Ophthalmic surgery : a treatise on surgical operations pertaining to the eye and its appendages, with chapters on para-operative technic and management of instruments
£££^:<^Si$<$$?:$:«£ y> W^^^^^^^^Kf ^^^^S^:^:$:^$^: &8$S8^&«£.;%::*<<'X<N*:< *<• ^^^^<^:^:-^t-::<;:':.:«:':^: f:'^ THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES MicU LoutfalU APR 3o 1943 ^B. Loutfatlak OPHTHALMIC SURGERY BEARD MicU LouifalU OPHTHALMIC SURGERY A TREATISE ON SURGICAL OPERATIONS PERTAINING TO THE EYE AND ITS APPENDAGES, WITH CHAPTERS ON PARA-OPERATIVE TECHNIC AND MANAGEMENT OF INSTRUMENTS BY CHARLES H. BEARD, M. D. SURGEON TO THE ILLINOIS CHARITABLE EYE AND EAR INFIRMARY; OCULIST TO THE PASSAVANT MEMORIAL HOSPITAL, CHICAGO; EX-PRESIDENT OF THE CHICAGO OPHTHALMOLOGICAL SOCIETY; MEMBER OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY, ETC. WITH 9 PLATES, SHOWING 100 INSTRUMENTS AND 300 OTHER ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1910 COPYRIGHT, 1910, BY P. BLAKISTON'S SON & Co i fainted by The Maple Press York. Pa. lef PREFACE. THE selection of the matters discussed in the following pages and the manner of treating them are the results of the careful study and practical application of the involved principles made in hospitals, dispensaries, and in private practice, extending over a period of twenty-six years. They began while the author was a student under Agnew and Knapp, in 1883, were later continued in England and on the Continent of Europe, and have ever since been diligently prosecuted. There has been no separate work on the surgery of the eye published in the United States for nearly half a century, and but little written upon the subject in connection with the more general treatises on ophthalmology, if we except the admirable contribu- tion of Knapp to the System of Norris and Oliver some twelve years ago. The object here has been to supply a work that would embody not only what ^experience has taught and judgment prompted as being the more valued measures of all countries, but, in particular, those of our own country. The presentation of portions devoted to the history of the dif- ferent procedures is deemed of great importance, but to keep them from appearing obtrusive they have been made as concise as practicable. The classification followed has seemed the logical one to adopt. The chapter on the extraction of foreign bodies from the interior of the eye has been placed in a class of its own instead of with the operations upon the globe. In the author's opinion, the VI PREFACE. handling of foreign bodies in the eye is a subject apart, the methods employed in their diagnosis, localization, and extraction involving so much that is not in line with other branches of ophthalmic surgery. In view of the fact that the illustrations have been chiefly the fruits of his individual labor, the writer begs his confreres not to consider them in the light of mere pictures or from the stand- point of artists, but as conceptions of how these things should appear by one with considerable experience in the matters de- picted and with a little facility in the power of delineation. In closing, the author offers his sincere thanks to all others who have been instrumental in supplying whatever of merit this volume contains. CHARLES H. BEARD. Chicago, 1910. LIST OF CONTENTS. CHAPTER I. PAGE PARA-OPERATIVE TECHNIC i The preparation of surgeons, assistants, patient, instruments, and dressings. Sterilization, anesthesia, blood-letting; in short, all appliances, applications, and methods employed in connection with ophthalmic operations and with their after-treatment. CHAPTER II. INSTRUMENTS AND THEIR MANAGEMENT 55 The approved qualities and forms of the instruments used in ophthalmic surgery, and what features are commendable and what objectionable in them, with reasons and explana- tions. Minute descriptions of models, and, in conclusion, the manipulation or handling, and the care or maintenance of eye instruments. CHAPTER III. OPERATIONS UPON THE APPENDAGES OF THE EYE. THE LACRIMAL APPARATUS 123 The surgical treatment of affections of the lacrimal canal, together with detailed descriptions of the principal oper- ations performed upon the entire lacrimal apparatus, both secretory and drainage. CHAPTER IV. THE APPENDAGES CONTINUED. OPERATIONS UPON THE EXTRINSIC MUSCLES OF THE EYE 158 The different kinds of squint and a history of the surgery of the defect. The technic of the leading measures for its correction, including tenotomy, advancement, shortening and lengthening of tendons and check ligaments, and the acci- dents and complications that may occur. Critical consider- ations of methods of advancement. CHAPTER V. THE APPENDAGES CONTINUED. OPERATIONS UPON THE LIDS . . . 206 Eversion, epilation, and electrolysis of cilia, methods for chalazion, canthoplasty, tarsorrhaphy, and epicanthus. vii yiii LIST OF CONTENTS. CHAPTER VI. PAGE THE APPENDAGES CONTINUED. OPERATIONS FOR PTOSIS . • - • 228 Kinds of ptosis, history of the surgical measures devised for it, with the principles underlying them. Descriptions of the technic evolved in the leading methods for righting the fallen lid, and an extended summary dealing with the different procedures and their relative values. CHAPTER VII. THE APPENDAGES CONTINUED. OPERATIONS FOR ENTROPION, ECTROPION AND BLEPHAROPLASTY ............. 250 Operations for spastic entropion, cicatricial entropion and trichiasis, with the history and evolution of such surgery. 'Ectropion, its varieties, such as spastic, mechanical, mucous, atonic, and cicatricial. Blepharoplasty in all its phases, as by sliding and pedunculated flaps, by dermic and epidermic grafts, etc., with exhaustive detail of technic under each of the several headings. CHAPTER VIII. THE APPENDAGES CONTINUED. OPERATIONS UPON THE CONJUNCTIVA. 321 The surgery of partial and total symblepharon, and the restoration of the conjunctival cul-de-sacs. Pterygium, true, false, and recurrent, and appropriate surgical measures for the different kinds, including excision, transplantation, ligation, cauterization, and skin grafting. Peritomy and peridectomy. CHAPTER IX. THE APPENDAGES CONTINUED. THE SURGICAL TREATMENT OF TRACHOMA ...................... . 356 Historical. The classification of methods into mechanical, chemical, and operative. Details of technic relative to each class, as scraping, massage, expression, cauterization, radiation, and excision. The last comprises all forms of excision, whether of conjunctiva alone or of that membrane combined with excision of the tarsus. CHAPTER X. OPERATIONS UPON THE GLOBE 371 These relate first to the outer walls of the globe — comprised by cornea and sclera. Measures for foreign bodies in the cornea, corneal cautery, paracentesis, massage, keratoplasty, anterior staphyloma, conical cornea and tattooage. The scleral surgery includes sclerotomy, anterior and posterior, cyclodialysis, trephining, amputations, exenteration, enuclea- tion, and the substitution of a prothesis in the globe or in Tenon's capsule. Operations upon the iris. Iridotomy, irito-dialysis, irito-ectomy, synechiotomy, and iridectomy in all its forms and phases. LIST OF CONTENTS. IX CHAPTER XI. PAGE OPERATIONS UPON THEGLOBE CONTINUED. EXTRACTION OF CATARACT. 478 Preparation of the patient and of the eye. Description of approved technic for the various forms of extraction. Ex- tended commentary on the accidents and complications incident to extraction, their causes and their remedies. Discission of primary and secondary cataract, couching or depression, and suction. Extraction of the lens in its capsule. The history of extraction and its instrumentation, with concluding dissertation on the modern corneal section. CHAPTER XII. OPERATIONS UPON THE ORBIT 598 The surgery of foreign bodies in the orbit. Kronlein's operation and its modifications. The removal of tumors. Incisions of the orbit evacuant and diagnostic. Exenter- ation, partial and total. CHAPTER XIII. THE REMOVAL OF FOREIGN BODIES FROM THE INTERIOR OF THE EYE . 610 Their abstraction from the anterior chamber; from the iris; from the posterior chamber; from the vitreous chamber. Their localization in the eye and in the orbit. Magnet operations and their technic. CHAPTER XIV. ALPHABETICAL INDEX 659 OPHTHALMIC SURGERY. CHAPTER I. PARA-OPERATIVE TECHNIC. Asepsis. — According to Snellen, all wounds, especially those of the eye, tend to heal per primam intentionem, and it is gratifying to know that the work of the ophthalmic surgeon has made good this assertion. While it is true that this branch of surgery has seemed to profit more than the others by antiseptic measures, yet, when we consider the status of our knowledge of the value and of the means of asepsis, our operative results are a reproach. The fact remains that the vast majority of untoward consequences are due to some form of infection. Thus the advantage is still on the side of the operator who is most thorough and consistent in carrying out antiseptic precautions, rather than on the side of mere skill. Lack of these precautions oft turns into abject failure the most brilliantly executed surgical measure, while attention to them can make a perfect triumph of a wretched bungle. We are in constant need not only of an "antiseptic conscience," but of an aseptic subconsciousness as well. We should acquire a habit of surgical cleanliness and try to impart it to everybody about us. Unless one is broadly grounded in this training, he is being forever the victim of his own anti-climaxes, as, for example, picking his teeth with his finger-nail, scratching his head, or taking an instrument between his lips just after having made the most elaborate and up- to-date preparation for an operation. With some of the older ones the genuine habit is difficult — at times impossible — to attain. With the younger ones it should be easy. The key-note to asepsis is sterilization. This is of two kinds, relative and absolute. The first refers to the preparation of the hands and persons of surgeons, attendants, patients, and of the i 2 PARA-OPERATIVE TECHNIC. parts concerned in the proposed surgical measure. The second is applicable only to inanimate objects, such as instruments, articles used in making applications, the materials for dressings, etc. Obviously vital animal tissue cannot be subjected to this form of sterilization Therefore, in the use of purifying solutions upon it, one is inclined to make up in abundance what is lacking in strength. Preparation of the Hands and Forearms. — It is well to include the hands and arms of the patient as well as those of the operator and all of his aids in this process. They are first scrubbed with good soap, liquid or solid, and tepid water, by means of a brush that is not too stiff. The nails are trimmed, cleaned and scrubbed with the brush. The hands are then rinsed with pure warm water, using the brush. After drying on a sterile towel, they may now be anointed with a mixture of alcohol, glycerin, and one of the highly antiseptic essential oils, as that of cloves or of cinnamon, to be immediately followed by a good rubbing. This has the property of great penetration, entering into the ducts of the sweat and sebaceous glands, and permeating the deeper layers of epithelial masses. Lastly, they are washed lightly in sterile water and wiped perfectly dry on a sterile towel. Allowing the hands to dry spon- taneously is not so cleanly, as the moisture catches dust. The oft- repeated washing of the hands with solutions of irritating antisep- tics like sublimate, formalin, and carbolic acid has the effect of making them sore, and rough with dead epidermis, without in the least rendering them less infectious. A soap impregnated with a grinding material is excellent for hands that are inclined to be rough. Gloves. — The more important and exacting operations upon the eye are performed without the surgeon's fingers ever coming in contact with the field of operation. Hence, the wearing of rubber gloves on his part would be not only uncalled for, but when the extreme exactness of most opthalmic surgery as considered, positively unadvised. For all of his assistants, however, to wear them, were both prudent and desirable. Especially is this true as regards those who make and handle the cotton sponges, or thread, or any object that actually touches the site of operation. Sterilization of Instruments. — There are three methods more or less in use for this purpose, that by dry heat, that by moist heat, and that by strong antiseptics. It need hardly be said that this STERLIZATION OF INSTRUMENTS. 3 proceeding takes place immediately before the operation. When prepared by dry heat the instruments are put into some form of stove or oven, of which there are many efficient kinds on the market. Here they are exposed for twenty minutes, or longer, to a temperature of 300° F. This is applicable to all kinds of instruments, even to those with ivory handles. In winter, or in very moist weather, the door of the oven is left open for a few moments after the heat is started, in order to prevent the quick corrosion of fine edges and points that comes from condensation. Sterilizing in a flame is fatal to any instrument. By Moist Heat. — It is customary to put in this class sterilization by means of live steam, in an autoclave, under pressure. In reality, if carried out to the letter, this is a form of dry sterilization. In this country eye instruments are rarely subjected to this process. The method most in vogue, and most to be recommended is by boiling. Contrary to many adverse statements and comments, I believe this method the best for all kinds of eye instruments. That is, just as appropriate as any for the finer cutting implements. True the instruments must be manufactured with a view to being so treated. They must have metal handles — be all of metal, in fact, and the procedure must be conducted by one who knows and does full duty in the matter. I cannot do better than give a descrip- tion of it as practised in the Illinois Eye and Ear Infirmary. All the more delicate instruments are placed in a metal rack, provided with a handle and with a clamp which holds them securely, the points and edges of the sharp ones having been previously tested on the trial-kid. The rack projects beyond the extremities of the instruments so that they cannot be jammed against the boiler. There is a separate compartment in the boiler for this rack. The coarser and non-cutting articles are dropped carefully into another compartment. The boiler contains a solution of soda or borax, one to two parts per thousand. The presence of the salt serves to elevate the degree of ebullition and to restrain oxidation. The solution is perfect — i.e., there must be none of the salt undissolved. The instruments are not put in until the water reaches the boiling- point. Of course the boiling ceases the moment they are immersed. One waits, then, until it begins again before starting to time the sterilization. The time should not be less than ten minutes. 4 PARA-OPERATIVE TECHNIC. Fifteen would not be too long. The instruments are then lifted out drained, and laid on sterile towels on the trays of the serving tables. It would be well to have a small oven in which to dry them quickly just before using. The plan, so generally followed, of putting them fresh from the boiler into some liquid, there to remain till used, is not cons'stent with good surgery. It is not pleasant to either operator or operated to have water dropping into the eye from the instru- ments; besides, since the sterilization of the hands is only relative, infection could in this way, be carried from the ringers into the wounds. If promptly dried the moment they are removed from the sterilizer one need have no apprehension as to the points and edges of the finest knives. If left in the air, covered writh moisture, oxidation becomes at once very active, and it is precisely the thin edges and sharp points that will suffer most. All sutures are boiled ready threaded in their needles. If to be treated with paraffin, or other waxy material, this is best put on afterward, as the consider- able handling necessitated by the threading is apt to contaminate the suture. By Strong Antiseptics. — This is the least satisfactory method, and must ever be one of expedition, not of choice. It consists in letting the instruments lie for 15 minutes or longer in a bath of one of several liquids. The commoner are 40% formalin, 95% phenol, 95% alcohol, and pure chloroform. They are then taken out and washed in sterile water. This is an uncertain process, for if there be the thinnest possible film of any fatty or albuminous substance on the instrument it acts as a barrier to disinfection. Moreover, all these fluids attack the steel with some degree of activity. This form of sterilization is made much surer by wiping the instruments repeatedly, and hard, with sterile, soft linen just before putting them into the bath. If done intelligently, this also enhances the polish and the keenness of the trenchant articles wiped. It is not a bad idea to have the cloth wet with the antiseptic. It was the practice of Agnew, of New York, to wipe his Graefe knife long and hard with soft linen, before the days of antisepsis, to render it cleaner, brighter and sharper. Preparation of the Patient.— This is divided into general and local. General preparation is of two kinds, physical and mental. General preparation may be begun at an indefinite time previous PREPARATION OF THE PATIENT. 5 to the operation, and should never, in case of major operations, be started less than 24 hours previously. First, on entering the hospi- tal come the taking of the histories, family, personal, and clinical, then the physical examinations, general and local. These include urinalysis, inquiry into the state of circulatory and vascular systems (if subject is not young), nose, throat, lungs, heart, digestion, etc. The bowels are emptied by broken doses of calomel followed by citrate of magnesia or salts, or by castor oil. The diet is liquid or very light. If the operation is to be under narcosis, or if the subject is nervous or apprehensive, it is well to give a small dose of morphin, or chloretone, or bromid of sodium, thirty to forty minutes before the start for the surgical room. The patient is questioned as to cough, and, if general anesthesia is contemplated, as to behavior in any former narcosis. Both eyes and their ap- pendages are thoroughly examined and the results recorded. Partic- ular care is directed to the condition of the pupils, the fundi, the cornea, the conjunctiva and the lacrimal canals. Bacteriologic investigation of even the healthy appearing conjunctiva is of positive advantage in that an incipient pathogenic or pyogenic infection may be discovered and disaster averted by a postponement of the proposed operation. The vision, the refraction, fields, etc., are noted. The subject must be made as clean as possible, but it is best to leave it to the discretion of a trained attendant whether or not regular tub bathing and shampooing be resorted to. Along with all this goes the mental or psychologic preparation. The beauties and advantages of hospital life and treatment are extolled and instructions given as to how best to profit by them, how friendly everyone is to everyone else, etc. Incidentally the patient is put through a system of training in the matter of turning the eyes in various directions, opening and closing them without undue effort, and of having them touched and handled. Unless there is some positive indication, no local preparation is inaugurated prior to one hour, or even 30 minutes, before the operation. The use of antiseptics in the conjunctival sac and of bandages for a day or two before hand is omitted as worse than useless. Much of this subject is given in the Chapter on Extraction. Suffice it to state here that, by way of local preparation the eyelids and surrounding areas are scrubbed with sterile soap and warm water, followed by 6 PARA-OPERATIVE TECHNIC. rinsing with warm sublimate solution 1-2,000, the subject mean- while keeping the eyes tightly shut. The supercilia are not shaved unless extra heavy. The cilia are washed, and the lids manipulated to empty the Meibomian and other ducts along the free borders. The cilia before extractions and iridectomies are coated by wiping them with cotton wet with benzin, and, lastly, the conjunctival sac is copiously douched with w^arm boric acid solution. A light boric acid dressing is then put on the eye and fixed by a simple muslin strip tied on diagonally, to be left till the time for the opera- tion arrives. The hair of women is neatly combed back and braided. The nails are manicured and the hands are scrubbed. The patient is taken to the operating room in night clothing, i.e., all ready for bed. The eye is copiously flooded with warm boric or salt solution before, during, and after the operation. One at- tempts by this liberal use of a mild antiseptic to make up, as it were, for one's inability to employ a strong one. Sterilization of all dressings, such as bandages, cotton, gauze, and of gowns, caps, masks, inhalers, etc., is done by means of the large steam autoclaves. Usually the various articles are done up in stout cotton bags, which are securely tied. They are not removed either from the sterilizer or from the bags until needed. All ap- pliances, applications, implements, and drugs, of whatever descrip- tion, used before, during, or after the operation, are sterilized by either dry or moist heat. Everyone who has a duty to perform in connection \vith an opera- tion is clad in a sterile gown and in a cap to cover the hair. Nurses and aids wear gloves, while the surgeon and his immediate assistant have mouths and beards covered by masks. Surgeon's Operating Masks. — "The principal object of these convenient appliances is to protect the operative field against in- fection from the expiratory efforts of the operator and assistants in talking, coughing, sneezing, etc. They supersede the use, for the same purpose, of plain pieces of gauze tied over the lower part of the face around to the back of the head. By the latter method, however, aside from its being a far less convenient one than the other, to say nothing of the discomfort to the wearer, there was always more or less danger of having the operator's hands con- taminated by coming in contact with the hair while in the act of OPERATING MASKS. 7 tying the gauze at the back of the head. This and other objections to wearing some sort of shield have been done away with by such wire masks as we illustrate; these may be easily attached to the head in a manner similar to spectacles, requiring only the handling of the mask itself, which should be previously sterilized. Wilson, of Bridgeport, has attachments on the mounting of his operating spectacles for holding the gauze mask. "One of the two best-known patterns of these wire masks is that of Mikulicz, which consists of a wire framework so made that FIG. i. — Mikulicz mask. FIG. 2. — Mikulicz mask. when covered with two thicknesses of gauze stitched to all sides, it effectually covers the nose and mouth of the wearer when it is placed in position. It is instantly adjusted to the head, and when not in use a number of them may be nested and temple bars folded over, so as to take up a minimum amount of room. "The other pattern now being rapidly adopted by many leading surgeons and hospitals, as fulfilling the purpose admirably, is known as Tuttle's mask. This is a modification, by Dr. Edward C. Tuttle, of a somewhat similar contrivance used in some European hospitals; and while they are also made of wire, they are different in construction to those first described, as will be seen by comparing the illustrations shown herewith. On these frames the gauze is to be attached only to the upper part, but for the entire length of same, back to the very ends of the temple bars, so as to allow the gauze, after the mask has been put on, to hang down 16 to 18 inches 8 PARA-OPERATIVE TECHNIC. over the front and sides of the head, covering also the ears; the lower part of the gauze is then placed underneath the operating gown before the latter is buttoned up, afford 'ng protection in every needed way. It will be seen that the bottom part of the frame stands out from the lower part of the wearer's face in such a position as to hold the gauze away from it, thereby insuring comfort. "Of the two kinds of masks herein described, the first mentioned has the advantage of being instantly adjusted to the head, whereas the other, even though it may take a trifle longer to put on, is pre- FIG. 3. — Tuttle's mask. FIG. 4. — Tuttle's mask. ferred by many on account of its giving the desired protection in a more complete way. It is well to note that where an operating cap is worn with a Tuttle's Mask, only the eyes and their immediate vicinity are left exposed, while the remaining portions of more than the entire front half of head and neck are completely covered. Furthermore, it should be remembered that both types mentioned are so constructed as not to allow the gauze to rest against the face of wearer, thereby enabling him to feel at perfect ease, which is not the case where gauze alone is worn; also that the wire temple bars may be easily bent, so that the masks can be readily adjusted to fit almost anyone." The Operating Room.— The best sort of operating room, de- scribed in a general way, is one that is dry, commodious, that is well ventilated without opening windows or doors, easily heated in THE OPERATING ROOM. 9 winter, and that has an abundance of light. Particularly desirable is a broad north window. This insures a uniform light without interference by direct sunlight. If this window be set at an angle of 30° to 45°, inclining inward, it is preferable to a perpendicular window. Operations wherein corneal reflections can be a disturb- ing factor are made easier by a window thus inclined. With the patient lying on the table, feet toward the vertical window, as is the favorite position, unless the table be so far removed from the window as to greatly reduce the illumination, the image of the window lies inconveniently high up on the cornea. Now, if the window were tilted toward the table, just in proportion as the slant of the window would increase up to 45°, just in the same degree would the reflex be lowered. This is illustrated by the accompanying drawings. A B FIG. 5. — A, Reflex near vertical window. B, Reflex near inclined window. A and B represent the left eye of a subject lying on a table with feet toward the window. A shows the image of a vertical window and B that of one inclined inward about 40°, the distance of the table from the window being the same in both instances. Next in choice to the inclined window as a source of light is the vertical, though to get the best illumination the table would be placed diagonally, with the foot near the window. A sky-light is not satisfactory. Perhaps the best all-around light is the artificial, for by the use of portable electric phosphores, or other electric hand-lamps, and large biconvex lenses, one can get whatever intensity is desirable, and can cause the reflexes to fall wherever they are least in the way. Walls, ceiling, floor, woodwork and furniture of the room are all white and of materials, or covered with materials, that most readily admit of washing, fumigating, 10 PARA-OPERATIVE TECHNIC. or vigorous disinfection generally. Window shades are of a material easily cleaned, and work from below by heavy gilt (metallic) picture cord, so as to raise the least amount of dust in being put up or down. No pus cases and no re-dressings are allowed in the clean operating room. Anesthesia. — Instead of the classification "local" and "general," it would be simpler and better English to distinguish these two con- ditions by the terms anesthesia, meaning the loss of sensation in any particular part of the body due to the contact of the sensory nerves supplying that part with a drug that causes temporary paralysis, and narcosis, meaning that condition of general stupor and uncon- sciousness, resembling sleep, caused by the wide diffusion of the poisonous drug in the circulation. Thanks to local anesthetics the eye-surgeon is now enabled to dispense with narcosis for the vast majority of operations. Indeed, there is no surgical measure resorted to by the oculist for which narcosis is not, now and then, omitted. Local. — Local anesthesia is produced, in eye surgery, in several ways; as by the instillation of solutions of anesthetics into the con- junctival sac — applicable to operations upon the mucous membrane or upon the globe. Instillation of the same solutions into open surgical wounds — applicable to operations upon the globe or its appendages, and by the infiltration method of Oberst, or the com- bined infiltration and cocain method of Schleich; the last two being applicable only to operations upon the appendages. Another form of local anesthesia proper to mention is that by freezing with the spray of anesthyl or plain chlorid of ethyl or other highly volatile substance. This serves well for the incision of abscesses of the lids or orbit, especially in children or excessively sensitive adults. Of course, the eyeball must be protected from the cold. So far ophthalmic surgeons have had little or nothing to do with the intraneural method of Gushing, and nothing with the spinal anesthesia of Corning and Bier. Of all the local anesthetics cocain, after twenty-five years of trial, still retains its supremacy. Its maximum of efficiency can be obtained with solutions varying in strength from 2 to 4%. Stronger solutions only serve to increase the objectionable qualities of the drug. Holocain stands next in popularity. It is effective ANESTHESIA. II in solution of only i%, and has the advantage of retaining its proper- ties longer than cocain. The chief objections to cocain arise from overdosage or prolonged application. This leads to dryness and desquamation of the corneal epithelium, to dilation or relaxation of the blood-vessels, and to hypotonicity of the globe. The first favors infection, and the last two cause hemorrhage. The third objection is turned to a virtue, however, in glaucoma, where cocain, notwithstanding its mydriatic effect, may be used with impunity not only as an anesthetic, but also as a remedy. The first effects of cocain on the normal eye are contraction of the blood-vessels and perfect anesthesia. Hence, it is most expedient to operate during the primary stage in so far as it is possible. To this end the instillations should not be begun longer than ten minutes before the operation. A good rule is to start the boiling of the instruments and the application of the cocain simultaneously. Four drops with two-minute intervals is sufficient. If the eye be hyperemic it is less susceptible to the drug, but it can be blanched by adrenalin, and then anesthetized. A convenient and highly efficacious form of cocain application is the fresh sterile cocain ointment. This has such staying qualities that a single laying-on is enough. More- over, it is said not to disturb the corneal epithelium when fat instead of water is the vehicle. Ramsay recommends a few drops of 5% chloretone solution, along with the cocain, to offset the harmful results to the epithelium. It has been often denied that there is aught accomplished by dropping cocain into the open wound in operations upon the appendages, but the facts do not seem to up- hold the denial. Infiltration Anesthesia. — It had long been known that a dense infiltration, of the skin, for instance, caused anesthesia of the part. Oberst, in 1889, turned this to account by producing artificial infiltration, by means of a hypodermic syringe and distilled or salt water preparatory to the making of incisions. Schleich, in 1889, went further, and added a modicum of cocain (1/8 to 1/4%) to the fluid for the syringe. Both these methods are rather exten- sively employed in the surgery of the lids. A wheal, or a series of wheals, of edema is raised at the site of the proposed operation by introducing a fine hypodermic needle nearly its whole length into the skin, and gradually withdrawing it as the liquid is injected. 12 PARA- OPERATIVE TECHNIC. To be free from danger, if the Schleich method is used, either the cocain should be in very minute quantity or else the ring of a clamp should be thrown around the wheal to prevent the solution from entering the general circulation. The anesthesia is absolute, but the changed aspect of the tissues, and the swelling, are against the procedure, as is also the greater post-operative reaction which ensues. A good formula for the solution is that of Guttman, of New York, to wit: Natr. chlorid 0.2, cocain hydrobrom. 0.05, aqua destill., 100. Narcosis. — It would seem that there are always to be a certain number of operations, such as iridectomies for acute glaucoma, enucleations, extensive plastic measures, not to speak of those upon the timid and the very young, etc., that must be done under narcosis. How choose a narcotic ? This is a matter that is largely a question of natural selection. That is to say, it is decided mainly by the conditions — the age and physical state of the patient, the character of the operation, etc. My preference would be for ether, preceded by nitrous oxid, all things being equal, but I would not give ether to persons of advanced age with diseased lungs or kidneys or to those with bronchitis. For these, provided the operation were of short duration, I would choose nitrous oxid followed by ethyl chlorid — or even the latter alone — or either alone. Chloroform is the nicest of all narcotics, but the dangers — one death in a little over three thousand — to my mind, more than counterbalance its advantages. Nitrous oxid is the safest, but it is impracticable for any but the briefest operations. Ether is practically as safe — one death in 15,000. The risks with ether are almost nil and those of chloroform are greatly lessened if they are given properly warmed, and after the most approved methods. A tyro ought never to be entrusted with the narcosis, and constant watchfulness is necessary on the part of the most skilled anesthetist. It is important that the psychic state of the subjects be favorable. To this end they are encouraged and cheered in every possible way. In addition to these suggestive measures those who seem to be filled with dread or fright are given a dose of some calming drug — 1/6 to 1/4 gr. of morphin, 5 to 10 grains of chloretone, or 30 gr. of bromid of soda, 45 minutes to one hour before taking the anesthetic. The more composed the patient the more quiet the first stages of the narcosis, INHALER. 13 and the freer the post-narcotic period from nausea. The practice of bringing the patient into the operating room in a perfectly conscious state, there to be confronted by surgeons and attendants, all gowned, and by a great array of paraphernalia suggestive of blood, completely demoralizes certain timid subjects and is much to be deprecated. The narcosis should be produced either in the private room or in a special anesthesia chamber. Above all, perhaps, is the importance of making the period of narcosis as brief as possible. During any operation on the eye, the mucus which so frequently accumulates in the mouth and throat during the administration of ether, is most objectionable, as it necessitates stopping the opera- tion for its removal and endangers the field. This excessive secre- tion may be most effectually prevented by the hypodermic exhibi- tion of atropin sulphate gr. 1/200 to 1/150, combined with morphin sulphate gr. 1/16 to 1/8, about one hour before the operation. Inhalers. — As to inhalers the simplest apparatus is usually the best. The drop method on a simple, gauze covered wire inhaler for ether and chloroform is about as good as any. I prefer Jordan's inhaler for eye operations as there is a notch for the nose at the top, and the handle projects over the chin, thus putting the hand that holds it out of the way. Where this is not at hand, the cone of towel and paper with absorbent cotton to hold the liquid, for ether, or a simple towel or napkin for chloroform, will answer the purpose. The subject is first made to breathe with the inhaler in place, but uncharged with the anesthetic. The latter is then gradually added. Screaming children may have a deep cone, i.e., with plenty of air space, saturated with ether clapped on at once, trusting partly to asphyxia to produce sleep. Along with the tanks of nitrous oxid there is always one of oxygen, and hypodermic syringes are provided, ready loaded with strychnia, brandy, or other stimulants, nor is there wanting the means for making infusion of salt solution. All these things to be used in an emergency must be prepared and on the spot. The patient is carefully watched for an hour or two immediately after the narcosis for the double purpose of noting his physical condition and of preventing injury to the eye or derangement of the dressing by some unconscious act. 14 PARA-OPERATIVE TECHNIC. Dressings. — The materials that compose modern eye-dressings are not of great variety or overnumerous, but their forms and modes of application, at the hands of the different individuals, are diverse as well as interesting. Relatively few seem to be so precise and exacting as a matter of such prime importance demands. If the surgeon himself is negligent and slovenly in this respect what can be expected of other attendants like internes and nurses ? Gauze. — This fabric does not enter so largely into the needs of the opthalmic surgeons as into the requirements of those who practise other branches of the art. It comes in sealed packages, supposedly ready for use, but it is well to sterilize it again if means are at hand for doing so. For the most part plain gauze — not impregnated with any drug — is employed. This should be of soft texture and highly absorbent. Borated gauze is interchangeable with the plain and stands sterilization perfectly. Certain of the impregnated gauzes, however, as the moist ones, lose their properties by the process and must be used directly from the can. lodoform gauze is useful chiefly as a packing, e.g., in the form of tents for abscess cavities. Bichlorid gauze is apt to be irritating, especially to the skin of many patients. Cotton. — The quality of absorbent cotton as found on sale is an uncertain thing unless one knows and can obtain particular brands. The best cotton is white, clean, of long fibre, and is instantly absorbent. It comes neatly laminated, and with the great bulk of the fibres running lengthwise of the bolt or roll. A distinctive feature is its feel. It is clingy to the touch, and when rubbed between the fingers show great friction. Poor cotton is not white, not clean, is shoddy, or of short fibre, is irregularly laminated, and, because of the oil remaining in it, does not readily absorb liquids. To the touch it has a silky feel, and when rubbed between the fingers is slippery. Absorbent cotton is used either plain or borated. It cannot be trusted without being freshly sterilized. The roll of cotton is not made into pieces of appropriate size by cutting, but by pulling. When cut, the edges are too thick and abrupt. Bandages. — These are made of white flannel, gauze, muslin, or netting, cut into strips of suitable width and length. For a pressure bandage flannel is probably the most fitting fabric, because BANDAGING. 15 of its elasticity This same quality makes it objectionable for general use; besides, it is rather warm for summer. Muslin, ex- cept it be of the sleaziest, is too stiff and unyielding. Gauze makes a fine bandage, but to be good it is expensive. The material that seems most nearly to fulfill all requirements is a good quality of white mosquito netting. This was first employed for eye bandages at the Illinois Eye and Ear Infirmary 22 years ago. Its use has now become almost universal in this country. The choicest kind is quite white, is well covered with sizing, has a moderately small mesh, is free from bars of heavier weaving, and costs, now, about 70 cents per bolt. The bolts each contain a single piece eight yards long and two yards wide. The length is just right for one double or for two single bandages. It is so folded that by opening the bolt very slightly one has a strip 1/2 yard by 2 yards, containing sixteen thicknesses. By pinning this to a cloth on a table, it can be cut with heavy shears — or pinned to a regular cutting table, can be more accurately divided with a strong, sharp knife. Thus, a cut of 1 8 inches will make a strip 8 yards long. The strips are exactly three and one-half inches wide They are nicely rolled, and the end fastened \vith a pin. The goods must be folded straight, and the cutting done with exactness, else the bandage will be on the bias and ravel badly. This bandage is applied wet- soaking wret. With a little practice it can be put on quite smoothly. It conforms to the head and, when dry, has staying qualities that are truly remarkable. The netting bandage is never used a second time. In order to remove it from the head it is cut with strong, blunt-pointed scissors just above the unoperated eye, or at the temple. Starch bandages are rarely used in eye practice. There are two forms of bandage, the simple strip, or tie (Fig. 6), and the roller, or full length. The last may be either double or single. For the adult bandage the width is three inches — strip or roller; for children, somewhat narrower. The netting bandage is made wider because, being applied wet, it stretches and grows narrower. The length of the simple tie is about one yard, or meter; that of the roller, four yards. The double eye bandage is, of course, 8 yards long. Bandaging. — This is an art that few acquire to a high degree. Before applying the bandage a proper pad of cotton must be built i6 PARA-OPERATIVE TECHNIC. up over the closed lids. Dry cotton must never come in contact with the bare lids, either in bandaging or wiping an eye, as the loose fibres get into the palpebral fissure and irritate. This does not happen with wet cotton. A thin, gauze-like layer of cotton is lifted from a piece, it is fashioned into a rough square, measuring about two inches each way, dropped into a pan of boric acid solution, taken FIG. 6. — Netting strip. Also first step in application of collodion bandage. up dripping wet and applied to the gently closed lids, with the fibres running vertically — i.e., athwart the palpebral fissure. Thus, each fibre helps to hold the lids together. This veil-like piece of cotton is smoothed down — squeegeed, as it were — on the skin, by gentle touches with the bulbs of the finger. On this is built, in a number of successive layers, a generous pad of dry cotton, being careful to fill in, first, the deeper depression around the globe. The BANDAGING. 17 pad is not built straight out, i.e. — perpendicular to the plane of the front face — but inclined toward the temple, for the reason that the first turn of the bandage, coming as it does, from beneath the ear on that side, would, in the first instance, pull the pile of cotto over onto nose and forehead. It is highly imprudent and bungling to dab the whole quantity of dry cotton on in one big wad. The FIG. 7. — Collodionized netting bandage. greatest pressure is thus brought to bear upon the cornea alone, instead of being evenly distributed over the lids and globe as when the pad is properly built on. If it is to be a tie bandage, the strip is laid, near its middle, onto the pad of cotton, and diagonally, one end passing beneath the ear on the same side, and the other up-over the forehead on the opposite side, then the ends are brought to- gether and snugly tied a little to one side of the top of the head. l8 PARA-OPERATIVE TECHNIC. 