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Mechanically Effectual Procedure, That of Mackeown

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Mechanically Effectual Procedure, That of Mackeown are less nervous and not so depressed and apprehensive as cliiiniber is deep and the operation is altogether very difficult, when kept quiet in bed for some time after the operation, and during the healing afterward ordinarily one obtains a which latter I think every cataract patient without a suture tremendous amount of reaction and a very dense secondary or a good conjunctival flap should be. cataract. Dr. C. H. Williams, Boston: It was my good fortune ¡n 1 found very soon that 1 would need more than one five or or sometimes but I was years gone by to assist my father, H. W. Williams, in a suture, generally six, inure, number of cataract operations in which he used the suture able to produce a water-light closure of tlie wound and then the anterior chamber in the cornea. He preferred the corneal section known as by restoring with normal salt to the Le Brun section, which was made entirely in the cornea, solution in favorable cases 1 was able obtain at the a dilated upward, the apex of tho cut being just above the edge of the time of operation clear, round, pupil, and the of if moderately dilated pupil, giving a large corneal wound, The healing followed without the formation much any cataract. of rabbits under suture was placed at the apex of tho cut. The success of secondary In some my examined After the operation depended very largely on the needle used. The tho microscope there was no secondary cataract.. this work seemed to me that this suture so needle was flat with an extremely sharp point and a cutting it if was necessary edge one-fourth of the length of the needle, as sharp as a and yielded such wonderful results in the rabbit, in the it be cataract knife. The needle was % inch long and an ordinary human eye would equally advantageous, and I read forceps with straight points about % inch wide, strong and a paper before the Oplithalmologie Section of the Academy that be was roughened on the surface, was used for the needle holder. of Medi'-ine, recommending this suture used as advised Kalt and Dr. before him. I had a talk There was no catch and no jump when the forceps released by Williams with Dr. me the needle. The suture was a single strand of the finest Herman Knapp and he told that Schweiger bad sewing silk. The ideal position of the suture was to pass the tried it in some thirty eases, a report of which was published needle through the apex of the lower corneal flap, going in in the Archives of Ophthalmology, but he had abandoned it. through the corneal epithelium a little more than 1 mm. lie said, "Why would you use it in the human eye when wo from the edge of tho cut surface and bringing it out on the get such good results with the old-fashioned operation, and cut surface before reaching tho membrane of Descemet. The the suture does not oll'er any advantages? It complicates needle was again entered in the upper flap just outside tho the operation." membrane of Descemet and brought out on the corneal sur- I tried it on the human eye and I must confess that I face, and the ends tied. The suture caused very little irrita- have abandoned its use, and believe that it is generally tion. It was removed generally on the third day and kepi, unnecessary. Dr. E. the edges of the corneal wound in apposition until the process C. Ei.i.ktt, Memphis, Tenu.: I purposely omitted of healing had glued them together. The wound being any reference to the conjunctival suture as I did not think this In one of in the cornea, and not near the plane of the iris, that exactly bore on matter. the two papers entirely Dr. I there was very little trouble from iris prolapse. He generally of Williams' father am positive he says, "I have lately l)i-i-ii in the, habit of a avoided attempts to remove the last particles of cortical sub- extending this incision to include stance. The results he got were generally very satisfactory. conjunctival flap, and place the suture in its apex." But, of how much that his or We have with us to-day Dr. Post whose father had an extrac- course, was practice lor how long he it tion of this sort done on both eyes years ago and he can employed I have no way of knowing. T would like to tell you something of the operation, the healing and tho acknowledge my indebtedness to Dr. Hates' paper) to which lie has question of irritation from the stitch. The first cases reported referred, for a good deal of the information as to were in 1807 when there was no cocain anesthesia. A num- what had been done on this subject. If T remember rightly, Bates ber of operations were done under ether, but a number were Dr. was under the.'impression that this in and out suture not also done without any anesthetic. The insertion of this would answer, because instead of producing apposi- of suture was not easy. It required very delicate handling, tion of the edges the wound it would turn them in. and advocated a and for that reason was never generally adopted. I do not he through and through suture; but that prob- remember my father's using the conjunctival suture. I do not ably was due to the différence in the thickness of the rabbit's and the think ho used the corneal suture in the later years of his human cornea, and the thinner cornea might readily turned in I life, but ho did use it during most of his active practice. be flint way, but do not think that is apt to occur with When the operation of extraction with iridectomy was the the human cornea. generally adopted method he preferred to keep on with the simple extraction, which, under his hands, had given such good results. I afterward used the conjunctival suture. Dn. M. H. Post, St. Louis: Historically I think the opera- PREPARATORY tion referred to on my father occurred in 1804. The opera- CAPSULOTOMY IN EXTRAC- tion was done without nn anesthetic and with no iridectomy, TION OF IMMATURE SENILE and was done at different times on both eyes. Thfc result CATARACT Was ideal, with perfectly mobile pupils and with vision nor- mal. The operation was done when he was about 55 years PERCY FRIDENBERG, M.D. old. He lived to be 76 years old. After the operations which NEW YORK had to he done in connection with the first operation, a. those who are needling, the eyes were never subjected to anything but tho Except to prepared to extract any and lens fitting of glasses, and up to tho time of his death he read every cataractous in its capsule, the retention of with perfect ease, comfort, nnd with very great accuracy. At gelatinous cortex and the presence of portions of the the time of the operation he was con lined to bed and as I anterior capsule blocking the pupillary area are matters recollect, his hands were confined. He said the pain of the of serious concern, and any procedure which will cause operation was nothing compared with the pain of confine- that loosening or complete separation of the capsule ment to his back with his hands tied down. from the underlying capsule which clinical Dr. William H. Bates, New York: I read of this suture accompanies maturity must be greeted as a marked benefit and in the publications of Dr. Williams and Dr. Kalt and it advance in method. The ripening which looked promising to me. So I went to Dr. Prudden of operations very were in some do not seem to have the of and and in his pathologic vogue years ago College Physicians Surgeons, remained in favor. of the lens is carried laboratory did some experimental work for five years on the Massage out, it is some rabbit. It is very difficult to remove the lens from a true, by operators where preliminary iridec- rabbit. In the first place tho cornea is about one-eighth of tomy is performed, but the results do not indicate any the thickness of the human cornea. Tho lens .of the rabbit very decided, uniform or reliable effect. The only is very much larger than that of the human eye, the anterior mechanically effectual procedure, that of MacKeown, Downloaded From: http://jama.jamanetwork.com/ by a UQ Library User on 06/14/2015 consisted in injecting fluid directly under the lens 5. The less necessity there is for the introduction of capsule and was, obviously, too dangerous to gain a traction instrument to effect the removal of the lens, popularity. None of the other methods was reliable and the less interference there is with the natural position all were slow, if effectual at all. In June, 1911, my of the structures of the eyeball. attention was attracted by Dr. Homer Smith's essay, to Of 074 operations, seventy-nine, or 11.72 per cent., which tbe Lucien Howe prize had been awarded, in were unsuccessful. Of this number, 101 were for which capsulotomy was advocated as a means of rapidly Morgagnian cataracts. The iris was excised in only maturing senile cataract and facilitating its immediate seventy-five total cases. Chloroform was administered extraction. I was not able to test this procedure for in 654 cases, and the iris prolapsed in sixty-four, or some time, but my first experience was so favorable that 9.46 per cent., the latter accident being due, in several I determined to apply it more frequently.
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