were small marginal lens striations. An ophthalmoscopic examination showed a very large irregular crescent of choroidal atrophy around the disc. With a - lens he had if vision. The cataract extraction, under cocaine, on the oper- ating table, in the operating-room of the Presbyte- rian Hospital, was smooth. Only this eye was closed by an isinglass plaster strap, carefully adjusted. The other eye was left undisturbed, enjoying all the vision he had before the operation. He got down from the operating table, and without assistance walked up- stairs into the ward, and was not put to bed. As far as he individually was concerned he could appreciate no difference in his condition between the day before and the day after operation. For the past five years he had had but one good eye for use, and he continued to use it as heretofore. On my visit to the hospital the day after the operation, I found him walking about the ward. He had retired with the other patients, and had also gotten up with them, and had all the privileges which the other inmates of the ward were enjoying. On the fifth day, a period which experi- ence has taught me that protection was no longer necessary, I removed the adhesive strap. By the tenth day I found him with other patients looking out of the window into the sunny street, the blue curtain of the ward window having been drawn aside. He was detained in the hospital longer than usual, seventeen days, because I considered him a case of unusual interest. He went out without smoked 16 glasses, deeming them unnecessary. With 4- the vision in this eye was quite as good as in the eye not operated upon. On ophthalmoscopic examina- tion the eye from which the cataract was removed indicated also a large cresent with choroidal atrophy around the disc. This most satisfactory conduct of this patient's eye was an incentive for further trial of this new and revolutionary practice. On February 23 the second case of cataract extraction was submitted to the same treatment, and on February 28 the third case. As all of these did well, and seemed in no way injuri- ously affected by the great latitude allowed, it became from that time my established method of treatment. Now all my cataract patients have the inestimable comfort of having an eye for their guidance during the treatment for cataract extraction. This great privilege, with the freedom of their moderately lighted chambers and the simple transparent, light, perma- nent dressing, with no bed treatment, marks an era in eye surgery that cannot be too highly estimated. From my present experience I can clearly see how the congested, watery, sensitive eyes, so constantly met with after the bandages have been removed in the ordinary method of dressing eyes after cataract extractions as to be considered a proper part in the convalescence, are clearly traceable to the restrain- ing treatment. It is the heavy bandages with the dark rooms that does it; because when I do not use the compresses, and keep my patients in light rooms, I do not see these complications, antagonistic to rapid convalescence. In former years the Presbyte- rian Eye Hospital bought smoked glasses by the gross, and every iridectomy and cataract patient was supplied with them as soon as the bandages were re- moved. Now there is not one worn in the hospital, and very few patients see the necessity of putting them on when they leave the house. The year's experimental work undertaken at the Presbyterian Eye and Ear Charity Hospital of Bal- 17 timore has shown conclusively that a cataract patient not submitted to darkness, but with eyes bearing the light throughout the entire treatment, will have strong ones when the strap is removed on the fifth day. A very extensive experience of former years has also conclusively shown that if I keep an eye in the dark for even a few days, I will have one which must run water and show congestion when the light is admitted to it. If an eye is strong when both eyes are only lightly covered, the eye operated upon will be stronger if only one eye be covered, and the good eye be permitted to enjoy its accustomed stimulus (light) undisturbed. If only as good results are secured by this rational treatment, over the method of compresses, bandages, dark rooms and restraints of all kinds, then why should not patients enjoy the comforts of the one when contrasted with the annoyances of the other? My experiences of the past year show conclusively that not only is the patient made more comfortable by the plan suggested, but that a larger per cent, of good results can be secured. Of course there are certain unfavorable results at times obtained which no care can prevent. No one should look for abso- lute success in every case. Failures will now and then come to the most skilful. Of the sixty-seven iridectomies I lost none. Of the ninety eight cata- ract extractions I lost five eyes. Case i.-Mrs. A., aged 71, extremely myopic, cat- aract well matured in the left eye. Operation smooth. Had some pains during treatment. Left the hospital with good vision. Some days after dismissal plastic iritis ensued, and the eye was finally lost. Mrs. A. was in poor health, and was in deep grief from the recent loss of her husband. I do not know whether the return to her home, with its sad memories, had anything to do with the subsequent inflammation. This I count, however, as one of my losses. Case 2.-Mr. R., aged 92, an old, feeble man. Iri- tis came on during treatment, and the eye was lost. 18 Case 3.-Mr. B., aged 39; has had diabetes melli- tus for years, and passes over a gallon of urine per day, loaded with sugar. Has lost much flesh. Cata- ract matured in each eye. Left eye operated upon with restored vision, a perfect result; V. = Three weeks afterwards right eye operated upon. Inflam- mation ensued and this eye was lost. Case 4.-Mr. B., aged 65; cataract in each eye. Much depressed in spirits; thought himself well off financially, but has recently been beggared. Cat- aract fully formed in the left eye; still sees to get about with the right eye. Cataract extraction smooth. Eye pained from the first night, necessitating the lib- eral administration of opium. During the day there was not much suffering, it always appeared aggravated at night. The lid at no time red, nor any escaping secretions. The strap was removed on the fifth day. Cornea clear, eye injected; pupil free and fully di- lated under atropia, which had been daily instilled. Lymph masses seen in the vitreous. Hyalitis had established itself which eventually destroyed the eye. Case 3.-Mrs. B., jet. 74, in very feeble health; cat- aract fully formed in the right eye for six months; has vision enough to get about with the left eye. Lens extraction under cocaine smooth. Commenced to suffer pain soon after the operation. Lids com- menced to swell by the third day, and the eye was lost by panophthalmitis. A few days before she was operated upon four boys, aged from 10 to 14 years, were received from an industrial reformatory school. All had purulent conjunctivitis with corneal ulcera- tion and large iritic hernije. Septic germs were found in abundance in the eye secretions from the eyes of these boys, and three had to have iridecto- mies to save the cornea from general sloughing. By some oversight or careless manipulation this case seemed to me one of contagion. Case 6.-Mrs. K., aged 62, of a very nervous tem- perament, had a cataract fully formed in the left eye, and forming in the right eye. Her everyday life was 19 a very unhappy one, full of care and trouble. She was the second wife of an old man of 80 nearly an imbecile, with a number of grown step children liv- ing in the house who were always making trouble. Crying spells were of frequent occurrence during her treatment. She had iritis which has thoroughly shut up her pupil. She has a clear cornea and good light perception, so that there is a promise that this case can have sight restored by an iridectomy. If these cases be carefully analyzed, it may be considered an open question whether these eyes could have been saved under any method of treat- ment. Call them all however legitimate losses, and they still make an excellent showing for the proposed method of treating cataract eyes after extraction operations. Ninety-two useful eyes out of 98 ex- tractions, is satisfactory eye surgery, and is not often excelled. This method of treating cataract and iridectomy cases after operation has given me great satisfaction. The isinglass plasters and light rooms, as proposed to me by Dr. Charles Michel, with the withdrawal of nearly all restraint, leaving the eye not operated upon open for the guidance of the patient, as the fruit of my own experiments, makes an after-treatment which leaves but little to be desired. It is said that there is nothing new in all this, and such a statement is in a measure correct, as the fol- lowing extract from Mackenzie on "Eye Disease," American edition, of 1855, will show: After-treatment of Cataract Extraction Cases.-The patient should be put to bed with as little movement of the head and body as possible. The room is not to be made too dark. The length of time a patient is to be kept in bed, is a point upon which there has been a wide diversity of practice. Wenzel con- fined his patients to their backs, without change of posture, for a fortnight. Phipps, on the other hand, examined the eye on the morning after the operation, applied a shade and allowed the patient to rise. A middle course appears the most judicious. It is improper to cover up the eye too closely, and still more im- proper to load it with dressings and bandages. It is of the ut- most importance however to keep the eyelids still, and prevent 20 any attempts to use the eyes. These objects are completely ob- tained by the straps of court-plaster, from the employment of which I have never witnessed any bad consequences. I generally allow those which are applied immediately after the operation, to remain on for two or three days, but if the eye is easy for four or five days. Desmarres in his "Treatise on Eye Diseases," pub- lished in 1847, also refers to the adhesive straps as his sole dressing. From this extract so pertinent to the subject under discussion, (from Mackenzie's old work on eye disease,) it would seem that the common meth- od of dressing eyes after cataract extractions, in Europe forty years ago, was by adhesive strips, and in moderately lighted rooms. Also, while some operators were very rigid in bed restraints, keeping their pa- tients immovable on their backs for several days, others allowed much more latitude, even to sitting up on the second day. Why this good practice was abandoned and compresses with bandages substi- tuted is not made clear. Possibly the retching and vomiting accompanying the administration of a gen- eral anaesthetic, which about this time was introduced into eye surgery, seemed to demand more support and protection for the eye just cut open. Now that the local action of cocaine has removed this ugly complication in cataract extractions, there is no good reason why the adhesive strap should not be reestab- lished and generally adopted as the best and sole dressing. The only great novelty in the treatment which I suggest, is the leaving of one eye open for the guid- ance of the patient. So far as I have consulted the old authors, I have found no mention made of this item. A more careful search, however, may show that this is also no new thing. Grant it, that there is no real novelty in treating cataract cases as has been defined. Operating in the amphitheatre, closing the eye operated upon with isinglass plaster, leaving the other open for the guid- ance of the patient, allowing him to walk from the operating room to his chamber, not putting him to 21 bed, allowing him free movements and no restriction as to diet, or receiving the visits of friends, no dis- turbance of the dressings till the fifth day, then free- dom from all restraints after that time, even to the exclusion of smoked glasses. Also, grant that these methods as practiced by a former generation of eye surgeons have never been altogether abandoned. Against all this I do not hesitate to say, that what- ever may have been the method pursued in former times, it is now the habit of eye surgeons to treat cataract cases by the exclusion of light to eyes re- cently operated upon, by compresses and bandages, and in dark rooms and with bed restraints and after- wards by the wearing of smoked glasses. Since I have found that these annoyances are uncalled for and do not add to the comfort or safety*of the patient, I have for the past year been making war systematic- ally, against these universally established methods, because a large experience has taught me that the method of treating cataract extraction under band- age, in dark rooms and with bed restraints is unrea- sonable, unphysiological, and unnecessary. The year's work at the Presbyterian Eye and Ear Charity Hospital, of Baltimore, has proven to my en- tire satisfaction, and also to the satisfaction of many other surgeons, that the after-treatment which I was carrying out is by far the most comfortable for both patient and surgeon, and is also accompanied by fewer accidents. I have succeeded in making many con- verts to my way of treatment and before long hope to see compresses, bandages, dark rooms and re- straints, considered as relics by all the friends of progress in ophthalmic work.