A TREATISE ON 
CATARACT 
BY 
DONALD T. ATKINSON, M.D. 
FELLOW OF THE AMERICAN ACADEMY OF OPHTHALMOLOGY AND OTO LARYNGOLOGY, 
LIFE MEMBER OF THE AMERICAN MEDICAL ASSOCIATION OF VIENNA, 
MEMBER OF THE AMERICAN MEDICAL, THE SOUTHERN MEDICAL, THE 
NATIONAL TUBERCULOSIS AND THE AMERICAN SOCIAL HYGIENE 
ASSOCIATIONS. AUTHOR OF "GREAT MEDICAL INNOVATIONS," 
"ADENOIDS AND KINDRED PERILS OF SCHOOL LIFE." "A 
SOCIAL AND ECONOMIC CONSIDERATION OF VENEREAL 
DISEASES (SOCIAL TRAVESTIES AND WHAT THEY 
COST)," ETC., ETC. 
With Original Illustrations 
NEW YORK 
THE VAIL-BALLOU COMPANY 
PUBLISHERS Copyright, 1921 by 
VAIL-BALLOU COMPANY TO 
DR. SAMUEL E. THOMPSON 
EMINENT ALIKE AS A SCHOLAR AND A PHYSICIAN, AND ONE TO WHOM THE AUTHOR 
IS PROFOUNDLY INDEBTED, THIS LITTLE BOOK IS GRATEFULLY 
AND AFFECTIONATELY DEDICATED PREFACE 
In preparing this little volume it has been the aim of the 
author to give a general resume of the subject of cataract, 
and to place before the reader a synopsis of the most ap- 
proved methods for the operation and after-treatment of 
cataract cases. Careful attention has been given to the 
technic of each operation, with mention of a number of 
measures indicated to avoid the accidents so common in 
cataract cases. 
Special emphasis has been made of the importance, not 
only of making a guarded prognosis in advanced cataract, 
because the possibility of lesions of the fundus, but also 
of the necessity of examining the eye grounds and record- 
ing the findings in cases seen before the lens is sufficiently 
cloudy to obscure entirely the field, thereby securing valu- 
able data as a later aid to prognosis. 
In attempting to generalize the work I have pur- 
posely refrained from incorporating in it reports of indi- 
vidual cases. 
The cuts in the book are all original, and in preparing 
them the author has made an effort to present the technic 
of each step of the various precedures more clearly, per- 
haps, than they are represented in the average text book. 
518-21 Russell Bldg., 
San Antonio, Texas. CONTENTS 
PAGE 
Anesthesia 68 
Anterior Capsule, Second Stage, Efficient Rupture of the 131 
Anterior Chamber, Lavage of the 90 
Aphakia 114 
Cataract, Definition of 26 
Cataract, Diagnosis of Juvenile 118 
Cataract Extractions, End of Results of 114 
Cataract Operation, History of the 13 
Cataract Operation, Immediate Accidents in 96 
Cataract, Secondary 139 
Cataract, Third Stage, the Removal of, by Suction . . 131 
Cataract, Traumatic 135 
Cataract, Treatment of Juvenile 118 
Cataract, Usually One More Advanced than Other . . 48 
Cataract, Varieties of 26 
Cataract Cases, the Wisdom of a Guarded Prognosis in . 53 
Cataract Cases, the Pupil in 54 
Cataracts, Arrestation of 48 
Cataracts, Congenital or Juvenile 117 
Capsule, the Incision in the 84 
Complications, Mental 112 
Conclusions, General 132 
Conjunctive Flap, the Question of a 76 
Cornea, Treatment of Non-Union of the 112 
Corneal Section, the 73 
Corneal Wound, Non-Union of the Ill 
Corneal Wound, Suppuration of the Ill 
Crystalline Lens, Dislocation of the 136 
Discipline, Regarding Surgeon's Personal 59 
Don'ts 63 
Dressing, Subsequent 103 
Extraction, Dressing of the Eye Following 99 
Eyes, the Question of Operating One or Both .... 44 
Glaucoma, Postoperative , . 108 
Incipient Cases, Case Record Notes in 44 
Indian Operation, the Intracapsular or 141 
Instrument and Its Use 129 
Instruments 70 
Intra-Ocular Hemorrhage, Postoperative 107 CONTENTS 
PAGE 
Intra-Ocular Hemorrhage, Treatment of Postoperative . 107 
Iridectomy, the 79 
Iris, Postoperative Prolapse of the 104 
Iritis, Postoperative 108 
Iritis, Treatment of Postoperative 108 
Juvenile Cataract, After Treatment of 125 
Juvenile Cataract, Operation for Solution of . . . .121 
Juvenile Cataract, the Double Needle Operation for . .125 
Juvenile Cataracts, the Suction Operation for . . . .126 
Left Eye, the Section on 79 
Lens, Accidents During Delivery of the 93 
Lens and Capsule, Anatomy of the 22 
Lens, the Expulsion of the 86 
Operating Room, Taking the Patient from the Table and 
Away from the 100 
Operating Room, Patient to Be Led to 58 
Operating Room and Surgeon's Dress, General Considera- 
tion Regarding 58 
Operation, Conditions Contra-Indicating 49 
Operation, First Stage, Details of the 130 
Operation, Immediate Accidents in Cataract 96 
Operation, Selection of 121 
Operation, the Education of the Patient Preparatory to 54 
Operation, the Intracapsular 21 
Patient, Diet and General Care of 113 
Patient, Preparation of the 57 
Pain, Postoperative 112 
Room, the Patient's 108 
Secondary Cataract, Extraction of the Capsule in . .140 
Secondary Cataract, Operations for 139 
Senile Cataract, Causes of 30 
Senile Cataract, Diagnosis of 86 
Senile Cataract, Symptoms of 82 
Senile Cataract, Responsibility of General Practitioner in 
the Diagnosis of 89 
Solutions, Preparing the 69 
Suction Operation, Suitable Cases for 126 
Suction Operation, Unsuitable Cases 129 
Technique, Practice Necessary to Good 68 
Traumatic Cataract, Treatment of 136 
Vision in Patients Developing Cataract, Preliminary Iridec- 
tomy as a Means of Improving 47 
Wound, the Toilet of the 98 
Wound, Treatment of Suppuration of the Ill ILLUSTRATIONS 
FIGUBE 
1. Diagrammatic cross section of the eye showing the contour of 
the lens and its relation to adjoining structures.-Author 17 
2. Above: Immature cataract as seen by reflected light. Be- 
low: Same seen by aid of transmitted light.-Author . 21 
3. Above: Calcareous lens (exaggerated). Below: Partial 
dislocation of the lens downward.-Author . ... 25 
4. Proper way of holding Von Graefe knife 29 
5. Proper way of holding the iris forcep 32 
6. Proper way of holding the iris scissors 36 
7. The puncture; initial step in performing the corneal section. 
Demonstration upon model.-Author . . . ' . . .40 
8. The corneal section showing the puncture and counter punc- 
ture. Demonstration upon model.-Author .... 44 
9. The puncture and counter puncture of an unambidextrous 
surgeon showing a very frequent and sometimes fatal mis- 
step-the pricking of the unanesthetized lid with the point 
of the knife with consequent flinching of the patient.- 
Author 53 
10. The corneal section as made by the left hand. Demonstra- 
tion upon model.-Author 57 
11. Method devised by Jameson of replacing and protecting the 
iris after it has fallen in front of the knife. Demonstra- 
tion upon model.-Author 60 
12. Method of grasping iris with forceps in operation upon left 
eye where surgeon is not ambidextrous. Section has been 
made from opposite side of the patient.-Author ... 64 ILLUSTRATIONS 
FIGURE 
13. The iridectomy. Iris is drawn well beyond margin of 
wound. De Wecker's scissors in position preparatory to 
snipping off section. Demonstration upon model.-Author 73 
14. Very favorable position of hands in iridectomy upon right 
eye. Left hand supported by little finger on brow; right 
little finger in similar manner rests upon nose.-Author . 79 
15. Frequently adopted but improper method of performing cap- 
sulotomy.-Author 83 
16. Method of making the incision in the anterior capsule pre- 
paratory to delivery of the lens. Demonstration upon 
model.-Author 86 
17. Showing route traversed by the crystalline lens in cataract 
extraction accompanied by iridectomy.-Author ... 90 
18. Supporting the lens with a wire loop during the act of deliv- 
ery. Demonstration upon model.-Author .... 96 
19. Unsuccessful method, adopted by some surgeons, of freeing 
anterior chamber of shreds of capsule and remnants of 
cortex and vitreous by use of spatula, while operator stand- 
ing at right leans over patient. In addition to bad posi- 
tion lack of deep pressure from improper choice of instru- 
ment gives poor result.-Author 103 
20. Removing fragment of cortex from the anterior chamber by 
deep stroking of the cornea. Demonstration upon model. 
-Author 107 
21. Very frequently assumed but awkward position of hand in 
performing toilet of the wound. As will be observed the 
hand is entirely unsupported.-Author Ill 
22. The toilet of the wound: Freeing the incision of shreds of 
capsule or fragments of cortex or vitreous. Demonstra- 
tion upon model.-Author 114 
23. Proper method of applying cataract bandage . . . .118 
24. The woven wire cataract shield of Wiirdemann . . . .122 ILLUSTRATIONS 
FACING 
FIGUBE PAGE 
25. Method of applying the binocular convex cataract shield . 129 
26. Densest form of secondary cataract resulting from the ag- 
glutination together of the anterior and posterior opaque 
capsules.-Author 135 
27. The double needle procedure adapted to discission of dense 
secondary cataracts. Demonstration upon model.-Author 139 
28. Discission of the opaque capsule as performed where single 
Von Graefe knife is used. Demonstration upon Model. 
-Author 142 
29. Bandage well adapted to discission cases 146 A Treatise on Cataract 
History of the Cataract Operation 
The origin of the treatment of cataract is lost in the haze 
of antiquity. Among a number of ophthalmic instruments 
found in upper Egypt is a needle similar to the ones used 
by the couchers of Medieval Europe, and this relic of an- 
cient surgery has led many antiquarians to believe that 
the Egyptians were familiar with the cataract operation. 
That the ancient Greeks attempted to treat cataract is 
proven by the writings of Celsus, and an exhibit of ancient 
surgical instruments to be seen in the British Museum 
demonstrates beyond a doubt that the practice of depress- 
ing cataracts was common among the Romans of an early 
period. 
The cataract operation performed by the surgeons of 
the Renaissance was couching, a practice executed after 
the method of the ancients. This was a simple depression 
of the lens into the vitreous by means of a needle thrust 
through the cornea. The operation was done with the pa- 
tient sitting, and with no regard for cleanliness. The re- 
sults were often disastrous, for if the eye was not lost 
from infection, a glaucoma usually set up and soon ter- 
minated vision. If the patient escaped glaucoma and in- 
fection the lens would sometimes rise to its former posi- 
tion, thus reobscuring the vision. The couchers of cat- 
aracts were unscrupulous itinerants who became generally 
known throughout Europe as "eye destroyers," a term 
frequently used by the Dresden Surgeon, George Bar- 
tisch, 1535-1606, in his attacks upon them. 
13 14 
A TREATISE ON CATARACT 
The first European oculist of whom we have any defi- 
nite knowledge was this same George Bartisch, a German 
barber surgeon, who in 1853 published a book on diseases 
of the eye, profusely illustrated by wood cuts. Bartisch 
made a forward step in the evolution of the cataract op- 
eration but he did not understand that cataract was an 
opacity of the crystalline lens itself. Instead, he taught 
that it was a "skin" or pellicle within the capsule. It was 
not till 1706 that Brisseau discovered, while doing a post- 
mortem, that cataract was a cloudiness and hardening of 
the lens substance. 
As a substitute for couching, Bartisch instituted a 
method which has since been known as reclination but, 
though its author made extravagant claims for it, its im- 
provement over the old operation was not sufficiently great 
to mark an epoch. Bartisch performed this operation by 
introducing a needle through the sclera about six milli- 
meters behind the sclero-corneal margin. The point of 
the needle was drawn across the posterior capsule thus 
rupturing it. The needle was then slightly withdrawn 
and thrust between the iris and the lens. As soon as it 
was seen to appear behind the pupil its handle was carried 
forward, thus turning the lens backward upon the floor of 
the eye ball. As with the couching operation nearly all 
eyes succumbed, following this procedure, as the displace- 
ment of the cataract backward had the same effect which 
would have resulted from any other foreign body within 
the vitreous. 
The Bartisch operation often caused a dislocation of the 
lens into the anterior chamber, an accident usually brought FIGURE 1 
Diagrammatic cross section of the eye showing the contour of the lens and its 
relation to adjoining structures.-Author. A TREATISE ON CATARACT 
17 
about by an attempt at tearing the posterior capsule pre- 
vious to reclination, and it was following such an accident 
that Stephen Blaukaart, in 1688, removed the lens by an 
incision through the cornea. Blaukaart's case is the first 
cataract extracting on record. Taking his cue from 
Blaukaart, Jacques Daviel in 1748 originated the modern 
treatment of cataract by extraction of the lens. In 1752 
he reported to the Royal Academy of Surgery one hun- 
dred operations thus performed. Before his death, in 
1762, it is said that he had done four hundred and thirty- 
four extractions with but fifty failures. Daviel began his 
corneal section with a small triangular scalpel after which 
he enlarged the incision with a thin bladed, curved scis- 
sors. His section was always made downward. With a 
sharp pointed needle he then punctured the anterior cap- 
sule, and after elevating the corneal flap with a spatula he 
forced the lens out by pressing upon the lower lid. Fol- 
lowing the extraction extraneous pieces of lens matter 
were freed from the anterior chamber, either by using the 
spatula as a spoon or by stroking the cornea with it in 
much the same manner as is practiced by the modern sur- 
geon. 
Daviel's operation for cataract was the first important 
uplift given to ophthalmology since the days of Galen. In 
spite of this fact he was bitterly attacked from all quar- 
ters and his operation was assailed by the leading ophthal- 
mologists of Europe, which goes to show to what a degree 
surgical practice may be controlled by conventional habits 
of thought. 
No further important advance was made in the cataract A TREATISE ON CATARACT 
18 
operation until Albrecht Von Graefe, 1828-1870, intro- 
duced his combined method of extraction. In addition to 
a corneal section accompanied by a conjunctival flap, 
Graefe made a broad iridectomy. Previous to this time 
an iris, prolapsed at the time of extraction, was placed in 
position, only torn shreds being clipped off. 
"The results of Von Graefe's linear section," says 
Fuchs, "were in fact much better than those which the 
earlier methods had given. Suppuration of the wound in 
particular, had become less frequent. But yet the method 
had its dark side, too. Its performance required more 
operative skill, and the delivery of the lens was made more 
difficult, owing to the slight tendency to gape that the 
wound possessed. Other disadvantages arose from the 
peripheral situation of the section, which brought the lat- 
ter, especially at its extremities, close to the zonula and 
the ciliary body. Prolapse of the vitreous was frequently 
met with, and also inclusion of the limbus of the coloboma 
in the wound. While suppuration of the wound proved 
to be less frequent, iritis and irido-cyclitis became pro- 
portionately more common, and in consequence, sympa- 
thetic disease of the other eye was observed more fre- 
quently than before. These facts induced operators to 
depart more and more from this section, which was felt 
to be too peripheral in its situation, and in particular led 
them to place the extremities of the latter near the cor- 
nea. If Von Graefe's original section as Von Graefe 
himself gave it, was itself not a pure linear incision, this 
is still more the case with the section as it was subsequently 
performed. It had become a curved section, forming an FIGURE 2 
Above: Immature cataract as seen by reflected light. 
Below: Same seen by aid of transmitted light.-Author. A TREATISE ON CATARACT 
21 
arc of small altitude. Under this somewhat modified 
form, soleral extraction soon became the method that was 
generally employed." 
Graefe, during his life, performed over nine hundred 
extractions for cataract with only five per cent, of failures, 
a record of which any modern operator might be justly 
proud. Aside from the aseptic principles under which 
the operation is now done, and slight variations in tech- 
nique, there have been no essential improvements made 
since the days of this great German ophthalmologist. 
The Intracapsular Operation 
It is not known who was the first to perform the opera- 
tion for the removal of cataract in its capsule. It is 
thought by some that the linear extraction as performed 
by Daviel was in reality an intra-capsular operation, 
though nothing written by Daviel is in evidence to support 
this view. Sharp, an English surgeon, briefly describes 
an operation for cataract and though he does not mention 
the capsule of the lens he suggests a method of extracting 
the lens by pressure with the thumb. In his description 
of the operation he mentions the expulsion of the lens 
as a second step, and this has led some surgeons to be- 
lieve that he practiced the intracapsular method of ex- 
traction. 
The operation for removal of the opaque crystalline lens 
in its capsule was practiced extensively by Hermann Pag- 
enstecher, his first operation of this character being done 
in the year 1866. His results in uncomplicated cases were 22 
A TREATISE ON CATARACT 
said to have been very brilliant but because of the large 
number of eyes lost by expulsion of the vitreous the opera- 
tion was eventually abandoned by all except its originator. 
Pagenstecher's method consisted of introducing a small 
silver spoon behind the lens and then exerting pressure 
upon the cornea with a spatula so as to cause the lens to 
glide upward into the bowl of the spoon. 
Following Pagenstecher, though differing with him in 
technique, McNamara, Wright and Andrews performed 
and described in writing operations for the removal of the 
lens in its capsule. 
In 1871, the Native assistant to Col. Mulroney, then 
stationed at Amristsar, India, read a paper at Calcutta 
describing the intracapsular operation as done by his 
chief. From this time until the present various modifica- 
tions of Mulroney's operation have been done in India, but 
the method has only become world known through the ef- 
forts of Col. Henry Smith, who in 1917 had performed the 
operation on over 30,000 cases in his Indian Clinic. 
Anatomy of the Lens and Capsule 
The crystalline lens is a homogeneous, transparent bi- 
convex body which at birth is almost of fluid consistency. 
Later its protein element is increased, giving it a greater 
density, this density increasing from year to year. Its po- 
sition is directly between the posterior portion of the iris 
and the anterior portion of the vitreous humor. Its an- 
terior surface is slightly curved. Posteriorly the curve is 
greater than anteriorly. Passing from the anterior to the FIGURE 3 
Above: Calcareous lens (exaggerated). 
Below: Partial dislocation of the lens downward.-Author. A TREATISE ON CATARACT 
25 
posterior poles of the lens is an imaginary line known as 
the axis of the lens. 
At birth the lens is colorless, but a yellowish tinge be- 
gins to be seen at puberty. This tinge increases until sen- 
ile life when the normal lens becomes of a greyish amber 
color. In the phenomenon known as cataract these alter- 
ations in the color of the lens are more marked than are 
those found in normal senile lenses, which, as suggested 
by many authors, may be the result of these changes com- 
ing on early but manifesting themselves only in late adult 
life by marked coloration and density. In addition to 
changes in density and color, an alteration in the shape of 
the lens structure itself occurs during life. In infancy 
the lens is smaller and more globular than it is in adults, 
its growth throughout life being continuous. An explan- 
ation of this phenomenon is given by Priestly Smith, as 
follows: 
"The lens is derived from the cuticular epiblast and its 
mode of growth is analogous to the cuticle. But its cells, 
unlike those of the cuticle, are not cast off as they grow 
old: they are laid down, layer upon layer within a closed 
capsule, the younger fibres surrounding the older. In 
consequence of this unique arrangement, and in spite of 
the shrinking of the older cells which form the nucleus, 
the growth of the lens does not cease with those of the rest 
of the body, but is continuous unless some morbid pro- 
cess intervenes, through the whole period of life." 
From infancy to old age the substance of the crystalline 
lens may be said to be in constant change. Almost fluid 
at birth, its structure gradually takes on density until old 26 
A TREATISE ON CATARACT 
age appears when it may become solid and even calcar- 
eous. At a very early age a lenticular nucleus forms and 
becomes denser as the years pass until it takes on the nor- 
mal consistency of adult life. 
The lens is surrounded by a thin elastic membrane 
known as the capsule. It is epithelial in structure, being 
slightly more friable at its posterior portion. This is re- 
sponsible for the fact that the anterior portion more read- 
ily resists the touch of an instrument than does the pos- 
terior portion. The fibres of the equator of the capsule 
blend with these of the ciliary processes. 
The lens capsule is also subject to changes which are 
governed by age. At birth it is colorless and highly elas- 
tic. This elasticity disappears in a measure as age pro- 
gresses and the substance of the capsule also takes on 
changes in coloration similar to those found in the lens it- 
self. The distinct haziness of the pupil, as seen in elderly 
persons, is largely due to the amber tint imparted to it 
by the lens capsule. 
Definition of Cataract 
The term cataract is used to designate several types of 
opacities of the crystalline lens and its capsule. 
Varieties 
Cataracts are classified anatomically as: 
(1) Lenticular 
(2) Capsular 
(3) Capsulo-lenticular FIGURE 4 
Proper way of holding Von Graefe knife. A TREATISE ON CATARACT 
29 
Clinically they are spoken of as: 
(1) Senile 
(2) Congenital 
(3) Traumatic 
(4) After cataract 
All senile cataracts may be roughly divided into cortical 
cataracts, a cloudiness or loss of transparency of the cor- 
tex of the lens and nuclear cataracts, a hardening of the 
nucleus of the lens with opacity. 
In the cortical variety the substance of the lens sur- 
rounding the nucleus becomes opaque. This type of cat- 
aract is the one usually found in the individual under sixty 
years of age. The older the patient is before cataract 
begins the more liable he is to the central or nuclear type. 
Cortical cataract is a partially opaque cortex through 
which the nucleus may be seen with the ophthalmoscope as 
a dense yellow spot. As ripening progresses the cortex 
may shrink materially, the nucleus having the appear- 
ance of being surrounded by a heavy veil. At this stage 
the lens is said to be overripe, and the patient sometimes 
notices he sees slightly better than formerly, this being due 
to the fact that light rays are penetrating the cortex. A 
very marked difference may occur in the nature of the 
lenses in the same individual. I have observed a number 
of times a cortical and a nuclear cataract in the same 
patient. 
In very rare instances the nucleus moves about in the 
cortex, a condition known as Morgagnian cataract. In 
this variety of cataract an unusual optical phenomenon 
may be observed. The patient may see large objects re- 30 
A TREATISE ON CATARACT 
markably well for a few moments at a time, this brief 
period being followed by the usual obscuration of vision. 
Sometimes the process of ripening of senile cataract is 
accentuated by a too rapid abstraction of the fluid of the 
lens substance and a diminution of its supply, which inter- 
feres with its nutrition and transparency. This absorp- 
tion of the lens substance may be followed by deposits of 
phosphates or carbonates of lime within the substance of 
the lens and the establishment of calcareous cataract. 
These deposits early prevent the admission of light rays 
and, as in the case of black deposits in the lens, may inter- 
fere materially with diagnosis. Senile lenticular cataracts 
begin as a cloudiness of the lens structure in which changes 
in density and color are abnormally progressive. At first 
there seems to be but slight alteration of the substance of 
the lens. Much light is admitted to the eye and there may 
be for years little embarrassment to vision. Usually the 
nucleus of the lens is the first to become thoroughly 
opaque. 
Causes of Senile Cataract 
That opacities of the crystalline lens may be influenced 
by heredity cannot be doubted. In a great number of in- 
stances whole families have been known to become cata- 
ractous as old age draws near. Several children in the 
same family whose parents have been cataractous are often 
seen to have congenital cataract, this phenomenon, accord- 
ing to De Schweinitz, being transmitted through the fe- 
male line. In the congenital form of cataracts it is not A TREATISE ON CATARACT 
31 
uncommon to have some other defect of the eye which 
may be traced to an ancestral origin. 
Occupations which necessitate looking at intense light 
for long periods predispose to cataract. Glass blowers 
and stokers are known to frequently develop the disease. 
The condition is thought to be more common in the desert 
regions of the Southwestern states where the glow from 
the sun is continuous and excessive. 
Certain toxic agents are known to produce opacities 
of the crystalline lens. Rabbits fed upon naphthaline de- 
velop cataract in a few hours. When the naphthaline 
feeding is discontinued the lenses clear up completely. 
Ergotism is often complicated with cataract. During 
great European epidemics of this disease, then known as 
St. Anthony's Fire, large numbers of the victims of er- 
gotism became blind. 
Cataracts sometime develop simultaneously with disease 
of the optic nerve, from a lightning shock. I have had in 
my practice one such case. It is probable that the rapid 
absorption of actinic rays has something to do with 
the molecular changes which resulted in opacity of the 
lens. 
Cataract has been known to follow in the wake of the 
continued fevers. It is common in patients who have dia- 
betes, and is not unfrequently associated with Bright's 
disease. 
Some writers have held forth the theory that the differ- 
ence between the senile changes in the normal lens and 
senile cataract itself is only one of degree, this supposed 
fact making it impossible to decide when the one ends and 32 
A TREATISE ON CATARACT 
the other begins. As pointed out by De Schweinitz, ac- 
commodation strain is probably a pronounced factor in the 
production of senile cataract. A large number of senile 
cataracts are found in individuals known to be hyperopic 
and astigmatic, the preponderance of these cases being 
in uncorrected astigmatic cases of high degree. This is a 
very strong argument in favor of wearing correcting 
lenses in all cases of errors of refraction. Keeping in 
mind the fact that excessive light has, in many cases, been 
known to produce cataract, the various lenses for the ab- 
sorption of actinic or heat rays, now on the market, may 
be used to advantage while persons are being exposed to 
unusually bright lights. 
Symptoms of Senile Cataract 
In incipient cataract a number of premonitory symp- 
toms may be observed by the patient before any change 
can be seen by the unaided eye. 
Because of the swelling of the lens the patient is usually 
much gratified to learn that he sees ordinary print without 
his reading glasses, hence the lay term "second sight." 
Gradually a cloudiness of vision manifests itself; objects 
are seen as if through a fog. The patient complains of 
the sensation of having spots or cobwebs before his eyes. 
He is now apt to see badly in bright lights which contract 
the pupil but gets along easily at night and in cloudy 
weather. Diplopia often occurs as the disease progresses 
and objects are seen in distorted and fantastic shapes. 
These visual disturbances vary greatly in different pa- FIGURE 5 
Proper way of holding the iris forcep. A TREATISE ON CATARACT 
35 
tients, some being fortunate to retain a fair degree of 
vision until their opacities are far advanced. 
The degree of blindness which the patient is subjected 
to, during the maturation of a cataract, will depend 
largely upon the site at which the greatest degree of opac- 
ity exists. Except in very dense cataracts the patient will 
be able to indicate the point at which a light is burning in 
the room, and will recognize the figure of a hand when 
passed between his eye and a window at the distance of 
eighteen inches. A very marked opacity may be present 
at the periphery of the lens and the patient continue to 
attend to his daily routine of duties as if nothing had oc- 
curred. On the other hand, should the same degree of 
cloudiness be central, he will be almost helpless from loss 
of vision. When the cataract is thoroughly, ripe the pa- 
tient's vision is reduced to mere perception of light, re- 
gardless of the situation of the densest area in the lens. 
When the condition remains unaccompanied by other com- 
plications, such as opacity of the vitreous and changes in 
the retinal vessels and walls, the light perception is fairly 
acute. Should it be found absent it would indicate com- 
plications so grave as to make the case inoperable. 
Patients developing cataract often complain of a burn- 
ing sensation in their eyes and may actually develop a 
marked conjunctivitis during the progress of their dis- 
ease, this being due to the strain caused by imperfect 
transmission of light. Frequently the conjunctivitis is 
accompanied by a marked degree of pain. 
Photophobia is often present at the beginning of cat- 
aract and patients will be seen to avoid the light by shad- 36 
A TREATISE ON CATARACT 
ing their eyes with their hands. Subdued light gives a 
sense of relief because it admits of expansion of the pupil 
and the admission of light rays around a cloudy nucleus 
with accompanying vision devoid of pain. 
The primary swelling of the lens is in time followed by 
flattening of its surface due to an atrophy of the lens 
structure itself. Occasionally, during the process of 
ripening, the lens takes on a hue so dark as to be classified 
as black cataract. During January of this year I re- 
moved from a patient 83 years old a cataract in which the 
lens substance was almost entirely black at the nucleus, 
the coloration grading off to a light brown at the circum- 
ference. This patient had been blind for over five years, 
during which time his condition remained undiagnosed be- 
cause of the natural color which his pupil presented. 
Diagnosis of Senile Cataract 
In the hands of the ophthalmologist all tests for cataract 
are secondary to the findings of the ophthalmoscope. By 
reflecting the light into the eye with the ophthalmoscope the 
pupil will be seen to be greyish or even white depending 
upon the degree of opacity present. The lens, seen from 
transmitted light with the ophthalmoscope presents a dark, 
heavy appearance into which striae of light seem to bear 
from the periphery. The cataractous lens under oblique 
illumination presents practically the opposite picture, the 
peripheral striae being dark. 
A blunder, which unfortunately has been made by a 
number of experienced men, is that of mistaking the eat- FIGURE 6 
Proper way of holding the iris scissors. A TREATISE ON CATARACT 
39 
aractous lens of absolute glaucoma for true senile cat- 
aract. This error can only occur when the eye has been 
examined in the most superficial way; for the lusterless 
cornea, the sea green pupil, the motionless iris and the in- 
creased tension would at once indicate a diagnosis if the 
examination were not cursory and indifferent. 
The Responsibility of the General Practitioner in 
the Diagnosis of Senile Cataract 
A general practitioner said to the writer some time ago 
that he gave little thought to eye diseases and felt prac- 
tically no responsibility in his cataract cases for these he 
shifted to the shoulders of the ophthalmologist, to whom he 
sent them when ready for operation. Unfortunately, this 
is the attitude taken by a large per cent, of the medical 
profession and one which is altogether unjustifiable, as 
demonstrated by the hundreds of glaucoma cases which are 
every year mistaken for immature cataract. This error 
results not only in destruction of vision but often in loss of 
the globe as well. 
The largest per cent, of the population of this country 
live long distances from the cities and do not have access to 
the office of the eye surgeon. Under such conditions it 
would seem imperative that the general practitioner should 
correctly diagnose eye conditions, especially those of such 
grave importance as iritis, glaucoma and cataract. By 
observing a few simple principles which I will attempt to 
illustrate here, no one can easily be mistaken in recogniz- 
ing cataract and differentiating it from glaucoma, optic 40 
A TREATISE ON CATARACT 
nerve atrophy, glioma and other vision-destroying dis- 
eases. 
The general practitioner in the rural districts should 
not only be able to correctly diagnose cataract, but he 
should be prepared to advise his patient when to have the 
operation done. A common error is to wait until the 
lenses are over-ripe and the retina has become insensitive 
from disuse. I have seen several such cases which might 
easily have been successfully operated upon had the pa- 
tient not waited too long. It seems to be the general im- 
pression that a partly ripe cataract cannot be removed 
successfully, and this is often responsible for the over-ripe 
cataracts we see. The facts in the case do not bear out 
the validity of this opinion. We have seen partially ripe 
cataracts remain stationary for years, the unfortunate pos- 
sessors being deprived of their vision for many dreary 
months while they waited for the ripening of their lenses, 
the retina daily becoming less sensitive from disuse. It 
is decidedly better to operate these cases after the process 
of ripening becomes stationary, than to allow them to wait 
and commit them to partial blindness for months or even 
years, without any assurance that the long looked forward 
to "ripening" will be complete. The objection that sec- 
ondary cataracts, which often occur in these early operated 
cases, subjects the patient to unnecessary risk is not well 
taken in these days of surgical technique, which is so well 
perfected that the globe can be entered repeatedly with 
little danger to its structures. 
There are few conditions which are as simple to diag- 
nose as that of senile cataract. With the ophthalmoscope FIGURE 7 
The puncture; initial step in performing the corneal section. Demonstration 
upon model.-Author. A TREATISE ON CATARACT 
43 
it is done in a moment. Frequently, however, the general 
practitioner is not familiar with this instrument, so let us 
suppose that we are to examine a case without any equip- 
ment, and at the same time be as certain in our diagnosis 
as if we had all the modern paraphernalia at hand. First, 
let us take a candle and hold it in front of the pupil of the 
eye to be examined. The flame of the candle thus held 
shows three images in the normal eye, one caused by the 
cornea, one by the anterior surface of the lens, and one 
inverted picture on the posterior surface of the lens. If 
the lens is opaque, a shadow of the flame will be seen on 
the cornea; a very faint one will be seen on the anterior 
surface of the lens, but there will be no third image. 
In other words, two shadows, a bright and a dim one, 
instead of three bright ones, will be reflected from 
the pupil. This is an absolute and never-failing test for 
cataract. 
If the candle be held beside the pupil a shadow of the iris 
will be seen on the opaque lens. This is never seen except 
when opacity of the lens exists. The more opaque the 
cataract is the darker will be the shadow. The test is in- 
fallible. Now let us take an ordinary oil lamp or electric 
globe fitted with a reflector and direct the light into the 
eye. No red reflection or "glare" is seen if the case is one 
of cataract. There will be noticed, however, a greyish 
condition of the pupil and "flows" or striae will be seen in 
the lens. Before making these tests it is necessary to di- 
late the pupil somewhat. Atropin, however, should not 
be used for this as it predisposes to glaucoma. A mild 
mydriatic should be selected and to make the procedure 44 
A TREATISE ON CATARACT 
safer it is better to instil a weak solution of eserin in the 
eye following the examination. 
Case Record Notes in Incipient Cases 
In cases of incipient cataract, before the lens has become 
too dense to be penetrated by light rays, the ophthalmo- 
scope should be used to explore as well as possible the 
fundus, and the results should be noted and filed away for 
future reference. When the case is first seen after the 
fundus is obscured much may be ascertained by a close 
inspection of the external eye. Complications of the chor- 
oid are frequently revealed by the state of the iris. In 
chronic conditions the iris usually loses its luster. This is 
particularly to be noticed in light complexioned persons 
whose irides are grey or light blue. Modifications of the 
pupillary reflexes, when observed, are of great aid in 
formulating a prognosis. In a cataractous eye, otherwise 
normal, very little change may be seen in the pupillary re- 
flex. If, upon examining an eye with cataract the pupil 
be covered and then exposed to a moderately bright light 
which affects it so little that it stands almost motionless, 
it may safely be said that the internal structures of the 
eye are at fault, and a very guarded prognosis should be 
given. 
The Question of Operating One or Both Eyes 
Without the circumstances are unusual only one eye 
should be operated upon at a sitting even if both cataracts FIGURE 8 
The corneal section showing the puncture and counter puncture. 
Demonstration upon model.-Author. A TREATISE ON CATARACT 
47 
are mature. There is always the possibility of infection 
or some other untoward result following a cataract opera- 
tion which, should any one of the possible accidents occur, 
might involve both eyes resulting in their loss. For this, 
reason it would be a matter of poor judgment to risk both 
eyes at a single operation. To do so would be to reck- 
lessly throw away thirty per cent, or more of the patient's 
chances for vision. 
Occasionally the surgeon will be informed by the pa- 
tient, or members of his family, that one operation only 
will be submitted to. A decision of this kind upon the 
part of the patient is not right in cases where the opera- 
tion has been arranged for, except as a result of great 
financial sacrifice or when the patient lives in parts remote 
from medical centers. In such instances a double opera- 
tion may be done without hesitancy. 
Preliminary Iridectomy as a Means of Improving 
Vision in Patients Developing Cataract 
In the nuclear type of cataract a great deal of improve- 
ment may be made in the patient's vision by producing an 
artificial pupil by iridectomy. Frequently this may be 
done many months before the lens is ready for extraction. 
I have had patients with nuclear cataracts who success- 
fully did their work for long periods after I had performed 
iridectomy, who, before this simple procedure, were com- 
pletely incapacitated by faulty vision. This operation, 
in my opinion, is never contraindicated. There is abso- 
lutely less risk of iritis following a simple iridectomy than 48 
A TREATISE ON CATARACT 
when a combined iridectomy and extraction are done, be- 
sides the procedure lessens the possibility of glaucoma. 
Usually one Cataract more advanced than Other 
As the ocular changes which interfere with the success 
of a cataract extraction are numerous all available meth- 
ods of testing the general condition of the eye should be 
practiced. With senile cataract both eyes are affected 
simultaneously as a rule, though fortunately for the pa- 
tient the process in one lens is usually more advanced than 
in the other. This often enables the patient to retain 
useful vision in one eye till the cataract in the other eye 
has ripened and has been operated upon. 
Arrestation of Cataracts 
While a number of ophthalmologists throughout the 
country are more or less emphatic in the contention that 
senile cataract may be arrested, and even cured by treat- 
ment, there is no reliable evidence to substantiate this 
claim. A well-known pharmaceutical firm has long had 
on the market a preparation for the restoration to normal 
of the partially opaque lens, and though their claims are 
supported by over one hundred American ophthalmolo- 
gists, the results cited by these observers are entirely too 
extravagant to be accepted as truth. It is entirely possible 
that a corneal cloudiness resulting from long continued in- 
flammatory disease of the eye may clear up spontaneously 
as the inflammation subsides, or that a slight haziness of the A TREATISE ON CATARACT 
49 
lens resulting from diabetes may disappear while the pa- 
tient is under observation, and this fact, no doubt, has led 
several conscientious physicians to believe that a partially 
developed senile cataract has been cured. With the ex- 
ception of correcting lenses and due precaution against 
using the eyes beyond the period of fatigue there is prob- 
ably nothing else to be done toward mitigating, in any 
way, the progress of true senile cataract. 
Conditions Contra-Indicating Operation 
Advanced tuberculosis with cough is a bar to the cat- 
aract operation because of the improbability of favorable 
union of the corneal wound, and further because of the 
danger of expulsion of the vitreous during the act of 
coughing. Any character of violent and chronic cough 
will mitigate very greatly against favorable results. 
Chronic blepharitis or eczema of the eyelids should al- 
ways receive appropriate treatment before the operation is 
attempted. With chronic trachoma operations for cat- 
aract are hopeless. 
Chalaza, tarsal cysts and styes must not be present on 
the lids of the eye to be operated. 
Entropion with trachiasis is always accompanied by an 
inflammation of the conjunctiva, with secretion, and 
should be corrected by operation many weeks before an 
extraction for cataract is performed. 
Chronic purulent dacryocystitis is a grave menace to an 
eye about to be operated for cataract, and when it is pos- 
sible to obtain the patient's consent the lachrymal sac 50 
A TREATISE ON CATARACT 
should be removed before the cataract is operated. When 
an operation for the removal of the sac is refused the can- 
aliculus may be tied off with silk with some advantage be- 
fore the extraction is attempted. 
Patients with a recently acquired syphilis should receive 
appropriate treatment, and give a negative Wassermann, 
if this result is possible, before any surgical interference 
with the eye. 
Patients with chronic keratitis, recurrent iritis or in- 
flamed eyes from any cause are poor cataract risks. 
A patient without light perception should never be op- 
erated upon for cataract. A diseased lens never entirely 
shuts out light from the retina. Even when perception 
of light is present, but is very feeble, the operation may 
be followed with very disappointing results. 
Decreased tension of the globe with iris slightly tremu- 
lous may indicate deficient vitreous. An operation per- 
formed upon such an eye would be liable to be followed 
by detachment of the retina and intro-ocular hemorrhage. 
No patient should be operated upon for cataract who 
has pyorrhea with alveolar abscesses. It has been 
pointed out by a number of observers that infections sur- 
rounding the teeth may cause constitutional disease. Pa- 
tients with foci of infection in the mouth have been known, 
in many instances, to develop arthritis, acute appendicitis 
and even abscesses in remote portions of the body. In the 
latter cases examinations under the microscope have dem- 
onstrated the same type of bacteria as that of the original 
focus, pointing clearly to the likelihood of the infection be- 
ing carried by way of the blood stream. FIGURE 9 
The puncture and counter puncture of an unambidextrous surgeon showing a very 
frequent and sometimes fatal misstep-the pricking of the unanesthetized lid with 
the point of the knife with consequent flinching of the patient.-Author. A TREATISE ON CATARACT 
53 
Rosenow, of the Mayo Foundation, has made an ex- 
haustive study of focal infections of the mouth and their 
relation to constitutional disease, and in the light of his 
elaborate laboratory experiments there can no longer be 
any doubt regarding the mooted question of absorption of 
bacteria by the blood as well as by the lymph streams. 
With the conclusion of Rosenow in mind it would certainly 
seem hazardous to operate for cataract, in old and debili- 
tated patients, with mouths harboring virulent foci of in- 
fection. A great many operators in the past have been 
astonished to find their operated cases of cataract with ful- 
minating infections which could not be laid at the door of 
a faulty technique. There can no longer be any doubt 
that septic mouths were responsible for many of these un- 
fortunate terminations. 
A patient, then, who presents himself for operation 
should have his mouth taken care of and the sound teeth 
should be cleaned. Pyorrhea, if present, and it almost 
invariably is in the aged, should be treated, if the disease 
has not passed the curable stage. If a cure is unlikely 
the teeth should be removed and sufficient time be allowed 
for healing before the extraction is performed. 
The Wisdom of a Guarded Prognosis in Cataract 
Cases 
Before an operation for the extraction of cataract is 
performed the patient or the patient's friends should, by 
all means, be made familiar with the possibilities of compli- 
cations in even the most favorably appearing cases. 
Should any conditions, however slight, be present which 54 
A TREATISE ON CATARACT 
would make the result of the operation questionable this 
fact should be clearly and intelligibly stated. This is im- 
portant because it will mitigate the patient's distress should 
a success not be obtained and will relieve the surgeon of 
much embarrassment, to say nothing of the possibility of 
his being censured. 
The Pupil in Cataract Cases 
The size of the pupil should not be overlooked in arriv- 
ing at a prognosis in cataract cases. An expanded pupil 
which responds poorly, or not at all, to light should make 
the examiner conscious of the possibility of some deep 
seated disease of the eye. This is particularly suggestive 
of glaucoma if the tension be increased in the slightest de- 
gree. It must not be forgotten, however, that the pupil 
may vary in size in different patients as a result of their 
individual temperaments. Habitual morphine users have 
permanently contracted pupils with diminished reflexes. 
This peculiarity has often led examiners into error when 
dealing with unsuspected drug takers. Similar mistakes 
in prognosis have been made by physicians who have ex- 
amined patients with pupils dilated by a mydriatic who, 
for personal reasons, have denied that a drug had been 
used in their eyes. 
The Education of the Patient Preparatory to Op- 
eration 
The education of the patient, before the operation is 
important. It will be necessary to calm the fears of a FIGURE 10 
The corneal section as made by the left hand. Demonstration upon 
model.-Author. A TREATISE ON CATARACT 
57 
patient of nervous temperament, relative to the operation, 
before he goes to the operating room. Usually his ap- 
prehension will subside upon the assurance by the surgeon 
that his operation will not be attended with pain. He 
must be told to lie perfectly passive, and not to "squeeze" 
his eyes. Many eyes have been ruined by the surgeon's 
neglect to warn the patient regarding this very important 
precaution upon his part. I frequently start, days before 
the day of operation, to teach the patient to look up and 
down in a quiet manner. This education is of much im- 
portance and does away with the jerking movements of 
the eye too frequently seen at the time of operation. 
Preparation of the Patient 
In view of the fact that a wound is about to be inflicted 
upon an exceedingly sensitive and delicate organism it is 
obvious that the patient's general condition should be 
made as perfect as possible before the operation is at- 
tempted. Patients habitually constipated should have a 
laxative daily for a period of weeks before their extraction 
day. Debilitated patients should undergo a process of re- 
construction brought about by proper feeding, gentle but 
regular exercise, tonics and general care. The patient's 
blood pressure should be taken and if found abnormally 
high every effort should be made to reduce it as much as 
possible. The patient's age must be taken account of and 
this will govern largely the course to be pursued. 
One o'clock in the afternoon is the time usually selected 
by me for cataract extractions. I instruct the patient to 58 
A TREATISE ON CATARACT 
have a warm bath at his home the previous evening and to 
go to the hospital in the morning. This is preferable to a 
bath at the hospital and a night spent in anxiety and 
worry in a strange bed. It is well to remember that the 
less done to him before the operation the less demoralized 
he will be. Too much fussing and flurry at the hospital 
only adds to his nervousness and impresses him unneces- 
sarily with the gravity of his operation. After he enters 
the hospital a gentle scrubbing of his face with green 
soap, a boric acid irrigation of the eyes and a sterile dress- 
ing is all that he will need. 
Patient to be led to Operating Room 
It is preferable to have the patient led rather than 
wheeled to the operating room because the psychic effect 
produced by being pushed about on a vehicle which is 
novel and untried is not good. A stool should be provided 
to assist him in getting upon the table. 
After the patient is comfortably placed upon the table 
the preliminary dressing may be removed and the eye pre- 
pared by gently irrigating it, after which the local anes- 
thetic may be dropped in the eye. 
General Consideration regarding Operating Room 
and Surgeon's Dress 
No special requirements, except a good light, are needed 
for the operating room. Any operating table that is not 
unstable will answer the purpose. The ordinary surgical A TREATISE ON CATARACT 
59 
cleanliness should prevail. The surgeon's dress should be 
the same as for any major operation. It seems unneces- 
sary to say that he should wear a gown, yet I have seen 
several surgeons, one of international reputation, operate 
in their shirt sleeves. The surgeon's head should be cov- 
ered with a cap. Seborrheal scales falling from the scalp 
will not add to the asepsis of the field. By all means his 
mouth and nose should be covered with a gauze mask. 
The surgeon's mouth may not be the embodiment of clean- 
liness and his commands, if his mouth be not covered, may 
be accompanied by a spray of germs. I believe that it is 
better to work without gloves; for a cataract extraction, 
more than any other operation perhaps, demands dexter- 
ity. The hands, then, should be prepared with the most 
scrupulous care and must be thoroughly dry so that the 
rinsing solution will not gravitate down the handles of 
the instrument and contaminate them. Human hands 
cannot be boiled and, though prepared with great caution, 
should be kept as far from the cutting edge of instruments 
as possible. 
Regarding Surgeon's Personal Discipline 
The surgeon who undertakes cataract extractions should 
have himself under perfect control. He must have suffi- 
cient self-reliance but should guard against being over con- 
fident. He should be cautious and reserved in judgment 
but not timid. What is generally spoken of as poise is an 
asset which is invaluable to one attempting the delicate 
surgery of the eye. More than one internationally known 60 
A TREATISE ON CATARACT 
ophthalmologist is a failure, as far as executing eye surgery 
is concerned, because of his lack of poise. The inexperi- 
enced surgeon particularly is apt to lack the nervous stam- 
ina necessary to success as an eye operator. The very fact 
that friends of the patient or possibly other surgeons are 
present may unhorse him. Feeling the gravity of the re- 
sponsibility thrust upon him, and being conscious of the 
existing scrutiny of those present, he may become intoxi- 
cated with emotion, his trembling fingers indicating that 
he has not been schooled in mental discipline and that he 
lacks poise. Over confidence in a surgeon is a mental 
habit more reprehensible, and even more fatal, than is tim- 
idity. I have seen eyes ruined by improper counter punc- 
tures, split corneas, collapsed irides and other accidents at 
the hands of men whose over confidence had led them into 
a swaggering and spectacular technique without proper 
regard for the niceties of surgical detail. The surgeon 
should regulate his habits of thought and of bearing so 
that he may always be able to assume command of him- 
self. He should seek to live so that he can operate as a 
master of the situation, with a cool head and a steady hand. 
If such stimulants as alcohol and such diversions as mid- 
night carousals interfere with the steadiness of his good 
right arm and the consequent welfare of patients intrusted 
to his care, he should be willing to give up his surgery or 
his habits. A patient craving vision stakes his all on the 
ability of his surgeon and if the surgeon is not physically 
and mentally qualified to perform effective work, it would 
be the part of wisdom to admit the fact and not attempt 
an operation which promises only failure. FIGURE 11 
Method devised by Jameson of replacing and protecting the iris after it has 
fallen in front of the knife. Demonstration upon model.-Author. A TREATISE ON CATARACT 
63 
Stimulants, such as coffee, tea and tobacco seem not to 
interfere with the nervous constitution of certain individ- 
uals but where they are known to produce unsteadiness of 
the hand their use should be abandoned. 
Practice Necessary to Good Technique 
It would be well for the surgeon contemplating cat- 
aract extractions to familiarize himself with the technique 
of the operation by first operating upon animals' eyes. 
Various masks are on the market which are mechanically 
arranged so as to hold the eye in position. Pig's eyes 
simulate the human eye more than do the eyes of any other 
animal and for this reason they are to be preferred. 
Other animals' eyes answer the purpose very well if pig's 
eyes are unobtainable. During a vacation I once oper- 
ated upon the eyes of over twenty jack rabbits, using an 
improvised mask for the purpose. In operating animals' 
eyes one must be very careful not to vary from the tech- 
nique which would be used upon the living human eye, 
otherwise faulty habits may be formed which will mar 
rather than improve one's technique. 
Don'ts 
The following dorits formulated by Beard in his ''Oph- 
thalmic Surgery" may well be studied by any doing cata- 
ract extractions. 
"Don't get shaky. Pick up the knife, make a few fin- 
ger movements with it and, if the hand is turning craven, 64 
A TREATISE ON CATARACT 
just call a slight halt, resort to a little inward discipline, 
and one can usually regain his composure. A colleague 
once told me that when he found himself becoming demor- 
alized on the eve of an operation, he walked to the window 
and, while apparently taking in the view, proceeded to 
give himself, mentally, a sound castigation, with the in- 
variable effect of restoring his calm. 
"Don't drop cold or hot liquid into the eye during or 
after the operation-have it lukewarm. Don't let it fall 
from a height onto the eye and lids, as all tends to pro- 
duce wincing. Don't squirt nor fire solutions at the eye, 
but pour them gently over it, and always warn the patient 
of your intention. Don't permit sponges to touch the 
cornea and disturb the epithelium. 
"Don't begin the installation of the cocain solution until 
it is known that the operation can follow in not more than 
ten minutes. Don't let the speculum fly out of the fingers 
like a jack-in-the-box while in the act of putting it in 
position. Get a good, firm grip on it. 
"Don't pry the lids too far apart, for it induces spasm of 
the orbicularis and increases intraocular tension. Don't 
allow the speculum to rest heavily upon the globe. Don't 
fail to lift it away from the eye, and with a firm grasp, in 
removal. 
"Don't use fixation forceps that have a catch, and don't 
forget the hand that holds the forceps while fixing the eye. 
Don't rotate the eye with the forceps as if it rested with 
its posterior surface on a transverse vertical plane, but as 
it is, like a ball that turns on a universal central pivot. 
"Don't seize merely a fold of conjunctiva by which to FIGURE 12 
Method of grasping the iris with forceps in operation upon left eye where surgeon 
is not ambidextrous. Section has been made from opposite side of the patient.-- 
Author. A TREATISE ON CATARACT 
67 
steady the eye, but in addition, as much as possible of the 
subjacent tissues and as near as practicable to the cornea. 
Don't employ fixation after the bulbus is opened unless 
the need is urgent. 
"Don't neglect to test point and edge of both knife and 
cystotome before they are disinfected, to see that they are 
sharp. Don't use a knife with long needle-like point-the 
tip might break. Don't hold the knife so tightly as to 
cramp the fingers, nor yet so loosely as to cause wavering. 
Don't attempt either corneal or capsule incision free 
hand. No matter how steady the latter, always rest the 
little finger on the patient's face not only for support, 
but in order to move with him should he stir. 
"Don't haggle, fuss, nor hesitate in making the section, 
yet, while forging steadily ahead, do so with a certain 
deliberateness. Faulty sections, premature escape of 
aqueous, etc., come not so often of slowness as of vacilla- 
tion. 
"Don't lose sight of the patient's demeanor. If this be 
favorable throughout the corneal section, it is apt to be so 
for the entire operation. If he begins to squeeze, pause, 
even though in the midst of the incision, and remonstrate 
with him in a kindly tone, and have the assistant guard 
closely the brow and speculum. 
"Don't take the eyes off the sight of the operation for 
an instant. Have the assistants so trained that it will not 
be necessary for the operator to seek instruments and im- 
plements, nor to lay them down. Be in the closest touch 
with the subject, allowing not a single break in that subtle, 
intuitive current whereby we anticipate a move on his part. 68 
A TREATISE ON CATARACT 
"Don't scrawl all over the capsule and zonule with the 
cystotome. Take pains to place the point properly on 
the cataract just where the opening should begin-not 
hastily; elevate the handle until the point is sure to have 
engaged the capsule, then draw it very lightly along, 
making a definite cut, and note that the lens responds to the 
liberation by springing forward. If not, it is better to go 
over it a second time, there and then, trying to improve 
upon the first effort, than to be obliged to again enter the 
instrument. 
"Don't triturate the cornea too much with the spoon in 
delivering the cataract, nor rub it about in an aimless sort 
of way to get out the cortex. Be sure that the back and 
not the edge of the instrument is applied. Don't stop to 
pick up the extracted lens unless it is caught deftly upon 
the upper spoon-merely brush it aside until the operation 
is terminated. 
"Don't have the instrument dripping wet, as the liquid, 
streaming downward, carries bacteria from the fingers to 
the eye. Don't hold instruments in the mouth to disem- 
barrass the hands. Give them to an assistant or lay them 
down. 
"Don't talk any more than necessary, and never with 
explosive aspiration, to emit showers of germs, even 
though mouth and nose be covered by a mask." 
Anesthesia 
When possible the operation should be done under 
cocaine anesthesia. Occasionally one finds a patient so A TREATISE ON CATARACT 
69 
nervous and disturbed by fear that local anesthesia is 
entirely out of the question. Confronted with such an 
exigency one has to decide upon a general anesthetic. 
Ether is especially inapplicable because it causes post 
operative vomiting, a complication which is nearly always 
fatal to an operated eye for the reason that during the 
act of retching the contents* of the globe are apt to be ex- 
truded. Chloroform anesthesia of short duration may not 
be attended by vomiting and, therefore, is preferable to 
ether. Nitrous oxide is by far the best general anesthetic 
for cataract work. If it is used cautiously by an experi- 
enced anesthetist very little nausea occurs and the period 
of excitation following its use is brief. 
Cocaine is the best local anesthetic for cataract work. 
It should be used of a strength of ten per cent. A weaker 
solution than this will not produce complete anesthesia of 
the iris and when the iridectomy is done the patient will 
be apt to flinch. To my solutions of cocaine I usually add 
adrenalin chloride, one drachm to the ounce. This is of 
decided advantage for it lessens bleeding from the wound, 
if the conjunctiva is cut at the completion of the section, 
and it also prevents hemorrhage from the iris, with a con- 
sequent blurring of the field by an extravasation of blood 
into the remaining aqueous humor. 
Preparing the Solutions 
It is well for the surgeon himself to prepare the solu- 
tions to be used in his cataract work. If this important 
matter is left to the dispensary employe, or to the drug- 70 
A TREATISE ON CATARACT 
gist, the surgeon has no assurance that his solution will be 
sterile. 
Druggists, as a rule, have a very poor conception of 
asepsis and a dirty spatula, or an improperly prepared 
bottle will render futile the most aseptically performed op- 
eration. Some surgeons are in the habit of boiling their 
solutions after they are sent from the dispensary. This, 
from an aseptic standpoint, is an important precaution but 
in my own work I have found that cocaine solutions after 
having been thus treated are decidedly less efficacious than 
solutions unboiled. It is not well to use too much cocaine. 
Three or four instillations of a ten per cent, solution will 
produce anesthesia. More than this predisposes to hem- 
orrhage at the conjunctival margins of the wound and may 
cause a cloudiness of the cornea, due to softening of the 
epithelium. I have seen a surgeon of international repu- 
tation strip off the corneal epithelium, during the act of 
expressing the lens, in an eye over anestheticized. Be- 
tween instillations the lids should be kept closed in order to 
protect the cornea. 
Instruments 
The instruments required in an operation for cataract 
extraction are few. A speculum, a fixation and an iris 
forcep, an iris scissors, a spatula, an iris spoon and a knife 
will meet every need in an uncomplicated case. Any 
speculum sufficiently curved for its handle to be out of the 
way of the operator's knife will answer the purpose. 
There are on the market a number of specula in which the FIGURE 13 
The iridectomy. Iris is drawn well beyond margin of wound. De Wecker's 
scissors in position preparatory to snipping off section. Demonstration 
upon model.-Author. A TREATISE ON CATARACT 
73 
curve is almost absent. The use of such an instrument 
would certainly be attended with annoying difficulties. It 
is better to use a speculum provided with a stop attach- 
ment, so that no undue tension will be made upon the lids. 
The knife of Von Graefe is probably the best instrument 
to be used in making the section. In my opinion, this 
knife has several advantages which the Beers knife does 
not possess. It is smaller, less unwieldy, and conse- 
quently does not obscure so much of the field of operation. 
Being thinner than the Beers knife it does not cause so 
much gaping of the wound with attendant rapid loss of 
the aqueous humor. This is a decided advantage, for 
should the aqueous gush out quickly the sudden decrease 
in the tension of the eye is liable to be accompanied by 
intraocular hemorrhage. Another disadvantage of a 
bulky knife is its tendency to stretch and cause trauma to 
the corneal incision. 
The Corneal Section 
Anesthesia being complete the speculum is now ad- 
justed. Before introducing this instrument the patient 
should be told that something is about to be put between 
his lids to hold them open and that it will not hurt him. 
He is then instructed to look down and with his eye in this 
position, the lid is elevated and the upper blade of the spec- 
ulum slipped under it; next his eye is to be directed up- 
ward and during this movement the lower blade is put in 
place under the lid, after which the stop may be adjusted. 
The eye is now gently irrigated with a warm solution of 74 
A TREATISE ON CATARACT 
boric acid and the surgeon is ready to proceed with the op- 
eration. 
The speculum having been introduced, the operation is 
begun by making the corneal section. If the right eye is 
to be operated upon the surgeon stands at the head of the 
table and, with the left hand resting upon the patient's 
cheek, grasps the conjunctiva, two millimeters below the 
limbus with mouse tooth fixation forceps. The fixation 
forceps should be held lightly so as not to produce pressure 
which might cause a premature emptying of the anterior 
chamber. To prevent this accident the little finger of the 
hand holding the forcep should rest upon the patient's 
cheek, so that the hand may be steadied and undue pres- 
sure avoided. The fixation forcep should not have a lock 
adjustment. Such an arrangement may necessitate some 
little pressure in its being disengaged, and pressure of any 
character upon the globe should be avoided. Before the 
forcep is applied the patient's eye has been put in the 
proper position by asking him to look down. The sur- 
geon is now ready to make the incision. 
The corneal section should be made with great nicety. 
If it is too small it will prevent the free expulsion of the 
lens, which, in being delivered, may leave portions of its 
cortex floating in the anterior chamber. This accident, 
when it occurs, has a double disadvantage. Lens matter 
left in the anterior chamber, not being absorbed to any 
considerable degree by the aqueous humor, will act as a 
marked impediment to the proper admission of light rays 
and may also cause iritis by acting as a foreign body. 
Before the knife is introduced it should be carefully in- A TREATISE ON CATARACT 
75 
spected. It is a ludicrous fact that the Von Graefe knife 
has not infrequently been thrust through the cornea up- 
side down by careless or near-sighted surgeons. When 
this has happened its withdrawal, preparatory to reversing 
its blade, has sometimes occasioned a loss of aqueous and 
such a prolapse of the iris forward that the operation for 
a time had to be abandoned. The knife, held loosely be- 
tween the fingers, in the same manner in which a pen is 
held, is thrust through the cornea while being held at an 
angle of 45 degrees from the plane of its surface. If this 
precaution is not observed the point of the knife may glide 
between the layers of the cornea instead of entering the 
anterior chamber. The point of entrance should be about 
one and a half millimeters anterior to the sclero-corneal 
margin. The knife is now carried across the anterior 
chamber to a point as nearly as possible opposite to its 
point of entrance, care being taken that the iris is not en- 
gaged, and with a quick but gentle thrust it is made to 
emerge from the cornea. 
As the knife emerges the aqueous will escape and the 
cornea will fall in slightly toward the iris. The surgeon 
should now draw the knife back and forward with a saw- 
ing motion, avoiding all pressure, and being careful not to 
pull but to cut. Three or four sweeps of the knife will 
complete the section. 
Sometimes, in very old subjects, a collapse of the cornea 
has occurred, following the liberation of the aqueous. In 
this contingency Beard advises that the anterior chamber 
be gently flushed with normal salt solution, a maneuver 
which usually replaces the cornea. He further advises A TREATISE ON CATARACT 
76 
that if a piece of wet absorbent cotton be placed over the 
section, the anterior chamber will refill in a few minutes, 
at which time the operation may proceed. 
The Question of a Conjunctive Flap 
The largest per cent, of American surgeons make a con- 
junctival flap, though this is seldom done by European 
operators. This little procedure has advantages to recom- 
mend it but it also has its disadvantages. There is no 
doubt that it makes more secure the corneal incision and 
that it, to an extent at least, protects the eye against infec- 
tion. It occasionally happens, however, that the flap 
turns out, and when this occurs it has a tendency to make 
the wound gape. The greatest objection to this method is 
that there is often quite a profuse hemorrhage from the 
flap, this blood quickly flowing through the corneal wound 
into the anterior chamber, obscuring the field of opera- 
tion. 
Colonel Smith, who has done more cataracts than any 
surgeon, objects to the conjunctival flap for the following 
reasons: 
(1) Hemorrhage almost invariably takes place, the 
blood finds its way into the anterior chamber, thus annoy- 
ing the operator, not to speak of the manipulations, irriga- 
tions and instrumentation it entails. 
(2) Inversion of the flap in the anterior chamber of lips 
of the wound, which is objectionable at any stage of the 
operation, for it carries mucus, dead cells and tags into 
the wound, and necessitates manipulation and instru- FIGURE 14 
Very favorable position of hands in iridectomy upon right eye. Left hand sup- 
ported by little finger on brow; right little finger in similar manner rests upon 
nose.-Author. A TREATISE ON CATARACT 
79 
mentation, not to speak of the danger of infection of mild 
or severe grades to delay healing. 
(3) Greater astigmatism results as compared with the 
purely corneal section he makes. 
(4) Section is too far back for the primary safety of the 
eye; vitreous loss is more imminent at every stage of the 
operation where the section is well back in the endeavor to 
make a flap. 
(5) Chronic irido-cyclitis and more or less permanent 
disaster occurs among some cases where limbus incisions 
and conjunctival flaps are made, but in the truly corneal 
section that he advocates such disaster is most rare. 
I have entirely abandoned the use of the conjunctival 
flap and carry my incision only slightly into the conjunc- 
tiva or not at all. 
The Section on Left Eye 
When the surgeon is not ambidextrous the section upon 
the left eye will have to be made with the surgeon standing 
beside the patient instead of above his head. There is no 
particular disadvantage to this except that a few moments 
are lost in changing positions, preparatory to the com- 
pletion of the operation. 
The Iridectomy 
The next step in the operation is the performance of the 
iridectomy. This is of great advantage and at this time 
few operators are omitting it. Without the iridectomy 
the iris is liable to prolapse during delivery of the lens and 80 
A TREATISE ON CATARACT 
resist all attempts to put it in place, or it may even pro- 
lapse and become engaged in the wound after the opera- 
tion is complete, thus leading to the probability of the eye 
being lost. The technique of this step in the operation 
begins by gently insinuating the iris forceps between the 
lips of the wound, the eye being steadied by the fixation 
forcep applied to the conjunctiva as in the corneal 
section. If the iris forceps are applied without the eye 
being anchored with the fixation forceps in the hands of 
the assistant, a sudden turn of the eye upward may press 
the iris forceps against the upper lid and before the sur- 
geon can prevent it the blades of the forcep may dislocate 
the lens. The iris is now grasped with the forcep and 
should be gently drawn upward out of the wound with the 
slightest possible amount of traction, and should be 
snipped off with the iris scissors. 
Some operators are reverting to the old operation of 
linear extraction without iridectomy because of its cos- 
metic advantage. There is no argument against the claim 
that this operation leaves a more beautiful pupil than is 
obtained after an iridectomy is done but I question seri- 
ously if one is justified in eliminating the iridectomy. 
That there is more danger of subsequent prolapse of the 
iris into the corneal wound when the iridectomy is 
omitted is a fact beyond question, and as the prime object 
of the operation is vision and not appearance, this objec- 
tion alone should be enough to condemn the method of ex- 
traction without iridectomy. 
The disadvantages following an incarceration of the 
iris are well set forth by Casey Wood, as follows: FIGURE 15 
Frequently adopted but improper method of performing capsulotomy.-Author. A TREATISE ON CATARACT 
83 
"A distorted and displaced pupil is a common sequel of 
an incarcerated iris. Not only is the pupil often drawn 
quite up to the half-formed scar (cystoid cicatrix) but its 
area is likely to more or less occluded from iritic deposits. 
"Such a condition is a continual invitation to toxic and 
bacterial invasion of the intraocular tissues, and years 
after the operation uveitis and sympathetic ophthalmia 
may result from infection of the interior of the globe. 
"Although a conjunctival covering is a hindrance to and 
may entirely prevent these evil consequences of prolapse 
and hernia of the iris yet it must not be forgotten that even 
after superficial healing has taken place the deep wound 
may be prevented from uniting and so admit a part of the 
iris between its lips. In such cases there is probably a 
foreign body (capsular fibril or cortical remnant) wedged 
in between the lips of the deep incision. 
"If the hernia of the iris be wide a considerable amount 
of astigmatism is the result, and as this anomaly is likely 
to be of the irregular variety a serious interference with 
vision is certain to follow. 
"To add to the discomforts of the patient the uneven 
surface of the globe prevents the lid edges from perform- 
ing their proper cleansing functions, mucus, harboring 
bacteria and fouled with toxins, is insufficiently wiped off 
the eyeball and both conjunctival and ciliary irritation is a 
common consequence. 
"The treatment of iris prolapse should precede that for 
secondary cataract, to avoid, as much as possible, loss of 
vitreous. If the prolapse be observed within the first 
twenty-four hours (when the great majority of them hap- 84 
A TREATISE ON CATARACT 
pen) the eye should be cocainized, thoroughly disinfected 
and an attempt made to replace the errant tissue with the 
stream from an irrigator or by means of a spatula. This 
reposition should be followed by the use of eserin and 
the question may well arise as to the advisability in the 
particular case of resorting to the conjunctival flap of 
Kuhnt. 
"After the prolapse has assumed the condition of an 
actual incarceration, or has been exposed to external in- 
fection for several days, excision is the proper proceed- 
ing. The longer the interval between the prolapse and 
the operation the greater the difficulties to overcome. 
The wound is irritable, the eyeball tender and the iris con- 
gested; cocaine has little effect and neither fixation forceps 
nor speculum can be used for fear of vitreous loss. The 
eyeball and sac should be thoroughly irrigated with hot 
normal salt or boric solution, followed by the use of 
a few crystals of cocain to the wound." 
The Incision in the Capsule 
We are now ready to make our incision in the capsule 
preparatory to delivery of the lens. The free escape of 
the lens forward will only occur when this is done skillfully 
and thoroughly. The cystotome should be introduced 
into the anterior chamber with its cutting edge held par- 
allel with the surface of the capsule, and after having been 
carried to the lower periphery of the lens it should be 
turned so that its cutting edge is against the surface of the 
capsule. The cystotome should them be drawn upward A TREATISE ON CATARACT 
85 
until the upper margin of the lens is reached. I usually 
make a double incision in the capsule, which when finished 
resembles the letter X. 
Usually, when the capsule has been sufficiently lacer- 
ated the lens will be seen to bulge slightly forward. 
Much depends upon the technique of this part of the oper- 
ation. If the lens is pressed upon during the procedure 
it may break through posteriorly and be lost in the vit- 
reous humor; or if it is the capsular incision that is not 
effectively made, the lens is apt to be dislocated back- 
ward while the attempt is being made to deliver it. 
The technique of the incision in the Capsule is thus 
given by Fox. 
"Each cataract," he says, "is surrounded by a path- 
ologic capsule. This change may be invisible to the naked 
eye, or very much thickened and dense and easily detected 
by oblique illumination and yet it is very difficult to rec- 
ognize the different types. Diaphanoscopy does not help 
us; oblique illumination may in some cases, but it is not to 
be relied on. The author has found that the age of the 
cataract and the senility of the individual are the best 
guides. A cataract of two years' growth has a capsule 
with a pale color, moderately dense in appearance, a cater- 
act of three years' growth and over has a capsule of yel- 
low cast, and is dense and inelastic. As the cataract 
matures the capsule thickens, while the zonule of Zinn, or 
suspensory ligament, grows thinner or degenerates. This 
classification of cataracts has been found on the whole 
fairly accurate. In rupturing the capsule of the lens, a 
modified Jaeger's cystotome is employed, it being con- 86 
A TREATISE ON CATARACT 
sidered much less dangerous than the ordinary straight 
cystotome that is in common use. The author follows 
the method adopted by Jaeger, making a rectangular 
opening in the anterior capsule. The instrument is 
passed into the anterior chamber, gently pressed against 
the cornea on the nasal side until it reaches the pupillary 
margin of the iris below, slightly turned backward and 
hooked into the capsule-then drawn upward toward the 
top, lacerating the capsule in its upward movement. It 
is again passed downward through this same opening, 
passing across horizontally until the iris boundary is again 
reached; a second vertical tear is made to the top across to 
the first incision. In this way, a rectangular opening of 
a large size is made in the anterior capsule. Pressure on 
the cystotome must of course be avoided, otherwise the 
lens may be dislocated." 
The Expulsion of the Lens 
It is very probable that more accidents occur at this 
stage than during any other period of the operation. If 
the proper technique is not employed in delivery much 
harm may result and the eye may be lost. After the lens 
capsule has been sufficiently incised the surgeon places the 
spatula upon the lower portion of the cornea and makes 
slight pressure toward the center of the eyeball. As soon 
as the lens leaves its location the direction of this pressure 
is changed so as to be upward rather than backward. The 
pressure should be gentle and steady. Jerky movements 
with the spatula are apt to rupture the zonula and be at- Method of making the incision in the anterior capsule preparatory to 
delivery of the lens. Demonstration upon model.-Author. 
FIGURE 16 A TREATISE ON CATARACT 
89 
tended by a rapid loss of the vitreous or which is worse still, 
the lens may be dislocated backward into the vitreous. 
As the lens begins to glide upward into the corneal section 
its expulsion may be facilitated by a second spatula held 
under the corneal flap. Fisher, in a very ingenious man- 
ner pierces the protruding lens with a modified cataract 
needle, and with the aid of this instrument readily guides 
it through the opening in the cornea. 
Should the lens remain stationary after the admissible 
degree of pressure is exerted it would indicate that the 
capsule had not been properly incised. In this exigency 
the anterior chamber will have to be re-entered by the cys- 
totome, and the incision in the capsule be enlarged. 
Sometimes, when the anterior chamber is small and shal- 
low, the corneal section will be found insufficient for the 
delivery of the lens, and in this case it must be carefully 
enlarged with the scissors. It is better to do this than 
to run the risk of disorganizing the lens by attempt- 
ing to force it through an opening whose size is less 
than the diameter of the lens itself. Should this be at- 
tempted only the bulk of the lens will be expelled and a 
quantity of cortex matter will be left in the anterior 
chamber. 
After the lens has been expelled the spatula may be 
pressed against the lower portion of the cornea, and with a 
number of upward sweeping motions the anterior cham- 
ber may be pretty well freed of particles of cortex which 
have been left behind. 
" An idea of the completeness of the removal of the 90 
A TREATISE ON CATARACT 
cortex," says Geo. A. Berry, "may be got by seeing 
whether the patient can count fingers or not before apply- 
ing the dressing. If this can readily be done, it shows that 
the pupil is clear. If the operation has been performed 
for an immature cataract, there may be some clear cortex 
remaining, but all opaque matter at all events has been 
removed from the line of vision. When this clearing 
has been made to a sufficient extent, or as far as may be 
advisable in any particular case, the spud should be run 
along the wound, in case any piece of capsule or cortex 
should be caught in the wound." 
Should the vitreous begin to escape as the lens is being 
expressed the spatula should be put aside and an attempt 
at delivery of the lens be made with the lens hook. If the 
expression be continued while the vitreous is escaping it 
will only cause a fresh gush of vitreous without liberating 
the lens, and the eye may be lost. 
Lavage of the Anterior Chamber 
Some surgeons are in the habit of performing lavage 
of the anterior chamber. This, when successfully done, 
is of some advantage; but a number of dangers attend the 
procedure. With the cannula in the anterior chamber the 
patient is apt to flinch as soon as the solution is turned 
on, and the cannula be driven into the vitreous before it can 
be withdrawn. A flushing of the anterior chamber has, in 
many cases, been followed by violent iritis. Another dis- 
advantage is that the returning flow, by coming in con- 
tact with the cilia, may cause an infection of the eye. In FIGURE 17 
Showing route traversed by the crystalline lens in cataract extraction accompanied 
by iridectomy.-Author. A TREATISE ON CATARACT 
93 
view of these and other untoward possibilities resulting 
from anterior chamber irrigation, I believe it is the part 
of conservation to omit the procedure entirely. 
The Toilet of the Wound 
The lens and cortex being removed, the thin end of the 
spatula is now passed along the corneal incision for the 
purpose of removing shreds of capsule and particles of 
cortex from the wound. Should any foreign matter be 
allowed to remain in the incision healing will be delayed 
and corneal fistula or violent iritis may result. 
The toilet of the wound being complete the speculum 
may now be removed. The upper blade should be re- 
moved first. To accomplish this the patient should first 
be told to look down, and with the upper lid gently lifted 
the blade may now be disengaged and slipped out of its 
place. If the lid is not elevated before this is done the 
blade of the speculum may become engaged in the corneal 
wound. 
The surgeon must watch carefully that no instrument 
used in the operation be allowed to touch the lashes. If 
this precaution be overlooked infection may ensue, for no 
amount of sterilization of the eye can insure the cilia being 
surgically clean. 
Accidents during Delivery of the Lens 
De Schweinitz gives the following accidents any of 
which may be looked for during the performance of a cat- 
aract extraction: 94 
A TREATISE ON CATARACT 
"1. The knife may be introduced with the cutting-edge 
turned in the wrong direction. If this somewhat inex- 
cusable mistake should occur, the knife must be withdrawn 
and inserted properly. If this cannot be done, owing to 
the escape of the aqueous, postponement of the operation 
until the anterior chamber is refilled is necessary. 
"2. The conjunctiva in the neighborhood of the 
counter-puncture may become distended with aqueous 
humor. This produces an elevation resembling a blab. 
The section should be completed as if the accident had not 
happened. 
"3. The iris may fall before the knife. The incision 
should be completed in the ordinary way. An irregular 
coloboma will result which may be remedied by seizing 
the jagged edges with the iris forceps and trimming them 
with the scissors. 
"4. Free hemorrhage may occur if a conjunctival flap 
is made or in performing the iridectomy. Under pressure 
the bleeding will sometimes cease, and the operator should 
then endeavor to get rid of the blood in the manner 
already described. If success does not follow the 
manoeuver, the cystotome must be introduced, even 
though everything is obscured by the blood, the capsule 
lacerated, and the lens expelled. During its expulsion 
sufficient blood will often come away to clear the pupillary 
space. 
"5. The wound may be too small. This is a very un- 
fortunate occurrence, and can be remedied only by enlarg- 
ing the incision, which is best done with a small pair of 
probe-pointed scissors. A TREATISE ON CATARACT 
95 
"6. Undue pressure of the cystotome may cause the 
lens to be partially or completely dislocated. If the dis- 
location is partial, the eyes should be closed and gentle 
pressure should be made with a bandage, when the lens 
probably will right itself and can be delivered. If the dis- 
location is complete and the lens slips back into the vitre- 
ous, it must be removed by means of the scoop or wire 
loop. 
"7. The vitreous may escape before or after the expul- 
sion of the lens. If before the expulsion of the lens, 
the operator should at once remove the cataract with the 
wire loop, which is gently inserted behind the lens. At 
the same time all pressure upon the eye must be removed. 
If vitreous escapes after the lens has been extracted, the 
wound should be cleared of protruding vitreous as gently 
and rapidly as possible and a bandage applied. Al- 
though escape of vitreous is an undesirable accident, its 
consequences are not always serious and good visual re- 
sults may be obtained. If the escape of vitreous has been 
great, particularly if the vitreous is thin and there is 
tendency for the eyeball to collapse, a tepid, sterile, physi- 
ological salt solution should be injected into the vitreous 
chamber until the globe assumes its proper contour, as 
has been recommended by J. A. Andrews and Herman 
Knapp. 
"8. Occasionally the corneal flap is everted because it 
has been caught by the margin of the lid, owing to a 
sudden movement of the patient. It must be replaced 
and a bandage quickly applied. Sometimes immediately 
at the conclusion of the section or directly after the deliv- 96 
A TREATISE ON CATARACT 
ery of the lens, especially in old and feeble subjects, there 
is great collapse of the cornea, which, instead of keeping 
its proper curve, looks like a wrinkled membrane. Under 
these circumstances the anterior chamber should be filled 
with physiologic salt solution, which will not only aid in 
making proper coaptation of the lips of the wound, but will 
prevent the sucking of the conjunctival juices which might 
lead to infection. 
"9. Capsulotomy may not have been sufficient and 
pressure upon the inferior half of the cornea fails to cause 
the lens to present. In such a case the cystotome must be 
reintroduced and the laceration enlarged, or if the obstruc- 
tion is due to the presence of a tenacious center in the cap- 
sule, this may be removed with capsule forceps." 
Immediate Accidents in Cataract Operation 
A dislocation of the lens backward during an attempt 
at its removal is a most disastrous accident. Sometimes 
a lens thus lost in the vitreous may be lifted up and drawn 
into the anterior chamber with a wire loop, or it may, by 
special good fortune, be withdrawn with the small lens 
hook. Attempts at its removal should not be carried too 
far as too much churning of the vitreous will result disas- 
trously. When this embarrassing predicament occurs it 
would be better, after brief attempts to remove the lens 
with the loop or hook, to bandage the eye with the hope 
that the lens will rise to its normal position, which it has 
frequently done following this accident, when it may be 
recovered by a secondary operation. If vitreous be lost FIGURE 18 
Supporting the lens with a wire loop during the act of delivery. 
Demonstration upon model.-Author. A TREATISE ON CATARACT 
99 
the eye should have a light pressure bandage to it but be- 
fore it is dressed the section must be freed from incarcer- 
ated vitreous so that the wound will not gape. 
In very shallow anterior chambers and in cases where 
much aqueous has escaped before the section is complete, 
the iris is apt to bulge forward and become entangled in 
the knife. This is a very awkward accident, which may 
make the withdrawal of the knife necessary. Under such 
circumstances it would be better to wait for the anterior 
chamber to refill than to proceed with the section. Should 
the latter attempt be made it would very certainly result 
in a disfigurement of the iris. 
Dressing of the Eye following Extraction 
The method so often seen of plastering the eye with 
sterile vaseline after the operation is to be discouraged. 
Vaseline becomes fluid at body temperature and, running 
along the lids, may enter the wound bearing contamina- 
tion from the eyebrows, skin and lashes. If the cilia have 
been properly trimmed before the operation they will not 
adhere together and the vaseline is unnecessary. The eye 
should be first covered with a circular pad and this should 
be kept from crawling about over the face by anchoring 
it with two strips of adhesive plaster. These strips may 
be cut off with scissors at the first dressing instead of be- 
ing pulled off, a procedure which may cause the patient 
to squeeze the lids together with a possibility of opening 
the corneal wound. Following the circular pad a gauze 
dressing is applied and is kept in place with a roller 100 
A TREATISE ON CATARACT 
bandage. Both eyes must be bandaged. If one eye is 
left free, even if the vision in it is slight, it will cause the 
patient to open his eye unconsciously from time to time, 
and may result in a gaping of the wound and a loss of the 
operated eye. Some surgeons are in favor of using a 
wire mask. This shield has some decided advantages. 
It may prevent the patient or nurse from carelessly thrust- 
ing a hand against the eye and causing the wound to gape 
or the iris to prolapse. On the other hand it is often ob- 
jected to by the patient. If the shield is to be used the 
roller bandage will have to be left off. 
Taking the Patient from the Table and Away 
from the Operating Room 
The patient must be removed from the table to the 
ward carriage with the greatest care and only after having 
been instructed that he is not to attempt to help himself 
in the least. The carriage should be rolled cautiously and 
corners must be rounded slowly. This precaution, if not 
observed, may induce vomiting and be disastrous. It is 
better, if possible, to have the patient's room on the same 
floor as the operating room so that he will not have to be 
trundled in and out of an elevator. When the carriage 
reaches his room he may be drawn over upon the bed, be- 
ing careful to avoid the general shaking up which so often 
accompanies this action, and be placed upon his back. He 
should be instructed to remain quietly as he is placed, and 
not to attempt to get out of bed under any circumstances. FIGURE 19 
Unsuccessful method, adopted by some surgeons, of freeing anterior chamber of 
shreds of capsule and remnants of cortex and vitreous by use of spatula, while 
operator standing at right leans over patient. In addition to bad position lack 
of deep pressure from improper choice of instrument gives poor result.-Author. A TREATISE ON CATARACT 
103 
For at least three days following the operation the use of 
the bed pan and urinal will be absolutely necessary. 
The Patient's Room 
The patient's room should be kept well shaded as an 
excess of light may cause irritation and pain in the eye. 
As good ventilation is necessary, the room need not be 
kept entirely dark. Usually a shade may be arranged at 
the patient's head to protect his eyes. Ample light may 
always be admitted, without doing any harm, to enable 
the nurse to move about the room freely. When the eye 
is first dressed the electric light should be dimmed leaving 
just enough light for the surgeon to work, and to conduct 
his examination. 
Subsequent Dressing 
The day after the operation, if the patient is resting 
comfortably, it may be permissible to defer the dressing of 
the eye until the following day. Some surgeons do not 
make the first dressing until the third or even the fourth 
day. This is not a conservative thing to do, for should 
anything of an untoward nature have happened in the 
meantime it may be too late to correct it. Thirty-six 
hours is sufficient time for an incision in an uncomplicated 
case to seal over and, at the expiration of this time, the 
eye may be inspected with comparative safety. Opening 
the eye sooner than this may be attended by a gush of 
aqueous and, when the simple operation has been done, a 104 
A TREATISE ON CATARACT 
prolapse of the iris and an incarceration of a portion of it 
in the wound. 
Admission of light into the eye should be gradual and 
for this reason it is unwise to attempt to test the vision 
at the first dressing. 
After the initial dressing has been made the eye should 
have attention daily. Following an uncomplicated op- 
eration the corneal wound is sealed in a very brief period. 
As early as twenty-four hours after the operation the 
wound closure may be complete and the aqueous be so 
nearly reformed that the anterior chamber appears to be 
of normal depth. 
If the lids are not puffed and if the secretion be scant 
very little should be done. I believe the practice of daily 
dropping solutions into the eye, when no complication 
exists, is a bad one as it causes annoying irritation without 
accomplishing any good. The margins of the lids may be 
gently mopped with sterile gauze moistened with boric 
acid solution, and even this should be practiced with great 
care so as not to carry infection into the eye. 
Patients are often startled by the lids filling up with 
tears which, after a time, gush suddenly from the eye. It 
is always well to explain to the patient that he may have 
this experience, thereby protecting him from unnecessary 
alarm. 
Postoperative Prolapse of the Iris 
This may occcur in cases when the simple operation has 
been done. Usually the fault lies with the corneal wound FIGURE 20 
Removing fragment of cortex from the anterior chamber by deep stroking of 
the cornea. Demonstration upon model.-Author. A TREATISE ON CATARACT 
107 
which gapes before healing is complete. If the section 
permanently gapes this may be a beneficial accident, the 
iris helping to close a wound that otherwise would remain 
open and admit infection. The process is the same as that 
employed by nature in other penetrating wounds of the 
cornea where the iris is pushed forward to help seal over 
the opening. When a prolapse occurs very soon after 
the operation, the iris should be replaced; but when it oc- 
curs in wounds that show a dispostition not to heal, it is 
better to leave the eye alone. I have seen two cases, each 
with very good vision, in which this accident had hap- 
pened. 
Postoperative Intra-Ocular Hemorrhage 
This complication, which invariably ends in complete 
destruction of vision, is thought always to be preceded by 
some disease of the choroid. 
Treatment of Postoperative Intra-Ocular Hem- 
orrhage 
While the condition leaves no hope as far as vision is 
concerned, a lavage of the anterior chamber with a view 
to removing the clots and allowing the corneal wound to 
close may prevent the necessity of an enucleation. Fortu- 
nately, this accident is very rare. 108 
A TREATISE ON CATARACT 
Postoperative Glaucoma 
This complication is usually ushered in with pain which 
radiates along the branches of the fifth nerve. Unlike the 
periodic pain of iritis, the pain from glaucoma is constant. 
The iris is seen to push forward and the cornea becomes 
steamy and is insensitive. There is a deep injection of the 
conjunctiva which is general instead of peri-comeal as in 
iritis. If the combined operation has not been done, an 
iridectomy is indicated at once. Otherwise, eserin or 
pilocarpin may be used and may arrest the process. 
Postoperative Iritis 
This may present itself from the third to the tenth day. 
The initial symptom is pain, severe and lacerating, but 
periodic. It is usually very pronounced during the early 
morning hours. The iris becomes swollen and the pupil 
shows a tendency to contract. The cornea has a hazy ap- 
pearance, due to its posterior surface being studded with 
deposits. There is deep pericorneal injection and a very 
profuse lachrymation. 
Treatment of Postoperative Iritis 
The treatment of this condition should be both local and 
systemic. Free purgation should be instituted and the 
salicylates should be administered. Hot applications 
should be applied to the eye and a one per cent, or stronger 
solution of atropine should be dropped in the eye four or 
five times a day. The patient should be kept in bed. FIGURE 21 
Very frequently assumed but awkward position of hand in performing toilet of the 
wound. As will be observed the hand is entirely unsupported.-Author. A TREATISE ON CATARACT 
111 
Suppuration of the Corneal Wound 
Suppuration of the corneal wound may occur any time 
from the second day till the fifth or sixth day. It is usu- 
ally ushered in with a feeling of pain, described as some- 
thing sticking into the eye. In rarely fortunate cases the 
infection may be confined to the anterior chamber and may 
subside in a few days, leaving very little bad results; usu- 
ally, however, the suppurative process increases in sever- 
ity, pain is intense, the lids become greatly swollen, the 
corneal flap undergoes a sloughing process, and the eye 
is hopelessly wrecked. 
Treatment of Suppuration of the Wound 
During the last year or two Dakin's solution has been 
used as an irrigation with some success. Formerly lavage 
with a 1-2000 bichloride of mercury was suggested and is 
still used by some surgeons. Sub-conjunctival injections 
of normal salt solutions have been much lauded. Regard- 
less of treatment, nearly all infected eyes are lost. 
Non-Union of the Corneal Wound 
One of the most serious postoperative complications 
of cataract extraction is non-union of the corneal wound. 
This sometimes occurs in very old and debilitated patients 
or it may result from no apparent cause in patients previ- 
ously looked upon as splendid operative risks. Fre- 
quently some mechanical cause, such as tags of iris or 
shreds from the capsule, may be found responsible for A TREATISE ON CATARACT 
112 
non-union of the wound. Mueller believes that corneal 
epithelium, scraped into the incision by the spatula, may 
in some cases be responsible for a failure of the edges of 
the wound to unite. 
Treatment of Non-Union of the Cornea 
it is doubtful if meddling surgery will do otherwise 
than be productive of bad results. The wound should be 
kept sterile. Atropin should be dropped in the eye once 
or twice a day, and a bandage should be gently applied. 
Care should be exercised in the application of the dress- 
ings. If they are too firmly applied they will only add 
to the gaping of the wound. The patient must be kept 
in bed and be well nourished. 
Mental Complications 
Acute insanity may be a complication of cataract 
extraction. Aside from the fact that this unfortunate 
sequel may leave lasting results it is Hable to end in dis- 
aster to the eye, for during an unguarded moment, the 
bandage may be torn off and the eye infected, or the vio- 
lent struggles of the patient may end in a reopening of 
the wound and an expulsion of the contents of the globe. 
Postoperative Pain 
A considerable proportion of cataract extractions are 
followed by a certain amount of pain or at least a sense A TREATISE ON CATARACT 
113 
of uneasiness in the operated eye, ranging all the way from 
a slight smarting sensation, to pain more or less acute. 
This discomfort usually subsides after a few hours, leav- 
ing no bad result. The nurse should be cautioned not to 
administer an analgesic by mouth to a cataract case. Sev- 
eral years ago I had a patient lose an eye from violent 
vomiting brought about by the administration of a pow- 
der containing aspirin and Dover's powder, given by a 
sympathetic pupil nurse who acted upon her own initia- 
tive. If the uneasiness in the eye is sufficiently severe 
to cause the patient to be restless an opiate may be given 
hypodermically. 
Diet and General Care of Patient 
The majority of surgeons restrict their cataract pa- 
tients' diet to liquid for several days following the opera- 
tion. It seems to me that this is an unnecessary precau- 
tion and a mistake. The muscles controlling mastication 
are in no way associated with the eye and because of this 
fact it is difficult to believe that the act of chewing can be 
productive of harm. Patients, especially elderly ones, 
who are put through a process of semi-starvation rapidly 
lose strength and vigor, and the healing process in the cor- 
nea may be delayed thereby. I have found that semi-solid 
food, carefully selected and prepared, is not contraindi- 
cated in any way and that patients thus fed do better than 
do those confined to the liquid diets, which I formerly 
prescribed. 
The patient's bowels should have the closest attention. 114 
A TREATISE ON CATARACT 
If he fails to have bowel movements the first and second 
day following the operation enemata should be adminis- 
tered. After the third day moderate doses of cascara may 
be given, the size of the dose depending upon the degree of 
constipation. As stated in a previous chapter, the bed 
pan is absolutely essential for the first three or four days. 
Aphakia 
Removal of the crystalline lens produces a result which 
is technically known as aphakia, and which can only be 
corrected by convex lenses. Providing that the patient 
has not previously been myopic, ten or more diopters cor- 
rection will usually be necessary. In addition to the high 
degree of aphakic hyperopia an astigmatism of three or 
four diopters, "against the rule" is apt to be present. The 
eyes should not be fitted, however, until all symptoms 
associated with the extraction are absent. The patient 
should be provided with two pairs of glasses; one pair for 
distance and a pair for reading which usually must be 
three diopters or more in advance of his distance correc- 
tion. 
End of Results of Cataract Extractions 
A great variety of opinions exist in reference to the de- 
gree of vision, with correcting lenses, that must be ob- 
tained before a cataract operation may be classified as a 
success. Statistics regarding the percentage of successes 
made by men of established reputation vary to a remark- FIGURE 22 
The toilet of the wound: Freeing the incision of shreds of capsule or frag- 
ments of cortex or vitreous. Demonstration upon model.-Author. A TREATISE ON CATARACT 
117 
able degree. A well known American surgeon recently 
reported a series of one hundred cataract extractions, 
ninety-five of which were tabulated as successful. 
Among these one-eighth were said to have vision of 20-20. 
Without presuming to question the authenticity of this 
report I am taking the liberty of quoting the following 
opinion given by De Schweinitz of Philadelphia, in his 
book: Diseases of the Eye. 
"Perfect acuity of sight," he states "is frequently se- 
cured 20-20, but more often patients must be content 
with lower degrees, or according to some operators 
1-10 of normal vision being sufficient to place the case 
within the category of success." 
Ball considers vision of 20-20 to be a good result and 
vision from 1-200 to 18-200 to be a moderate result. 
This classification is conservative and is probably more 
nearly borne out by the experience of American surgeons 
than any other. 
Congenital or Juvenile Cataracts 
Rarely do children develop cataracts in early childhood 
that are not of congenital origin. When they are dis- 
covered in early life they may be looked upon as accentua- 
tions of opacities which existed at birth rather than as re- 
cent developments. A slight haziness of the lens may be 
entirely overlooked in infancy, the disturbance of vision 
which it causes being attributed to "near sight." It is 
only after the child begins to read, that the defect mani- 
fests itself. 118 
A TREATISE ON CATARACT 
A small per cent, of cataractous children are bom with 
their lenticular opacities complete. These opacities may 
be capsular or nuclear. More frequently the opacities are 
partial, the child reaching puberty before the stage of even 
partial blindness is reached. 
Congenital cataracts are usually divided into six types: 
(1) Central or nuclear type, similar in appearance to 
the beginning nuclear cataract of senile life. 
(2) Lamellar type, in which the opacities are in the 
layers of the lens between the nucleus and cortex. 
(3) Anterior polar cataracts, usually due to pupillary 
adhesions to the anterior capsule. 
(4) Posterior polar cataract, thought to be occasioned 
by a persistent hyaloid artery. 
(5) Punctate cataracts, which are very rarely observed. 
(6) Axial cataracts in which the opacity extends 
through the lens of its axis, from the anterior to the pos- 
terior portion. 
Diagnosis of Juvenile Cataract 
The diagnosis of juvenile cataract is based upon the 
same clinical observations that apply to the senile variety. 
The lens, however, may have a hue different from the 
mature type and may present a bluish white rather than 
a grey appearance. 
Treatment of Juvenile Cataract 
In cases of juvenile cataract, when little interference 
with vision occurs, the child may be fitted with lenses cor- FIGURE 23 
Proper method of applying cataract bandage. A TREATISE ON CATARACT 
121 
recting refractive errors, and the case may be let* alone. 
If there is much disturbance of vision operation is indi- 
cated. 
Selection of Operation 
Three different operations may be performed for con- 
genital opacities of the lens, the character of operation 
best suited to the individual case being the one that should 
be selected. These operations are discission, iridectomy 
and expression. In the punctate variety an iridectomy 
will usually suffice. It would be the height of poor judg- 
ment to needle or express a lens of this type and create all 
the disadvantages that are associated with an aphakic eye 
when an iridectomy will uncover sufficient clear lens tis- 
sue to establish vision. In nearly all the other types of 
early cataract the operation for solution is indicated. 
Operation for Solution of Juvenile Cataract 
This is performed by puncturing the lens and admitting 
the aqueous humor to it. By the macerating influence of 
the aqueous, the lens tissue rapidly disintegrates and dis- 
appears. Before attempting this operation the pupil 
should be widely dilated with atropin. The patient must 
be under a general anesthetic. 
With the speculum in place a knife needle, either 
straight or curved, is thrust through the cornea at the 
sclero-corneal margin, and carried to the anterior pole of 
the lens. With much nicety it must now be made to divide A TREATISE ON CATARACT 
122 
the anterior capsule. If this portion of the operation is not 
done with extreme care the lens may be dislocated back- 
ward into the vitreous where it will act as a foreign body 
and may result in loss of the eye. For this reason the 
needle must not be carried too deeply into the lens tissue, 
and its motion must be restricted. The less leverage given 
it the better, and if the lens is seen to move in the slightest 
degree the needle should be at once withdrawn. 
Another reason for not producing too much mechanical 
disturbance to the lens is that lens tissue so treated swells 
greatly and consequent pressure upon the iris may give 
origin to adhesions between it and the capsule, which may 
be broken up with difficulty or not at all. 
Frequently flocculent portions of the lens may escape 
into the anterior chamber, where they are usually absorbed 
without any disturbance. In rare instances, however, lens 
materials in the anterior chamber may give rise to violent 
symptoms of pain, inflammation and vomiting. When 
this unfortunate condition is met with, the cornea must be 
incised and the lens material swept out in much the same 
way that the cortex is removed following an extraction of 
senile cataract. 
Nuclei of cataracts falling into the anterior chamber late 
in the treatment, the result of absorption of the surround- 
ing lens tissue, usually do not create the disturbance which 
is seen when the cortex matter so invades the chamber. 
Usually nuclei thus displaced may remain several days or 
weeks before disappearing, their position not being at- 
tended with any bad results. FIGURE 24 
The woven wire cataract shield of Wiirdemann. A TREATISE ON CATARACT 
125 
The Double Needle Operation for Juvenile Cat- 
aract 
Dilaceration, or the double needle operation, is the one 
favored for juvenile cataract by a small per cent, of sur- 
geons. In performing this operation one needle is entered 
at the outer side of the cornea and is carried obliquely in- 
ward until it is seen to pierce the capsule. Another needle 
is now introduced at an opposite point in the cornea and is 
also carried through the capsule, after which the handles of 
both instruments are elevated, this manoeuver separating 
the blades simultaneously, thus tearing an opening in the 
capsule. 
When the capsule is very thick and dense the operation 
for extraction of the capsule is indicated. A good hold is 
taken upon the conjunctiva with the fixation forceps and 
an incision is made in the cornea similar to the initial sec- 
tion, except that it should be less extensive and should be 
carried through the capsule at a point opposite its entrance. 
After Treatment of Juvenile Cataract 
The pupil must be kept dilated for several days follow- 
ing a needling of the lens. Usually very slight inflamma- 
tion occurs subsequent to this operation when it is well 
executed, but it is well to keep the child in bed for a day 
or two. 
The operation may have to be repeated several times 
before all lens matter disappears; but, as a general rule, if 
a sufficient time elapses between the needlings, the case will 
not have to undergo more than two or three operations. A TREATISE ON CATARACT 
126 
When solution is complete an artificial lens having the 
refraction value of the crystalline lens just removed must 
be fitted and constantly worn. 
The operation for solution is readily performed by any 
one who has the least aptitude for surgery. In cases of 
soft cataract the results are fully as good as when expres- 
sion is done, and the operation is not attended with the 
danger associated with a corneal section. In my opinion, 
expression for juvenile cataracts is a procedure to be con- 
demned unless the circumstances surrounding the case are 
unusual. 
The Suction Operation for Juvenile Cataracts 
A very popular operation, a few years ago, for juvenile 
cataract was that of suction. This method is very graph- 
ically described by Haynes Walton, as follows: 
Suitable Cases for Suction Operation 
"All full-bodied complete cataracts in persons under the 
age of forty. Herein are included cataracts spontaneously 
formed; diabetic cataracts, a most favorable class; trau- 
matic cataracts, in which, from the rent in the capsule 
being of moderate extent, the eye remains quiescent until 
the cataracts is entirely developed; in complete cataracts, 
which have been rendered complete by the careful punc- 
turing of the anterior capsule. FIGURE 25 
Method of applying the binocular convex cataract shield. A TREATISE ON CATARACT 
129 
Unsuitable Cases 
"Incomplete or immature cataracts, in which portions 
are transparent and glutinous, and would require great suc- 
tion force to draw them into the curette; traumatic cata- 
racts in which the eye is in a state of excitement, or involved 
in iritis or where there has been rupture of the posterior 
capsule, or in which from lapse of time the bulk of the cata- 
ract has been so far reduced that the anterior and posterior 
capsules are almost in contact. Cataracts which are con- 
genital, or have formed in early life, or are of traumatic or- 
igin, and have undergone wasting and calcareous degen- 
eration. 
Instrument and Its Use 
"The glass stem, five inches in length, allows the operator 
to watch the progress of the suction. The India rubber 
tube, eleven inches in length, and furnished with a mouth- 
piece, allows the operator to apply the suction either with 
considerable force, or with the most exquisite gentleness, 
and to use his tongue as a piston under the most perfect 
control. 
"The tubular curette is the most critical portion of the 
instrument, and the one in which deviations from a correct 
form are most liable to lead to disappointment. My orig- 
inal idea was taken from the old-fashioned curette used in 
flap extractions. This was roofed in so as to form a tube 
with a small opening near its extremity. In size and 
curve, the original was all that could be desired, but it has 
been improved by being shortened to five-eighths of an 130 
A TREATISE ON CATARACT 
inch, and by being slightly convex on its upper surface, 
instead of being flat, the whole calibre occupying an open- 
ing in the cornea no larger than would be required for the 
common curette. The point should be as round and blunt 
as possible, and the opening in the upper surface should be 
in size equal to the section of the tube, and as near to the 
extremity as the required bluntness will permit. In order 
to facilitate the access of the lenticular matter to the open- 
ing in the curette, side notches were made in the margin of 
the aperture, thus defeating the cardinal point of safety, 
that the cornea should act as a stop-valve, when drawn 
down upon the flat margin of the orifice, and defend the 
iris and eye from the dangerous effects of prolonged suc- 
tion. For a short period I used such an instrument, and 
was annoyed by the difficulty of avoiding injury to the iris. 
Details of the Operation, First Stage 
"The pupil having been well dilated by atropin, and the 
eyelids fixed by the wire retractor, the eyeball should be 
steadied by conjunctival forceps in the left hand of the op- 
erator, whilst the opening in the cornea is made by a needle 
of sufficient width held in his right hand. The needle 
should enter the cornea at a point opposite the margin of 
the fully dilated iris, and passing obliquely through the 
substance of the cornea, should enter the anterior chamber 
at a point opposite to the margin of the pupil when of me- 
dium size. Such a valvular opening will provide that there 
is no scar in front of the pupil; that the wound is not so near 
to the attached margin of the iris, as to favour prolapse of A TREATISE ON CATARACT 
131 
the iris or adhesion of it to the corneal wound, and that the 
curette may not, when introduced, rest on or bruise the iris. 
Second Stage. Efficient Rupture of the Anterior 
Capsule 
"This is, perhaps, the most difficult and important part 
of the operation. Sometimes Mr. Teale tears the capsule 
by two needles before making the opening in the cornea. 
On the whole, however, he thinks the best method is to 
effect a free opening with Graefe's cystotome passed 
through the opening made by the broad needle, care being 
taken to carry the instrument to the opposite edge of the 
pupil before making any breach in the capsule, for the sim- 
ple reason that the object of this step is not merely to lib- 
erate the cataract, but also to insure such a tearing up of 
the anterior capsule that it may curl back from the area of 
the pupil and be lodged behind the iris. At the same time 
he endeavors to avoid injuring the posterior capsule, a cau- 
tion to be especially borne in mind in those cases in which 
the anterior capsule is tough, and in traumatic cataracts, 
in which the lens has been much reduced in bulk by absorp- 
tion. 
Third Stage. The Removal of the Cataract by 
Suction 
"The operator carefully introducing the curette through 
the corneal wound, the eye being still fixed by the conjunc- 
tival forceps, should steadily hold it with the opening look- 132 
A TREATISE ON CATARACT 
ing up towards the cornea, in the area of the pupil, and 
gently bury it in the opaque material, by pressing the con- 
vex surface, not the point, backwards towards the posterior 
capsule. The suction power should then be carefully ap- 
plied, and continued gently as long as opaque matter comes 
forward into the pupil. When all is clear, the curette may 
be withdrawn, and the eye gently rubbed through the upper 
eyelid, which will bring into the pupil any remains of cata- 
ract that may have been lodged behind the iris. The 
curette must on no account be swept either in front or 
behind the iris in search of portions of cataract. If the 
suction be continued after the cataract has been removed, 
the cornea is drawn upon the opening in the curette, blocks 
it up, and thereby arrests the suction before the iris can be 
drawn into the tube and so injured. In the more tenacious 
forms of cataract, considerable suction power must be 
exerted. 
General Conclusions 
"If the operations have been efficiently performed, it will 
be found that the cataract has been completely withdrawn 
from the eye through an opening no larger than would be 
required by the common curette, without rupture of the 
posterior capsule, and with such complete division of the 
anterior capsule that it has disappeared completely behind 
the iris. It will also be found in such cases that recovery 
is most speedy, that the operation is followed by little or 
no irritation of the eye, that the patient in a week or less 
can read No. 1, Jaeger, and that the conditions which FIGURE 26 
Densest form of secondary cataract resulting from the agglutination together of the 
anterior and posterior opaque capsules.-Author. A TREATISE ON CATARACT 
135 
usually produce opacity of capsule, and demand secondary 
operations, have been guarded against. In one of my 
cases, the patient could read No. 1, Jaeger, immediately 
after the operation. Several others have been so well on 
the third or fourth day that they could return home into 
the country. Very few cases have required secondary 
operation for opaque capsule. I have rarely seen the 
operation followed by destructive inflammation never as 
far as I can remember where the cataract, on the posterior 
capsule, has been in good condition. 
"I am firmly convinced that within certain limits extrac- 
tion by suction can be made more certain, more speedy and 
more brilliant than any other mode of removal of cataract, 
and that we are now in a position to define those limits 
with tolerable accuracy." 
Traumatic Cataract 
Traumatic cataract, as indicated by its name, results 
usually from a penetration of the lens substance from some 
flying missile, or from a blow of sufficient force to rup- 
ture the capsule of the lens, either anteriorly or posteriorly. 
Injuries to the crystalline lens from penetrating wounds 
resulting from sharp instruments are usually attended with 
pain, swelling and photophobia. If these symptoms sub- 
side without infection of the wound and loss of the eye a 
cataract results. Following a rupture of the capsule a 
cataract may develop without any untoward symptoms, 
and the vision be lost for weeks or even months before the 
cataract is discovered. 136 
A TREATISE ON CATARACT 
Injury to the crystalline lens occurring in adult life is 
of greater significance than similar accidents among juve- 
niles. If the lens is severely injured glaucomatous symp- 
toms may present themselves in a few hours, giving rise 
to the necessity for operation. It is better, under the cir- 
cumstances, to extract the lens through a linear incision in 
the cornea, preceded by a broad iridectomy. Secondary 
or capsular cataract, which may follow this procedure, is 
to be dealt with in the same manner as that suggested for 
the relief of capsular cataract occurring after senile lens 
extractions. 
Treatment of Traumatic Cataract 
In children with traumatic cataract, solution often takes 
place, this being due to the disintegrative action of the 
aqueous upon lens tissue. The greater the rent in the cap- 
sule and the younger the patient, the more rapid will be 
the absorption of the lens. In young children whose lens 
capsules have been injured, but who have not suffered a 
penetrating wound of the globe, nothing should be done to 
the eye except to dilate the pupil. When the rupture of 
the capsule is associated with a penetrating wound from 
some sharp instrument, in addition to atropinization, the 
eye should be sterilized and dressed. 
Dislocation of the Crystalline Lens 
Dislocation of the crystalline lens forward or backward 
may be associated with a rupture of the capsule. Not in- The double needle procedure adapted to discission of dense secondary cataracts. 
Demonstration upon model.-Author. 
FIGURE 27 A TREATISE ON CATARACT 
139 
frequently the lens is dislocated in its capsule and is ex- 
truded between the conjunctiva and the sclera or is lodged 
under the capsule or tenon. These accidents, not coming 
under the classification of true cataract, will not be further 
considered here. 
Secondary Cataract 
In a great proportion of cases in which a cataract has 
been removed a later operation upon the capsule will be 
found necessary. Fox states that, when capsulotomy has 
not been performed at the time of extraction of the cata- 
ractous lens, at least twenty-five per cent, of cases will de- 
velop opacities in the remaining capsule. The percentage 
of these cases will be found to depend largely upon the 
degree of maturity of the extracted lens, and the amount 
of cortical matter that was left behind at the time the lens 
was delivered. If much lens matter has been allowed to 
remain in the anterior chamber secondary cataract may be 
looked for in almost every case. 
Operations for Secondary Cataract 
A number of surgical methods have been devised for 
attaining increased acuity of vision in cases of after cata- 
ract. Of these discission, or the cutting operation, is most 
in vogue; due to the ease with which it is accomplished> 
and because of the comparative safety attending its per- 
formance. In this operation the knife needle should be 
used, for the capsule must be clearly incised without any 140 
A TREATISE ON CATARACT 
unnecessary dragging upon the ciliary muscle. The pupil 
should be thoroughly dilated, the eye cocainized and the 
knife needle inserted at the limbus, the exact point of en- 
trance to be governed by the character and density of the 
capsule. After the instrument enters the anterior chamber 
it should be carried obliquely inward to a point as far 
opposite to its point of entrance as the iris will permit. Its 
cutting edge is then directed toward the point of entrance 
so that in raising the handle it will cut its way through the 
membrane. If the cut is clearly made, and if it is suffi- 
ciently long, the elasticity with which the capsule is en- 
dowed will cause it to gape, thereby creating a permanent 
opening in the capsule. 
Extraction of the Capsule in Secondary Cataract 
In performing this operation a small corneal section is 
made. A five or six millimeters incision is usually suffi- 
ciently long to admit the capsule forcep, which is now 
introduced into the anterior chamber. The capsule is 
grasped by it, drawn out and snipped off. It is impor- 
tant, during this step of the operation, not to produce too 
much dragging upon the ciliary body, else an iritis or an 
iridocyclitis may result. Operations upon the capsule 
should not be attempted without the aid of a reflected light 
sufficiently brilliant to enable the surgeon to obtain a good 
view of the capsule. 
Following the operation for secondary cataract the pa- 
tient should be confined to his bed for forty-eight hours, 
after which time he may be about the room. The eye A TREATISE ON CATARACT 
141 
should be dressed daily and be protected from the light 
until all untoward symptoms disappear. 
The Intracapsular or Indian Operation 
The technique of the intracapsular operation does not 
differ materially from the classical extraction as done by 
the European and American surgeon except in the method 
of expulsion of the lens and the character of the incision. 
Colonel Smith makes his corneal section in the usual man- 
ner, but its base is much broader and the conjunctival flap 
is invariably omitted. The technique of extractions in the 
unruptured capsule is described by Smith as follows: 
"When the incision is finished and the iridectomy per- 
formed (if the operator decides to do one) the speculum 
is removed, and the operator proceeds without speaking to 
the patient. In the case of an immature lens or of a hard 
cataract, with a spatula in the operator's left hand for use 
if required, he proceeds to press back with the point of a 
strabismus hook towards the optic nerve, the point of the 
hook being placed over the lower third of the cornea. 
The pressure is steady and the point of the hook should 
not be moved until the upper edge of the lens tilts forward 
and is thus seen to be dislocated, having been made to 
swing round on its transverse axis. The moment the lens 
is seen to be dislocated, the pressure through the point of 
the hook is gradually turned more and more towards the 
wound, pressure being maintained all the time so as to keep 
the lens up to the sclerotic margin, the pressure with the 
hook becoming gradually lighter and lighter and the hook 142 
A TREATISE ON CATARACT 
gradually sliding after the lens until the cornea is folded 
beneath it. At this stage it is delivered. In a low tension 
eye the beginner should follow up the lens with the spatula 
in addition to the hook, as with it he can maintain a suffi- 
cient tension in the eye and thus allow his right hand instru- 
ment to follow up the lens more lightly. In rare cases of 
low tension eyes he might find it advantageous when the 
lens is half way out to apply a little counter-pressure 
above the wound with the spatula. In the case of intum- 
escent lenses and Morgagnian cataract (in which the nu- 
cleus is small and is surrounded by a considerable amount 
of soft disintegrated lens matter) the capsule is generally 
extremely delicate and if dislocated in the manner above 
described, is liable to burst when the lens is half way out, 
allowing the nucleus to escape and to be itself retracted 
with considerable amount of lens matter. The operator is 
then placed in a difficult position, the capsule being dislo- 
cated at the wound. To overcome this I observed that 
lenses of this class occasionally turn a half somersault, dis- 
locating opposite the wound, and that having done so, the 
capsule very seldom bursts and when it did burst it was at- 
tached only in the neighborhood of the wound and was not 
drawn back, and that under these conditions it was very 
easily caught with a pair of dissecting forceps and re- 
moved entirely without inserting any instrument into the 
eye. I proceeded to imitate this accident with this class of 
cataracts, first by applying pressure over the ciliary re- 
gion, but soon desisted as I had a few cases of expulsive 
hemorrhage from choroidal detachment, which I attrib- 
uted to my manipulation of this region. I then com- FIGURE 28 
Discission of the opaque capsule as performed where single Von Graefe knife 
is used. Demonstration upon model.-Author. A TREATISE ON CATARACT 
145 
menced to press with the point of the strabismus hook suf- 
ficiently deep over the lower border of the lens. I then 
found I could almost invariably make these lenses dislo- 
cate below and then turn a half somersault. This pres- 
sure and traction are always over the zonule. 
"As soon as the lens turns up into the wound, showing 
that it is freely dislocated below, the operator should cease 
to make traction toward the patient's feet but make direct 
pressure backwards, then backwards and upwards and, 
finally, more and more towards the wound, folding the 
cornea beneath the lens until it falls on the outside of the 
cornea. At this stage the capsule has not been dislocated 
from the zonula in the neighborhood of the wound. The 
hollow of the curve of the strabismus hook should now be 
made to sweep along between the lens and the wound to 
complete the detachment. The beginner, while using the 
hook thus, would do well in all instances to put the spatula 
on the cornea so as to keep up sufficient tension in the eye 
and so prevent the lens from slipping back into the eye 
in this latter stage whether it be of hard or of soft consist- 
ency, since a lens is occasionally liable in this stage to slip 
back into the eye and then to be exceedingly difficult to 
remove. 
"The hypermature cataract is, of all cataracts the most 
difficult to dislocate. It has become shrunken, its capsule 
thickened, and its attachments have become firmer than is 
the case with any other senile cataracts. The operator in 
this case should proceed with the strabismus hook as in the 
case of immature and hard cataract. The spatula in his 
left hand should be in position at the margin of the wound A TREATISE ON CATARACT 
146 
to drop behind the lens the instant the edge of it is seen at 
the wound, as otherwise pressure on the cornea will only 
squeeze out vitreous, the lens refusing to move. It should 
be dropped almost straight down into the eye, the back of 
it being kept thoroughly against the sclerotic margin of 
the wound. The lens should be pressed against it with the 
hook from the outside and thus made to slide up along the 
inclined plane of the spatula. The spatula should be kept 
steady in position, care being taken to not use it as a means 
of lifting out the lens. If used to lift out the lens, the 
capsule is very liable to be ruptured and vitreous escape 
behind it at the same time. It does not require to be in- 
serted behind the lens to more than a trifling distance; it 
is thus used to prevent the pressure from the hook on the 
outside from putting objectionable pressure on the vitre- 
ous. The spatula for this purpose should have a slight 
curve and be about 7/16 inches broad and not sharp any- 
where, so as to avoid the risk of injury to the capsule. A 
dextrous operator, if he follows these directions and the 
patient being fairly well behaved, will be able to extract 
hypermature cataracts thus with escape of vitreous in a 
trifling percentage of cases. I believe that hypermature 
cataract is infinitely more common in India than in America 
or Europe, as in these countries patients have their cat- 
aracts extracted before they reach this advanced stage. 
There is one other variety of cataract worthy of mention. 
It is a rare form, the color of coarse white soap, a charac- 
teristic color when once seen. It is exceedingly difficult to 
dislocate and when recognized the operator should proceed 
as in the case of hypermature cataract. FIGURE 29 
Bandage well adapted to discission cases. A TREATISE ON CATARACT 
149 
"The iris being a sticky membrane, is found, after the 
lens is extracted in capsule, sticking to the sclerotic and in 
angles of the wound. Whether an iridectomy has been 
done or not its careful reposition in this operation is of the 
utmost importance. The assistant firmly holding up the 
eyelids and brows as before, it will be observed that the 
cornea drops back and that the iris, not in the neighborhood 
of the wound, falls on the vitreous leaving the aqueous 
chamber and the space which the lens occupied vacant. 
With a suitable repositor the operator should release the 
remaining parts of the iris from the sclerotic and from the 
angles of the wound. When this is properly done the op- 
erator is able to see back to the very base of the iris all 
round in the neighborhood of the wound. There need be 
no hurry about the reposition of the iris. . It can and should 
be done with the utmost care. If this is done and the eye 
carefully dressed and not redressed until after the eighth 
day, and the patient behaves sensibly, iris prolapse will sel- 
dom be seen. Complications of the iris in the wound are 
generally due to not replacing it properly and to meddle- 
some dressings and meddlesome inspections and foolish 
conduct on the part of the patient. 
"If vitreous escapes it should be snipped off with scissors 
and not left hanging in the wound where it will act as a 
drain preventing union. As iritis, iridocyclitis and sepsis 
are so exceedingly rare following this operation, the after 
treatment is almost nil. Atropin is not necessary." 
That the Indian operation is not well adapted to the 
Occident is suggested by the following extract from Tif- 150 
A TREATISE ON CATARACT 
fany's criticism of the method which would indicate that 
even the Indian surgeons recognized its limitations. 
"Colonel Maynard told me that he operated for some 
time in conjunction with Colonel Smith, and that he now 
makes the intracapsular operation in about 30 per cent, of 
his cataract cases. He thought that the intracapsular 
method is well adapted to hypermature cataracts, and said 
that most of the Indians do not seek surgical advice until 
the cataract is over-ripe. He added that it had been his 
experience to find that hypermature cataract frequently 
presented itself as soon as the incision was made, and that 
consequently we might all of us occasionally extract the 
lens with the capsule intact. Colonel Maynard said that 
in his opinion the operation is not at all adapted to Euro- 
pean or American cases; and that if he were practicing 
ophthalmology in Europe, he certainly would not use this 
method in his private practice. He felt that it involves too 
great danger of loss of vitreous, and subsequent deteriora- 
tion of the globe; for he was not of Smith's opinion that the 
vitreous is restored."