LIPPINCOTT: Imgation of the..Anterior Chamber.
341
IRRIGATION OF THE ANTERIOR CHAMBER-A NEW SYRINGE FOR EFFECTING IT. BY J. A. LIPPINCOTT, M.D., PITTSBURGH, PENN.
SINCE McKeown five years ago introduced the procedure of syringing out the anterior chamber in operating for cataract, this method of removing cortical remains has been adopted by distinguished operators in different parts of the world. But the number of those who use the intraocular syringe is up to the present time quite limited, and the value of this recent addition to our armamentarium is still regarded by many as doubtful. My own experience is not extensive enough to form a basis on which to formulate very positive opinions. Nevertheless, I beg to present it as so much evidence on the general question as to whether syringing out the anterior chamber is a justifiable or useful measure. During the past seven months I have used the syringe in fifteen cataract extractions. Of these cases five were hypermature, .eight were mature, one was glaucomatous, and one traumatic. In two of the cases the cortical had become so softened that when the nucleus escaped, the great mass of the lens remained behind, filling up the pupillary area, and practically leaving the vision as bad as before touching the eye. In the mature cases more or less cortical matter remained. As to visual results: In 2 cases, S. (corrected) = 20/xx. In 2 cases, S. (corrected) =20/xx . In 3 cases, S. (corrected) = 20/Xxx. In 3 cases, S. (corrected)= 20/XL. In 2 cases, S. (corrected)=20/LX. In i case, S. (corrected)-=20/LXXX. In I case, S. (corrected)--8/c. In the remaining case the extraction was made a week ago, at a distance, and the corrected vision cannot be given.; but the operation was absolutely smooth, and the immediate visual result was all that could be desired. Of the two instances in which Vn. = 20/LX one was a case of
342
LIPPiNCOTT: Irrigation of the Anterior Chazmber.
traumatic cataract with a broad anterior synechia requiring an extensive iridotomy before washing out the lens-matter. The other was a case of glaucoma the progress of which had been previously checked by an iridectomy. In adjusting the glasses the media were found perfectly clear, the impairment of vision being accounted for by well marked glaucomatous changes in the disc. In the worst two cases, with vision respectively 20/Lxxx and 8/c, the media were also clear, and the imperfect vision found to be due to atrophy of the optic nerves. In but one case was it necessary to do a second operation., In this case the posterior capsule was so thick and tough that puncturing it effected no material benefit, and the dense membrane was removed with the forceps. The above facts and statistics are not presented as particularly brilliant evidence of the value of the intraocular syringe in cataract extraction, but they may be regarded as tending to show at least that the employment of this instrument is attended with no radical disadvantages. As a matter of fact, I think we are guided in deciding on the relative merits of different methods not so much by masses of statistics, as by close observation of particular cases and circumstances. Looking at the matter from this point of view, whoever uses the intraocular syringe must be convinced that we have in it a means of removing lenticular debris from the anterior chamber tuto, cito et jucuinde. Especially is its usefulness apparent in those cases in which the cortical has degenerated into a more or less liquid state. In these cases, and even in extracting cataracts whose peripheral layers are not speciallv soft, a certain amount of cortical frequently remains after as long and thorough stroking of the cornea as may be considered safe. The residual debris may indeed not be abundant enough to very seriously obstruct vision, and the pupil may look fairly black in good daylight, but the fierce light from the electric lamp reveals a grey film which, on the introduction of the syringe, at once disappears, leaving an unobstructed pupil. Beside cataractous debris, clotted or liquid blood may be removed in the manner we are considering, more easily and per. fectly than in any other way. Every one knows how innocuous and how readily absorbed is even a notable quantity of blood in
LiPPINCOTT: Irrigationl of the Anteror Chiamber.
343
the anterior chamber if the lens capsule is unbroken. But my experience leads me to believe that blood remaining in the eye after removal of the lens is not so readily disposed of, but leads to irritation and inflammation of the iris,-and consequent lessening of the visual acuity. The intraocular syringe has been employed not only in cataract extraction, but also in removing collections of pus from within the eye. The two following cases illustrate its advantages in this regard. CASE i.-J. B., aet. 12, presented himself at my office on the afternoon of February 4, I889, with his right eyeball intensely red, and a hypopyon five mm. wide at its center, while the aqueous was decidedly turbid. There was a broad posterior synechia in the lower outer region. A small scar was seen on the cornea opposite the adhesion. The boy had been struck in the eye with a flying splinter eight days before, while chopping wood. The patient was sent to the Allegheny General Hospital; and the same evening an incision was made under ether at the corneal margin opposite the synechia. With the exit of the aqueous a small quantity of the pus also escaped. The adherent portion of the iris was now seized, torn from its attachment,.and snipped off, whereupon some soft opaque lens-matter appeared in the wound. The removal of the segment of iris also disclosed the fact that a considerable quantity of pus lay in the posterior chamber. Up to this time I had never seen or made use of McKeown's method, and I was not prepared with a suitable instrument. An ordinary eye-dropper with a very slender nozzle was however quickly cleansed, and charged with a i per cent. solution of boric acid and its contents expressed into the anterior chamber. This was repeatedly done -the nozzle helping to break up the lens tissue and render it viable. Presently, the pus and much of the lens having been removed, the penetrating electric light revealed a small dark object which was grasped with a pair of smooth iris-forceps and removed. It proved to be a piece of wood iI mm. long. The washing out process was kept up until the eye looked perfectly clean, when atropine was instilled and a bandage applied. No reaction followed. The wound healed in a few days, and the boy was
344
LIPPINCOTT: Imrgation of the Anterior Chamber.
discharged in a week with the eye entirely free from irritation, but with a rather dense capsule through which however he could dimly count fingers. CASE 2.- W. E., a glassworker, aet. 40, consulted me May 4, I889. On his left cornea was a very small ulcer surrounded by a faint nebulous area. The cornea was surrounded by a broad livid-red zone. The pupil was dilated (presumably by atropine). Learning that the man was exceedingly intemperate, he was urged to go into the hospital, but without avail. Three weeks later he again presented himself, having been since his last visit on one continuous debauch. The whole globe was intensely injected and somewhat cedematous. The anterior chamber was four-fifths full of pus. The cornea pointed near the lower margin. The eye appeared to be doomed. The patient was sent to the Allegheny Hospital, and soon afterward etherized. During the administration of the anaesthetic the cornea, without any violence on the part of the patient, burst at its prominent point, but no pus escaped. The opening was enlarged with a Graefe knife whereupon a small drop of pus came out. It was now evident that the purulent collection was largely made up of cheesy masses of considerable size, which gentle manipulation failed to dislodge. The nozzle of the intraocular syringe was introduced, and a quantity of i per cent. boric acid solution was run into the eye and out again, driving easily and rapidly before it all pus, solid and liquid, and cleansing the eye in a surprising manner. The pupil, which was 5 mm. in diameter round, and apparently free, was nevertheless' irresponsive -probablyfrom inflammatory changes in the texture of the iris. Besides, the surface of the iris had a pasty look. A continuous heat apparatus was applied over a light pressure bandage, and, on account of the condition of the iris, a solution of atropine and boric acid was directed to be instilled every two hours. Twenty-four hours later the globe was less congested and the iris looked decidedly cleaner, but there was a small collection of fresh creamy pus at the bottom of the anterior chamber. After a moment's deliberation as to whether the wound should be re-opened and the irrigation renewed, it was decided to trust to the therapeutic efficacy (already many times
LIPP1NCOTT: Irrigation of the Anterior Chamber.
345
demonstrated in my experience) of the continuous dry heat. The treatment already instituted was therefore continued. During the next twenty-four hours the fresh accumulation of pus entirely disappeared. The corneal wound was well closed and the corneal curvature restored. The anterior chamber was filled with perfectly transparent aqueous. The pupil was more dilated and the tissue of the iris looked well. The vision was not seriously impaired. The congestion of the globe was markedly lessened. Two days later the condition of the eye had still further improved, and the patient was on the high road to complete recovery, when, by an unhappy mistake, he was permitted to leave the,hospital. He did not re-appear until three weeks had elapsed, when the eye was found to be in a hopeless condition. Of course this case had an unfortunate termination, but that does not militate against the fact of the brilliant, if temporary, result of the irrigation in a very unpromising case. I think it will be readily granted that a syringe for washing out the anterior chamber ought to stand the following tests: ist. It should be easily made and kept aseptic. 2d. It should always be ready for use, or capable of being quickly made so. 3d. It should be easily handled, and its movements readily and absolutely controlled with one hand alone, the other being free for other purposes. 4th. Its ejecting force ought to be capable of being accurately estimated and regulated. 5th. It should not throw bubbles of air into the eye. Among the latest intraocular syringes described are those of McKeown, Panas, and Wecker. McKeown's * is a piston syringe with flat curved nozzles. The instrument used by Panas is described by himself t as virtually a compte-gouttes armed with a hard rubber tube. Wecker's t syringe is shaped like an ear speculum with a thin India rubber membrane stretched across the large end and furnished with a silver tube at the other. Now, it appears to me that no piston syringe will fulfill any of * Ann. d Oculistique, Mars-Avril, i888, p. 144. t Quoted by McKeown, ibid, p. I45. Before the publication of McKeown's article, however, Panas had abandoned the instrument above referred to and substituted for it a piston syringe. Arch d'Ophthalmologie, Vol. VI, p. 471. t Described by McKeown, Ann. d'Oculistique,. Mars-Avril I888, p. 145.
346
LIPPIRCOTT: lJrgation of the Anterior Chamber.
the conditions stated above except the last; and that any instrument constructed on the principle of Wecker's or Panas' first syringe, while it may stand the first and second, or even perhaps the third test, cannot fulfill the last two conditions. The first cataract case in which I irrigated the interior of the eye was that of the glaucomatous cataract mentioned above. Suspecting that a good deal of cortical matter might remain after the expulsion of the nucleus, I had carefully cleansed the instrument which I have for years used for syrO inging the nasal duct, and which consists of the rubber portion of an eye-dropper attached to a fine curved silver nozzle - being thus practically the same as the original Panas syringe. I found that it required great care and constant watching of the point of the instrument to prevent the entrance of air into the nozzle 'ii and thence into the anterior chamber. A small bubble did in fact get into the eye, but I was able to wash it out, and no injury resulted. The syringe which I have the honor to present to-day is sim- ple in principle, and can be briefly described. It consists essentially of a bit , ^ of black rubber tubing with a curved flat gold nozzle at one end, and a small metal reseri voir * at the other. To control * the movements of the nozzle, the latter is fitted into a hollow, ANTERIOR CHAMBER SYRINGE. hard rubber handle through (Natural Size.) * Since this paper was read I have used the syringe with the upper end of the rubber tube attached to a Graefe's " undine " instead of to the metallic reservoir and found the former to answer very well.
LTPPINCOTT: Irrigation of the Anterior Chamber.
347
which the rubber tubing passes. To the handle is attached a short metal piston which can be pressed by the index finger down upon the tubing and thus stop or retard the current. Let us see how this syringe responds to the tests. Ist. As there is no backward flow, it has no tendency to become septic in use except at the point of the nozzle, and the latter can be readily pulled off and thrown into boiling water or alcohol. If the purity of the oth2r parts of the apparatus is suspected, it is easy to place the reservoir in boiling water, and to replace the old rubber tubing with a new piece. 2d. This instrument can always be depended upon to work smoothly. 3d. It-is held like a penholder, and is as easily and' securely handled. 4th. As the ejecting force is proportional to the height of the column of liquid, it is of course under absolute control. I have found as a matter of practice that when the reservoir is at a height of eight inches above the eye, the stream is as strong as required; and this height should not be much exceeded. It may be added that should a per sal/um movement be desired, this can be effected by rapid up and down movements of the reservoir, which is held by an assistant, or by intermittent pressure on the short piston. 5th. It goes without saying that in using this syringe there is no possibility of the entrance of air into the eye. As to the fluid injected; the chief desideratum, in my judgment, is that it be clean in all senses of the word. Distilled water, filtered and boiled shortly before using, should be employed. No chemical is needed, as the object is not to disinfect the anterior chamber,-an effectual disinfectant would be too irritating to be used safely- but there is no objection to the employment of non-irritating substances such as boric aci'd or common salt in very weak solution. Finally, the fluid as it enters the eye ought to be about blood heat. If much higher than this, the sensation is not pleasant, and if much lower, decided pain is experienced, and, what is more important, a spasmodic contraction of the pupil is apt to take place. The reservoir is fitted with a receptacle for a thermometer by which to regulate the temperature. This syringe is madz by Feick Bros. of Pittsburgh, and Reynders of New York.
348
LIPPINCOTT: Irnigation of the Anterior Chtamber.
DISCUSSION. DR. EMIL GRUENING, New York.- I agree with the reader as to the cito etjucunde, but I disagree as to the tuto. I think that the instrument does not fulfill all the indications which Dr. Lippincott requires. It is not easy to keep it absolutely clean. It is not impossible that air may enter. I have of late used a very simple instrument for this purpose which is a glass flask, the undine devised by Alfred Graefe. The flask has a spout, and is filled with the solution desired. I have used a one-half per cent. solution of salt. The injecting force may be graduated by raising or lowering the flask. When the eye is irrigated there seems to be a suction exerted. Water thrown from a certain distance enters the chamber. I have used this instrument in hypopyon with brilliant results. I have brought out thick pus which could not otherwise be removed.
341
IRRIGATION OF THE ANTERIOR CHAMBER-A NEW SYRINGE FOR EFFECTING IT. BY J. A. LIPPINCOTT, M.D., PITTSBURGH, PENN.
SINCE McKeown five years ago introduced the procedure of syringing out the anterior chamber in operating for cataract, this method of removing cortical remains has been adopted by distinguished operators in different parts of the world. But the number of those who use the intraocular syringe is up to the present time quite limited, and the value of this recent addition to our armamentarium is still regarded by many as doubtful. My own experience is not extensive enough to form a basis on which to formulate very positive opinions. Nevertheless, I beg to present it as so much evidence on the general question as to whether syringing out the anterior chamber is a justifiable or useful measure. During the past seven months I have used the syringe in fifteen cataract extractions. Of these cases five were hypermature, .eight were mature, one was glaucomatous, and one traumatic. In two of the cases the cortical had become so softened that when the nucleus escaped, the great mass of the lens remained behind, filling up the pupillary area, and practically leaving the vision as bad as before touching the eye. In the mature cases more or less cortical matter remained. As to visual results: In 2 cases, S. (corrected) = 20/xx. In 2 cases, S. (corrected) =20/xx . In 3 cases, S. (corrected) = 20/Xxx. In 3 cases, S. (corrected)= 20/XL. In 2 cases, S. (corrected)=20/LX. In i case, S. (corrected)-=20/LXXX. In I case, S. (corrected)--8/c. In the remaining case the extraction was made a week ago, at a distance, and the corrected vision cannot be given.; but the operation was absolutely smooth, and the immediate visual result was all that could be desired. Of the two instances in which Vn. = 20/LX one was a case of
342
LIPPiNCOTT: Irrigation of the Anterior Chazmber.
traumatic cataract with a broad anterior synechia requiring an extensive iridotomy before washing out the lens-matter. The other was a case of glaucoma the progress of which had been previously checked by an iridectomy. In adjusting the glasses the media were found perfectly clear, the impairment of vision being accounted for by well marked glaucomatous changes in the disc. In the worst two cases, with vision respectively 20/Lxxx and 8/c, the media were also clear, and the imperfect vision found to be due to atrophy of the optic nerves. In but one case was it necessary to do a second operation., In this case the posterior capsule was so thick and tough that puncturing it effected no material benefit, and the dense membrane was removed with the forceps. The above facts and statistics are not presented as particularly brilliant evidence of the value of the intraocular syringe in cataract extraction, but they may be regarded as tending to show at least that the employment of this instrument is attended with no radical disadvantages. As a matter of fact, I think we are guided in deciding on the relative merits of different methods not so much by masses of statistics, as by close observation of particular cases and circumstances. Looking at the matter from this point of view, whoever uses the intraocular syringe must be convinced that we have in it a means of removing lenticular debris from the anterior chamber tuto, cito et jucuinde. Especially is its usefulness apparent in those cases in which the cortical has degenerated into a more or less liquid state. In these cases, and even in extracting cataracts whose peripheral layers are not speciallv soft, a certain amount of cortical frequently remains after as long and thorough stroking of the cornea as may be considered safe. The residual debris may indeed not be abundant enough to very seriously obstruct vision, and the pupil may look fairly black in good daylight, but the fierce light from the electric lamp reveals a grey film which, on the introduction of the syringe, at once disappears, leaving an unobstructed pupil. Beside cataractous debris, clotted or liquid blood may be removed in the manner we are considering, more easily and per. fectly than in any other way. Every one knows how innocuous and how readily absorbed is even a notable quantity of blood in
LiPPINCOTT: Irrigationl of the Anteror Chiamber.
343
the anterior chamber if the lens capsule is unbroken. But my experience leads me to believe that blood remaining in the eye after removal of the lens is not so readily disposed of, but leads to irritation and inflammation of the iris,-and consequent lessening of the visual acuity. The intraocular syringe has been employed not only in cataract extraction, but also in removing collections of pus from within the eye. The two following cases illustrate its advantages in this regard. CASE i.-J. B., aet. 12, presented himself at my office on the afternoon of February 4, I889, with his right eyeball intensely red, and a hypopyon five mm. wide at its center, while the aqueous was decidedly turbid. There was a broad posterior synechia in the lower outer region. A small scar was seen on the cornea opposite the adhesion. The boy had been struck in the eye with a flying splinter eight days before, while chopping wood. The patient was sent to the Allegheny General Hospital; and the same evening an incision was made under ether at the corneal margin opposite the synechia. With the exit of the aqueous a small quantity of the pus also escaped. The adherent portion of the iris was now seized, torn from its attachment,.and snipped off, whereupon some soft opaque lens-matter appeared in the wound. The removal of the segment of iris also disclosed the fact that a considerable quantity of pus lay in the posterior chamber. Up to this time I had never seen or made use of McKeown's method, and I was not prepared with a suitable instrument. An ordinary eye-dropper with a very slender nozzle was however quickly cleansed, and charged with a i per cent. solution of boric acid and its contents expressed into the anterior chamber. This was repeatedly done -the nozzle helping to break up the lens tissue and render it viable. Presently, the pus and much of the lens having been removed, the penetrating electric light revealed a small dark object which was grasped with a pair of smooth iris-forceps and removed. It proved to be a piece of wood iI mm. long. The washing out process was kept up until the eye looked perfectly clean, when atropine was instilled and a bandage applied. No reaction followed. The wound healed in a few days, and the boy was
344
LIPPINCOTT: Imrgation of the Anterior Chamber.
discharged in a week with the eye entirely free from irritation, but with a rather dense capsule through which however he could dimly count fingers. CASE 2.- W. E., a glassworker, aet. 40, consulted me May 4, I889. On his left cornea was a very small ulcer surrounded by a faint nebulous area. The cornea was surrounded by a broad livid-red zone. The pupil was dilated (presumably by atropine). Learning that the man was exceedingly intemperate, he was urged to go into the hospital, but without avail. Three weeks later he again presented himself, having been since his last visit on one continuous debauch. The whole globe was intensely injected and somewhat cedematous. The anterior chamber was four-fifths full of pus. The cornea pointed near the lower margin. The eye appeared to be doomed. The patient was sent to the Allegheny Hospital, and soon afterward etherized. During the administration of the anaesthetic the cornea, without any violence on the part of the patient, burst at its prominent point, but no pus escaped. The opening was enlarged with a Graefe knife whereupon a small drop of pus came out. It was now evident that the purulent collection was largely made up of cheesy masses of considerable size, which gentle manipulation failed to dislodge. The nozzle of the intraocular syringe was introduced, and a quantity of i per cent. boric acid solution was run into the eye and out again, driving easily and rapidly before it all pus, solid and liquid, and cleansing the eye in a surprising manner. The pupil, which was 5 mm. in diameter round, and apparently free, was nevertheless' irresponsive -probablyfrom inflammatory changes in the texture of the iris. Besides, the surface of the iris had a pasty look. A continuous heat apparatus was applied over a light pressure bandage, and, on account of the condition of the iris, a solution of atropine and boric acid was directed to be instilled every two hours. Twenty-four hours later the globe was less congested and the iris looked decidedly cleaner, but there was a small collection of fresh creamy pus at the bottom of the anterior chamber. After a moment's deliberation as to whether the wound should be re-opened and the irrigation renewed, it was decided to trust to the therapeutic efficacy (already many times
LIPP1NCOTT: Irrigation of the Anterior Chamber.
345
demonstrated in my experience) of the continuous dry heat. The treatment already instituted was therefore continued. During the next twenty-four hours the fresh accumulation of pus entirely disappeared. The corneal wound was well closed and the corneal curvature restored. The anterior chamber was filled with perfectly transparent aqueous. The pupil was more dilated and the tissue of the iris looked well. The vision was not seriously impaired. The congestion of the globe was markedly lessened. Two days later the condition of the eye had still further improved, and the patient was on the high road to complete recovery, when, by an unhappy mistake, he was permitted to leave the,hospital. He did not re-appear until three weeks had elapsed, when the eye was found to be in a hopeless condition. Of course this case had an unfortunate termination, but that does not militate against the fact of the brilliant, if temporary, result of the irrigation in a very unpromising case. I think it will be readily granted that a syringe for washing out the anterior chamber ought to stand the following tests: ist. It should be easily made and kept aseptic. 2d. It should always be ready for use, or capable of being quickly made so. 3d. It should be easily handled, and its movements readily and absolutely controlled with one hand alone, the other being free for other purposes. 4th. Its ejecting force ought to be capable of being accurately estimated and regulated. 5th. It should not throw bubbles of air into the eye. Among the latest intraocular syringes described are those of McKeown, Panas, and Wecker. McKeown's * is a piston syringe with flat curved nozzles. The instrument used by Panas is described by himself t as virtually a compte-gouttes armed with a hard rubber tube. Wecker's t syringe is shaped like an ear speculum with a thin India rubber membrane stretched across the large end and furnished with a silver tube at the other. Now, it appears to me that no piston syringe will fulfill any of * Ann. d Oculistique, Mars-Avril, i888, p. 144. t Quoted by McKeown, ibid, p. I45. Before the publication of McKeown's article, however, Panas had abandoned the instrument above referred to and substituted for it a piston syringe. Arch d'Ophthalmologie, Vol. VI, p. 471. t Described by McKeown, Ann. d'Oculistique,. Mars-Avril I888, p. 145.
346
LIPPIRCOTT: lJrgation of the Anterior Chamber.
the conditions stated above except the last; and that any instrument constructed on the principle of Wecker's or Panas' first syringe, while it may stand the first and second, or even perhaps the third test, cannot fulfill the last two conditions. The first cataract case in which I irrigated the interior of the eye was that of the glaucomatous cataract mentioned above. Suspecting that a good deal of cortical matter might remain after the expulsion of the nucleus, I had carefully cleansed the instrument which I have for years used for syrO inging the nasal duct, and which consists of the rubber portion of an eye-dropper attached to a fine curved silver nozzle - being thus practically the same as the original Panas syringe. I found that it required great care and constant watching of the point of the instrument to prevent the entrance of air into the nozzle 'ii and thence into the anterior chamber. A small bubble did in fact get into the eye, but I was able to wash it out, and no injury resulted. The syringe which I have the honor to present to-day is sim- ple in principle, and can be briefly described. It consists essentially of a bit , ^ of black rubber tubing with a curved flat gold nozzle at one end, and a small metal reseri voir * at the other. To control * the movements of the nozzle, the latter is fitted into a hollow, ANTERIOR CHAMBER SYRINGE. hard rubber handle through (Natural Size.) * Since this paper was read I have used the syringe with the upper end of the rubber tube attached to a Graefe's " undine " instead of to the metallic reservoir and found the former to answer very well.
LTPPINCOTT: Irrigation of the Anterior Chamber.
347
which the rubber tubing passes. To the handle is attached a short metal piston which can be pressed by the index finger down upon the tubing and thus stop or retard the current. Let us see how this syringe responds to the tests. Ist. As there is no backward flow, it has no tendency to become septic in use except at the point of the nozzle, and the latter can be readily pulled off and thrown into boiling water or alcohol. If the purity of the oth2r parts of the apparatus is suspected, it is easy to place the reservoir in boiling water, and to replace the old rubber tubing with a new piece. 2d. This instrument can always be depended upon to work smoothly. 3d. It-is held like a penholder, and is as easily and' securely handled. 4th. As the ejecting force is proportional to the height of the column of liquid, it is of course under absolute control. I have found as a matter of practice that when the reservoir is at a height of eight inches above the eye, the stream is as strong as required; and this height should not be much exceeded. It may be added that should a per sal/um movement be desired, this can be effected by rapid up and down movements of the reservoir, which is held by an assistant, or by intermittent pressure on the short piston. 5th. It goes without saying that in using this syringe there is no possibility of the entrance of air into the eye. As to the fluid injected; the chief desideratum, in my judgment, is that it be clean in all senses of the word. Distilled water, filtered and boiled shortly before using, should be employed. No chemical is needed, as the object is not to disinfect the anterior chamber,-an effectual disinfectant would be too irritating to be used safely- but there is no objection to the employment of non-irritating substances such as boric aci'd or common salt in very weak solution. Finally, the fluid as it enters the eye ought to be about blood heat. If much higher than this, the sensation is not pleasant, and if much lower, decided pain is experienced, and, what is more important, a spasmodic contraction of the pupil is apt to take place. The reservoir is fitted with a receptacle for a thermometer by which to regulate the temperature. This syringe is madz by Feick Bros. of Pittsburgh, and Reynders of New York.
348
LIPPINCOTT: Irnigation of the Anterior Chtamber.
DISCUSSION. DR. EMIL GRUENING, New York.- I agree with the reader as to the cito etjucunde, but I disagree as to the tuto. I think that the instrument does not fulfill all the indications which Dr. Lippincott requires. It is not easy to keep it absolutely clean. It is not impossible that air may enter. I have of late used a very simple instrument for this purpose which is a glass flask, the undine devised by Alfred Graefe. The flask has a spout, and is filled with the solution desired. I have used a one-half per cent. solution of salt. The injecting force may be graduated by raising or lowering the flask. When the eye is irrigated there seems to be a suction exerted. Water thrown from a certain distance enters the chamber. I have used this instrument in hypopyon with brilliant results. I have brought out thick pus which could not otherwise be removed.
