In eye surgery my practice has been to wash my hands, wipe the instruments with absorbent cotton, have the patient’s face washed and check, lid and brow wiped with cotton. The cocaine solution I make myself in small quantities using always hydrant water.
In eight years’ private hospital and college clinic practice, I have yet to see suppuration in a single case of bad effects that could be traced, remotely even, to germinal influence. I do not wish to be understood as advocating carelessness. Reasonable precautions should be taken in every case; but this striving after perfect antisepsis is, to my mind, a useless waste of time and energy. Careless handling, bruising of parts during operations, has much to do with causing suppuration.
Surgical Interference in Heterophoria.-It is the consensus of opinion, I think, that high degrees of heterophoria, especially exophoria, can be cured by complete tenotomy, also that many cases of low degree get relief by systematic exercising of the muscles with prism. What to do with the medium grades is as yet, with me, an unsolved problem. I have nothing satisfactory to offer on the subject. Unfortunately, I have seen so many cases operated upon by others where the condition was actually made worse, or at best not benefited, that it has deterred me from experimenting to any extent.
Strabismus Operations.-The advancement of a muscle. In my library there are works on the eye by thirteen different authors. In describing this operation, all say substantially the same thing, only that some recommend two sutures, some three or more. But all claim that a diverging eye can be brought into position and held there by passing the sutures through the flap of conjunctiva only, at the margin of the cornea. Utter failure was the record of my efforts to advance a muscle in bad cases of divergence, until I learned how to make the operation. But not a hint is given in these thirteen books mentioned of the necessary proceedings to ensure success. And that is the method of Dr. Wray, mentioned in the paper.
One end of the sutures must be secured to the stump of the tendon at its insertion into the sclerotic to relieve the strain upon the conjunctiva or the sutures will tear out. Ninety-five per cent. of the operation for advancement are made upon the internal rectus, and usually upon adults. The eye seems to have become almost fixed in this position, and considerable power must be exerted to bring it into place, much more in my experience than the thin delicate conjunctiva is capable of sustaining.
Immature Cataracts-Artificial ripening of the lens. My experience head me to declare against the procedure, from the fact that I have been unable to accomplish anything of the kind. The growth or formation of a senile cataract is a physiological progressive sclerosis. That of soft cataract regressive metamorphosis, different processes entirely. It is true that you may puncture the anterior capsule, perform iridectomy or institute any of the procedures mentioned in the paper and set up this regressive process, and any transparent portions of a lens in a very short time will become opaque.
But this portion artificially ripened is no harder than before, no more easy to operate upon for removal. It is possible that this cortical, opaque, pasty mass might harden if left long enough, though I have waited a year and upon removal found no evidence of any hardening. I make no further attempt to artificially ripen a senile cataract.
DR. VILAS: In undertaking to discuss the paper of Dr. Bissell, I am embarrassed at the outset in that direction by a hearty concurrence in nearly all contained therein. Moreover, on so vast a subject, so well treated by the essayist, I can hope to shed no additional light, but perhaps may emphasize some of the points made. .
It seems to me that if I were asked to name the greatest aid to the ophthalmologist supplied during the time I have practiced ophthalmology, I should answer the present use of cocaine. It has altered the whole course of professional life of an oculist, while to those who ar constantly in the surgical arena it has proved invaluable.
I shall not dwell on the reasons for this warm encomium, because its advantages have been well set forth by the essayist, in whose method of use I concur. It requires a little experience to get its best effects, however, even with the method given. Were I not confined to its surgical aspect, much more concerning its use might be said.
The attention which anti-and asepsis has attracted can only be for the nest interests of the profession, and yet I am of the opinion that reputation shave been made by many of the special procedures connected therewith, only to quickly pass away. In my judgment absolute cleanliness secured and maintained by the simplest methods, is the result to the sought after; and I cannot but believe that too much and too careful irrigating and drenching of the eye, internally and externally, is on the whole not only unnecessary, but often harmful. Too much care to the sterilization of instruments, lotions, and all adjuvants to an operation, and to the cleanliness of the patient and operator, can hardly be given, however; and it is oftener that the result is affected by neglect of this precaution than from apparently injurious pathological surroundings.
In my own practice I also prefer to combat the dangers which may arise from an immature lens in a cataract extraction, than to attempt to artificially ripen it; and yet, unless some excellent reason (one almost imperative) compels, I prefer to forego the operation rather than to tempt disaster by too boldly attacking a lens which seems not yet fully ready for successful delivery.
With the exception of the conclusions as to the results of operations fro heterophoria, which I consider too optimistic, I agree in the main with the balance of the paper-all of which is a valuable contribution to our proceedings.
DR. RANDALL: I have seen a little in some of the journals in regard to Phenic Acid obviating the systemic affection. I would like to know if any one has had any experience with that agent?.
HAROLD WILSON, M.D., of Detroit: I wish to mention an operation for convergent strabismus, which, although perhaps not altogether novel, has not to my knowledge been brought particularly to the knowledge of the profession. It is an operation which I have derived from my father, and from what source he obtained it I do not know, but I have used it for some time. It consists, briefly, in making two incisions through the conjunctiva, one parallel to the lower border, and one parallel to the upper border of the rectus muscle.
The conjunctiva or the sub-conjunctival tissue is then dissected up with scissors back under the caruncle, and as far laterally as may be desired. The hook is then introduced under the muscle through one of these incisions, and the point brought out through the other. The muscle is then severed. If further correction is desired, lateral incisions into the capsule may be made. The advantages of he operation are the slight disfigurement and no (or very little) retraction of the caruncle.
F. PARKE LEWIS, M.D.: Just a word about the use of stronger cocaine in lowering the vision of the eye in the extraction of cataract, in four-grain solution, continued for ten or fifteen minutes. I believe that a certain amount of elasticity is necessary in the lens, and if, after using your cocaine ten minutes or more, you find all the elasticity is gone, and you have to squeeze the lens out, you very seriously imperil the result of the operation. I thoroughly agree in limiting the time for the use of cocaine in extracting the cataract. I very often use the cocaine two to four minutes; it is quite enough. During the last year I have several times made operations, in one instance with very peculiar results.
The patient, an old man with the lens so far matured as to make reading impossible, and locomotion difficult; after having made an operation the patient was told to come back in three or four weeks and have the lens removed. Not doing so after two months, inquiry was made, and it was found the operation had cured the lens in such a degree as to make it possible for him to read. No operation was, of course, necessary; he could easily get around, and could read large print. It was rather a unique instance, and worth putting on record. In regard to the immediate capsulotomy, which Dr. Bissell has referred to: while I was not aware, at the time I first made it, that it had been made by others, I subsequently learned by conversation with Dr. Knapp, that the same operation had been made, and had been discontinued.
The completing of an operation at one time is to me an important matter. The patient may come fifty, one hundred, or two hundred miles to have an extraction made. If you can finish the operation at the time the patient is convalescing, it is a very important thing, and it the does not necessitate any long operation. Moreover, the division of the capsule is in some instances followed by a general inflammatory condition. it is by no means a simple operation, or one devoid of danger. If, therefore, you can complete your operation at the time corneal incision is made and the lens removed without adding to the danger of your operation, you have added enormously to the value of your primary operation.
