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Statistics of the Operations for Cataract.

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globe, one-third of it lying in the cornea, the other two-thirds occupying the outer side of the sclerotic. Like that which protruded from beneath the lid, this was of a deep, pink hue, and slightly lobulated on the surface, not unlike a half-ripe raspberry. A gush of scalding tears, attended with increased pain and photophobia, followed immediately this examination. We at once pronounced them to be congenital tumours in a state of inflammation, and such they were; that which encroached on the cornea had several light-coloured hairs growing from its surface. These generally lay quiescent between the palpebral aperture, or projecting slightly over the edge of the lower lid, seldom caused any inconvenience. The largest had, however, two days before, turned_up_under the superior lid, and gave rise to all the symptoms we have described. Its removal caused them to subside almost immediately. The case is interesting and instructive on account of its having been first seen during an attack of inflammation, or, more properly speaking, inflammatory irritation, and from the possibility of its being thus mistaken for a sudden morbid growth. What first awakened suspicion, the moment the lids were separated, was the fact of the tumour being covered with cutaneous epithelium, which, as in cases of xeroma, gave it the appearance of being oiled or varnished, so that the tears did not flow over it, and moisten all its surface, but lay upon it in detached globules. This cuticular character is peculiar to all those growths from which hair grew which we have examined. We have since seen the eye in a quiescent state, and find our conjectures were correct."

Cataract.

Although several of Mr. Brett's observations will be found useful to the young operating surgeon, we are at a loss to discover sufficient novelty in these to call for the publication of a new work upon Cataract, Artificial Pupil, and Strabismus." Indeed, little is to found in it that is not far more amply detailed in most other works-Mr, Jones' Manual among the rest. The statistics of various operations for cataract have been so variously stated by different observers, as to have little claim to our notice. Mr. Brett refers to some of these discrepancies; but we should have better like to have seen a detailed account of the results of his own practice in India, which we believe some recent advertisements stated to have been both extensive and remarkably successful. Mr. Wilde furnishes us with an abstract of Dr. E. Jäger's account of his father's practice at Vienna. It seems, between 1827 and 1844, he operated upon 1011 cataracts: 728 times by superior extraction, 9 by inferior, 50 by partial extraction; 129 by depression, and 87 by absorption. Of this number, 63 were unsuccessful; the proportion of those who have irrecoverably lost their vision to those who have been successfully operated upon are, in extraction 43 per cent.; in depression 16; and in breaking up 8 per cent. This is indeed high testimony in favour of extraction; but Mr. Wilde considers the tables as very defective in some necessary details. Mr. Brett remarks, that extraction is much oftener preferred in Germany and England than in France, which he attributes to the absence of special eye infirmaries in the latter country, and a consequent want of opportunity of practically examining into the merits of this operation. In his own practice, Mr. Brett observes, In India, in the healthy and robust natives of the Western provinces, I have found extraction the most successful; whilst, in the lower provinces of Bengal, where the inhabitants are more feeble, I have not found extraction so successful; but, at the same time, it must be admitted, that we

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have not many opportunities of watching the result for a long period after the operation." The following is his general summary of the advantages and disadvantages of the respective methods.

By extraction, the obstruction to vision is entirely removed. It is not usually painful, is seldom followed by internal inflammation, neither the ciliary nerves nor the ciliary vessels are wounded, the whole of the interior of the eye is untouched, the retina, the choroid, ciliary circle, &c.; and, lastly, secondary capsular cataract is less liable to follow this than any other operation. On the other hand, the iris may be cut, and the vitreous humour may escape; if the wound of the cornea does not unite by the first intention it may ulcerate, and the iris will prolapse; inflammation and suppuration of the globe may be the result at all events, the pupil will become closed.

"In depression, purely so called, the vitreous humour does not escape, the cornea preserves its transparency, there is no chance of prolapsus iridis, or of its excision, and the operation may be repeated if requisite; but, on the other hand, the evils of the operation are acknowledged by all, and are numerous. The lens acts as a foreign body, and often causes much irritation at the bottom of the eye-it is liable to re-ascend: the operation is frequently followed by membranous cataracts, by iritis, deep-seated pain, and general nervous irritation. The needle necessarily penetrates the choroid, the retina, the vitreous humour ; and the ciliary processes are at least somewhat disturbed: inflammation is as frequent as after extraction. The wound of the sclerotic, the choroid, the retina, and the vitreous body, does not necessarily produce more pain or injury than that of the cornea, when carefully done. With due precautions it is easy to avoid wounding the nerves or vessels, or the ciliary body. When the capsule of the crystalline is well cut up, there will be less chance of secondary membranous cataract in short, much depends upon the skill and address of the operator to avoid most of the evils of depression, to prevent the lens rolling round the needle, or falling into the bottom of the anterior chamber, and to place it flat-wise at the bottom of the vitreous humour." P. 51.

From this extract it is not very easy to decide which operation the author prefers. Mr. Jones speaks far more precisely in the following passages.

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By the operation of extraction, the cataract is removed wholly and at once from the eye, and very good vision restored: but the operation is a nice, if not a very difficult one, and liable to the occurrence of the various untoward circumstances above mentioned, by which its success may be marred.

"The operation of displacement, which may be performed in the same cases as extraction, is neither so nice or so difficult, does not expose the eye to the same risk of immediate destruction, and though the cataract is apt to return to its former place, the operation may be repeated; but though displacement may have succeeded as an operation, and vision be restored, the eye is not so safe as after successful extraction, but is liable to become affected with internal inflammation, which ends in amaurosis.

"Extraction thus possesses a decided advantage over displacement, and is therefore generally preferred, except when the unfavourable complications abovementioned (viz. unsteadiness on the part of the patient, dyspnoea, overhanging orbit and eye-brow, narrow palpebral fissure, very sunk or prominent eye-ball, unhealthy, small, or flat cornea, and consequently small anterior chamber, synechia, small and undilatable pupil, and especially a dissolved state of the vitreous body and its connexions) exist. The degree of softening of the vitreous body requisite to admit of safe displacement of the lens is not so great as to forbid extraction, but of course, if, in the cases in which the vitreous body is so much dissolved that the displaced lens is apt to float up again, displacement be contra-indicated, extraction is much more so. All other things being equal, it

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Brett on the Operation for Strabismus.

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might perhaps be laid down as a general proposition, that, in the very cases in which displacement admits of being most readily and safely performed, extraction is less safe; whilst, on the other hand, in the cases in which, in consequence of the soundness of the vitreous body, extraction is most safely and easily performed, displacement is least so.

"As the cases for which division is best fitted are different from those in which extraction or displacement is indicated, there is no comparison to be made between them. It is, however, to be observed, that a combination of division and extraction is sometimes had recourse to in cases of common lenticular cataract of old people. The object of having recourse to this compound operation is that the lens may, by solution and absorption of its soft exterior parts, be reduced to its hard nucleus, which, in consequence of its small size, will admit of being extracted through a small section of the cornea."-Manual, p. 292.

M. Laugier described, in a recent number of the "Annales d'Oculistique," an operation for cataract, which he terms by "Aspiration" performed by means of a Scarpa needle rendered tubular and adapted to Anel's syringe. This is carried completely into the crystalline, care being taken not to injure either capsule, and, in the case of soft or partially soft cataract, the opaque body is removed by exhausting the tube of the knife of the air it contains by means of the syringe attached to its handle. The priority of the contrivance has been contended for by subsequent correspondents of the Journal; and it is certain that suction has, in different manners at different periods, been applied to this purpose. Ingenious as M. Laugier's modification is, we fear it is destined to be of little practical utility.

The Operation for Strabismus.

Mr. Brett, as the result of his own practice in India, and his observation of that followed upon the Continent, offers the following suggestions.

"1. To use the scissors always in preference to the knife and director, because by the former you can more readily divide every contiguous fibre both above and below. To the practised hand the point of the scissors grates along the hard fibrous sclerotic coat, and the operator is quite certain that he cuts every muscular fibre. 2. Never to use the hook to claw out the eye, which has always appeared to me at least an unsightly instrument, and somewhat painful, but chiefly because it must be entrusted to the hands of an assistant, who, unless he possess the delicate touch of an artist, and the steadiest hand, may rotate the eye not precisely in the horizontal line. If he give the instrument the least obliquity, he disconcerts the operator in his search after the muscle he has to divide, and he finds it either above or below where he expects it. 3. The operator should have the lids and eye-ball completely under his command; and this is effectually attained by the speculum of Velpeau. The ordinary speculum often slips, and confuses or obscures the operation; so do the fingers. This cannot be the case with the speculum of the Professor of La Charité. I have always operated with the scissors, and I have never met with an instance of the return of the squint; but I have never seen the inconveniences of that part of the duty which devolves on the assistants so happily obviated as by the mode I witnessed in Paris, adopted by Professor Velpeau. I now proceed to describe the operation upon the principles by which we should be guided in all surgical operations, viz. with the least possible pain, the greatest facility and rapidity, in the safest and most effectual

manner.

"The surgeon must bear in mind the insertion of the muscles into the sclerotic three lines and a half from the circumference of the cornea. The patient is placed before a clear light; the opposite eye is obscured; the head supported by

an assistant; the lids separated by the elastic wire speculum (the blephareirgon). The surgeon seated in front seizes the conjunctiva, together with the attachment of the muscle itself by means of the forceps, near its insertion into the sclerotic, about four lines from the margin of the cornea. This gives the operator complete controul over the eye, and by it he is enabled to draw the eye outwards. Immediately after this, he grasps the belly of the muscle with a second pair of forceps. This latter is entrusted to an assistant. The muscle is thus raised and stretched between two pairs of forceps. Its section between the two points of transfixion is now an instantaneous affair. The smooth and bluish-white sclerotica shines beneath the incision, and the operator satisfies himself that every fibre is divided, carrying the scissors above and below until the cornea assumes its central position, and the patient can turn the eye to the opposite side, yet is unable, by any effort, to squint. Finally, the tendinous edge of the muscle grasped by the first pair of forceps, together with some loose portions of conjunctiva, is excised by a stroke of the scissors. This last procedure prevents a very common occurrence, viz. a fungoid granulation, formed from the ragged edge of the tendinous extremity of the muscle, and some cellular tissue beneath the conjunctiva. The eye is cleansed from blood by sponging with cold water. Obscure the opposite eye for some days. Let the patient use the eye which has been operated on in a moderate light. This prevents adhesion and contraction, which might cause a return of the squint." P. 8o.

We cannot quote any observations calculated to facilitate the performance of this operation without declaring that it has been undertaken, during the last few years, with a recklessness and charlatanerie truly disgraceful to our profession, whether we consider the great fundamental principle which should always guide the surgeon, of never performing an unnecessary operation, or the disastrous consequences which have sometimes followed its apparently trifling infringement in so simple a case as this.

In conclusion, we may observe that the works of both Mr. Jones and Mr. Brett are freely illustrated with wood-cuts, and that of the former gentleman contains a good etymological glossary, as indispensable an accompaniment in the study of the diseases of the eye as is a dictionary for the mastery of a foreign language. Certainly single terms, however barbarous, are better than circumlocutions, but surely they are unnecessarily multiplied in ophthalmology, e. g. Amphiblestroiditis for Retinitis; Blepharoblenorrhea, the first stage of puro-mucous inflammation of the conjunctiva ; Blepharophthalmia, the same fully formed; Dacryo-cysto-blenorrhea, discharge from the lachrymal sac, &c. &c.

I. A TREATISE ON THE INHALATION OF THE VAPOUR OF ETHER FOR THE PREVENTION OF PAIN IN SURGICAL OPERATIONS, &c. By James Robinson, Surgeon Dentist to the Metropolitan Free Hospital. 8vo. pp. 64. Webster, 1847.

II. GAZETTE MEDICALE, 1847.

Few persons will forget the sensation excited in professional circles, towards the end of last December, by the rapid propagation of the report that

1817] Robinson on Inhalation of the Vapour of Ether. 531

Mr. Liston had succeeded in practising one of the capital operations of surgery, the patient having meanwhile been rendered totally insensible to pain by the inhalation of ether. The incredulity attending the first reception of the news, was, upon its verification, succeeded by an enthusiasm which has ever since held the public and the profession well-nigh spellbound. Excusable as this is in a matter of such momentous interest, we fear it has led to a too indiscriminate adoption and a too exaggerated estimate of the value of the remedy, and has certainly given rise to practices which are highly derogatory to professional dignity. The theatres of our hospitals have been made the scenes of operative display before crowds of "fashionables, lords, princes, distinguished foreigners," and the like, and the proceedings within their walls chronicled in the columns of the daily press with all the tact, exaggeration, and conventional phraseology of the penny-a-liners; who, we sincerely hope will not be allowed to convert the entrée, so injudiciously granted them upon the present occasion, into a precedent. Mr. Robinson, in his pamphlet, tells us that some of the higher classes of society have graciously condescended to try the effects of the ether upon their own persons; and, referring to some experiments he had the honour to make upon Lady Blessington, Prince Bonaparte, the Marquis of Douro, Count d'Orsay, &c. &c., adds,

"I have mentioned these trials to shew that the experiments have not been confined to the poor, but that persons holding a high position in the aristocracy of intellect and rank, have submitted to the inhalation, merely to test its effect: and this is as it should be; as the opinion of such distinguished individuals will naturally favour the practice and lessen the prejudices against it in all classes of society." P. 23.

The "opinion of such distinguished individuals" is literally not worth a straw, and, indeed, pro tanto is adverse to the probability of any scientific fact it is given in favour of. It is of this class of persons the ignorant portion of the public and the medical profession have just right to complain. The patrons of every system of quackery and delusion that offers itself, nothing is too preposterous for its credulity, or too absurd for its practical adoption: and, in the place of holding out an example to the less educated members of the community, it falls the victim to duperies, which their poverty or their natural common sense preserve these latter from. In respect to the proceedings of the medical body itself, we fear that some of the remarks, made some time since by the Editor of the Gazette Medicale, are still applicable upon this side of the Channel.

"What should be our object; first of all to verify the fact, to establish it in its purely experimental reality, and to lay down with precision its laws and conditions; secondly, to determine its theory and physiological signification. Instead of this, what has been done. We see persons more eager to mingle up their names with whatever this discovery may possess of novelty and popularity than to do anything to render it more useful to science and humanity. Most of the essays hitherto made are imprinted with this unreflecting precipitation. Patients, in whose cases operations might perhaps have been dispensed with, have been sacrificed to this desire to have one's doings talked off; and, instead of the production of precise, well analysed, clearly established results, there is furnished but a vain gratification of public curiosity, and pretexts for the distrust and slanderings of those who are jealous of all progress. Doubtless we must make allowance for that precipitation and enthusiasm which are inseparable from