IpmiHttiomi of Judical ^oqiqticji. CALCUTTA MEDICAL SOCIETY. At
a
recent
meeting of the above Society
at the
Medical College Hospital, Dr. Dehknduonath Roy, the Vice-President, occupied the chair.
In the absence of Dr. M. Gupta, Dr. K. Das " A Method of read the following paper on in Senile Cataracts." Operating ON A METHOD OF OPERATING IN SENILE
CATARACTS.
By Asst.-Surgeon Monomohun Gupta, l.m.s., Late House Surgeon, Eye Infirmary, Medical College Hospital, Offg. Civil Medical Officer, Balasore. THE remarkable success which attends Dr. Sanders's operations for cataract at the Eye Infirmary, Medical College Hospital, prompts me to publish the method of operation with its after-treatment, as practised by him in that hospital. The subject may be conveniently described under the following heads: /. Selection of patients.?As to the general health of the patieDt, it is desirable, asas in every other surgical operation, possible. that it should be as good Diabetes is no contra-indication ; heart disease, anaemia obstacles form ; person's over eighty years any and age do not have been successfully operated on. Patients suffering from chronic Bright's disease, with a large quantity of albumen in the urine, are to be rejected, as in these cases there is a of the cornea; and, further, the great danger of sloughing operation might be rendered unsuccessful by the case being with retinal previous changes. complicated As to the condition of the eye itself, it should be asceris cataract the that quite mature by the aid of the tained
Feb.1898
TRANSACTIONS OF CALCUTTA MEDICAL SOCIETY.
]
The eye should be carefully examined for intra-ocular diseases. It is the usual practice here to examine the fundus of every patient suffering from incipient cataract, and to note down the result in his ticket for future reference. When the lens of the eye to be operated on is too opaque for ophthalmoscopic examination, we may sometimes get some useful information by examining the fundus of the other eye. But, unfortunately, we often get cases with advanced mature cataract in both eyes. In such cases, our chief reliance is on the patient's perception of light. This should be examined with the utmost care. In an uncomplicated case of cataract of the most opaque kind, perception of light is al-
ophthalmoscope.
ways
present.
The
drooping head, the wrinkled forehead, and the cautious walking of a cataract case, may be well contrasted with the erect head, the vacant staring look, and the peculiar walk, of a case complicated with serious changes in the fundus. The condition of the appendages of the eye should be examined. Granular ophthalmia, conjunctivitis and diseases of the lachrymal passages should be cured or relieved as much as possible before the operation is undertaken. Successful operation may, however, be performed in the presence of slight
granular ophthalmia.
Of other minor complaints, cough, if troublesome, will have to be relieved before the operation. II. Preparation of the patient.?Soon after admission into the hospital, the patient is given a good bath (preferably a hot one), and his clothes are changed. Whenever possible, the patient is allowed to rest for three four days or more before the operation. or This is all the more important in the case of the half-starved patients, that we often get here. During this period boric acid lotion (gr. viii to 1 oz.) is dropped into both eyes three times a day. On the day previous to the operation, a mild purgative is given, and atropine lotion (gr. ii to 1 oz.) is dropped into the eye thrice daily. On the previous evening and on the morning of the operation, the eye and its neighbouring parts, especially the inner and outer canthi of each eye are thoroughly washed with tepid boric lotion. Bichloride of mercury lotion is never used, as it always excites some irritation in the eye and tends to produce some haziness of the cornea. A few minutes before the operation, while the instruments are being prepared, a few drops of cocain solution (gr. xvi to 1 oz. freshly prepared with boiled distilled water) are dropped into the eye at intervals of a few minutes; care being taken not to drop too much of cocain, as when put in excess it has a tendency to lower the vitality of the cornea, which is so important for subsequent
healing.
III. Instruments, dressings and lotions to be kept ready .?A lid spring top speculum (Weiss), one fixation forceps (with double teeth by Francis, without a spring catch), von Graefe's cataract knife?as sharp as possible,?curette, cystitome (Graefe's), and a hard rubber spoon ; and in case there be occasion to use it, a bent iris forceps, iris scissors and a scoop. Preferably these instruments should be by Weiss. During the whole period of operation, a small quantity of boric lotion is kept boiling in a small toy degchi on a retortstand heated with the flame of a spirit lamp. The instruments is are kept in a clean, dry porcelain dish, and each of them dipped into the boiling lotion just before use. The instruments are boiled every time they are used. (Before the instruments are finally put back in the box, each of them is boiled, carefully dried, and dipped into absolute alcohol.) Small bits of sponge or absorbent cotton-wool are kept wet with tepid boric lotion in a clean porcelain cup. These are used to wipe away discharges, cortical masses, &c., from the conjunctiva and are not used a second time. The assistant hands over each instrument in its turn in such a manner as to make it unnecessary for the operator to look away from the field of operation. for As to dressings : two pads of sal alembroth wool (one each eye), a little sanitas vaseline and soft muslin roller The following eye lotions should are all that is are
be
kept
required.
in readiness 1.
Sol.
:
atrophia; sulph. (gr. sulph. (gr. ii
iv to 1 oz.)
to 1 oz.) IV. The position of the patient?The patient lies down jus he>au on a table or couch of convenient height, with of nis resting on a pillow high enough to make the plane face horizontal. In hospital practice where several patients to are to be operated on at the same time, it is a good plan tne spread a canvas stretcher over the table, so that when bed his to operation is over the patient can be easily carried without the least exertion on his part. The table should be so arranged that good light falls on the patient's face, and no shadow is cast on it by the operator's hand. Direct sunlight and draughts are to be carefully avoided. In case of deficiency of light, an assistant can reflect light with an ordinary hand mirror. 2.
Sol. eserine
73
The operation.? The operation usually performed here goes name of von Graefe's modified method. Iridectomy isnot performed as a routine practice. In cases complicated with posterior synechia), or where there is any excess of intraocular tension, or where the lens is unusually big, iridectomy is performed. Just before the operation, the operator and his assistant wash their hands with antiseptic soap and water. While the instruments are being made ready the cocain drops are put in. Generally three instillations of a few drops each are quite sufficient to produce the necessary anaesthesia. Sometimes for nervous patients it is better to put a few drops of cocain lotion in the other eye also. The head of the patient should be covered with a clean towel. The patient is directed to look downwards with his mouth slightly open; he is not to strain or make himself stiff in any way. The operator stands behind the patient, and the speculum is applied. He holds the knife in the right hand for the right eye, and in the left for the left eye, and with the other hand he holds the fixation forceps. The globe is seized and drawn slightly downwai'ds by the conjunctiva and subconjunctival tissues close to the cornea on its outer side, a little below the termination of its vertical axis. The forceps should be held at right angles to the surface of the globe, drawing the conjunctiva away from its surface, and it should exert no pressure over the eye-ball. The section is made on the upper edge of the clear cornea " The so as to include about two-fifths of its circumference. precise length of the incision, as determined by the points at modified in accorbe should puncture and counter-puncture dance with the surgeon's estimate of the diameter of the hard nucleus." The point of the knife is entered in the margin of the clear cornea just in front of the sclero-corneal margin and is first directed towai-ds the centre of the eye-ball; and as soon as the anterior chamber is reached, the handle of the lcnife is depressed and the blade is carried across in front of the iris, so as to transfix the cornea at the same level as its point at entrance. By a few gentle sawing movements of the knife the incision is completed, keeping the edge of the knife well Just before the completion upon the border of the cornea. of the section, as the knife is cutting its way out, its edge is that the middle of the incision sloped a little forwards?so is on a slightly anterior plane to that of either end. By this procedure a little lid is formed, which helps so much in the ready union of the wound. It will be observed that the incision is confined strictly within the corneal tissue. In case of cataracts with milky cortex, the section should be smaller as the nucleus is always a small one. 2nd stage: Capsulotomy.?Now the surgeon puts away his knife and introduces the cystitome flatwise. With the blunt angle of its end first, keeping it well up, close to the posterior Then the instrument is turned so surface of the cornea. that its point is directed towards the lens, and the capsule is torn freely by a few gentle rounded movements. During this process, the cystitome should be held in a slightly oblique manner, and it should not dig into the lens, as then it is apt to dislocate it. The cystitome is withdrawn sideways with its blunt end directed towards the wound. No sooner is the capsule torn than the lens advances forwards, distending the enlarged pupil before it. Third stage: Delivery of Cataract.?Now the patient is directed to look downwards towards his feet, avoiding all efforts at straining. The eye is steadied as before by the fixation forceps, care being taken that it does not exert any pressure over the globe. The convex surface of a shell spoon is now laid against the lower part of the cornea, corresponding with the lower margin of the lens, and firm and at the same time gentle pressure is applied, at first in a backward direction, so as to cause the lens to rotate on its horizontal axis and to present its upper margin at the wound ; then the pressure is changed into a backward and upward direction, so as to coax the cataract out. As soon as the diameter of the lens has passed through, the pressure is relaxed, and as the cataract slips through the wound, the spoon is made tofollow it. With a bit of wet sponge or with the back of the shell spoon, any cortical fragments at the margin of the incision are swept off. Now, at this stage, sometimes a bit of iris is found to be protruding through the wound. This should be at once reposed by gently separating the lips of the wound with the edge of the spoon or with a spatula. The proper management of pressure is indeed a very important portion of the operation, and can only be learnt by experience. In inexperienced hands the escape of the vitreous with consequent loss of the eye is mainly due to improperly applied pressure. Dr. Carter'truly remarks that "the proper management of pressure is the last attainment of operator for cataract." Fourth stage or toilette of the wound.?After the delivery of the cataract, the cortical masses are removed in the same manner as the lens by gentle pressure with the curette or
by the
74
INDIAN MEDICAL GAZETTE.
with a, bit of wet sponge. To press the cortical matter oat, the pressure should be directed backwards and slightly upwards. Any cortical masses sticking inside the anterior chamber or at the upper part close to the section are removed by introducing the curette and drawing them out. In this stage, if the capsule is seen to be opaque, it is gently pulled Thus the pupil is freed out with a pair of bent iris forceps. of everything till it becomes quite black, and the vision becomes such that he is able to count fingers at several feet. Now, if the patientbegins to move his eye about, or to strain (as he often does at this stage), it is wiser to take off the speculum and to leave the eye-lids to the charge of the assistant, as the speculum always exerts a certain amount of pressure on the eye-ball, and more so when the eye is moved in different directions, and this pressure is quit'e enough to rupture the hyaloid membrane and cause an escape of the vitreous. As to the introduction of scoop and other instruments into the anterior chamber, it might be said that the fewer the number of times instruments are introduced inside the eye the better. The less the eye is handled, the quicker the wound heals, and the less the chance of complications. In experienced hands, one introduction of the curette is quite enough to clear the pupil. Sometimes a second introduction becomes necessary. After this, the wound itself will have to be seen too. If the pupil is noticed to be irregular or not quite round, then it will be soon found that a fold of the iris This is easily is caught between the lips of the wound. remedied by separating the lips of the wound with a curette to its falls back at once iris or spatula, and the original position by its own elasticity. Then the wound should be freed from any tag of capsule adhering to the wound. Now the conjunctival sac is thoroughly cleansed of cortical masses, &c., and both eyes are closed. If there be much contraction of the pupil or if there be any suspicion of a bit of cortex having been left behind,a drop of atropine lotion is put in over the closed lids,a circular piece of soft muslin (big enough to cover both the lids) smeared with sanitas vaseline or pure vaseline is placed, and moulded to them in such a manner as to be without a wrinkle. Over it a small ball of sal alembroth wool big enough to cover the lids is placed ; over the other eye also a pad of sal alembroth wool is put and a figure of 8 bandage is applied, and the patient is put to bed. The vaseline prevents the dressing from becoming hard or from sticking to the skin of the lids, and makes it easy to take off the first
dressing.
The patient is not allowed to move about, or sit up in the bed or strain or to talk much for the first 24 hours. He is kept on slops for the first 48 hours, after which he is allowed soft food, and to sit up a little in bed. If the patient happens to be very feeble, he is allowed a couple of ounces of brandy for the first three or four days. Dressing. ?After 24 hours the first dressings are changed. If everything goes on well, the examination of the eye is put off till the fifth morning. Swelling of the lids, cliemosis, watery, or muco-purulent discharge or pain in the eye-ball call for an early examination and appropriate treatment. At the first and subsequent dressings, the lids are freely douched with tepid boric lotion and a drop of atropine lotion is instilled. Subsequent dressings are made every 24 hours. Both eyes are kept closed with light pads of sal alembroth wool till the fifth morning, when, if the case has been progressing normally, the wound is found to have united, the pupil is dilated and black with only a slight ring of redness round the cornea. From the fifth day, the eye operated on is kept closed with a lio-ht pad and bandage. This is continued as long as tliere? is much congestion. Afterwards a green shade is put on. Before concluding, I desire to expre.ss my indebtedness to Bde.-Surgn.-Lieut.-Col. R. C. Sanders for kindly permitting me to publish this paper, and also for going over the
manuscript.
The Chairman thanked Dr. Gupta for communicating to the Society the above eminently practical paper, recording as it did, in detail, the method of operation adopted by such an eminent and experienced Ophthalmic Surgeon as Dr.
sianders.
[Fkb.
1898.
a
recent
meeting of the above Society
at the
Medical College Hospital, Dr. Dehknduonath Roy, the Vice-President, occupied the chair.
In the absence of Dr. M. Gupta, Dr. K. Das " A Method of read the following paper on in Senile Cataracts." Operating ON A METHOD OF OPERATING IN SENILE
CATARACTS.
By Asst.-Surgeon Monomohun Gupta, l.m.s., Late House Surgeon, Eye Infirmary, Medical College Hospital, Offg. Civil Medical Officer, Balasore. THE remarkable success which attends Dr. Sanders's operations for cataract at the Eye Infirmary, Medical College Hospital, prompts me to publish the method of operation with its after-treatment, as practised by him in that hospital. The subject may be conveniently described under the following heads: /. Selection of patients.?As to the general health of the patieDt, it is desirable, asas in every other surgical operation, possible. that it should be as good Diabetes is no contra-indication ; heart disease, anaemia obstacles form ; person's over eighty years any and age do not have been successfully operated on. Patients suffering from chronic Bright's disease, with a large quantity of albumen in the urine, are to be rejected, as in these cases there is a of the cornea; and, further, the great danger of sloughing operation might be rendered unsuccessful by the case being with retinal previous changes. complicated As to the condition of the eye itself, it should be asceris cataract the that quite mature by the aid of the tained
Feb.1898
TRANSACTIONS OF CALCUTTA MEDICAL SOCIETY.
]
The eye should be carefully examined for intra-ocular diseases. It is the usual practice here to examine the fundus of every patient suffering from incipient cataract, and to note down the result in his ticket for future reference. When the lens of the eye to be operated on is too opaque for ophthalmoscopic examination, we may sometimes get some useful information by examining the fundus of the other eye. But, unfortunately, we often get cases with advanced mature cataract in both eyes. In such cases, our chief reliance is on the patient's perception of light. This should be examined with the utmost care. In an uncomplicated case of cataract of the most opaque kind, perception of light is al-
ophthalmoscope.
ways
present.
The
drooping head, the wrinkled forehead, and the cautious walking of a cataract case, may be well contrasted with the erect head, the vacant staring look, and the peculiar walk, of a case complicated with serious changes in the fundus. The condition of the appendages of the eye should be examined. Granular ophthalmia, conjunctivitis and diseases of the lachrymal passages should be cured or relieved as much as possible before the operation is undertaken. Successful operation may, however, be performed in the presence of slight
granular ophthalmia.
Of other minor complaints, cough, if troublesome, will have to be relieved before the operation. II. Preparation of the patient.?Soon after admission into the hospital, the patient is given a good bath (preferably a hot one), and his clothes are changed. Whenever possible, the patient is allowed to rest for three four days or more before the operation. or This is all the more important in the case of the half-starved patients, that we often get here. During this period boric acid lotion (gr. viii to 1 oz.) is dropped into both eyes three times a day. On the day previous to the operation, a mild purgative is given, and atropine lotion (gr. ii to 1 oz.) is dropped into the eye thrice daily. On the previous evening and on the morning of the operation, the eye and its neighbouring parts, especially the inner and outer canthi of each eye are thoroughly washed with tepid boric lotion. Bichloride of mercury lotion is never used, as it always excites some irritation in the eye and tends to produce some haziness of the cornea. A few minutes before the operation, while the instruments are being prepared, a few drops of cocain solution (gr. xvi to 1 oz. freshly prepared with boiled distilled water) are dropped into the eye at intervals of a few minutes; care being taken not to drop too much of cocain, as when put in excess it has a tendency to lower the vitality of the cornea, which is so important for subsequent
healing.
III. Instruments, dressings and lotions to be kept ready .?A lid spring top speculum (Weiss), one fixation forceps (with double teeth by Francis, without a spring catch), von Graefe's cataract knife?as sharp as possible,?curette, cystitome (Graefe's), and a hard rubber spoon ; and in case there be occasion to use it, a bent iris forceps, iris scissors and a scoop. Preferably these instruments should be by Weiss. During the whole period of operation, a small quantity of boric lotion is kept boiling in a small toy degchi on a retortstand heated with the flame of a spirit lamp. The instruments is are kept in a clean, dry porcelain dish, and each of them dipped into the boiling lotion just before use. The instruments are boiled every time they are used. (Before the instruments are finally put back in the box, each of them is boiled, carefully dried, and dipped into absolute alcohol.) Small bits of sponge or absorbent cotton-wool are kept wet with tepid boric lotion in a clean porcelain cup. These are used to wipe away discharges, cortical masses, &c., from the conjunctiva and are not used a second time. The assistant hands over each instrument in its turn in such a manner as to make it unnecessary for the operator to look away from the field of operation. for As to dressings : two pads of sal alembroth wool (one each eye), a little sanitas vaseline and soft muslin roller The following eye lotions should are all that is are
be
kept
required.
in readiness 1.
Sol.
:
atrophia; sulph. (gr. sulph. (gr. ii
iv to 1 oz.)
to 1 oz.) IV. The position of the patient?The patient lies down jus he>au on a table or couch of convenient height, with of nis resting on a pillow high enough to make the plane face horizontal. In hospital practice where several patients to are to be operated on at the same time, it is a good plan tne spread a canvas stretcher over the table, so that when bed his to operation is over the patient can be easily carried without the least exertion on his part. The table should be so arranged that good light falls on the patient's face, and no shadow is cast on it by the operator's hand. Direct sunlight and draughts are to be carefully avoided. In case of deficiency of light, an assistant can reflect light with an ordinary hand mirror. 2.
Sol. eserine
73
The operation.? The operation usually performed here goes name of von Graefe's modified method. Iridectomy isnot performed as a routine practice. In cases complicated with posterior synechia), or where there is any excess of intraocular tension, or where the lens is unusually big, iridectomy is performed. Just before the operation, the operator and his assistant wash their hands with antiseptic soap and water. While the instruments are being made ready the cocain drops are put in. Generally three instillations of a few drops each are quite sufficient to produce the necessary anaesthesia. Sometimes for nervous patients it is better to put a few drops of cocain lotion in the other eye also. The head of the patient should be covered with a clean towel. The patient is directed to look downwards with his mouth slightly open; he is not to strain or make himself stiff in any way. The operator stands behind the patient, and the speculum is applied. He holds the knife in the right hand for the right eye, and in the left for the left eye, and with the other hand he holds the fixation forceps. The globe is seized and drawn slightly downwai'ds by the conjunctiva and subconjunctival tissues close to the cornea on its outer side, a little below the termination of its vertical axis. The forceps should be held at right angles to the surface of the globe, drawing the conjunctiva away from its surface, and it should exert no pressure over the eye-ball. The section is made on the upper edge of the clear cornea " The so as to include about two-fifths of its circumference. precise length of the incision, as determined by the points at modified in accorbe should puncture and counter-puncture dance with the surgeon's estimate of the diameter of the hard nucleus." The point of the knife is entered in the margin of the clear cornea just in front of the sclero-corneal margin and is first directed towai-ds the centre of the eye-ball; and as soon as the anterior chamber is reached, the handle of the lcnife is depressed and the blade is carried across in front of the iris, so as to transfix the cornea at the same level as its point at entrance. By a few gentle sawing movements of the knife the incision is completed, keeping the edge of the knife well Just before the completion upon the border of the cornea. of the section, as the knife is cutting its way out, its edge is that the middle of the incision sloped a little forwards?so is on a slightly anterior plane to that of either end. By this procedure a little lid is formed, which helps so much in the ready union of the wound. It will be observed that the incision is confined strictly within the corneal tissue. In case of cataracts with milky cortex, the section should be smaller as the nucleus is always a small one. 2nd stage: Capsulotomy.?Now the surgeon puts away his knife and introduces the cystitome flatwise. With the blunt angle of its end first, keeping it well up, close to the posterior Then the instrument is turned so surface of the cornea. that its point is directed towards the lens, and the capsule is torn freely by a few gentle rounded movements. During this process, the cystitome should be held in a slightly oblique manner, and it should not dig into the lens, as then it is apt to dislocate it. The cystitome is withdrawn sideways with its blunt end directed towards the wound. No sooner is the capsule torn than the lens advances forwards, distending the enlarged pupil before it. Third stage: Delivery of Cataract.?Now the patient is directed to look downwards towards his feet, avoiding all efforts at straining. The eye is steadied as before by the fixation forceps, care being taken that it does not exert any pressure over the globe. The convex surface of a shell spoon is now laid against the lower part of the cornea, corresponding with the lower margin of the lens, and firm and at the same time gentle pressure is applied, at first in a backward direction, so as to cause the lens to rotate on its horizontal axis and to present its upper margin at the wound ; then the pressure is changed into a backward and upward direction, so as to coax the cataract out. As soon as the diameter of the lens has passed through, the pressure is relaxed, and as the cataract slips through the wound, the spoon is made tofollow it. With a bit of wet sponge or with the back of the shell spoon, any cortical fragments at the margin of the incision are swept off. Now, at this stage, sometimes a bit of iris is found to be protruding through the wound. This should be at once reposed by gently separating the lips of the wound with the edge of the spoon or with a spatula. The proper management of pressure is indeed a very important portion of the operation, and can only be learnt by experience. In inexperienced hands the escape of the vitreous with consequent loss of the eye is mainly due to improperly applied pressure. Dr. Carter'truly remarks that "the proper management of pressure is the last attainment of operator for cataract." Fourth stage or toilette of the wound.?After the delivery of the cataract, the cortical masses are removed in the same manner as the lens by gentle pressure with the curette or
by the
74
INDIAN MEDICAL GAZETTE.
with a, bit of wet sponge. To press the cortical matter oat, the pressure should be directed backwards and slightly upwards. Any cortical masses sticking inside the anterior chamber or at the upper part close to the section are removed by introducing the curette and drawing them out. In this stage, if the capsule is seen to be opaque, it is gently pulled Thus the pupil is freed out with a pair of bent iris forceps. of everything till it becomes quite black, and the vision becomes such that he is able to count fingers at several feet. Now, if the patientbegins to move his eye about, or to strain (as he often does at this stage), it is wiser to take off the speculum and to leave the eye-lids to the charge of the assistant, as the speculum always exerts a certain amount of pressure on the eye-ball, and more so when the eye is moved in different directions, and this pressure is quit'e enough to rupture the hyaloid membrane and cause an escape of the vitreous. As to the introduction of scoop and other instruments into the anterior chamber, it might be said that the fewer the number of times instruments are introduced inside the eye the better. The less the eye is handled, the quicker the wound heals, and the less the chance of complications. In experienced hands, one introduction of the curette is quite enough to clear the pupil. Sometimes a second introduction becomes necessary. After this, the wound itself will have to be seen too. If the pupil is noticed to be irregular or not quite round, then it will be soon found that a fold of the iris This is easily is caught between the lips of the wound. remedied by separating the lips of the wound with a curette to its falls back at once iris or spatula, and the original position by its own elasticity. Then the wound should be freed from any tag of capsule adhering to the wound. Now the conjunctival sac is thoroughly cleansed of cortical masses, &c., and both eyes are closed. If there be much contraction of the pupil or if there be any suspicion of a bit of cortex having been left behind,a drop of atropine lotion is put in over the closed lids,a circular piece of soft muslin (big enough to cover both the lids) smeared with sanitas vaseline or pure vaseline is placed, and moulded to them in such a manner as to be without a wrinkle. Over it a small ball of sal alembroth wool big enough to cover the lids is placed ; over the other eye also a pad of sal alembroth wool is put and a figure of 8 bandage is applied, and the patient is put to bed. The vaseline prevents the dressing from becoming hard or from sticking to the skin of the lids, and makes it easy to take off the first
dressing.
The patient is not allowed to move about, or sit up in the bed or strain or to talk much for the first 24 hours. He is kept on slops for the first 48 hours, after which he is allowed soft food, and to sit up a little in bed. If the patient happens to be very feeble, he is allowed a couple of ounces of brandy for the first three or four days. Dressing. ?After 24 hours the first dressings are changed. If everything goes on well, the examination of the eye is put off till the fifth morning. Swelling of the lids, cliemosis, watery, or muco-purulent discharge or pain in the eye-ball call for an early examination and appropriate treatment. At the first and subsequent dressings, the lids are freely douched with tepid boric lotion and a drop of atropine lotion is instilled. Subsequent dressings are made every 24 hours. Both eyes are kept closed with light pads of sal alembroth wool till the fifth morning, when, if the case has been progressing normally, the wound is found to have united, the pupil is dilated and black with only a slight ring of redness round the cornea. From the fifth day, the eye operated on is kept closed with a lio-ht pad and bandage. This is continued as long as tliere? is much congestion. Afterwards a green shade is put on. Before concluding, I desire to expre.ss my indebtedness to Bde.-Surgn.-Lieut.-Col. R. C. Sanders for kindly permitting me to publish this paper, and also for going over the
manuscript.
The Chairman thanked Dr. Gupta for communicating to the Society the above eminently practical paper, recording as it did, in detail, the method of operation adopted by such an eminent and experienced Ophthalmic Surgeon as Dr.
sianders.
[Fkb.
1898.
