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THESIS ON THE CATARACT, 
 
 WITH SOME REMARKS ON 
 
 THE EYE. 
 
 BY 
 
 ARTHUR B. STOUT. 
 
 PRESENTED TO THE FACULTY OP THE COLLEGE OP PHYSICIANS AND SURGEONS, 
 OF NEW-YORK, FOR THE DEGREE OF DOCTOR OF MEDICINE. 
 
 April, 1837. 
 
 NEW.YORK: 
 PUBLISHED BY HENDERSON GREENE, 435 BROADWAY. 
 
 1 s :i 7 . 
 
,ib, 1 Apr. 2 93 
 
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 OOIiUMBIANA 
 
 
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TO THE 
 
 FACULTY 
 
 COLLEGE OF PHYSICIANS AND SURGEONS OF 
 NEW-YORK, 
 
 THESIS ON CATARACT 
 
 13 RESPECTFULLY ADDRESSED 
 
 THEIR. MUCH OBLIGED PUPIL, 
 
 ARTHUR B. STOUT. 
 
This opportunity of expressing his gratitude, esteem, and 
 affection, to 
 
 Dr. Edward Delafield, 
 Dr. John Kearny Rodgers, and 
 Dr. James Edward Cornell, 
 for their constant kindness, while under their observation at the 
 College and Hospital, and the many facilities for improvement 
 afforded him from their private practice, is embraced with 
 much pleasure, by their 
 
 Attached friend, 
 
 ARTHUR B. STOUT. 
 
ON THE EYE, 
 
 OPHTHALMIC SURGERY. 
 
 The eye is the most perfect object in Nature ; and, as per- 
 fection and order constitute beauty, it is also the most beautiful. 
 Within the narrow limits of its orbit, may be found illustrated 
 nearly all the grand physiological phenomena of the animal 
 system. With the exception of the functions of respiration, di- 
 gestion, and ideality, there are none, I believe, of the great 
 processes of animal nature, which are not discoverable in the 
 eye ; and manifested there in the utmost perfection. 
 
 The delicacy, and minuteness of its anatomy, are no where 
 surpassed in the body ; and, with regard to the globe of the 
 eye, its normal structure is less frequently departed from than 
 in any other organ. The distribution of its blood vessels, 
 which elsewhere admits of variation, is always precise ; neither 
 are adventitious muscles ; an unusual formation of bone ; or 
 irregular position of parts, ever found in this admirable and 
 wonderful organization. The result of such accuracy of ar- 
 rangement, is the great perfection and harmony of its functions. 
 Where is the process of secretion more completely elaborated ? 
 the crystal dew is not so transparent as the humors of the 
 eye. As rapid as thought is its muscular motion ; and intense 
 as is this action, the utmost skill, and care of the artist cannot 
 direct an instrument so precisely to the point required, as the 
 
muscles of the eye adjust its position. The iris, which is now 
 admitted to be muscular, displays the most astonishing celerity, 
 and precision of motion ; in constant readiness to protect the 
 nerve of vision from the effect of too much light, it yet never 
 prevents its receiving enough. Viewed as an instance of invol- 
 untary muscularity, it is assuredly the most perfect specimen in 
 the body. The combination of power in the external volun- 
 tary muscles of the eye, is a peculiar endowment found in no 
 other part of the muscular system. Though they are usually 
 considered, and are in the main, voluntary muscles, they are, 
 also, to a certain extent, involuntary. If the eye be directed to 
 one object, to the exclusion of every other, for a very short 
 space of time, the object becomes obscure, and presently can- 
 not be seen. When, however, the slightest variation of the 
 eye admits the rays of light from another object, the former is 
 instantly seen with clearness. The sensibility of the eye seems 
 to require this constant relief. But the will cannot be supposed 
 to take cognizance at all times, of the time and necessity for 
 this slight alteration in the direction of the eye ; nor can the 
 motion be made without the assistance of the external mus- 
 cles. In this respect, therefore, their action is involuntary — 
 though they are still constantly subject to the influence of the 
 will. The endowments of the eye, attributable directly, and 
 solely, to the nervous system, are its sensibility and the 
 sense of vision ; and no where in the body is sensibility more 
 exquisite, than in this organ. From the facility with which so 
 delicate a structure may be deranged, it has been rendered 
 by an all-provident Creator intensely alive to the least approach 
 of danger. In regard to the sense of sight, what would be 
 man exiled from intercourse with the natural objects which 
 surround him ! Herein comparison with the other senses is 
 impossible, for all are exquisite and perfect. But as it con- 
 tributes essentially to the happiness of man, it is certainly 
 among the most important of the animal functions ; and it is far 
 beyond comparison with any of the known attributes of inani- 
 mate nature. 
 
It is curious, that nearly all the elementary tissues enume- 
 rated by Bichat may be found in the orbital space ; affording 
 a study, on a small, but perfect scale, of most of the structures 
 in the animal economy. Thus, the dermoid tissue covers the 
 palpebral ; the adipose, constitutes the soft cushion in the orbit, 
 whereon the eye rests, and which supports the ophthalmic ves- 
 sels and nerves ; the cellular is every where, but is probably 
 finer in its texture between the coats of the eye than in any 
 other situation. The muscular is illustrated in the external 
 muscles of the eye, and still more beautifully in the iris. The 
 sanguineous, is found in the ophthalmic vessels : and three at least 
 of its six terminations, viz. into veins, by exhalents, and by inos- 
 culation are here apparent. The lymphatic system exists in 
 the eye, as elsewhere ; and the glandular is found in the lach- 
 rymal and Meibomian glands. The nervous system is devel- 
 oped in all its varieties, except that devoted to ideality; the 
 optic, is the nerve of sense ; the sympathetic, or nerve of or- 
 ganic life, pervades every part of the system, and hence must 
 also be here ; and the lenticular ganglion, where a nerve of 
 sensation and one of motion unite, to proceed in conjunction to 
 the interior of the eye, constitutes another beautiful example of 
 the wisdom and design manifested in the human frame. The 
 orbit itself, displays the osseous system ; the conjunctiva, the 
 mucous ; and the serous, is developed in the hyaloid mem- 
 brane, and in that of the anterior chamber of the eye. These 
 are sufficient examples. 
 
 Another striking evidence that the eye is the most delicately 
 formed, and highly perfected of the Creators works, is the care 
 with which He has guarded it from injury. Observe the situa- 
 tion of the elaborate mechanism of the ear ; deeply lodged in 
 the centre of the hardest of the bones, and remote from the sur- 
 face of the body, it cannot be assailed by any but the most 
 destructive and fatal violence. Nor can the anatomist ap- 
 proacfa it without the greatest difficulty. Like it, the eye is 
 nearly mrroanded by bone; and, in front, where it appears 
 more exp os e d, it is equally well protected. The palpebral de- 
 
10 
 
 fend it from trifling injuries ; while every muscle in the body- 
 may be thrown into instantaneous action to guard it from ruder 
 assaults. 
 
 Such are a few of the points of beauty in the physical func- 
 tions and structure of the eye. Did none such exist, its en- 
 dowments alone are sufficient to elevate the mind to the highest 
 degree of wonder and admiration. If the great universe be 
 created on a scale too comprehensive for the mind to embrace, 
 and thus ascend from nature to nature's God, in this small or- 
 gan it may range at large ; and those unacquainted with the 
 construction of the instrument, have yet a more ample scope 
 for their imagination in its two-fold endowments. Its first, the 
 power of vision, scarcely surpasses its second, the power of ex- 
 pression ; and if it be incomprehensible how the image of an 
 object on the retina produces an idea of that object in the mind, 
 we are equally lost when we inquire into the mysterious faculty 
 of the eye, to embody and express to another our inmost 
 thoughts and feelings. 
 
 In the eye, the surgeon possesses the most interesting field 
 for practice, and also for pathological research. Anatomy 
 and observation make known to him the precise normal condi- 
 tion of the organ. He is, thereby, enabled to discover the least, 
 and earliest departure from it ; and thence, the origin, progress, 
 and decline of disease are delineated, as by a picture, to his 
 view. The remark is true of nearly all the structures of the 
 eye. As, however, disease in each assumes a different form 
 according to its organization, the surgeon has the enviable op- 
 portunity of forming a perfect diagnosis between them. In the 
 varieties of the same disease, alike facilities are afforded ; for, as 
 it is viewed where it exists, and not by remote symptoms, the 
 slightest changes in form may be noted. Witness the simple 
 and metastatic iritis. The acute form of all diseases are com- 
 paratively easy of management ; but the atonic, and chronic 
 forms, often baffle the most skilful and experienced. It is 
 here, the ophthalmic surgeon enjoys his greatest advantage. He 
 has seldom to discriminate between the primary and secondary 
 
11 
 
 affection ; and as its pathological condition is not concealed, he 
 may observe the precise effect of remedial agents ; the time 
 they prove of service : and when they cease to be of benefit. 
 
 The preservation of sight, is secondary only to the preser- 
 vation of life. Though the ophthalmic surgeon is not denied the 
 fame derived from the second, his reputation is chiefly due to 
 the first. And yet, so immediate and palpable is the change he 
 may often effect for his patient, translating him as it were from 
 darkness to light, that more eclat may accompany his career, 
 than often the physician enjoys, who preserves life, but whose 
 strength has been expended in a hidden course, where neither 
 the intensity of disease, nor his skill could be adequately ap- 
 preciated. 
 
 Notwithstanding its advantages, this beautiful, and now, 
 highly perfected branch of surgery is in this country neglected. 
 In America, general surgery and medicine may be deemed to 
 have attained as high a rank as in Europe ; but in ophthalmic 
 surgery, Germany and England are yet far in the advance. With 
 the exception of a few distinguished persons, scarcely any are 
 sufficiently acquainted with the diseases of the eye to have con- 
 fidence in their own knowledge. In our colleges the subject is 
 cursorily glanced at in the courses on general surgery, and the 
 student becomes too much engrossed in them during his short 
 term of study, to resort privately to the imported books on 
 the .subject. From this indifference at the fountain head of 
 learning, a general ignorance is allowed to exist throughout the 
 profession. The surgeon, who while a student received no im- 
 pulse, and was too deeply engrossed in general pathology to 
 commence alone, having retired to his office, or the country, 
 finds in his vis inertia; a sufficient argument to prevent a prose- 
 cution of the study. In Germany and England, the universi- 
 ties are endowed with a distinct professorship for ophthalmic 
 surgery, while at Vienna the subject is divided into two 
 branches, viz : a practical and genera] course of ophthalmology. 
 Of these, 1 1 » * - practical course consisted of five lectures 
 weekly, and was of ten months duration. In all i best; places 
 
12 
 
 numerous treatises on the eye have been published. Journals 
 devoted to ophthalmic surgery, are also supported in the great 
 cities of Europe. The consequence of such attention must be 
 a general diffusion of knowledge : and the student, if only par- 
 tially instructed, has at least, been far enough introduced to 
 estimate the beauty, and the value, of the study. He is compe- 
 tent to continue his researches alone ; and soon enabled to con- 
 tribute to the advancement of the science. Were such efforts 
 made in our own country, the same proficiency might be 
 effected in this branch, that has been obtained in the general 
 sciences. Perhaps no fact will better illustrate the general 
 deficiency of knowledge in ophthalmic surgery than the records 
 of the New York Eye, and Ear Infirmary. This institution 
 was founded in 1620, by Drs. Delafield and Rodgers, and until 
 the last year has been the only institution of the kind in the city. 
 None previously existed. It has possessed no means of obtain- 
 ing notoriety beyond the gradual diffusion of its name through 
 those who had enjoyed its benefits. Without a public building 
 to command attention ; or a corporation to give it eclat, and 
 attract the confidence of the public, it has received between 
 one and two thousand patients during the year. And since 
 its foundation has afforded relief to seventeen thousand persons. 
 Another ophthalmic institution, recently commenced in the 
 city, is already in a flourishing condition : — and the few surgeons 
 who have devoted particular attention to the eye, in their prac- 
 tice constantly receive patients, not only from physicians in the 
 country, but from those in the city, who are compelled to de- 
 cline the cases. 
 
 In making these remarks, I presume not to speak as one 
 acquainted with the subject ; but the neglected condition of 
 ophthalmic surgery must be apparent to any who will give it a 
 moment's attention. I speak, but as one willing to commence 
 its study with ardor and perseverance. 
 
CATARACT. 
 
 The one of the many diseases of the eye, I shall attempt to 
 describe, is cataract. 
 
 This affection occurs in the crystaline humor of the eye, and 
 its investing membrane. These parts it is necessary to under- 
 stand in their normal state, and relations, before their dis- 
 eased condition can be properly described. 
 
 Anatomy. — The eye consists of three transparent substan- 
 ces, called humors ; a nervous expansion, termed the retina ; 
 and certain membranes, which surround them, retain them in 
 their situation, and contribute to their nourishment. 
 
 These humors are named the aqueous, the crystaline, and the 
 vitreous. They fill the eye ; the aqueous being situated anteri- 
 orly ; the crystaline, in the middle ; the vitreous, posteriorly ; 
 and they are held distinct by membranous septa. 
 
 The vitreous humor occupies two-thirds of the cavity of the 
 globe ; the remainder is devoted to the aqueous, and crystaline 
 humors, with the exception of the space occupied by the iris, 
 and ciliary processes. 
 
 The crystaline humor is concerned in cataract ; to it there- 
 fore I confine my attention. This humor, or the lens, as it is 
 a~ frequently termed, is situated in a concavity in the centre of 
 the anterior surface of the vitreous humor, immediately behind 
 the iri- and pupil. The canal of Petit surrounds its circumfer- 
 ence. Though so near the surface its transparency renders it 
 im isible. 
 
 The lens is the most firm and dense of the humors. It is 
 perfect!} transparent, and possesses a high refractive power. 
 It measures about two and a half lines in thickness, and twelve 
 or fourtei D in circumferance. The convexity of the anterior 
 
14 
 
 and posterior surfaces differs very considerably ; the former 
 being the segment of a sphere -about five lines in diameter, 
 while the posterior is one from six to nine in diameter. The 
 size of the lens, however, is not constant. It varies much in 
 different persons, and frequently also, in the two eyes of the 
 same person. Neither is its form always so perfect as it is usu- 
 ally represented. The lens consists of two portions ; an exter- 
 nal softer part, called the cortical substance, and the central por- 
 tion, or nucleus. This soft, gelatinous, substance is arranged, in 
 regular concentric layers, increasing in density as they approxi- 
 mate the centre of the lens. These may be easily separated 
 when the lens is hardened by alcohol, or by boiling. The layers 
 are slightly connected by cellular substance, and have between 
 them a trace of fluid. The exterior of the lens is bathed by 
 a fluid, which separates it from its investing membrane, and is 
 called, from the name of its discoverer, the fluid of Morgagni. 
 
 A distinct investing membrane, called the capsule of the 
 lens, surrounds this body in every part. This is thicker than the 
 hyaloid membrane which invests the vitreous humor, and is 
 more vascular. It possesses a fibrous texture. Owing to dif- 
 ferent portions of it becoming opake in different cases, it is 
 divided for the sake of convenience into an anterior capsule or 
 that portion which covers the anterior convexity of the lens ; 
 and a posterior capsule, or the investment of the posterior con- 
 vexity. There is, however, no natural division. This capsule 
 is plentifully supplied with blood ; but nerves have never been 
 detected in its substance. The arteria centralis retinae sup- 
 plies the posterior portion ; and branches are given off from 
 the short ciliary arteries which ramify upon its anterior surface. 
 The veins of the choroid coat, receive the blood from the pos- 
 terior capsule ; but in the anterior no veins have been discov- 
 ered. It is the capsule of the lens which probably secretes the 
 fluid of Morgagni, for its outer surface is connected by cellular 
 substance to the hyaloid membrane ; and the canal of Petit, 
 with which it communicates, is always empty ; while its inner 
 surface is smooth and soft, like that of a secreting membrane. 
 
15 
 
 Its possessing also a free distribution of blood vessels, only a 
 a very few of whose branches enter the lens, would appear to 
 indicate it as a secreting membrane. 
 
 The lens and its capsule, are retained in their proper situa- 
 tion by the hyaloid membrane. This membrane, after covering 
 the posterior portion of the vitreous humor, arrives at the cir- 
 cumference of its anterior surface. It here turns upon the 
 anterior part of the vitreous humor, and lies beneath the 
 ciliary processes, where from some peculiarities it possesses, it a is 
 called the zonula of Zinn. At the apices of these processes, the 
 hyaloid divides into two layers, each of which is, however, as 
 firm as the single membrane. One layer now passes behind 
 the lens and capsule, closely attached to the vitreous humor, 
 and also adherent to the capsule of the lens. The other 
 passes over the anterior surface of the capsule, forming a close 
 connexion with it. It is bathed in front by the aqueous humor. 
 By this division, a small space is left between it and the cir- 
 cumference of the capsule of the lens. This was first detected 
 by M. Petit, and after him, is called the canal of Petit. It does 
 not contain a fluid. These membranes, like the humors they 
 inclose, possess the most perfect transparency. 
 
 Definition. — Cataract is an opacity, either partial or com- 
 plete, of the crystaline humor of the eye ; of its capsule ; or 
 of both conjointly. 
 
 It is usual to include in the definition of cataract, an opa- 
 ity of the fluid of Morgagni ; but as this fluid exists in an 
 extremely small quantity ; and is so situated that its discoloration 
 alone cannot be recognised, I prefer to omit it. Indeed any 
 opacity of this fluid, per se, is doubted ; or if it could exist, the 
 disease would probably have extended to the lens or capsule 
 before any d<rangement of the eye was suspected. Again, the 
 fluid of Morgagni must bo a secretion, either from the lens, or 
 capsule, probably from the latter, and consequently could not 
 become altered in <lmraeter, without previous disorder of its 
 secreting .surface. It would not be more refined to indicate as 
 
16 
 
 a division of the disease, opacity of the hyaloid membrane 
 which covers the capsule, than to designate as a separate affec- 
 tion, that of the fluid it contains. 
 
 Mr. Lawrence, in his recent work on the eye, adds to the 
 definition of cataract," opacity" &c, " with corresponding dimi- 
 nution of sight." The loss of sight, however, is but an effect of 
 the disease. It is a consequence of the exclusion of light, and 
 is not a part of the disordered action which constitutes the 
 affection. If it be proper, to add one of its effects or symptoms 
 to the definition of the disease, it must also be necessary to 
 include them all, and hence if " diminution of sight" be neces- 
 sary to the definition, the difficulty of walking alone, or the 
 white pupil apparent to the observer of the eye, would be of 
 equal importance to its completeness. Conciseness is the 
 chief requisite of a definition ; and when the pathological con- 
 dition of the disease is known, it is immediately derived there- 
 from. Symptoms are only resorted to when this condition is 
 not ascertained. In cataract it has been but partially discov- 
 ered, and surgeons therefore define the disease " opacity" &c. ; 
 but if it were proved to consist always in an imflammatory ac- 
 tion the definition would simply be, inflammation of the lens, &c. 
 For these reasons I have restricted my definition to a statement 
 of the parts involved in disease, and of that principal change 
 without which the affection cannot exist. 
 
 Derivation. — The name cataract is derived from the Greek 
 word catarasso, to confound or disturb, because the disease in- 
 terferes with vision. 
 
 Divisions. — The number of circumstances under which 
 cataract occurs has given rise to a variety of classifications, 
 These have been founded upon the relative importance which 
 authors attached to certain features of the disease. An arrange- 
 ment which would early suggest itself is that of the simple 
 form, when only the lens and capsule are implicated, and the 
 complicated where it takes part with some more general affec- 
 tion. This method has been superseded. The term spurious 
 
17 
 
 cataract was introduced by the celebrated Beer, of Vienna, 
 and applied to matters effused in the posterior chamber, before 
 the lens, so as to resemble cataract. But this term is discarded, 
 as whatever is not an opacity of the lens or capsule is not cat- 
 aract at all. Another division is that of mature and immature 
 cataract, signifying that the opacity has, or has not, proceeded 
 to its utmost extent. This is of no other importance than that 
 it shows the existence of two such states. 
 
 A classification, which is much more interesting, as it gives 
 an idea of the origin of the disease, consists of four varieties, 
 the spontaneous, the sympathetic, the traumatic, and the con- 
 genital cataracts. The first arises without any known cause 
 and is also called idiopathic. The second occurs in company 
 with other deep-seated affections of the globe ; the third is the 
 result of injuries by external violence, and the fourth is found 
 at, or before, the time of birth. As all these varieties have 
 marked peculiarities, and require corresponding variations in 
 their treatment, the arrangement is one of value and impor- 
 tance. The division of cataract, according to the situation 
 of the opacity with regard to the lens or capsule, is the most in 
 accordance with the present natural system of nomenclature, 
 that of naming a disease according to its pathological condition ; 
 and dividing it, according to the tissues in which it occurs. 
 Hence, the classification of cataract into 1st, capsular ; 2d, len- 
 ticular ; and 3d, capsulo-lenticular — as it affects the capsule, the 
 lens, or both together, is that now generally received. It is the 
 more important, as it is of the greatest consequence in practice. 
 The capsular, and lenticular cataracts have each several spe- 
 cies, which I refer to their respective heads. 
 
 Description. — When an eye which contains a simple, ma- 
 tun: cataract is examined, the first appearance which attracts 
 the attention, is a white, or yellowish white spot, occupying the 
 pupil, and intercepting toagreateror less extent the passage of 
 light to the retina. In every other respect, the eye appears 
 natural; there is no increase of vascularity in the external 
 tunics ; the iris possi jes its proper form and action ; n<> pain is 
 
18 
 
 experienced, and the only complaint of the patient is his loss 
 of sight. This white spot is found, on closer inspection, to be 
 situated immediately behind the iris ; and is the opaque lens and 
 capsule. That it is in no other situation, is immediately proved 
 by looking at the eye obliquely, by which means, any opacity 
 of the cornea will be detected, the corneal opacity being then 
 seen quite superficial, and preventing a distinct view of the iris 
 opposite the side examined. It is no deeper, for the vision of 
 the observer is arrested at the pupil. This opacity does not 
 entirely prevent vision. It will be found that the patient can 
 distinguish light from darkness ; perhaps can point to the win- 
 dow, and if the fingers be passed before his eye while so doing, 
 will perceive that something dark has moved before him. In 
 general, he will only distinguish light, the amount of which he 
 can perceive depending upon the density of the cataract and 
 the dilatation of the pupil. The state of the pupil is of great 
 importance in the examination of a cataract, for however great 
 the opacity, some rays still penetrate it, and consequently the 
 greater the space for their admission the more the patient can 
 perceive. Some useful experiments may by this means be 
 made to prove its existence. If the patient be turned from 
 the light, the pupil enlarges to admit a greater number of rays, 
 and he perceives more light than when he looks in the direction 
 whence it comes. For the same reason, he will see better 
 towards evening, than by mid-day. Artificial dilatation of the pu- 
 pil may be effected by means of the stramonium, or belladonna, 
 and this may be done to such a degree that the patient sees with 
 comparative distinctness. In some cases it obviates the neces- 
 sity of more radical treatment. The perception of more light 
 after its use, is always evidence that the opacity is a cataract. 
 With the exception of this variation of sight from the contrac- 
 tion of the iris, the condition of vision is always constant ; and 
 its diminution in the progress of the disease equally so, 
 depending solely upon the increase of opacity. Such is 
 cataract in its simple state. 
 
 The first indication of its commencement is a cloudiness, or 
 
19 
 
 mist observed before the eye, and obscuring vision. When at 
 this early period, the eye is examined, a slight, diffused haziness 
 may be observed behind the iris ; having a bluish white ap- 
 pearance. If now the patient look at a candle, it appears dim> 
 and has a halo around the flame. This halo, in cataract, is al- 
 ways the same, being only an appearance of the radiation of 
 light from the candle. From this time, the diminution of sight 
 continues gradually, and regularly, to increase ; and the nebula 
 perceptible in the eye, becomes more white and dense until the 
 cataract is fully formed. The duration of the process is ex- 
 tremely variable. A perfect cataract may be formed in three 
 days, or the patient may be conscious of a gradual diminu- 
 tion of sight for several years. Neither are both eyes simulta- 
 neously affected ; one eye may remain always sound : and when 
 both are the subject of disease, the affection in the one gene- 
 rally commences when the cataract in the other is quite or nearly 
 mature. The progress of the disease is frequently so mild, and 
 gradual that the patient is unconscious of a diminution of sight 
 in the affected organ, until told that something is growing in his 
 eye, he is induced to close the healthy eye in order to detect it. 
 It is not, however, invariably so. The disease is sometimes 
 ushered in with acute inflammation. In this case it is accom- 
 panied with iritis. The patient is conscious of some pain and 
 fulness in the eye ; sometimes there is pain in the head ; the 
 pupil is sluggish ; the vessels of the sclerotic are enlarged where 
 they penetrate that coat near the cornea, and the white zone, 
 which occurs around the cornea in iritis, may be seen. The 
 mist is now observed before the eye, and increases rapidly in 
 density. 
 
 Mr. Stratford, of the London Dispensary for diseases of the 
 eye, states that if the organ be now examined with a magnify- 
 ing glass, vessels may be seen ramifying on the anterior capsule, 
 forming :i perfect network, and depositing fibrin either in its 
 centre, or along their course. If the disease be checked by 
 active treatment, it may Bubside, leaving the capsule in this 
 Htate ; or the severity of the symptoms may abate, and a slow 
 
20 
 
 deposition of fibrin take place until a perfectly opaque cataract 
 be formed. This leads me to the variety of appearances which 
 the cataract may assume, depending upon the manner in which 
 fibrin is deposited, either in the lens or capsule ; and also, upon 
 the duration of the disease. The opacity may exist in the cap- 
 sule, in the lens, or in both ; constituting the division into capsu- 
 lar, lenticular, and capsulo-lenticular. In each of these situations, 
 its appearance is modified. The cataract also differs in density 
 and this circumstance also affects its appearance. These states 
 it is necessary carefully to discriminate, as the treatment of the 
 disease depends upon them. 
 
 Capsular Cataract. — Disease of the capsule, in general, soon 
 affects the lens, and consequently the capsulo-lenticular variety 
 is the most common. Still, opacity of this part may exist alone. 
 It may also be confined to the anterior capsule, or the posterior ; 
 the cataract being then named in accordance, anterior capsular, 
 or posterior capsular. Sometimes both portions are involved ; 
 and the term complete capsular is then applied to the cataract. 
 The opacity of the lens and capsule is owing to the deposition 
 in their texture of white fibrin from vessels which naturally 
 convey and secrete a colorless fluid. The vessels of the capsule 
 ramify freely on its surface, some forming inosculations, and 
 some terminating in exhalents. In disease, fibrin is poured out 
 more abundantly by some than by others, and sometimes is de- 
 posited in the centre of the capsule, and at others near its cir- 
 cumference ; again, it may thus become arranged in striae, in 
 spots, in angular figures, or like the veins of marble. This gives 
 rise to the various species of capsular cataracts which are enu- 
 merated by authors. There is the cataracta marmoracea, or 
 variegata, in which the lines on the capsule run in a variegated 
 manner — the c. punctata or stellata, or mottled deposition — 
 c. fenestrata, where the lines are like the bars of a window — 
 c. striata, or streaked — c. dimidiata, in which one half the 
 capsule is opaque — c. trdbecularis, where a single thick bar 
 extends across the capsule — and c. centralis, where a white spot 
 is seen directly in the centre of the capsule. Various changes 
 
21 
 
 which the cataract undergoes in the course of disease, has also 
 given rise to other species. Hence the c. pyramidalis, in which 
 a dense mass projects into the pupil. The c. arida siliquata, 
 or dry-shelled cataract, in which the lens having been absorbed, 
 the two capsules come in contact, and present a thickened and 
 shrivelled appearance. Sometimes by this means the capsule 
 becomes separated from its adhesions, and may be observed to 
 tremble ; tins is the c. tremula : occasionally it slips through 
 the pupil, and moves about in the aqueous humor ; and is then 
 called c. natatilis, or floating. The c. gijpsea consists of a 
 change of the capsule into a cretaceous yellowish shell. In the 
 progress of disease, the cataract sometimes comes in contact 
 with the iris ; and after a period of time again retires, but car- 
 ries with it some of the coloring matter from the uvea which 
 gives it a brown appearance. This variety is called c. choroi- 
 dalis. 
 
 In the early stage of anterior capsular cataract, it may be 
 distinguished from lenticular cataract by the striated appearance 
 of the opacity, and the transparent spaces between the striae. 
 The opacity usually begins at the circumference of the capsule 
 and runs in shining, glistening streaks, towards the centre. 
 Their color is nearly white, and becomes more apparent when 
 the iris is contracted by stramonium. When the capsule is en- 
 tirely opaque, the appearance is dull. The cataract approaches 
 the iris so closely as to obliterate the posterior chamber, and 
 appears directly in the pupil. Sometimes the iris is pressed 
 forward. As the lens is generally at the same time cataractous, 
 it may be seen through the capsule of a different color. The 
 membrane is usually thickened, and hence the cataract appears 
 full and large. 
 
 Posterior capsular cataract may be recognised from the 
 former, by the evidenl deep situation of the opacity. The ne- 
 bula, though probably striated, has not the bright glistening 
 appearance it pos» wes when situated anteriorly. The action 
 of the iria u perfectly free, and the posterior chamber, or a space. 
 behind the iris, may be recognised. The opacity is dim, deeply 
 
22 
 
 situated, and has a bluish white appearance. It often happens 
 that a patient complains of imperfect vision, but on looking into 
 the eye no opacity can be discovered. When, however, artifi- 
 cial dilatation is employed, some faint spots, or striae are disco- 
 vered near the outer margin of the capsule. If deep seated, 
 they appear dim, and however faint, sufficiently account for the 
 loss of sight. The gradual manner in which the opaque spot is 
 shaded towards its edges until it blends with the transparent 
 capsule, renders it impossible to judge how far the nebula ex- 
 tends ; and the shading makes the central spot appear less deep 
 than it actually is. The posterior, like the anterior capsular 
 cataract, seldom continues long without involving the lens. 
 
 Lenticular Cataract. — This variety differs from the capsu- 
 lar in color, in density, in depth, and in size. It is that form to 
 which the old are subject, and that, likewise, which constitutes 
 the congenital cataract. Both senile and congenital, may also 
 include the capsular opacity. Lenticular cataract is generally 
 gradual in its formation. The opacity commences in the centre 
 of the lens : and, early in the disease, the use of stramonium to 
 dilate the pupil, almost entirely restores the sight. The deposi- 
 tion of fibrin taking place in the centre or nucleus of the lens, 
 increases its density, and as it gradually extends towards the 
 surface, the several layers are rendered harder than natural. 
 The cataract thus formed is small, compact, and hard. It is 
 distinguished by an amber, or yellow color, and appears deeply 
 situated. An evident space exists between the iris and the 
 opaque spot. A black ring is often seen around the pupil, which 
 is differently accounted for. It is most frequent in blue eyes. 
 Some authors consider it an eversion of the margin of the iris, 
 by which the uvea becomes visible in consequence of pressure. 
 Others state that a black ring always exists around the inner 
 margin of the iris, but is not observed on account of the black- 
 ness of the pupil. When, however, a cataract is formed, the 
 white ground behind the iris brings the ring in view. If now 
 the pupil be dilated by stramonium or belladonna, the depth of 
 opacity, and the amber color diminish towards the circumference, 
 
23 
 
 owing to the lens being there thinner than at the centre. This 
 is a useful diagnostic in distinguishing lenticular and capsular 
 cataracts. The lens in this state is without vitality, it therefore 
 soon acts upon the capsule as a foreign body, and creates irri- 
 tation, or inflammation, with consequent opacity. It is thus very 
 rarely that cataract remains confined to the part in which it 
 originates. Lenticular cataracts are not always firm in con- 
 sistence. They are frequently soft or fluid ; and in different 
 cases vary considerably in their degree of fluidity or hardness. 
 This circumstance has occasioned a division of them into several 
 species. These are cataracta dura, or tenax — c. Jluida — 
 c. caseosa, in which it has the consistence of cheese, and 
 c. gelatinosa, that of jelly. The c. jiuido-dura is that in which 
 the nucleus of the cataract is hard, while the external portion is 
 soft. An exception to the usual nature of lenticular cataract 
 sometimes occurs in the c. radiata. In this variety, radii or 
 striae are seen shooting in every direction from the centre of 
 the lens to the circumference. They are sometimes most appa- 
 rent at the centre ; and at others, only perceptible when the 
 pupil is dilated by stramonium. The completion of this form 
 usually occupies several years. 
 
 The congenital cataract comes to maturity more rapidly, 
 and hence does not allow the humor to become so hard, and 
 firm, as in the affection of the old. The cataract remains soft, 
 and never acquires a deep amber color. It appears large, is of 
 a bluish white color; and is without stria? or spots. The trans- 
 parent membrane investing it, produces a smooth polished sur- 
 I i< . The general aspect of the cataract is nebulous. The 
 opacity is deeper in some places than in others, but is diffused, 
 and without any transparent space between the denser parts. 
 The cataract is sometimes so soft, that it is flocculent, and if the 
 eye can be kept perfectly quiet for a few moments the denser 
 flocculi subside. The congenital cataract appears to have a 
 more rapid, and definite course than any other variety. The 
 lens by -"iir meane become detached from the capsule, and 
 thus losing its Bource of nourishment, dies. It then acts as a 
 
24 
 
 foreign substance, irritating the capsule, and producing an in- 
 creased secretion of the Morgagnian fluid. This fluid, in its 
 turn, reacts on the lens and dissolves it, or promotes its absorp- 
 tion. At the same time the irritation produced in the capsule 
 renders it, likewise, opaque. The cataract, enlarged by the in- 
 creased secretion and by the thickening of the capsule, presses 
 forward the iris, and appears to project into the anterior cham- 
 ber. At this time a change takes place, the solution of the lens 
 is finished, and the fluid begins to be removed by absorption. 
 The cataract retires, and diminishes in size, the iris regaining its 
 natural situation. As absorption proceeds, the capsule contracts 
 and shrivels until at the end of the process it remains a mere 
 membrane. It may by contraction be separated from the ci- 
 liary processes ; and a dark ring is then sometimes observed 
 around it, owing to the choroid membrane being visible through 
 the space. A trembling or vascillating motion of the iris is in 
 such a case occasionally observed, attributed by Mr. Stratford 
 to the loss of support suffered by the iris from the absorption of 
 the contents of the capsule. 
 
 Capsulo-lenticular cataract. This is the common form in 
 which cataraet usually exists. It is recognised by its large size ; 
 its position immediately behind the iris, obliterating the posterior 
 chamber ; and by its mixed color. The cataract appears to oc- 
 cupy the pupil ; sometimes it encroaches upon the iris, projects 
 it forward, and causes its partial contraction. When the iris is 
 artificially contracted under such circumstances, it relaxes again 
 very slowly, and with difficulty. The thickness of the opaque 
 substance renders the transmission of light so difficult, that the 
 patient scarcely recognises it. In its color may be discovered 
 that of the preceding varieties in their separate state, viz. a su- 
 perficial white, cloudy, or radiated appearance, like mother of 
 pearl ; and a deeper yellowish or greyish tint, sometimes ap- 
 proaching to an amber color, which is the opaque lens. The 
 color of these cataracts, however, is liable to great variation. It 
 may consist entirely of a bluish white, or light grey color ; or 
 in some cases may be of a deep brown. Mr. Lawrence states 
 
25 
 
 that he has never seen a cataract of a deeper color than that of 
 mahogany, but in the German authors black cataracts are de- 
 scribed. The brown variety is very rare, and indicates great 
 hardness of the lens. The nearer the color approaches a milky 
 white, the softer the cataract may be considered. It will be 
 difficult, however, to form a diagnosis of these varieties from 
 mere description. They require great minuteness of observa- 
 tion and a well-tried experience. The only advantage of the 
 diagnosis is the variation of treatment to which it leads. 
 
 Traumatic cataract is an interesting variety of the affections 
 of the lens and capsule. Its marked peculiarities render it wor- 
 thy of separate notice. These are its rapid formation with acute 
 inflammation ; its occasional spontaneous disappearance ; its dis- 
 location in many instances to various parts of the eye ; the irri- 
 tation and inflammation it occasions in such situations ; and the 
 nature of the treatment required for its cure. Traumatic cata- 
 ract may originate in two modes ; from an injury which produces 
 concussion of the globe, without laceration of its textures ; and, 
 secondly, by a penetrating wound of the globe in which the 
 capsule or lens is ruptured. The former, or cataract from con- 
 cussion, may ensue from a blow received on the forehead, or 
 over the eye ; or from a blunt instrument being thrust against 
 the ball. It has been known to arise from a spent shot which 
 has struck the eye without penetrating its coats. Unless the 
 injury has been very severe, producing general inflammation, 
 glaucoma, or amaurosis, the cataract seldom forms immediately. 
 After the lapse of several days, or perhaps weeks, the person 
 begins to experience some uneasiness about the eye, as slight 
 pain, or sense of fulness and distention, and also complains of 
 I obscurely as through a mist. If the eye be now exam- 
 ined, the commencing opacity will be discovered, which pro- 
 wit h greater or less rapidity, and with its usual symptoms, 
 to the formation <>l'a perfect cataract. Sometimes the iris par- 
 tie, pates in the disease, and appears thickened and sluggish; or 
 it may contract and adhere to the capsule. The symptoms are 
 ionallym re, and their progress more rapid. The 
 
26 
 
 lens and capsule may be involved in disease with the other tex- 
 tures, and* from the severity of the concussion, the capsule may 
 be ruptured, the lens be dislodged, and falling into the anterior 
 or posterior chamber, prove a new source of irritation. Mr. 
 Travers mentions a case in which suppuration took place within 
 the capsule after an injury without laceration, but accompanied 
 with much acute inflammation. A globular cataract projected the 
 iris against the cornea, and evidently consisted of the lens in- 
 volved in purulent matter. After a time both lens and pus 
 were absorbed by the use of mercurials, and only a capsular 
 cataract remained. 
 
 There are a variety of displacements to which the lens 
 is liable when dislocated from its capsule, either by the im- 
 mediate concussion, or in consequence of the supervening inflam- 
 mation. Thus it may fall into the posterior chamber, and be 
 partially concealed from view. It usually, however, slips through 
 the pupil and occupies the anterior chamber. The lens has 
 been known to enter the anterior chamber transparent, and 
 remain there in that state for a length of time. In general it is 
 opaque, and acting on the delicate iris as a foreign body, pro- 
 duces iritis. Sometimes the lens remains in the anterior cham- 
 ber without causing inflammation, and is finally absorbed. 
 Though a capsular cataract commonly remains after such cases, 
 it is now and then absorbed, and vision is recovered. In- 
 stead of passing into the anterior chamber, the lens may come 
 in contact with the iris and thrust it forward against the cornea. 
 This case always produces severe iritis, and general internal 
 inflammation ; and demands the immediate removal of the lens 
 by a surgical operation. Again, the rupture of the capsule may 
 not occur until disorganization have taken place in the vitreous 
 humor, when the lens may fall backward, sink out of the axis 
 of vision, and be absorbed. The sight of the patient is some- 
 times restored, but in general, it is destroyed by the existing glau- 
 coma. Mr. Mackenzie, from a number of whose cases in the 
 Medical Gazette, vol. 9, page 3, I have collected these varieties, 
 states that by some injury, probably a lacerating one, the lens 
 
27 
 
 has got through the choroid and sclerotic coat, and has been 
 discovered under the conjunctiva. 
 
 2. The traumatic cataract, from direct injury of the capsule 
 and lens, is formed immediately on the receipt of the wound. 
 It is not always accompanied with acute symptoms, but these 
 parts cannot be wounded without opacity being the result. 
 Generally violent inflammation is the immediate effect. The 
 wound may pass through the cornea, or the sclerotic coat, and 
 is generally made by some pointed instrument. Frequently 
 bits of iron or stone, which fly in cutting these materials, strike 
 the cornea, where they are commonly arrested ; but they 
 sometimes penetrate it and enter the capsule either through the 
 pupil or through the iris. A speck of iron has thus been driven 
 into the capsule and remained there without occasioning in- 
 convenience until a capsular cataract was formed. In general, 
 immediate and violent inflammation ensues, accompanied with 
 symptomatic fever, and requiring the most active depletory 
 treatment. Suppuration of the lens, with general inflammation 
 of the internal tunics follows, and if the foreign matter be not 
 removed, causes rupture of the globe and discharge of its con- 
 tents. Sometimes the substance may be seen and be removed 
 by an operation. The inflammation then subsides ; the sequel 
 of the case depending upon the extent of its ravages. 
 
 Secondary cataract is the only variety remaining to be ob- 
 served. The term is applied to those cases which occur after 
 operations. In the formation of an artificial pupil in the iris, 
 the capsule may be cut, and the consequent cataract is called 
 secondary. But it is usually the result of the operation, called 
 couching, in which the lens is removed from its situation 
 but the capsule remains. It becomes opaque and requires a 
 second operation for its removal. The symptoms and appear- 
 ances of these are the same as the cases already described. 
 
 Complications. — The cataract does not always exist in this 
 simple and isolated sf;it<\ It is often complicated with other 
 affections. Glaucoma and amaurosis are' its frequent concomi- 
 tants ; though the cataract is generally formed subsequent to the 
 
28 
 
 existence of the former diseases. Often, the iris is found adhe- 
 rent to the lens. This may exist to a sufficient extent to prevent 
 any operation for the removal of the cataract, though in gene- 
 ral, it is only attached at particular points. Sometimes these 
 attachments are separated, when stramonium is applied to cause 
 contraction of the iris, and the case is then rendered simple. 
 A case is reported by Mr. Travers, Med. Gaz. vol. v. p. 67 J , in 
 which the cataract was projected forwards, and had formed an 
 adhesion to the cornea. There is now at the N. Y. Eye Infirmary 
 an interesting case of cataract, with extensive adhesions of the iris ; 
 excessively irregular pupil, though it dilates by the application of 
 stramonium ; and opacity of the cornea. The case is render- 
 ed more unusual by its occurrence in a very young boy, after 
 severe iritis and ophthalmia. The cataract is capsular and im- 
 perfect, there being three circumscribed and distinct specks on the 
 capsule which are white and glistening, forming a strong con- 
 trast with the dim and cloudy corneal opacity. There is also 
 a dark brown deposition which is a portion of the uvea. The 
 treatment of the case is directed to remove the corneal opacity. 
 The management of complicated cases is always difficult. In 
 cataract with glaucoma or amaurosis, nothing can be done for 
 its relief until the latter diseases are removed. When adhesions 
 exist the difficulty of an operation is always increased, and such 
 cases are extremely liable to terminate unfavorably. 
 
 Diagnosis. — There are a number of the diseases of the eye 
 with which cataract may be confounded. Nor is their diag- 
 nosis at all times easy, for those of the most experience and 
 skill have committed errors. As, however, the diagnosis mate- 
 rially influences the future conduct of the surgeon, its correct- 
 ness is all-important ; and with sufficient care may be made 
 exact. The diseases which may be mistaken for cataract are 
 amaurosis ; glaucoma ; fungus haematodes ; opacity of the cor- 
 nea ; and adventitious deposits in the posterior chamber, and be- 
 fore the crystalline humor. In all these diseases an opacity is 
 perceptible in the interior of the eye ; but they all possess certain 
 peculiarities by which they may be distinguished : or if their 
 
29 
 
 appearance approach so nearly to that of cataract to render 
 the distinction doubtful, the history of their origin and progress 
 will decide the question. 
 
 Cataract and Amaurosis. — In some forms of amaurosis an 
 organic change takes place in the condition of the retina, attri- 
 buted to a deposition of fibrin within its naturally transparent 
 texture. This causes an opacity which is apparent on examina- 
 tion, but which differs from that of cataract in appearing very 
 deeply situated in the eye. It is seldom very dense like cata- 
 ract, but a dim, diffused cloudiness is seen behind the pupil ; 
 and if this be dilated by stramonium the patient's vision is not 
 improved. With this opacity, insufficient in its apparent den- 
 sity to account for great diminution of sight, vision may be 
 entirely lost ; and if the disease exist in both eyes, the patient 
 may be involved in total darkness. In cataract, light is al- 
 ways perceptible. Where the sight in amaurosis is still re- 
 tained to some extent, the diminution is not proportionate to the 
 opacity ; and now an important symptom is manifested. If a 
 strong light be presented to the eye, vision is improved, owing 
 to the powerful stimulus given to the sensibility of the retina. 
 Persons having cataract see more distinctly by a very moderate 
 light. There is a peculiar difference in the appearance of the 
 flame of a candle in those affected with cataract or amaurosis. 
 The flame appears to an amaurotic eye, surrounded with a halo of 
 various colors ; while the halo in cataract is always white, ap- 
 pearing composed of rays of light radiated from the flame and 
 somewhat obscured by mist. The sight in amaurosis is not 
 constant. Though it continues to decline, if the disease be not 
 checked, it is subject to fluctuations, being sometimes worse, and 
 at times improved. This is not invariably the case. Some- 
 times flashes of light dash across the eye, and colored spots, or 
 images float before the sight. This is not the case in simple 
 cataract. Assistance may be derived from the state of the 
 other eye, for if its pupil be perfectly clear, but the eye be 
 amaurotic, the inference may be that in the suspected eye there 
 is also amaurosis. Again, the condition of the iris constitutes 
 
30 
 
 a valuable diagnostic. The iris in amaurosis may be either 
 preternaturally contracted or relaxed ; and in either state may 
 be motionless ; it may be sluggish in its movements, or may 
 retain its natural action. It seldom remains perfectly natural. 
 When, however, the pupil is thus dilated or contracted, and this 
 state is not manifestly owing to a cataract of unusual size coming 
 in contact with it, it is evident the disease is amaurosis, (or glau- 
 coma). Were these distinctions insufficient, the accession, and 
 progress of the affection, in the course of which the opacity was 
 produced, would determine its being cataract or amaurosis. 
 I have said that cataract was formed, except in some 
 traumatic cases, without derangement of the general health. 
 The contrary occurs in amaurosis. This disease commen- 
 ces with an increased sensibility to light ; and clearness of 
 vision, which is, however, of short duration, and is succeeded by 
 diminished sight. Pain, frequently of the most agonizing inten- 
 sity, and violence is experienced in the head or eye. In the more 
 chronic form, a severe, but dull pain is suffered in the forehead 
 just over the orbit, or it may be confined to the globe of the 
 eye. It is always of an obstinate character. Amaurosis, how- 
 ever, frequently occurs without its presence. Pain in the 
 head, or a deep-seated pain in the eye infallibly indicates that 
 the opacity in question is not cataract ; or, if it be proved 
 from other reasons that the eye contains a cataract, that it is 
 complicated with other internal disease of the organ. The 
 acuteness of the amaurotic inflammation, or the continued pain 
 in the head, seldom fail to derange the general health, and this 
 derangement is usually manifested in the digestive organs. 
 Amaurosis is likewise a frequent consequence ofsuch disorder : 
 thus it, together with the resulting pain in the head, often pre- 
 cede by several months the disease in the eye. However this 
 may be, derangement of the digestive organs, occurring in con- 
 junction with the pain in the head, together with the local symp- 
 toms enumerated, is an important auxiliary in determining the 
 diagnosis. 
 
 Cataract and Glaucoma. — Glaucoma is an inflammation, 
 
31 
 
 either acute or chronic, of the vitreous humor, in which its 
 transparency is lost. The opacity thus produced may be mis- 
 taken for cataract. Its giadual increase causes obscurity of 
 vision, as in the formation of the latter disease ; but it differs 
 from it in color, in apparent volume, and in depth of situation. 
 The commencement of the disease is attended with pain either 
 m the eye, or forehead, and it seldom continues long without 
 producing amaurosis, iritis, and cataract itself, with general in- 
 flammation of the globe of the eye. The opacity is of a green, or 
 greenish yellow color — very different in this respect from cata- 
 ract. It appears very deep in the eye, and is sometimes evi- 
 dently concave anteriorly. The opacity is diffused, like a 
 cloud, but has a shining appearance, so as sometimes to resem- 
 ble a piece of polished metal in the eye. Occasionally the 
 arteria centralis retinas may be seen running through it. Not- 
 withstanding that an evident space may be distinguished be- 
 tween the iris and the opaque substance, the functions of the 
 former arc generally deranged. The iris becomes languid in 
 its movements ; often, is altered in color and thickness. It will 
 frequently be found contracted, or relaxed, and also motionless. 
 A remarkable effect of glaucoma, in many cases, is to render 
 the iris tremulous ; and, if the vitreous humor be increased in 
 volume, it may be pressed forward so as to appear convex ; or 
 it may even be forced against the cornea. Another important 
 diagnostic is the condition of the globe. In cataract, it re- 
 mains natural. Glaucoma frequently deforms, renders it soft, 
 and lessens the thickness of the external tunics. A glaucoma- 
 tous eye appears blue from the choroid being seen through the 
 sclerotic, and large varicose vessels generally run beneath the 
 conjunctiva, Disordered health then; pain; loss of sight dis- 
 proportionate to the degree of opacity, and frequently total 
 blindni --: together with the green color of the opacity, and 
 derangement of the iris, attend this complaint and clearly dis- 
 tinguish it from cataract. 
 
 ("i'n act and /''i/./i'j'/s Ha;mat,o(l< j :;. — The opacity which 
 
32 
 
 characterizes the commencement of fungus nematodes, has too 
 remarkable an appearance to be readily mistaken for cataract. 
 The opaque body is seen deeply located in the posterior part of 
 the eye, and has a light yellow color, often approaching that of 
 amber. It appears like a polished metalic disk ; often seems 
 concave, and sometimes the iris may be seen reflected upon it. 
 When it has increased in size, its surface is irregular, and by 
 this time sight is destroyed. Its progress is accompanied with 
 fever, and a peculiar languor. The most distressing pain both 
 in the head and eye, attend its course at irregular intervals. 
 When the fungus has arrived at the pupil, its amber color 
 might cause it to be pronounced cataract, did not the history of 
 the case, the loss of sight, the disordered iris, and its occurrence 
 for the most part during childhood, almost preclude the pos- 
 sibility of error. 
 
 Cataract and Opacity of the Cornea. — The only condition of 
 the cornea which is liable to occasion an incorrect diagnosis, is 
 a slight nebula, situated on its posterior lamina, and near the 
 centre. Such an opacity has been pronounced cataract. The 
 diagnosis is of much importance, for, on the supposition that the 
 case was a forming cataract, a patient might be directed to 
 wait for its completion, during which time the corneal opacity 
 may become too fixed for treatment, and might have been 
 cured. If the eye be examined obliquely, the superficial situa- 
 tion of the disease will be discovered, while behind it may be 
 seen the iris with a perfectly black pupil. The sight is only 
 obscured, and the eye manifests no other derangement. 
 
 Cataract and adventitious deposit before, the Lens. — The 
 sequel of iritis is frequently an effusion of fibrin or purulent 
 matter in the posterior chamber, where it appears like a mem- 
 brane, and may be mistaken for cataract. Such depositions 
 have been termed false cataracts They are either of a white 
 or yellow color, and appear dull, and irregular. The iris is 
 generally adherent to them, and presents marks of having suf- 
 fered from disease. At times, these deposits project into the 
 
33 
 
 anterior chamber, and then become more easily recognized. 
 An effusion of blood in this manner has been seen, the deposit 
 appearing white, with red spots scattered on its surface. 
 
 Causes. — The known exciting causes of cataract are nu- 
 merous, and for this reason the disease is not an uncommon 
 one. It may arise from injury, either direct or indirect, inflicted 
 on the lens and capsule by external violence. The presence 
 of a sense of fulness and distention in the eye during its forma- 
 tion, shows it sometimes to result from congestion of the organ. 
 An extension of the inflammation in iritis, amaurosis, &c. to the 
 capsule of the lens, is often its cause. Too constant use of the 
 eye in literary pursuits, or in such of the arts as require minute 
 and long-continued inspection, particularly if with this an unu- 
 sually strong light be employed, however unaccountable its 
 action on the lens may be, yet frequently gives rise to cataract. 
 The affection as it occurs in old persons, or the senile cataract, 
 is frequently insidious, and slow in its approach, requiring several 
 years for its completion, and happens to those in other re- 
 - so perfectly healthy, that it cannot be attributed to any 
 known cause. Not a few cases are also on, record where the 
 disease was hereditary ; in some of which as many as five of a 
 family have been affected. I have seen Dr. Delafield operate 
 on two of a family at once, for congenital cataract, in which all 
 the children had been born with the disease. Mr. Stratford, 
 of London, states that congenital cataract frequently occurs 
 after protracted labor ; and considers, that in the compression 
 which the frontal bone experiences, the globe must also be 
 compressed, by which means the delicate vessels attaching the 
 to its capsule arc ruptured, and cataract consequently 
 is. In thus explaining congenital cataract, he states that 
 ii may also result from local chronic inflammation. It may not 
 be an altogether fanciful conjecture, to imagine, that this cata- 
 netim - the consequence of the rupture and absorp- 
 tion of the membrana pupillaris. The arteria centralis retinas, 
 which branches to the capsule of the lens, also in the 
 
 in tus supplies this membrane. The increased action which 
 
34 
 
 takes place by the rupture of these branches, and by the absorp- 
 tion which is going on, may occasion a slight deposition of 
 fibrin ; and, an obstruction once created in the course of the 
 vessels, would cause total opacity of lens and capsule. 
 
 There appears much reluctance in the writers on cataract 
 to consider it the result of actual inflammation and the terms 
 " acute" and " chronic inflammation," or " irritation," as they are 
 applied to other diseases are seldom used. But traumatic cat- 
 aract clearly shows that acute inflammation may occur in the 
 lens and capsule, as well as in the other tissues of the eye ; 
 while the result of the inflammation is a cataract similar in its 
 formation and appearance to that whose progress is almost im- 
 perceptible. When also, the disease is not the consequence of 
 external injury, its course is sometimes attended with a manifest 
 sense of fulness and distention, or even pain, in the eye. Again 
 in the cases where the cataract is rapidly formed, if the pupil 
 be examined with a magnifying glass, vessels may be seen ram- 
 ifying over the capsule, which in the healthy eye are invisible ; 
 proving an increase of the circulating fluids of the part. These 
 fluids are naturally transparent ; but in disease, they are denser, 
 or acquire a more or less white color. The increase of 
 volume which the cataract sometimes possesses over the natural 
 size of the capsule and lens, must be the result either of deposi- 
 tion of fibrin in their texture, or of an increased secretion of 
 the fluid of Morgagni ; while, in other cases, the gradual absorp- 
 tion of the contents of the capsule, until only a shrivelled mem- 
 branous or capsular cataract remains proves that all the results of 
 inflammation in other parts, viz : deposition of fibrin ; preternatu- 
 ral secretion ; and subsequent absorption, also take place here. 
 The low degree of vitality attributed to these parts by some 
 authors, renders them, they think, insusceptible of inflammation ; 
 and some affirm that the lens has no vitality. But can a body pos- 
 sessed of such a perfect organization, and wherein the natural 
 processes of exhalation and absorption, must continue with the 
 most undeviating exactness, to preserve the transparency of 
 these delicate parts have a low degree of vitality ? or rather, 
 
35 
 
 must not these functions possess a very high degree of vitality 
 to continue their healthy condition, notwithstanding the frequent 
 abuse of the organ from exposure, and improper or excessive 
 employment ? And if they possess this vitality, together with 
 unusual delicacy of structure, are they not also liable to all the 
 derangements to which all other highly organized parts are sub- 
 ject ? If acute inflammation can occur in the lens and capsule, 
 as proved in traumatic cataract, chronic inflammation may also 
 take place, because wherever the acute form has been known, 
 the subacute has also existed. And the pathology of both are 
 essentially the same. In regard to the senile cataract, may not 
 a slow deposition of fibrin take place in the lens, in the same 
 manner, and by the same morbid action, as occurs in the depo- 
 sition of bone in the arteries of old persons ? If the production 
 and developement of miliary tubercles in the lungs is sometimes 
 so imperceptible that no idea of their progress can be formed, 
 and they are allowed to be the result of chronic inflammation or 
 irritation, I should imagine the same tardy action in the vessels 
 of the lens and capsule might occasion an equally slow produc- 
 tion of cataract. The exciting causes then being ascertained, 
 and the proximate cause, or in other words, the disease itself 
 being understood, as much, I believe, is known of the cause of 
 cataract as of any other disease. 
 
 Prognosis. The treatment of cataract has contributed 
 much to enhance the reputation of surgery. So rapid and 
 palpable is its effect, and so perfect the relief afforded, that it 
 cannot but be beheld with wonder anu admiration. The inge- 
 nuity to devise, and the boldness to execute the operation 
 called couching must have elevated Celsus, who first performed 
 it, to the highest place in the esteem of his countrymen, and of 
 his profession. 
 
 Nothing is available in the cure of cataract but a surgical 
 operation, and that may be completely effectual. To those 
 
 however. ;n<ii^toiiie(l to imagine a far less injury to the eye 
 
 than is produced by plunging an instrument to its centre, as 
 
 fatal to vision, the surprise at the proposal of an operation is 
 
36 
 
 only equalled by their dread of its severity. Such are in con- 
 sequence extremely solicitous to know its result ; and if their 
 joy and happiness in its success be great, their disappointment 
 at its failure is still more manifest. In its event, therefore, the 
 reputation of the surgeon is greatly concerned : and his duty, so 
 far to warn his patient of the dangers which surround him, and 
 of the liability of the operation to failure, as not to deter his 
 attempting the last expedient, without affording a too flattering 
 prospect of relief, is delicate and difficult in the extreme. Yet 
 this is the only just, and proper course. The complications of 
 the disease are numerous, and the result of an operation is 
 always involved in uncertainty. To the inquiry if the cataract 
 will not disappear without an operation, the reply may be 
 given, that when once produced, it always remains. It is true 
 that a few cases are known where spontaneous cure Occured, 
 but such, only go to prove the general rule. The most, likewise, 
 of the reported cases are those of traumatic cataract in which 
 accident rudely executed what the surgeon would have per- 
 formed with more neatness. A more genuine instance of spon- 
 taneous cure is reported by Mr. Estlin of Bristol. Med. 
 Gazette, vol. 3, p. 566. A simple mature cataract occuring in a 
 person whose habit is rather spare, and who leads a temperate 
 life, is the most favorable for operation. But little doubt of 
 success need here be entertained, and it is fortunate for surgery 
 that, as I am informed by Dr. Delafield, the great majority of 
 the cases of cataract which occur in practice are free from 
 complication with other diseases. It is unadvisable, however, 
 to operate where only one such cataract exists, for though the 
 event be satisfactory, the sound eye will alone be used. The 
 only reason for exposing the person to the dangers of inflamma- 
 tion which may follow the operation, being the improved 
 appearance of the face. Mr. Travers' advice in this case is to 
 operate, his reasons for which, he gives in his work on the eye, 
 p. 338, but it has been overruled by other authority. 
 
 The removal of such a cataract in a plethoric person, or one 
 whose constitution is broken, whose health is deranged, or 
 
37 
 
 whose habits are intemperate, is attended, even after careful 
 preparatory treatment, with much liability to inflammation 
 from the incision, and the injury done the internal parts of the 
 eye ; and of this the patient should be forewarned. Indeed, if 
 the general health be deranged, no operation should be attempt- 
 ed until measures have been taken to repair it. Derangement 
 of the stomach and bowels ; a rheumatic diathesis ; the presence 
 of pulmonary catarrh ; or eruptive diseases, all tend to occasion 
 an unfavorable termination, and should therefore modify the 
 prognosis. The existence of hoemorrhoids, or of obstinate con- 
 stipation, are also enumerated by Dupuytren, as reasons for de- 
 ferring an operation. On the other hand, if a perfectly formed 
 cataract exist in one eye, while the other is affected by the in- 
 cipient disease, an operation should be performed, that the indi- 
 vidual may not be deprived of sight during its completion. 
 Where two mature cataracts exist, one only should be removed 
 at a single operation. The practice of some surgeons, at once 
 to remove both, exposes the patient to a greater danger of sub- 
 sequent inflammation ; or, if by untoward circumstances, the 
 operation fail, there is no further resource, unless a secondary 
 operation be practicable. In complications of the cataract with 
 other local diseases, the prognosis is always unfavorable. If 
 amaurosis, or glaucoma be present to any extent, an operation 
 is not only useless, but reprehensible, from the great liability to 
 excite violent inflammation where disease already exists. It is 
 said that in mild cases of amaurosis, when the progress of the 
 se is arrested, and the retina retains some sensibility to 
 light, tin; cataract may be removed with advantage. If, how- 
 ever, in such cases tin: patient wore informed of the danger of 
 supervening inflammation, the only partial relief he will obtain, 
 and the probability that his sight would always be weak, and 
 insufficient, he would generally decline an operation. The eye 
 i~ fp quently subject to rheumatic inflammation, which locates it- 
 self [neither the sclerotic coat, or the iris. Where iliis disposition 
 prevails, the removal of ;i cataract is extremely liable to excite, 
 or renew the disease in these tunics. This is not, however, 
 
38 
 
 a sufficient reason to prevent an operation and consign a patient 
 to blindness. If due preparatory treatment be used ; care be 
 had to meet with active remedies the least sign of subsequent 
 inflammation, and the patient be advised of the hazard, it may 
 be attempted with propriety. Extensive adhesions of the iris to 
 the capsule of the lens should forbid an operation, for the lesion 
 produced in the attempt to detach it would not fail to cause 
 destructive inflammation. When, however, the attachments are 
 slight, as by single shreds or points, and the pupil is fully dilated 
 by stramonium, a skilful surgeon will readily divide them, and 
 remove the cataract. Opacities of the cornea, occurring in 
 conjunction with cataract, must be removed, if possible, pre- 
 viously to an operation. It is in some such cases that the eye 
 displays the great extent to which it will bear surgical opera- 
 tions, and also the great recuperative powers of the system. 
 Sometimes the corneal opacity may be removed by medical 
 treatment from all but the centre of the membrane, the cataract 
 may be dislodged, and finally the operation to form an artificial 
 pupil, may be successfully accomplished. If the corneal opacity 
 be great, operations upon a cataract are obviously without ad- 
 vantage. In congenital cataract, a favorable prognosis may 
 always be given. The injury inflicted by the operation being 
 slight, the liability to consecutive inflammation is diminished ; 
 the cataract is soft, and being broken up, presents ample surface 
 for the action of the absorbents ; while the great activity with 
 which the vital functions are performed ensures its rapid ab- 
 sorption. The prognosis of the traumatic form must necessarily 
 be uncertain. If it arise from concussion, some other disease 
 will generally accompany it. When it is the result of a direct 
 injury, and the lens is dislodged, an immediate operation may 
 be necessary, but its result, in regard to sight, must depend 
 upon the degree of injury primarily inflicted, and the event of 
 an additional wound in an already inflamed organ. Where the 
 cataract exists after the subsidence of all inflammation, and 
 there is no other complication present, it may be removed with 
 a sanguine hope of success. It is frequently necessary to repeat 
 
39 
 
 the operation in consequence of incomplete absorption, or of the 
 formation of a capsular cataract after the lens has been removed, 
 and in giving an opinion upon the result of an operation, this 
 should always be clearly stated. 
 
 Another source whence assistance may be derived in esti- 
 mating the probable success of an operation, is the comparative 
 result of previous experience. The practice of Dr. Delafield 
 has led him to estimate the proportion of successful operations 
 at about six in seven cases. This is not, however, the propor- 
 tion of cures without supervening inflammation. In rather more 
 than one half the cases, he thinks, inflammation occurs subse- 
 quent to an operation, and this is only removed by the most 
 active treatment. In fine, then, the prognosis of a simple idio- 
 phatic cataract, as the congenital or senile, may be as favora- 
 ble as the usual certainty of operations will allow. The symp- 
 tomatic, or that resulting from other general or local affections, 
 offers less hope of perfect relief. The complicated cases de- 
 pend upon the extent of internal disorganization ; and the trau- 
 matic varieties are involved in uncertainty, in which the judg- 
 ment of the surgeon must be exercised according to the 
 individual peculiarities of the case. 
 
 Treatment. — It is now universally admitted, that no treat- 
 ment is of any avail in the cure of cataract, but its removal from 
 the axis of vision by a surgical operation. Recurrence, there- 
 fore, to the various modes of medical treatment, which have 
 been attempted, as the use of narcotics, stimulants, and counter- 
 irritants is unnecessary. 
 
 There is DO operation in surgery which involves more medi- 
 cal and surgical skill, than that for the removal of cataract. 
 Minute anatomical knowledge, an extensive acquaintance with 
 theraputics, combined with the greatest skill and delicacy in 
 Burgeiy, an: here in requisition. The utmost quickness of per- 
 ception to detect the accidents which i hrcaten every step oft ho 
 Burgeon's progress, must be combined with the most prompt 
 and dexterous execution to counteract their occurrence. 
 
 No case of cataract present! itself which is prepared for im- 
 
40 
 
 mediate removal. A preparatory treatment of greater or less 
 extent, according to the condition of the system, is always re- 
 quired. The great liability of the eye to severe subsequent 
 inflammation, demands the closest attention, and often the de- 
 cided energy of the surgeon. Indeed, it has been remarked by 
 Dr. Delafield, that the success of an operation is as much depend- 
 ant upon the preparatory, and subsequent treatment, as upon 
 the operation itself. The treatment of cataract is hence sub- 
 ject to three divisions. 1st, the preparatory treatment ; 2d, the 
 operation ; and 3d, its subsequent management. 
 
 1. The indications for preparatory treatment are derived 
 from the temperament of the person, the general health, and 
 the local condition of the eye. A simple cataract appearing in 
 a spare habit, and a sound constitution, is in the most favorable 
 state for operation. The only treatment which need here pre- 
 mise it, is an abstemious diet for a few days ; attention to the 
 digestive organs ; and venesection the previous evening if there 
 be the least pain, or sense of fulness about the head or eye. It 
 is always important that one or two active cathartics be given 
 at the outset, and that the bowels be then kept in a free con- 
 dition by milder aperients. Venesection the preceding evening 
 or morning would probably seldom be injurious, unless debility 
 exist, and is frequently necessary. When the consequences of 
 insufficient preparation are so dangerous, the fear of doing a 
 little too much need not be dreaded. There is less liability to 
 subsequent inflammation, and the surgeon proceeds with more 
 confidence. Plethoric persons and those disposed to determina- 
 tion of blood to the head, require active depletion. Venesec- 
 tion should be repeated several times, strict diet be enjoined, 
 and a cathartic be administered every two or three mornings 
 for a couple of weeks previously to the operation. And notwith- 
 standing all this reduction, inflammation is very apt to supervene. 
 
 If, together with this habit of body, the health be impaired, 
 as indicated by a furred tongue, deranged digestion, and dimin- 
 ished or capricious appetite, the use of evacuants, regulated ac- 
 cording to the condition of the bowels, is of the highest impor- 
 
41 
 
 r 
 
 tance. The health must be restored by several weeks' strict 
 attention to a proper diet. In such cases, calomel in small 
 doses, or the pil : hydrarg : taken at night, and followed the next 
 morning by sulph : magnes : alone, or with senna ; or the 
 eccoprotic mixture are preferable to drastic purgatives. The 
 warm bath to excite a healthy action in the cutaneous vessels, 
 may be in many instances productive of advantage. By these 
 means, the tongue will resume its natural appearance ; the ap- 
 petite, and digestion be restored ; and a manifest improvement 
 is often observed in the disposition, and countenance of the 
 patient. When this derangement of health occurs in more 
 weak, and nervous constitutions, the same treatment, exclusive 
 of the free loss of blood, is indicated. 
 
 The presence of any rheumatic affection is a serious obsta- 
 cle to success, and an operation should be delayed until all the 
 symptoms are removed by appropriate treatment. 
 
 A rheumatic diathesis is always unfavorable to operations 
 on the eye. The wound is extremely liable to excite the pecu- 
 liar inflammation of rheumatism in either the fibrous sclerotic 
 coat, or in the iris. On this account the state of the weather 
 should be carefully regarded in determining the time for opera- 
 tions. Indeed, the remark may be extended to all persons, 
 without confining it to the rheumatic. I saw the result of an 
 operation during the last winter held a long time in doubt from 
 an unavoidable exposure to cold. The patient being obliged to 
 remain in a cold room, after having undergone active prepara- 
 tory depletion was attacked, after the operation, with extremely 
 severe internal and external ophthalmia. It obstinately resisted 
 b< >th general, and local depletion, as well as mercurials, and 
 counter irritants, until the patient was removed to a more com- 
 fortable apartment. The disease then rapidly yielded to treat- 
 ment. 
 
 The failure of some cases has been clearly traced to the ex- 
 istence of eruptive diseases. U, therefore, any such be disco- 
 vered, tin v should be subjected to treatment before the cataract. 
 
 Pulmonary diseases an; likewise prejudicial to the treatment. 
 
 ft 
 
42 
 
 The act of coughing, they occasion, according to Mr. Dupuy- 
 tren, produces congestion of the head, which may be the means 
 of exciting ophthalmia. 
 
 In regard to the condition of the eye itself, the presence 
 of any inflammation, or irritation about the organ must be 
 completely removed before an operation is commenced, ex- 
 cept in cases of traumatic cataract, where the lens acts as a 
 foreign substance to keep up inflammation. Such traumatic 
 cases are only to be operated upon after the most decided 
 depletion. If amaurosis or iritis exist, the remedies em- 
 ployed in those affections must be premised until no trace of 
 those diseases be left. Sometimes a slow disorganizing action 
 goes on in the vitreous humor until the lens looses its support, 
 and falls into the anterior chamber. After a time the disease is 
 recovered from, and the vitreous humor is restored to a healthy 
 state. It is then, that the dislocated lens may, with propriety, 
 be removed. Five or six such cases have occurred to Dr. Dela- 
 field, upon which he has operated at this period with entire 
 success. When the health has been thus restored, and the eye 
 reduced to a perfectly quiet condition, the only remaining pre- 
 caution is to secure an ample dilatation of the pupil by means 
 of the extract of stramonium, or belladonna. This should be 
 applied in a thick paste around the palpebrae the evening, and 
 morning preceding the operation. When used, it should be 
 kept moist for some time to promote its absorption. 
 
 2. The Operations. — The controversy which the opera- 
 tions proposed for the cure of cataract have occasioned, has 
 elicited the most minute and extended descriptions. Objections, 
 fancied and real, have been advanced against them ; and each 
 has been extolled, to the exclusion of the others, by the various 
 writers who have invented them, or practised them with the 
 greatest facility. To describe all these minutiae, to examine 
 and relate the objections, and detail all the precautions enumera- 
 ted, would only be to make a prolix rehearsal from these authors. 
 I shall, therefore, briefly mention the different operations, and 
 the manner of performing them as now generally received ; the 
 
instances to which they are severally the best adapted ; and the 
 instruments at present preferred. 
 
 There are three operations by which the cataract may be 
 removed, viz. by depression; by extraction; and by absorp- 
 tion. 
 
 1. The operation by depression, or couching, as it is also 
 termed, consists in removing the cataract from the axis of vi- 
 sion by depressing it into the vitreous humor, where it remains 
 until reduced by the action of the absorbents. This method has 
 two varieties, called the anterior and posterior operations : 
 the former, implying that the instrument is passed into the cata- 
 ract through the cornea, the anterior chamber of the aqueous 
 humor and the pupil ; the latter, that it is introduced posteriorly 
 to the iris, through the opaque membranes of the eye, and the 
 posterior chamber. The terms are derived from the circum- 
 stances of the operation being performed either anteriorly, or 
 posteriorly to the iris. There is a variety of the posterior ope- 
 ration termed reclination, in which the vertical plane of the 
 lens is made the horizontal before the depression is commenced. 
 This method is now abandoned. 
 
 2. The operation by extraction consists in making a section 
 through the cornea sufficiently large to permit the exit of the 
 
 which is detached from its capsule, and pressed through 
 the incision. Of this operation there are also two varieties ; 
 one, in which the incision is made along the inferior margin of 
 the cornea ; the second, in which it is carried along the superior 
 margin. The flap of the cornea in the former is turned down- 
 ward ; in the latter it is directed upward. 
 
 3. The operation by absorption consists in introducing an 
 instrument into the cataract, breaking it up without dislodging 
 it from the axis of vision, and so lacerating the capsule that the 
 aqueoui humor is admitted upon the lens, by which means the 
 latter becomes absorbed. This method is also called solution, 
 from an opinion thai the aqueous humor dissolved the lens. 
 
 The instrument may here also be introduced anteriorly, or pos- 
 
r 44 
 
 teriorly to the iris, as in depression. When passed through the 
 cornea, the operation is called keratonyxis. 
 
 Depression was first performed by Celsus. Extraction was 
 first described by Daniel, though Freytag first practised it in a 
 case where the lens had fallen into the anterior chamber. The 
 operation by absorption was discovered by Messrs. Pott and 
 Hey. 
 
 These operations are severally applied to the varieties of 
 cataract, as they prove most applicable to particular cases. In 
 general, depression is preferred in this country, but extraction 
 appears to be the favorite in Europe. Dr. Delafield has in- 
 formed me that at one time he operated alternately by extrac- 
 tion, and depression, but. finally adopted the latter, except in 
 particular cases, from having found it the more successful. 
 M. Dupuytren once gave extraction the preference, but has 
 since given his opinion in favor of depression. 
 
 When either of these operations is to be performed, stramo- 
 nium must be applied to the eye several hours previously, that the 
 fairest possible view may be obtained of the cataract. A situ- 
 ation is then selected near a window, at which a full light enters, 
 without the admission of the rays of the sun. A northern 
 exposure is the best for this object. Strong light should be 
 excluded the room from every other source. The object in the 
 arrangement of the light is to permit as much as possible to 
 strike the eye, but in such a manner that none of the rays re- 
 flected from the cornea shall be visible to the operator. If the 
 surgeon operate equally well with both hands, the patient may 
 always sit before him, but if he only use the right hand, the pa- 
 tient must lie down when the right eye is the subject of opera- 
 tion. The surgeon, in the latter case, places himself at the head 
 of the table, on a seat so elevated, that he may easily overlook 
 the patient's face. When the sitting posture is chosen, the sur- 
 geon takes a position partially between the light and the pa- 
 tient, having the cataractous eye rather to the right, and the 
 nearer of the two to the window. A pledget confined by a 
 
45 
 
 slight bandage should always be placed over the eye on which 
 no operation is proposed. The patient endeavors to see what 
 is passing before him, and the consequent movement of the 
 eye, being communicated to the other, prevents its being kept 
 at rest. This difficulty the bandage obviates. The seat of the 
 patient should have a back which affords a firm support for the 
 head, though if the surgeon have a steady assistant, he may 
 confine it against his breast with sufficient firmness. The assis- 
 tant who supports the head, also elevates the lid and contrib- 
 utes to fix the eye. The management of the lid is a matter of 
 nicety. The assistant should first partially raise the lid, with 
 the forefinger of the left hand, to enable him to place that of 
 the right distinctly upon the tarsal edge of the lid, under the 
 eyelashes. He then elevates it to the orbital ridge, and gently 
 presses on the globe of the eye. If extraction be performed, 
 he must not press in the least upon the eye, but simply elevate 
 the lid. When the finger is placed above the eyelashes, instead 
 of on the tarsal margin of the lid, the action of the eye during 
 the operation everts the lid, the fold falls over the cornea, and 
 the surgeon is compelled to withdraw his instrument. When 
 the cataract is to be removed by depression, the instrument 
 used is called a couching needle. That invented by Scarpa, 
 with some modification, is now generally employed. It is about 
 an inch long, with its pointed extremity slightly curved ; the con- 
 cavity being flat, and the convex surface rounded. Just above 
 the curvature the diameter of the needle is somewhat dimin- 
 ished. This instrument is only used in the posterior operation. 
 The anterior, requires Saunder's straight spear-pointed needle. 
 All the preliminary arrangements being made, the operator 
 the needle between the thumb and two forefingers, the 
 second being advanced nearer the needle than the first. The 
 finger! are then drawn back, that the instrument may be 
 passed into the eye, by their action alone, and not by a move- 
 ment of the hand and arm. If the surgeon's hand be un- 
 steady, he ma) have a Bupport for the elbow, or may rest the 
 little finger on the patient's cheek bone \ but it is always advisa- 
 
46 
 
 ble to avoid such assistance, as it interferes with the free mo- 
 tion of the hand. The instrument is then applied, perpendicu- 
 larly, to the sclerotic conjunctiva about a line beyond its junc- 
 tion with the cornea. The flat surface of the needle should be 
 parallel with the horizontal plane of the eye, and a little below 
 its centre, in order to avoid dividing the long ciliary artery be- 
 tween the sclerotic and choroid coats. The needle is then 
 passed gently, but firmly and steadily through the membranes, 
 after which the handle is immediately directed backward, if the 
 patient be sitting ; downward, if he be lying, until the point of 
 the needle is in the posterior chamber behind the iris. Great 
 care is necessary to avoid wounding or passing the needle 
 through this body. Immediately the needle enters the posterior 
 chamber, its concave surface must be turned towards the cata- 
 ract. This motion will consequently directly follow the back- 
 ward, or downward movement previously directed. The point 
 of the needle is now advanced until distinctly seen through the 
 pupil, to the centre of which it is to be passed, when by a 
 prompt action it is thrust through the capsule into the lens. 
 The needle is then in the situation for depressing the cataract. 
 This is done by inclining the handle upward towards the fore- 
 head. The lens and capsule are thereby torn from their at- 
 tachments and forced into the vitreous humor, where they be- 
 come engaged, and remain. The needle should then be par- 
 tially removed to discover if the cataract follow it, if so the 
 depressing motion must be repeated until it continues in the 
 vitreous humor. When the cataract is lenticular, the transpa- 
 rent capsule may remain in its situation, and, becoming after- 
 wards opaque, constitute a secondary cataract. To prevent 
 this, the point of the needle should be turned previously to 
 being withdrawn from the eye, towards the cornea, and be 
 freely moved about to lacerate the capsule and thus hasten its 
 absorption. The instrument is then carefully withdrawn, and 
 the assistant instantly lets fall the lid. After a short interval, 
 the eye may again be opened to examine its state, and gratify 
 the patient with a moment's enjoyment of vision. It is then to 
 
47 
 
 be immediately closed, and covered with a slip of muslin, wet 
 with cold water. A bandage is then passed around the head, 
 having a little drop curtain attached which falls before the eye, 
 and excludes the light. The muslin is to be kept constantly 
 wet with cold water, and the patient be placed in a darkened 
 room. Thus terminates the operation. 
 
 The parts through which the needle has passed to arrive at 
 the cataract, are the conjunctiva, the sclerotica, the choroid 
 membrane, the retina, the ciliary processes, and the posterior 
 chamber of the aqueous humor. In the depression of the 
 cataract, the hyaloid membrane and the vitreous humor are 
 injured. 
 
 The various movements of the instrument while in the eye 
 must be made by employing it as a lever, the fulcrum of which 
 is the membranes punctured by its introduction. 
 
 It is seldom that the instrument takes precisely the course 
 described. Instead of passing through the posterior chamber, 
 after penetrating the coats of the eye, and being then plunged 
 into the lens through the anterior capsule, it generally enters 
 the cataract directly it has punctured the membranes, slightly 
 lacerating in its course the hyaloid membrane and the vitreous 
 humor. This is a point of practical importance, for if the point 
 of the instrument in this case be turned backward, as for rup- 
 turing the capsule, it becomes more deeply imbedded in the 
 cataract, and the anterior capsule is then liable to remain unin- 
 jured when the lens is depressed. When, therefore, the needle 
 is not distinctly seen in the posterior chamber before the de- 
 »n is commenced, its point should be turned forward 
 towards the cornea to break up the anterior capsule. After 
 which it is again directed upon the cataract to depress it, this 
 accident is particularly liable to happen in pure lenticular cata- 
 ract, and if the anterior capsule have not been broken, a sec- 
 ondary capsular cataract is the consequence. 
 
 If the cataract have been soft, the aqueous humor will be 
 rendered turbid, and portions of the lens will enter the anterior 
 chamber. This circumstance as it prevents immediate vision, 
 
may cause some disappointment ; but these parts are soon 
 absorbed, and the humor again rendered transparent. 
 
 The Anterior Operation is seldom employed for depression, 
 It is chiefly confined to the operation by absorption ; and, for 
 the most part, to the congenital cataract. It is much more 
 simple than the former, and consists in introducing the straight 
 needle through the cornea and pupil into the cataract, whence, 
 after being freely moved about to lacerate the capsule and lens, 
 it is immediately withdrawn. The chief precautions to be ob- 
 served, are to present the needle perpendicularly to the cornea, 
 or it may pass between its lamina and fail to enter the eye : 
 and, secondly, to avoid running the needle through the iris. 
 This is often very difficult on account of the involuntary 
 and forcible action of the globe, by which the needle is diverted 
 from its course. In operating upon children, they should al- 
 ways be laid on a table, and be firmly secured by assistants. 
 The surgeon sits at the head of the table, or by the side of the 
 patient, as suits his convenience. The same directions in re- 
 gard to the preliminary arrangements, and subsequent manage- 
 ment apply to all the operations. 
 
 Operation by Absorption. — The mode of proceeding in this 
 operation, is the same in every respect as that for depression, 
 except that the cataract is not removed from its natural situa- 
 tion. The anterior, or the posterior operation may alike be 
 employed. The needle is introduced into the cataract, and 
 then freely moved about to break it down. The congenital 
 cataract is, however, generally and most properly treated by 
 the anterior method. This operation was proposed by Messrs. 
 Hey and Pott, from having observed that when portions of 
 opaque matter obtained access to the aqueous humor, they soon 
 disappeared, and the pupil became clear. It was hence sup- 
 posed that the aqueous humor dissolved the cataract, but this 
 has been disproved ; and, it is now only known, that the ad- 
 mission of the aqueous humor to the cataract promotes its ab- 
 sorption. The object of the operation, therefore, is to admit 
 this humor to the cataract, exposed to its action by as much of 
 
49 
 
 its surface as possible. The operator may push some portions 
 of the broken cataract into the anterior chamber with advan- 
 tage. There is less danger of subsequent inflammation by this 
 process than by any of the others ; for less injury is inflicted 
 upon the tunics of the eye. It is not applicable to hard cata- 
 racts, on account of the difficulty in dividing them, and the 
 slowness with which they are absorbed. The chief inconve- 
 nience of the operation is, that in consequence of incomplete ab- 
 sorption in some cases, a second becomes necessary. It is for- 
 tunate, however, in this respect, that the eye can bear two or 
 three operations as well as one. 
 
 The return of the cataract to its original place in the axis 
 of vision is an occurrence which sometimes happens. It may 
 take place a few days after the operation ; or, as has in a few 
 instances been known, after the lapse of several years. In the 
 former case a second operation is necessaiy when the effects 
 of the first have been removed. The operation of extraction 
 might be performed in either instance ; but in the latter, it is the 
 most advisable. 
 
 Operation by Extraction. — The intention in this operation 
 is to get rid of the cataract by removing it from the eye 
 through the cornea. Extraction is decidedly the most difficult 
 mode of operating, from the precision and accuracy with which 
 it is necessary to manage the instrument, and the accidents 
 which constantly threaten to thwart its success, and sometimes 
 even its completion. It is performed with a knife, first used by 
 Mr. Barth of Vienna, but known as Beer's knife. The inten- 
 tions to be fulfilled by the instrument, are first to puncture the 
 cornea, for which purpose it has a lancet-shaped point; sec- 
 ondly, to make a section of the cornea, and it therefore has one 
 long cutting edge ; thirdly, to fill entirely, during the execution 
 of these objects, the incision it makes, until the whole section be 
 completed. The shape of the knife is, therefore, triangular, the 
 apex being the point, and the longest side the cutting edge. 
 The necessity that the incision should be constantly filled by 
 the knife, is that the aqueous humor may not escape. The 
 
 7 
 
50 
 
 occurrence of which circumstance causes the cornea to become 
 flaccid, and consequently to receive an irregular or jagged sec- 
 tion. The knife should, therefore, not only gradually increase 
 in breadth, but also in thickness. The whole blade is eighteen 
 lines in length. The instrument is to be taken in the hand, and 
 managed in the same manner as the needle is in depression. 
 The mode of conducting the operation is as follows : — 
 The point of the instrument is presented perpendicularly to 
 the cornea, a short distance below its horizontal diameter, and 
 abou a line from its outer margin ; the flat side of the knife 
 being in the vertical plane of the eye. The cornea is then 
 punctured, and immediately the knife is turned in such a man- 
 ner, that the point enters the anterior chamber parallel with the 
 surface of the iris. The knife is then passed steadily, and as 
 rapidly as is consistent with safety, through the anterior cham- 
 ber, until the point reaches the cornea on the inner side of the 
 globe. In this course, the surgeon's eye should be constantly 
 fixed on the point of the instrument, to see that it does not 
 touch the iris. Having reached the internal surface of the cor- 
 nea on the inner side, the knife is firmly forced through, and is 
 then carried forward towards the nose until it cuts itself out 
 with a clean, smooth incision. If the blade prove not long 
 enough, a steady back stroke is made to finish the section. Es- 
 pecial care is here requisite to keep the side of the knife paral- 
 lel with the iris, or it may turn inward and cut the sclerotica ; 
 or outward, and emerge too near the horizontal diameter of the 
 cornea. The section of the cornea being made, a delicate hook, 
 or curved needle is introduced under the flap, with its convexity 
 turned upward, and passed through the pupil to lacerate the 
 capsule by two free strokes made at right angles. The cata- 
 ract is then seized with the instrument and withdrawn through 
 the section. Tnis part of the operation sometimes demands 
 great caution, for a large cataract does not readily pass through 
 the pupil. When the extraction is made slowly, the pupil gradu- 
 ally expands, and suffers the cataract to pass, though it some- 
 times appears that the iris is about to be torn from its attach- 
 
51 
 
 menls. The moment the extraction is completed, the assistant 
 allows the lid to fall. 
 
 During the several processes a number of accidents 
 may befall the operator. Thus, if the knife be not placed 
 perpendicularly upon the cornea, it may pass between its 
 lamina and fail to make the required incision. The puncture 
 of the cornea may be followed by the escape of the aque- 
 ous humor, by which means the cornea loses its convexity and 
 is liable to receive a rough incision. The iris likewise, being 
 deprived of its support, may fall forward and be wounded. 
 When the escape of the aqueous humor produces these changes 
 in the situation of the cornea and iris, to guide the knife between 
 them is a delicate task, and the surgeon is involved in the most 
 difficult part of the operation. If the iris fall before the knife, 
 the instrument must be withdrawn. Sometimes stimulating the 
 iris by allowing the lid to fall while the surgeon keeps the knife 
 at rest, and then quickly opening it again, causes a contraction 
 which liberates it from before the edge of the instrument. The 
 same object is sometimes attained by gently rubbing the globe 
 of the eye with the finger nail, or the handle of a cataract nee- 
 dle. Again, when the second puncture of the cornea is to be 
 made, the pressure of the knife may force the globe inward 
 by which means the puncture may not be formed sufficiently 
 near the inner margin of the cornea to afford an ample incision. 
 The corneal section may be followed by prolapsus iridis, which 
 must be returned before the operation can proceed. If the lid 
 be allowed to fall and remain a few moments over the eye, and 
 be then quickly opened towards a strong light, the natural 
 action of the iris may restore it to its place. If this fail it must 
 be returned by means of a curette ; and, finally, when the cata- 
 ract is withdraw!:, prolapsus iridis may again occur, or the 
 \iii' miis humor may escape. The prolapsus must be returned 
 in the same manner as before. Loss of the vitreous humor is 
 of but little consequence* It is quickly reformed, and vision 
 do< - not suffer. To prevent these accidents the precautions 
 given should be carefully followed; the patient should be ope- 
 
52 
 
 rated upon lying on his back, to prevent as far as possible the 
 escape of the vitreous humor ; and, if this do happen, to allow 
 the iris to fall backward ; the assistant should avoid pressing the 
 globe ; and the surgeon should have practised the operation as 
 far as possible on the dead eye, and then operate with firmness 
 and presence of mind. 
 
 Baron Wenzel, is stated to have said, that "before he 
 learned to extract, he had destroyed a hat full of eyes :" and, 
 from the reports of some of the present French surgeons, it 
 would appear that they use still larger measures. The dangers 
 of the operation, together with the greater liability to future 
 inflammation, are considered just reasons for the preference 
 given to depression. 
 
 When extraction is performed, it is generally selected for 
 hard cataracts, though any, but such as are very soft, may be 
 thus removed. In traumatic cataract, where the lens has en- 
 tered the anterior chamber, it is most advantageously employed. 
 When the lens is in this situation, it usually follows the removal 
 of the knife, and the operation is then finished. Sometimes 
 from the collapse of the cornea, it returns to the posterior 
 chamber, and must then be extracted by the hook, or by gentle 
 pressure on the globe. It has, also, been known to escape into the 
 vitreous humor, out of the axis of vision, and be then absorbed. 
 If secondary capsular cataract follow, it may be removed by 
 the operation of absorption. 
 
 The second mode of operating by extraction, is performed in 
 the same manner as the former, except that the section is made 
 in the superior instead of the inferior part of the cornea. It is 
 most highly recommended by Graefe of Berlin, who reports the 
 cure of seventeen out of eighteen cases by this operation. The 
 advantages he attributes to it are, that the aqueous humor is less 
 liable to escape ; and that prolapsus iridis takes place with 
 greater difficulty. 
 
 3. Treatment after the operation. — Within six hours after 
 the operation on a cataract, the eye should be examined, and 
 active treatment be commenced, if the least unfavorable symp» 
 
53 
 
 torn exist. The indication of treatment is to prevent the occur- 
 rence of inflammation ; and not to subdue it when it has once 
 commenced. All the parts wounded in the operation by depres- 
 sion are subject to subsequent inflammation, but its most frequent 
 seat is the iris. If disease in these cases be not checked by 
 energetic management, it proceeds to a destructive extent. 
 Severe iritis, together with external ophthalmia, may be con- 
 joined with amaurosis or glaucoma, giving rise to niuch suffer- 
 ing, and perhaps the loss of the eye. If, then, at the first exami- 
 nation any pain be present in the head, or eye, or any evidence of 
 commencing inflammation be detected, blood should immediately 
 be taken from the arm. If the symptoms be very trivial, the 
 application of cups to the temple, together with an active ca- 
 thartic will suffice. When, however, they manifest any sever- 
 ity, venesection should at once be resorted to. With this, anti- 
 monial solution ; or magnes : sulph : with antimon : tartr : may 
 be prescribed, as the case may require. 
 
 The following formula possesses great power in reducing 
 acute external inflammation of the eye, as of the conjunctiva 
 and cornea. 
 
 Yjc. Magnes : Sulph : § ii. 
 Antimon : Tartr : gr. iii. 
 Aq : Purae § xvi. M. 
 
 Of this §ii may be taken every hour until an emetic and 
 cathartic effect are produced. It should be then discontinued ; 
 and be repeated the first or second day afterwards as occasion 
 may demand. With this, fomentation of the eye with warm 
 water, or the lot : opii should be conjoined. This remedy 
 is much less effectual in iritic inflammation, or any form of in. 
 ternal ophthalmia. 
 
 In very severe iritis it is necessary to obtain the constitu- 
 tional effects of mercury in the most speedy manner. For this 
 purpose the combination of calomel and pulv: antimon: 
 fy. Calomel : gr. ii. 
 
 Pulv: Antimon: gr. iii. M. 
 Fit in pi]. 
 
54 
 
 may be prescribed every third or fourth hour. When the 
 symptoms are less acute, the mercury may be introduced into 
 the system more gradually. Under this treatment the inflam- 
 mation seldom fails to subside. 
 
 The temperature of the patient's apartment should not be 
 disregarded, for exposure to cold is sufficient to thwart the 
 most active, and well-directed remedies. 
 
 A long course of treatment of a general antiphlogistic char- 
 acter sometimes induces a state of debility in which the inflam- 
 mation remains obstinately stationary, or becomes worse ; re- 
 course, in this state, to a tonic regimen, often produces a decided 
 improvement. 
 
 The occurrence of glaucoma, or amaurosis after the opera- 
 tion, may be removed by the same remedies employed for iritis. 
 The actual existence of iritic inflammation must be overcome 
 by the use of mercury in small, often-repeated doses, until it 
 affects the system sufficiently to control the disease. The ac- 
 tion of mercury requires also the aid of frequent cupping, the 
 application of blisters, and strict attention to diet. If either of 
 these affections continue with unusual obstinacy, as sometimes 
 occurs, the application of blisters requires some management- 
 One may be applied over the eyebrow ; and, when after four or 
 five days it has healed, another may be put behind the ear ; a 
 third may be placed on the nape of the neck ; and thus a suc- 
 cession may be used, if necessary, at intervals of a few days. 
 This course obviates the necessity of applying a new blister to 
 an already inflamed surface, and yet maintains an active and 
 constant counter-irritation. 
 
 cThe conjunctival inflammation which follows'an operation is 
 sometimes accompanied with chemosis. This effusion is, how- 
 ever, absorbed as the inflammation is subdued. It does not 
 require that the conjunctiva should be punctured, unless its 
 distention be very great, and threaten to rupture the mem- 
 brane. 
 
 Contraction of the pupil may occur as the sequel of iritis. 
 
55 
 
 In this case, an operation to form an artificial pupil will be 
 necessary. 
 
 Prolapsus iridis occasionally happens a short time after the 
 operation of extraction, exciting inflammation, and causing an 
 adhesion to it of the edges of the cornea. In addition to the 
 general treatment for the inflammation, it will be necessary 
 either to cut oflf the prolapsed portion of iris, with a curved 
 scissors, or to touch it with the argentum nitratum. 
 
 The surgeon should be careful to examine the eye within a 
 short time after an operation of extraction, to ascertain if the 
 edges of the corneal incision be precisely in coaptation. They 
 sometimes become so separated that the inner edge of one flap 
 unites to the external edge of the incised surface on the other. 
 This circumstance creates additional irritation in the wound, 
 protracts the process of adhesion, causes a greater deposition of 
 fibrin, and consequently a larger cicatrice. 
 
 Vomiting, which may happen after an operation, is always 
 a dangerous occurrence. From the violent agitation of the 
 head which it causes, the depressed cataract may again rise to 
 the axis of vision, while the cerebral congestion it occasions, is 
 liable to induce inflammation. It is chiefly incident to old per- 
 sons who have led an intemperate life ; and, if its occurrence 
 could be correctly foretold, would forbid an operation. The 
 vomiting must be allayed by narcotics, or such remedies as the 
 state of the stomach indicates. 
 
 When no untoward symptoms appear, the patient should be 
 kept for a few days in a darkened room ; a shade should be 
 kept before the eye to prevent any sudden admission of light ; 
 his regimen should be of the mildest character ; and the occa- 
 sional use of an aperient should be resorted to. This cautious 
 system should he continued for a couple of weeks, or until the 
 wounds in the eye have entirely united, and all preternatural 
 excitemenl of the organ has subsided. The person may then 
 gradually return to his usual exercise, and diet. Several months 
 should elapse before the "'ye is in any manner tasked. 
 
 Afj now, the natural refracting lens of the eye has been re- 
 
56 
 
 moved, its place must be supplied by one which is artificial 
 A double convex glass, adapted to the patient's vision should 
 be procured, and be constantly worn. Two glasses of different 
 powers are generally required ; one adjusted for distant objects, 
 and one for subjects requiring minute inspection. The use of 
 the glass must not be commenced until every trace of irri- 
 tation be removed, and the eye have regained its natural tonic 
 condition. In regard to the selection of glasses, particular 
 directions cannot be given. The eye must be tried with sev- 
 eral of different power ; and that chosen which enables the 
 patient to see most distinctly, without occasioning any sense of 
 straining, or smarting in the eye. The glasses which most fre- 
 quently suit the eye-fbr reading, are those which have a focus 
 of two or three inches. The focal distances of glasses for gen- 
 eral use vary, in most instances, between three and a half, and 
 five inches. 
 
 Having thus fulfilled, though indifferently, the requisition of 
 the college, it only remains for me to thank the professors for 
 the instruction I have derived from their knowledge ; and to 
 assure them, that the hopes they have expressed for the future 
 success of the graduate, are reciprocated in a sincere wish for 
 their continued prosperity. 
 
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