able to treatment: in short, a success of 94.1 per cent. of the whole number.

The influence of age upon the success of the operations can be seen at a glance at the foregoing table, the greatest percentage being between the ages of 50 and 60.

The duration of the treatment in the different cases was quite variable, as can be seen from the following table.

They were dismissed from treatment as follows:

making the average time under treatment, that is before their dismissal, about twenty days for each case.

The case of sudden death is left out of this table, inasmuch as po change of importance is produced thereby in making up the general average. The cases of discision are also here included, and it must be mentioned that upon most of them a second, and upon a few a third, operation was necessary, the length of time that they were kept under treatment, after each, was about the same, and corresponds to the smallest numbers of days in the table.

but

Below is a table showing the amount of vision had by the different cases after the operation (i. e., upon their dismissal), tested by means of double convex (cataract) glasses. They are arranged in groups, several having the same amount of vision.

The remaining nineteen cases are made up of the "four complicated" (viz., cataract resulting from irido-cyclitis, which again appeared acutely after the operations, and destroyed what little vision was gained thereby-not to be classed in the results), the four (partial successes, or "curable blindness") which still require secondary operations to give them good vision, and the eleven resulting in complete failure, making, with those enumerated in the above table, the entire number (185) of cases.

In operating upon these cases, no regard whatever has been paid to the season of the year in which they presented themselves, so that, indeed, every season and every month have been thoroughly tested, so to speak, and as yet I have found no reason for preferring one season or one month to another, with the view of affording a more favorable progress or a better termination of the cases. The heat of summer makes the necessary confinement of about a week to the bed and room quite uncomfortable to the patient, but it does not exert the least influence upon the ultimate result of the case. In short, so far as the success of the operation itself is concerned, no particular time or month seems to possess any special advantage over another.

In conclusion, I merely wish to call attention to the wellknown advantage of quinine in surgical operations. It is not necessary for me to speak of its action, but there is no doubt of its beneficial effects in cataract operations.

ON CATARACT EXTRACTION.

By H. KNAPP, M.D.,

NEW YORK.

I HAVE Compiled from the annual reports of the Ophthalmic Institutes of Heidelberg and New York, which have been under my charge, the statistics of all the cases of extraction that I have made from the year 1862 to the present day. They give a sum total of 916 extractions: 553 were performed in Heidelberg, during eight years; 363 in New York, during ten years and a half.

At once the striking fact shows itself that the number of cataract operations was relatively much greater in Heidelberg than in New York, for the number of eye-patients that came under my care in Heidelberg was a great deal smaller-not much more than half the number of those in New York. I do not presume to explain this discrepancy, as the reason of it may be personal, at least in part, though the same scarcity of cataracts has been noted in the majority of American ophthalmic hospitals. as compared with European institutions.

Flap Extraction.

In the first years of my practice I extracted all hard cataracts by the flap section, which I performed, on the whole, 140 times. The results were as follows:

During the first years I practised the old, classical method, with a Beer's knife. The globe was steadied with the toothed fixing forceps, which are still in general use; the capsule was divided in the centre by a crucial laceration with a Graefe's cystitome, and no iridectomy was performed. All kinds of reaction followed this procedure. About one-tenth of the eyes were lost by suppuration, either primary or secondary, of the cornea. Another very unpleasant consequence was prolapse of the iris, which

frequently necessitated the removal of the protruding part, either some hours or some days after the operation. Thirdly, there were the frequent iritic processes, leading to more or less complete obstruction of the pupil, requiring after operations, e. g., iridectomy, iridotomy, division of pseudo-membranes by one or two needles. I had no reason to be more satisfied with my success in the classical flap extraction than the majority of operators had with theirs, and therefore tried the different modifications which at that time were proposed and gained temporary favor, in particular, Jacobson's large peripheral flap section, Mooren's preliminary iridectomy, and V. Graefe's flap section combined with simultaneous iridectomy. No one of these modifications had such advantages over the classical flap as to insure its adoption as a general method. Then followed

Von Graefe's Combined Peripheric Linear Extraction, with which I became acquainted not only through reading, but in the institution of Von Graefe himself. The merits of this method have always appeared to me so great, that up to this day it has remained with me the general method. Only twice, during thirteen years, have I temporarily abandoned it, to try A. Weber's method-incision with a large curved lance-shaped knife-and Pagenstecher's method of removing the lens within the unbroken capsule. The results which Graefe's operation gave me, in the first three hundred cases, were very favorable; later, they were somewhat less so, yet, on the whole, they were better than those obtained from the regular flap operation.

I have made the regular Graefe's operation over six hundred times. Including the other methods mentioned before, which all were combined with iridectomy, the number of modified extractions which I have performed sums up to 735. The results

These results are, on the whole, satisfactory, and harmonize well with those of such operators as have published extensive statistics. I have, therefore, no reason to abandon Von Graefe's method.

With regard to the execution of the operation, I may mention that I now make the section less peripherically than at first, preserving, however, the linear principle. This necessitates the

I was

excision of a large piece of iris, lest incarceration of that membrane ensue at the corners of the wound. As to the division of the capsule, I have abandoned the central crucial or multiple laceration which I practised at first, as well as the excision of a squareshaped piece of the anterior capsule, which I practised about eight years. For almost two years I have divided the capsule only at the periphery, either by a large horizontal division along the corneal section and a short vertical division joining it in the centre, or by a long horizontal division alone. prompted to resort to the peripheric division of the capsule by the many reactive processes that followed the central division and excision. As far as my experience goes, these reactive processes are greatly diminished by the peripheric opening. The capsular bag commonly closes in the first night after the operation, shutting up all remnants of cataract. The anterior chamber and iris are, therefore, uninfluenced by remnants of lens and shreds of capsule. The recovery is commonly very smooth, and distinguishes itself by the exceedingly rare occurrence of iritic and capsular processes. Up to the present day, I have divided the capsule according to this method in seventy cases, the visual results of which have been as follows:

Failure 66 4 "

=4.3 per cent.

=5.7 per cent.

These results, gentlemen, are mostly final; in a certain number only they are primary, requiring an after-operation, i. e. the subsequent division of the centre of the capsule, which in the great majority of the cases seems to be necessary, and always has been successful.

About the technique of the primary and the secondary divisions of the capsule, gentlemen, I beg leave to show the instruments which I think most appropriate, and to give some illustrations on the blackboard, referring for fuller information to a paper on a sixth hundred of Graefe's cataract extractions, which

I have learned, subsequently, that M. Gayet, of Lyons, has practised the peripheric division of the capsule as a method since 1873.