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FLAP OPERATION FOR CATARACT.
866 ball, the dilatability of the pupil, the presence
his experience of a similar movement at Birmingham. He said the successful conduct of the movement would require tact and good humour, and even a little diplomacy, and much labour. All Christians in Birmingham joined. And i even the Jews, in order that they might co-operate in such i a movement, had a rabbi from London, and special sermons and collections on the Sunday. He urged that only institutions for the relief of physical suffering should be recognised, and insisted strongly on the importance of one definite day being set apart for the collection. He regretted the objection that subscriptions would be injured, maintaining, on the contrary, that by the publicity given to the institutions by subscription papers distributed in the churches, the subscriptions would be increased. He thought it a grand thing in Birmingham, where political feelings and passions ran high, that all these should be suppressed for one day by common contribution to the sick. Archbishop Manning entirely endorsed all that Canon Miller had said. He was sure that by setting apart one day for the collection, he would not say a spirit of rivalry, but a sense of common work would be everywhere excited that could not but be productive of good. He remarked on the number of wealthy people who might, but do not, subscribe to hospitals, and argued that these would have this matter brought under their notice. Allusion having been made by the chairman to the question of dispensaries, and to the opinion of THE LANCET that they could not be excluded, the Archbishop said on that point he felt very strongly in favour of the inclusion of the dispensaries. It was finally resolved that a certain number of gentlemen, including the clergy and representatives of every denomination, should meet on Monday at three o’clock, to organise a public meeting to be held in the Egyptian Hall
or
absence
synechise, the strength of the orbicularis muscle and its spasmodic action, &c., must suggest modifications in many
of
cases. As an
instance of the value of modifications in particular the following recent case in my own practice is not inappropriate. A man, aged sixty years, had a cataract in the right eye, which presented several unusual appearances. 1. It had an almost uniform 11 gruelly" aspect. 2. There were a few points on its anterior aspect with a quasi-metallic lustre, but no radiating striae. 3. The nucleus could not be seen through the cortex either by focal illumination or by ophthalmoscopic illumination. Under these circumstances, I suspected a very bulky and semi-flaid cortex, and a small nucleus; but in order to satisfy myself on this point before making the corneal section, I introduced a fine, slightly curved needle through the lower part of the cornea, and lacerated the capsule, acting upon a suggestion of Signor Correnti, of Florence. A perfectly fluid, milky cortex escaped into the anterior chamber, and the cataract became suddenly reduced to one-third of its original bulk. I was now assured that I could extract it through a small aperture, and, accordingly, made a small section of the cornea, and, without making any iridectomy, easily forced out the nucleus through the pupil and the corneal wound, the fluid cortex escaping almost entirely with the first rush of aqueous humour. The patient has hitherto gone on well, the operation having been performed ten days ago. In many other cases a tentative puncture of the anterior capsule may enable the operator to regulate the size and form of his corneal section according to the ascertained size of the nucleus and the consistency and bulk of the cortex; and it is always more easy to lacerate the capsule before letting out the aqueous humour than after this has escaped, and on an early day. the pupil has contracted, as it almost always does after the corneal section has been completed. On other occasions I have found it necessary to perform the operation of removing the lens in its capsule, and without lacerating it; and 1 believe that it will be found that "Audi alteram partem." the tendency of ophthalmic surgery at present* is to an absolute eclecticism, not pinning our faith to any one proceedFLAP OPERATION FOR CATARACT. ing to the exclusion of all others, but carefully selecting cases suitable to each particular method, and making the Editor THE To the LANCET. of exactness of the guide in our choice rather than Sm.—Mr. Jeaffreson of Newcastle, in his interesting re- the teaching diagnosis of statistics, which must always be liable to port in your last number, comes forward as the champion fallacies and inaccuracies of detail. I am, Sir, your obedient servant, of the old flap operation for cataract, and adduces 15 cases W. SPENCER W. SPENCER WATSON. treated by himself by that method as evidence of the adHenrietta-street, Cavendish-square, Dec. 9th, 1872. over and more recent methods it other vantages possesses of operating. Permit me, then, to inquire what is the staTHE POOR-LAW MEDICAL OFFICERS’ ASSOCIAtistical value of this report. Out of 15 cases Mr. Jeaffreson succeeded in restoring TION AND THE PUBLIC HEALTH ACT. good " or perfect " vision to 14. This would give To the Editor of THE LANCET. nearly 7 per cent. of failures. But we find that in two of trust SIR,-I other cases was to the of the you will permit me to reply to the stateiridectomy superadded steps the operation, and it is, therefore, only fair to exclude these ments made by Mr. Barnes, which appeared in your last from consideration. The average of failures will then be week’s issue, especially as, if not controverted, very erro7’77 per cent. neous conclusions will be deduced therefrom. If we compare this result with the statistics of Graefe’s Mr. Barnes is correct in stating that the provincial memoperation, the latter will be found to have a much larger bers of Council do not attend our meetings; nor is there amount of success. Knapp lost only 3’04 per cent. De Wecker lost, in his earlier cases, 4’5 per cent., and in his much reason why they should, as the subjects which come later series, 3’48 per cent. Von Graefe had only 2’8 per up for consideration at the Council meetings have generally cent. of failures. Mr. Taylor of Nottingham (in his first been such as could be dealt with without requiring the modification of the flap operation), lost only 3 cases by sup- sacrifice of time and money involved in a lengthened jourpuration out of 105. ney. I am also prepared to admit, with Mr. Barnes, that Mr. Jeaffreson, therefore, in order to complete his argu- deference has been paid to the views of provincial members; ment, should give the results of the total of his operations, for as nine-tenths of the communications forwarded to the which he tells us are nearly 100 in number; and it would Association during the last two years have been addressed also add much to the value of his report if he would define to and acknowledged by myself, it has been my duty to clearly the amount of vision which he designates as 11 per- submit them. Again, I am not prepared to object to the fect" after an extraction, and also that degree which he general principles involved in Mr. Barnes’s resolutions, as considers " good " vision. they have been, in one shape or other, publicly advocated Why, however, should we pledge ourselves to one or even by me years before that gentleman came forward as a Poortwo methods of operating ?P May not the flap operation be law reformer; but what I do object to is, that resolutions suitable to certain cases,-the Graefean operation to others, affecting the status and interests of provincial medical -and other modifications to a third set? The varying rela- officers exclusively should have been brought forward and tive sizes of the nucleus and cortex of the lens, and the sanctioned at a meeting of Council constituted of metroconsistence of the cortex, must make a small open- politan medical officers only, especially too as they were varying ing sufficient in some cases, and a larger one necessary in thus brought forward in avowed opposition to the principles others. Other conditions, such as the tension of the eye- contained in the resolutions sanctioned by a general meeting cases,
Correspondence.
I z,
"
,
his experience of a similar movement at Birmingham. He said the successful conduct of the movement would require tact and good humour, and even a little diplomacy, and much labour. All Christians in Birmingham joined. And i even the Jews, in order that they might co-operate in such i a movement, had a rabbi from London, and special sermons and collections on the Sunday. He urged that only institutions for the relief of physical suffering should be recognised, and insisted strongly on the importance of one definite day being set apart for the collection. He regretted the objection that subscriptions would be injured, maintaining, on the contrary, that by the publicity given to the institutions by subscription papers distributed in the churches, the subscriptions would be increased. He thought it a grand thing in Birmingham, where political feelings and passions ran high, that all these should be suppressed for one day by common contribution to the sick. Archbishop Manning entirely endorsed all that Canon Miller had said. He was sure that by setting apart one day for the collection, he would not say a spirit of rivalry, but a sense of common work would be everywhere excited that could not but be productive of good. He remarked on the number of wealthy people who might, but do not, subscribe to hospitals, and argued that these would have this matter brought under their notice. Allusion having been made by the chairman to the question of dispensaries, and to the opinion of THE LANCET that they could not be excluded, the Archbishop said on that point he felt very strongly in favour of the inclusion of the dispensaries. It was finally resolved that a certain number of gentlemen, including the clergy and representatives of every denomination, should meet on Monday at three o’clock, to organise a public meeting to be held in the Egyptian Hall
or
absence
synechise, the strength of the orbicularis muscle and its spasmodic action, &c., must suggest modifications in many
of
cases. As an
instance of the value of modifications in particular the following recent case in my own practice is not inappropriate. A man, aged sixty years, had a cataract in the right eye, which presented several unusual appearances. 1. It had an almost uniform 11 gruelly" aspect. 2. There were a few points on its anterior aspect with a quasi-metallic lustre, but no radiating striae. 3. The nucleus could not be seen through the cortex either by focal illumination or by ophthalmoscopic illumination. Under these circumstances, I suspected a very bulky and semi-flaid cortex, and a small nucleus; but in order to satisfy myself on this point before making the corneal section, I introduced a fine, slightly curved needle through the lower part of the cornea, and lacerated the capsule, acting upon a suggestion of Signor Correnti, of Florence. A perfectly fluid, milky cortex escaped into the anterior chamber, and the cataract became suddenly reduced to one-third of its original bulk. I was now assured that I could extract it through a small aperture, and, accordingly, made a small section of the cornea, and, without making any iridectomy, easily forced out the nucleus through the pupil and the corneal wound, the fluid cortex escaping almost entirely with the first rush of aqueous humour. The patient has hitherto gone on well, the operation having been performed ten days ago. In many other cases a tentative puncture of the anterior capsule may enable the operator to regulate the size and form of his corneal section according to the ascertained size of the nucleus and the consistency and bulk of the cortex; and it is always more easy to lacerate the capsule before letting out the aqueous humour than after this has escaped, and on an early day. the pupil has contracted, as it almost always does after the corneal section has been completed. On other occasions I have found it necessary to perform the operation of removing the lens in its capsule, and without lacerating it; and 1 believe that it will be found that "Audi alteram partem." the tendency of ophthalmic surgery at present* is to an absolute eclecticism, not pinning our faith to any one proceedFLAP OPERATION FOR CATARACT. ing to the exclusion of all others, but carefully selecting cases suitable to each particular method, and making the Editor THE To the LANCET. of exactness of the guide in our choice rather than Sm.—Mr. Jeaffreson of Newcastle, in his interesting re- the teaching diagnosis of statistics, which must always be liable to port in your last number, comes forward as the champion fallacies and inaccuracies of detail. I am, Sir, your obedient servant, of the old flap operation for cataract, and adduces 15 cases W. SPENCER W. SPENCER WATSON. treated by himself by that method as evidence of the adHenrietta-street, Cavendish-square, Dec. 9th, 1872. over and more recent methods it other vantages possesses of operating. Permit me, then, to inquire what is the staTHE POOR-LAW MEDICAL OFFICERS’ ASSOCIAtistical value of this report. Out of 15 cases Mr. Jeaffreson succeeded in restoring TION AND THE PUBLIC HEALTH ACT. good " or perfect " vision to 14. This would give To the Editor of THE LANCET. nearly 7 per cent. of failures. But we find that in two of trust SIR,-I other cases was to the of the you will permit me to reply to the stateiridectomy superadded steps the operation, and it is, therefore, only fair to exclude these ments made by Mr. Barnes, which appeared in your last from consideration. The average of failures will then be week’s issue, especially as, if not controverted, very erro7’77 per cent. neous conclusions will be deduced therefrom. If we compare this result with the statistics of Graefe’s Mr. Barnes is correct in stating that the provincial memoperation, the latter will be found to have a much larger bers of Council do not attend our meetings; nor is there amount of success. Knapp lost only 3’04 per cent. De Wecker lost, in his earlier cases, 4’5 per cent., and in his much reason why they should, as the subjects which come later series, 3’48 per cent. Von Graefe had only 2’8 per up for consideration at the Council meetings have generally cent. of failures. Mr. Taylor of Nottingham (in his first been such as could be dealt with without requiring the modification of the flap operation), lost only 3 cases by sup- sacrifice of time and money involved in a lengthened jourpuration out of 105. ney. I am also prepared to admit, with Mr. Barnes, that Mr. Jeaffreson, therefore, in order to complete his argu- deference has been paid to the views of provincial members; ment, should give the results of the total of his operations, for as nine-tenths of the communications forwarded to the which he tells us are nearly 100 in number; and it would Association during the last two years have been addressed also add much to the value of his report if he would define to and acknowledged by myself, it has been my duty to clearly the amount of vision which he designates as 11 per- submit them. Again, I am not prepared to object to the fect" after an extraction, and also that degree which he general principles involved in Mr. Barnes’s resolutions, as considers " good " vision. they have been, in one shape or other, publicly advocated Why, however, should we pledge ourselves to one or even by me years before that gentleman came forward as a Poortwo methods of operating ?P May not the flap operation be law reformer; but what I do object to is, that resolutions suitable to certain cases,-the Graefean operation to others, affecting the status and interests of provincial medical -and other modifications to a third set? The varying rela- officers exclusively should have been brought forward and tive sizes of the nucleus and cortex of the lens, and the sanctioned at a meeting of Council constituted of metroconsistence of the cortex, must make a small open- politan medical officers only, especially too as they were varying ing sufficient in some cases, and a larger one necessary in thus brought forward in avowed opposition to the principles others. Other conditions, such as the tension of the eye- contained in the resolutions sanctioned by a general meeting cases,
Correspondence.
I z,
"
,