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 ON CATARACT, 
 
 OPERATION 
 
 REMOVAL BY ABSORPTION, 
 
 THE FINE NEEDLE 
 
 THROUGH 
 
 THE COENEA. 
 
 ARTHDR JACOB, M.D., F.R.C.S., 
 
 PROFESSOR OF ANATOMY AND PHYSIOLOGY IN THE ROYAL 
 
 COLLEGE OF SURGEONS IN IRELAND, 
 
 AND SURGEON FOR DISEASES OF THE EYE TO THE 
 
 CITY OF DUBLIN HOSPITAL. 
 
 DUBLIN: 
 PRINTED AT THE MEDICAL PRESS OFFICE. 
 
 1851.
 
 CATARACT. 
 
 STRUCTURE OF THE LENS 
 
 NATURE OF ITS OPACITIES. 
 
 It is scarcely necessary to state that cataract is the name 
 given to that disease of the eye in which blindness is caused 
 by loss of transparency in the crystalline lens ; and under 
 that name, therefore, all opacities whatever of that pai^t 
 should be considered. Certain appearances, generally 
 accompanied by defective vision, have been denominated 
 glaucoma ; but if it is meant to attribute these appearances 
 and the defective vision which accompanies it to any loss 
 of transparency in the crystalline lens, the term should not 
 be used, the disease being in that case only a form of cata- 
 ract. The application of two different names to the same 
 disease is calculated to create confusion. T am not here, 
 however, going to inquire what the disease called glaucoma 
 is, I only want to have it settled that it is not cataract, or 
 that if it is, it should be so called. 
 
 Notwithstanding all that has been already written on the 
 subject, I think it is necessary to preface what I have to 
 say respecting changes in structure of the crystalline lens 
 by a description of that part in its natural and healthy 
 state. It is, as every one knows, what is called a double-
 
 OS CATARACT. 
 
 convex lens, or rather like two plano-convex lenses united 
 at their plane surfaces ; for its anterior surface is much less 
 curved than its posterior : if not so, we should have it 
 touching the iris, and perhaps interfering with the contrac- 
 tions of the pupil. Its minor axis measures about seven-for- 
 tieths of an inch ; or in other words, it is seven-fortieths of 
 an'inch thick; being about one half the length of its major 
 axis or breadth. If we consider the surfaces of the lens to 
 be spherical, we may say that the posterior is a segment of a 
 smaller sphere than the anterior j or in other words, it is much 
 more convex : the surfaces are not, however, strictly speak- 
 ing, spherical, but perhaps spheroidical, or even elliptical 
 or hyperbolical. These curvatures, it must also be recol- 
 lected, are very different at different periods of life. In 
 youth, perhaps we may say to the period of puberty, they 
 are more curved, but from this period to forty-five or fifty, 
 they remain stationary, when they become less so ; in fact, 
 the lens in children is much thicker or more convex, while 
 in old persons it becomes less convex, thinner, and flatter. 
 The consideration of these changes are of great importance 
 in a practical point of view, because although the greater 
 convexity in early life does not seem to render the eye 
 myopic, the flattening in advanced life causes it to become 
 presbyopic. The greatest difference also often exists in 
 different individuals in this respect, causing short or long 
 sight throughout life, and even in the same individual the 
 lenses appear to be frequently unequal, causing serious 
 imperfection of vision. In incipient cataract, the curva- 
 tures of the lens often alter, sometimes causing persons to 
 lay aside their spectacles, and sometimes to change them for 
 others of a different focus. I am of course aware that the 
 differences above alluded to may be attributed to other 
 causes, but the undisputed fact that the lens becomes much 
 flatter as we advance in life, and that at the same time the
 
 ON CATARACT. 3 
 
 eye becomes presbyopic, appears conclusive as to the cause 
 and effect. 
 
 With a view to determine the causes of the changes which 
 take place in vision from age or alteration in structure, it 
 is necessary to consider the refractive power of the crystal- 
 line lens. The refractive power of the capsule has not 
 been ascertained, but it is probably greater than any other 
 of the transparent parts, although from its being so very 
 thin it has little effect in altering the direction of the rays 
 of light. The body of the lens is not of equal density 
 throughout, being scarcely denser than water at the sur- 
 face, but increases gradually in density to the centre, so 
 that probably the rays do not pass through it in straight 
 lines, but more or less curved. The mean refractive index 
 is, however, held to be 1.384, and its principal focal length 
 in air about one-third of an inch, perhaps its power may 
 therefore be considered half way between water and glass. 
 The density, and consequently the refractive power of the 
 lens, becomes greater in advanced life, and for anything 
 we know to the contrary, there may be some difference in 
 this respect, as well as in the curvatures of the surface, in 
 different individuals ; so that, whether from this cause, or 
 from some peculiarity in organization, or from defect of 
 adjustment in the size or place of the pupil, very serious 
 imperfections of vision frequently occur, and are often con- 
 founded with incipient cataract or impartial amaurosis. I 
 every day meet with cases in which one eye is almost use- 
 less from some of these causes or a combination of them, 
 and in which I know there is no loss of transparency of the 
 lens or diminution in sensibility of the retina. In such 
 cases relief may sometimes be afforded, especially in near- 
 sighted persons, by the use of glasses calculated to com- 
 pensate for or neutralise the defect ; or perhaps we may 
 effect some improvement by influencing the state of the
 
 4 ON CATARACT. 
 
 pupil by external applications. Imperfections of vision 
 from the causes here noticed sometimes occur at the com- 
 mencement of the period when the lens begins to flatten, 
 and disappear in a year or two when the change in form 
 arrives at its utmost extent. 
 
 Having premised so much with respect to the form and 
 refractive power of the lens, it may not be superfluous to 
 repeat what I have already stated respecting this part of 
 the eye in the Cyclopaedia of Anatomy ;* being convinced 
 that a correct knowledge of the structure of any part is 
 the first requisite towards a correct comprehension of the 
 changes It undergoes from disease, and that no brief or 
 meagre description is sufficient to convey that knowledge : 
 it is as follows : — 
 
 "It has been already stated that there is a double con- 
 vex lens within the sphere of the eye, at a short distance 
 behind the external lens or cornea. This is the crystalline 
 lens or crystalline humour, which gives additional conver- 
 gence to the rays of light transmitted through the pupil. 
 It is placed in a depression, formed for its reception on the 
 anterior, compressed, or truncated portion of the vitreous 
 humour, where that body approaches the back of the iris, 
 
 * For the article Eye in the Cyelopsedia of Anatomy here 
 alluded to, I venture to take this opportunity ot claiming a 
 fair consideration at the risk of being charged with undue 
 partiality towards it, because it was prepared by myself. 
 Articles in encyclopaedias are frequently looked upon as mere 
 compilations, and are therefore seldom referred to as deposi- 
 tories of original information, but many of those of the Cyclo- 
 paedia of Anatomy were of the latter description. Upon the 
 article on Anatomy of the Eye, no expense was spared by 
 the then publishers, and I can safely say that no trouble 
 was spared by me. I therefore can refer those who attach 
 value to information derived from this source to it with 
 confidence.
 
 ON CATARACT. 5 
 
 and constitutes part of the boundaries of the posterior 
 chamber of the aqueous humour. In this depression it 
 adheres firmly to the hyaloid membrane, and from the ves- 
 sels of that structure derives its nutriment. 
 
 This double convex lens does not present the same cur- 
 vature on both surfaces, the anterior being less curved than 
 the posterior, in the ratio of about four to three. Attempts 
 have been made to determine with accuracy the nature of 
 these curvatures, first by Petit, and subsequently by Win- 
 tringham, Chossat, and others. The results of the numerous 
 experiments of Petit lead to the conclusion, that the an- 
 terior curvature is that of a portion of a sphere from six to 
 seven lines and a half in diameter, the posterior that of a 
 sphere of from five to six lines and a quarter. From the 
 same source it appears that the diameter is from four lines 
 to four lines and a half, the axis or thickness about two 
 lines, and the weight three or four grains. 1 am, however, 
 inclined to agree with the observation of Porterfield, that, 
 ' as it is scarce possible to measure the crystalline and the 
 other parts of the eye with that exactness that may be 
 depended on, all nice calculations founded on such mea- 
 sures must be fallacious and uncertain, and therefore 
 should, for the most part, be looked on rather as illustra- 
 tions than strict demonstrations of the points in question.' 
 The method by which Petit arrived at these results must 
 render them of doubtful value, the curvatures having been 
 determined by the application of brass plates cut to the 
 requisite form. The results of Chossat's experiments, con- 
 ducted with great care, and with the assistance of the me- 
 gascope, are thus stated by Mr. Lloyd in his treatise on 
 Optics : — ' This author has found that the cornea of the 
 eye of the ox is an ellipsoid of revolution round the greater 
 axis, this axis being inclined inwards about 10 deg. The 
 ratio of the major axis to the distance between the foci in 
 the generating ellipse he found to be 1.3 ; and this agree- 
 ing very nearly with 1.337, the index of refraction of the 
 aqueous humour, it follows that parallel rays will be re 
 fracted to a focus, by the surface of this humour, with 
 mathematical accuracy. The same author found likewise 
 
 2 A
 
 6 ox CATARACT. 
 
 that the two surfaces of the crystalline lens are ellipsoids 
 of revolution round the lesser axis ; and it is somewhat 
 remarkable that the axes of these surfaces do not coincide 
 in direction either with each other, or with the axis of the 
 cornea, these axes being both inclined outwards, and con- 
 taining with each other, in the horizontal section in which 
 they lie, an angle of about o deg.' It must not be forgotten 
 that these observations apply to the crystalline of the ox, 
 not to that of man, and also that, as Chossat himself admits, 
 the evaporation of the fluid part of the lens, or the absorp- 
 tion or imbibition of the water in which it is immersed, may 
 materially alter the curvature. I cannot myself believe 
 it possible to separate a fresh lens in its capsule perfectly 
 from the hyaloid membrane without injuring its structure, 
 and endangering an alteration in its form. Haller states 
 that Kepler considered the anterior CvOnvexity to approach 
 to a spheroid, and the posterior to a hyperbolic cone. 
 Wintringham states the results of his inquiries as to this 
 matter as follows : — ' In order to take the dimensions of 
 the eye of an ox, I placed it on a horizontal board and 
 applied three moveable silks, which were kept extended 
 by small plummets, so as to be exact tangents to the arc 
 of the cornea, as well at each canthus, as at the vertex ; 
 then applying a very exactly divided scale, I found that 
 the cord of the cornea was equal to 1 .05 of an inch, the 
 versed sine of this cord to be 0.29, and consequently the 
 radius of the cornea was equal to 0.620215 of an inch. I 
 then carefully took off the cornea, and replaced the eye 
 as before, and found, by applying one of the threads as a 
 tangent to the vertex of the crystalline, that the distance 
 between this and the vertex of the cornea was 0.355 of an 
 inch. Afterwards I took the crystalline out without in- 
 juring its figure, or displacing the capsula, and then ap- 
 plying the threads to each surface of this humour, as was 
 done before to the arch of the cornea, I found that the 
 cord of the crystalline was 0.74 of an inch, and its versed 
 sine, with respect to the anterior surface, to be 0.189 of 
 an inch, and consequently the radius of this surface was 
 0.45665 of the same. In like manner the versed sine to
 
 ON CATARACT. 7 
 
 the same cord, with respect to the posterior surface of 
 the crystalline, I found to be equal to 0.38845 of an inch. 
 Lastly, I found the axis of the crystalline and that of the 
 whole eye from the cornea to the retina to be 0.574, 2.21 
 respectively. Whatever doubts may be entertained re- 
 specting the accuracy of the measurements of the lens, 
 there can be none that the form is different at different 
 periods of life, in the human subject. It also appears to 
 differ in different individuals at the same period of life, 
 and probably the curvature is not the same in both eyes. 
 In other animals the difference in form is most remarkable. 
 In the human foetus, even up to the ninth month, it is 
 almost spherical. Petit stales that he found the anterior 
 curvature in a foetus of seven months, a portion of a sphere 
 of three lines diameter, and the posterior of two and a half, 
 and the same in a new-born infant. In an infant eight 
 days old, the anterior convexity was a portion of a sphere 
 of four lines, and the posterior of three. All anatomists 
 concur in considering the lens to approach more to a sphere 
 at this period. In childhood the curvatures still continue 
 much greater than in advanced life ; from ten to twenty 
 probably decrease, and from that period to forty, forty -five, 
 or fifty, remain stationary, when they become much less ; 
 being, according to the tables of Petit, portions of spheres 
 from seven to even twelve lines in diameter, and on the 
 posterior of six or eight. Every day's observation proves 
 that the lens becomes flattened, and its curvatures dimin- 
 ished as persons advance in life. It is seen in dissection, 
 when extracted by operation, and even during life ; the 
 distance between its anterior surface and the back of the 
 iris being so great in some old persons, that the shadow of 
 the pupil may be seen upon it, while at an earlier period 
 it actually touches that part of the membrane. This dimi- 
 nution of the curvatures of the lens commences about the 
 age of forty-five. Petit found the anterior convexity vary- 
 ing from a sphere of about seven to twelve lines diameter, 
 and the posterior from five to eight in persons from fifty to 
 sixty-five years of age. The alteration in power of adap- 
 tation, and the indistinctness of vision of near objects which
 
 8 ox CATARACT. 
 
 takes place at this period, is probably to be attributed to 
 this cause, although a diminution of the muscular power 
 of the iris, and consequent inactivity of the pupil, may 
 contribute to the defect. It is also to be recollected that 
 the density of the lens is much increased at this period, and 
 that the young person whose lens presents greater curva- 
 tures does not require concave glasses, as the old person 
 requires convex ones. The state of the eye, after the re- 
 moval of the lens by operation for cataract, proves that it 
 is a part of the organ essentially necessary for correct 
 vision. A^'hen the eye is in other respects perfect, without 
 any shred of opaque capsule, any irregularity or adhesion 
 of the pupil, or any alteration in the curvature of the 
 cornea, as in young persons who have had the lens pro- 
 perly broken up with a fine needle through the cornea, 
 vision is so good for distant objects, that such persons 
 are able to pursue their common occupations, and walk 
 with safety through crowded streets, but they require the 
 use of a convex lens, of from three and a half to five 
 inches focus, for reading or vision of near j old persons, 
 however, generally require convex glasses on all occasions 
 after the removal of the lens. That the curvatures of the 
 lens are frequently different in difierent individuals may 
 be inferred from the frequency of short sight, or defective 
 power of adaptation, not attributable to any peculiarity of 
 the cornea. Petit states that he found lenses of which the 
 two convexities were equal, and others of which the an- 
 terior was greater than the posterior, and more tl.an once, 
 one more convex on its anterior surface in one eye, while 
 that in the other eye was in a natural state. He also oc- 
 casionally found the lens as convex in the advanced period 
 of life as in youth. I have repeatedly observed the per- 
 fection of vision and power of adaptation much greater in 
 one eye than the other in the same individual, without any 
 defect of the cornea, pupil, or retina; and occasionally 
 have found young persons requiring the common convex 
 glasses used by persons advanced in life, and old persons 
 becoming near-sighted, and requiring concaves. The an- 
 nexed letters show the difference of curvature at the dif-
 
 ON CATARACT. 9 
 
 ferent periods of life, as represented by Sommerring. C 
 is the lens of the fcetus ; B, that of a child of six years of 
 age J and A, that of an adult. 
 
 The colour of the lens is also different at different periods 
 of life. In the foetus it is often of a reddish colour ; at 
 birth and in infancy it appears slightly opaque or opaline ; 
 in youth it is perfectly transparent ; and in the more ad- 
 vanced periods of life acquires a yellowish or amber tint. 
 These varieties in colour are not visible, unless the lens 
 be removed from the eye, until the colour becomes so deep 
 in old age as to diminish the transparency, when it appears 
 opaque or milky, or resembling the semitransparent horn 
 used for lanterns. The hard lenticular cataract of ad- 
 vanced life appears to be nothing more than the extreme 
 of this change of colour, at least when extracted and placed 
 on white paper it presents no other disorganization ; but 
 the lens of old persons, when seen in a good light and with 
 a dilated pupil, always appears more or less opaque, al- 
 though vision remains perfect. The depth of colour is 
 sometimes so great, without any milkiness or opacity, that 
 the pupil appears quite transparent although vision is lost. 
 This is perhaps the state of lens vaguely alluded to by 
 authors under the name of black cataract. 
 
 The consistence of the lens varies as much as its colour. 
 In infancy it is soft and pulpy, in youth firmer, but still 
 so soft that it may be crushed between the finger and thumb, 
 and in old age becomes tough and firm. Hence it is that 
 in the earlier periods of life cataracts may be broken up 
 completely into a pulp, and absorbed with certainty, while 
 in old persons they adhere to the needle, unless very deli- 
 cately touched, and are very liable to be detached from the 
 capsule and thrown upon the iris, causing the destruction
 
 10 ON CATARACT. 
 
 of the organ. On this account, therefore, the operation 
 of extraction must generally be resorted to in old persons 
 labouring under this form of cataract, while the complete 
 division of it with the needle and exposure of the frag- 
 ments to the contact of the aqueous humour secures its 
 removal by absorption in young persons. It must not, 
 however, be forgotten that the softer lenticular cataract 
 occasionally occurs in advanced life. 
 
 The crystalline lens is a little heavier than water. Por- 
 terfield, from the experiments of Bryan Robinson, infers 
 that the specific gravity of the human lens is to that of the 
 other humours as eleven to ten, the latter being nearly the 
 same as water ; and Wintringham, from his experiments, 
 concludes that the density of the crystalline is to that of 
 the vitreous humour in the ratio of nine to ten ; the spe- 
 cific gravity of the latter being to water as 10024 to iOOOO. 
 The density of the lens is not the same throughout, the 
 surface being nearly fluid, while the centre scarcely yields 
 to the pressure of the finger and thumb, especially in ad 
 vanced life. Wintringham found the specific gravity of 
 the centre of the lens of the ox to exceed that of the en^ 
 tire lens in the proportion of twenty seven to twenty-six. 
 The refractive power is consequently greater than that of 
 the other humours. On this head, Mr. Lloyd, in his 
 Optics, says — ' In their refractive power, the aqueous and 
 vitreous humours differ very little from that of water. The 
 refractive index of the aqueous humour is 1.337, and that 
 of the vitreous humour 1.339; that of water being 1.336. 
 The refractive power of the crystalline is greater, its mean 
 refracting index being 1.384. The density of the crystal- 
 line, however, is not uniform, but increases gradually from 
 the outside to the centre. This increase of density serves 
 to correct the aberration by increasing the convergence of 
 the central rays more than that of the extreme parts 
 of the pencil.' Dr. Brewster, in his treatise on Optics, 
 says — 'I have found the following to be the refractive 
 powers of the different humours of the eye, the ray of 
 light being incident upon them from the eye : aqueous 
 humour 1.336; crystalline, surface 1.3767, centre 1.3990,
 
 ON CATARACT. 11 
 
 mean 1.3839; vitreous humour 1.3394. But as the rays 
 refracted by the aqueous humour pass into the crystalline, 
 and those from the crystalline into the vitreous humour, 
 the indices of refraction of the separating surface of these 
 humours will be, from the aqueous humour to the outer 
 coat of the crystalline 1.0466, from the aqueous humour 
 to the crystalline, using the mean index, 1.0353, from the 
 vitreous to the outer coat of the crystalline 1.0445, from the 
 vitreous to the crystalline, using the mean index, 1.0332.' 
 Dr. Young says — ' On the whole, it is probable that the 
 refractive power of the centre of the human crystalline, in 
 its living state, is to that of water nearly as 18 to 7 ; that 
 the water imbibed after death reduces it to the ratio of 21 
 to 20 i but that on account of the unequable density, its 
 effect in the eye is equivalent to a refraction of 14 to 13 
 for its whole size.' 
 
 Respecting the chemical composition of the lens, Berzc- 
 lius observes, that ' the liquid in its cells is more concen- 
 trated than any other in the body. It is completely dia- 
 phanous and colourless, holding in solution a particular 
 animal matter belonging evidently to the class of albumin- 
 ous substances, but differing from fibrine in not coagulating 
 spontaneously, and from albumen, inasmu;:h as the con- 
 centrated solution, instead of becoming a coherent mass on 
 the application of heat, becomes granulated exactly as the 
 colouring matter of the blood when coagulated, from which 
 it only differs in the absence of colour. All those chemical 
 properties are the same as those of the colouring matter of 
 the blood. The following are the principles of which the 
 lens is composed ; peculiar coaguable albuminous matter 
 35.9, alcoholic extract with salts, 2.4, watery extract with 
 traces of salts 1.3, membrane, forming the cells 2.4, water 
 58.0.' 
 
 From the preceding observations it might reasonably be 
 supposed that the lens is composed of a homogeneous ma- 
 terial, such as albumen or gelatine, more consolidated in 
 the centre than at the circumference ; but this Is not the 
 case ; on the contrary, it exhibits as much of elaborate 
 organization as any other structure in the animal economy.
 
 12 
 
 ON CATARACT. 
 
 It consists of an outer case or capsule, so totally different 
 from the solid body contained within it, that they must be 
 separately investigated and described. The body of the 
 lens, it has been already stated, consists of certain saline 
 and animal ingredients combined with more than their 
 weight of water, and when perfectly transparent presents 
 the appearance of a tenacious unorsranized mass ; but when 
 rendered opaque by disease, loss of vitality, heat, or im- 
 mersion in certain fluids, its intimate structure becomes 
 visible. If the lens with the capsule attached to the hyaloid 
 membrane be removed from the eye and placed in water, 
 the following day it is found slightly opaque or opaline, 
 and split into several portions by fissures extending from 
 the centre to the circumference, as seen in fig. 2. This 
 appearance is rendered still more obvious by immersion in 
 spirit, or the addition of a few drops of acid to the water. 
 If a lens thus circumstanced be allowed to remain some 
 days in water, it continues to expand and unfold itself, 
 and if delicately touched and opened by the point of a 
 needle, and carefully transferred to spirit, and as it hardens 
 is still more unravelled by dissection, it ultimately presents 
 a remarkable fibrous or tufted appearance, as represented 
 in the figure below, drawn by me some years ago from a 
 preparation of the lens of a fish thus treated (the Lophius 
 piscatorius). The three annexed figures represent the 
 structure of the lens above alluded to : -4 is the human 
 crystalline in its natural state ; B, the same split up into 
 its component plates ; and C, unravelled in the fish. 
 Fig. 2. c 
 
 n. 
 
 
 
 This very remarkable structure of the body of the lens
 
 ON CATARACT. 13 
 
 appears to have been first accurately described by Leeuwen- 
 hoek, subsequently by Dr. Young, and still more recently 
 by Sir David Brewster. Leeuwenhoek says — ' It may be 
 compared to a small globe or sphere, made up of thin pieces 
 of paper laid one on another, and supposing each paper to 
 be composed of particles or lines placed somewhat in the 
 position of the meridian lines on a globe, extending from 
 one pole to the other.' Again, he says — ' With regard 
 to the before -mentioned scales or coats, I found them so 
 exceedingly thin, that, measuring them by my eye, I must 
 say that there were more than two thousand of them lying 
 one upon another : and lastly, I saw that each of these 
 coats or scales was formed of filaments or threads placed 
 in regular order, side by side, each coat being the thick- 
 ness of one such filament.' The peculiar arrangement of 
 these fibres he describes as follows: — ' Hence we may col- 
 lect how excessively thin these filaments are ; and we shall 
 be struck with admiration in viewing the wonderful man- 
 ner they take their course, not in a regular circle round 
 the ball of the crystalline humour, as I first thought, but 
 by three different circuits proceeding from a point, which 
 point I will call their axis or centre. They do not on the 
 other side of the sphere approach each other in a centre, 
 but return in a short or sudden turn or bend, where 
 they are the shortest,, so that the filaments of which each 
 coat is composed have not in reality any termination or 
 end.' 
 
 Dr. Young differs from Leeuwenhoek as to the arrange- 
 ment of the fibres and other particulars, and in his last 
 paper corrects the description given by himself in a former 
 one ; he says — ' The number of radiations (of the fibres) 
 is of little consequence ; but I find that in the human 
 crystalline there are ten on each side, not three, as I once 
 from a hasty observation concluded. In quadrupeds the 
 fibres at their angular meeting are certainly not continued 
 as Leeuwenhoek imagined.' 
 
 Sir David Brewster says that the direction of the fibres 
 is different in different animals ; the simplest arrangement 
 being that of birds, and the cod, haddock, and several other
 
 14 
 
 ON CATARACT. 
 
 fishes. In it the fibres, like the 
 meridians of a globe, converge to 
 two opposite points of a spheroidal 
 or lenticular solid, as in the an- 
 
 nexed figure. 
 
 The second or next simplest 
 structure he detected in the sal- 
 mon, shark, trout, and other fishes ; 
 as well as in the hare, rabbit, and 
 porpoise amon^ the mammalia ; 
 and in the alligator, gecko, and 
 others among reptiles. Such lenses 
 have two septa at each pole, as in 
 the annexed figure. 
 
 Fig. 4. 
 
 The third or more complex 
 structure exists in mammalia in 
 general, ' in which three septa di- 
 verge from each pole of the lens, 
 at angles of 120 deg., the septa of 
 the posterior surface bisecting the 
 angles formed by the septa of the 
 anterior surface,' as in the annexed 
 figure. 
 
 Fig. 5. 
 
 The mode in which these fibres are laterally united to 
 each other is equally curious. Sir David Brewster says 
 that he ascertained this in looking at a bright light through 
 a thin lamina of the lens of a cod, when he observed two 
 faint and broad prismatic images, situated in a line ex- 
 actly perpendicular to that which joined the common 
 coloured images. Their angular distance from the central 
 image was nearly five times greater than that of the first
 
 ON CATARACT. 15 
 
 ordinary prismatic images, and no doubt whatsoever could 
 be entertained that they were owing to a number of minute 
 lines perpendicular to the direction of the fibres, and 
 whose distance did not exceed the 12-300dth of an inch. 
 
 Fig. 6. 
 
 Upon applying a good micro- 
 scope to a well- prepared lamina, 
 the two fibres were found united 
 by a series of teeth exactly like 
 those of rack-work, the project- 
 ing teeth of one fibre entering 
 into the hollows between the teeth 
 of the adjacent one, as in fig. 6. 
 
 I have said that the lens consists of an outer case or cap- 
 sule totally different from the solid body contained within 
 it. This capsule is strong, elastic, and perfectly transpa- 
 rent. In the paper to which I have alluded in the Medico- 
 Chirurgical Transactions, I gave the following detailed 
 description of its nature and properties : — * The real na- 
 ture of the capsule of the lens has not, I think, been suflS- 
 ciently attended to ; its thickness, strength, and elasticity 
 have certainly been noticed, but have not attracted that 
 attention which a fact so interesting, both in a physiological 
 and pathological point of view, deserves. That its struc- 
 ture is cartilaginous, I should conclude — first, from its 
 elasticity, which causes it to assume a peculiar appearance 
 when the lens has been removed, not falling loose into folds 
 as other membranes, but coiled in different directions : or 
 if the lens be removed by opening the capsule behind, and 
 withdrawing it through the vitreous humour, allowing the 
 water in which the part is immersed to replace the lens, 
 the capsule preserves in a great degree its original form, 
 especially in the eye of the fish ; secondly, from the den- 
 sity and firmness of its texture, which may be ascertained 
 by attempting to wound it by a cataract needle, by cutting 
 it upon a solid body, or compressing it between the teeth ; 
 thirdly, from its permanent transparency, which it does
 
 ON CATARACT. 
 
 not lose except on the application of very strong acid or 
 boiling wat€r, and then only in a slight degree ; macera- 
 tion in water for some months, or immersion in spirit of 
 strength suflficient to preserve anatomical preparations, 
 having little or no effect upon it. If the lens be removed 
 from the eye of a fish dressed for the table, the capsule may 
 be raised by the point of a pin, and be still found almost 
 perfectly transparent. This combination of density and 
 transparency gives the capsule a peculiar sparkling appear- 
 ance in water, in consequence of the reflection of light 
 from its surface, resembling a portion of thin glass which 
 had assumed an irregular form while soft ; this sparkling 
 I consider very characteristic of this structure. The pro- 
 perties just enumerated appear to me to distinguish it from 
 every other texture but cartilage ; still, however, it may 
 be said that cartilage is not transparent, but even the car- 
 tilage of the joints is semitransparent, and if divided into 
 very thin portions, is sufficiently pellucid to permit the 
 perception of dark objects placed behind it, and we obtain 
 it almost perfectly transparent where it gives form to the 
 globe of the eye, as in the sclerotic of birds and fishes. If 
 the soft consistence, almost approaching to fluidity, of the 
 external part of the lens, be considered, the necessity of a 
 capsule capable itself of preserving a determinate form is 
 obvious. If the lens were enclosed in a capsule such as 
 that which envelopes the vitreous humour, its surface could 
 not be expected to present the necessary regular and per- 
 manent curvature; nor could we expect that if the form 
 of the lens were changed, it could be restored without this 
 provision of an elastic capsule.' 
 
 The capsule is liable to become opaque and constitute 
 cataract, as the body of the lens is. These capsular cata- 
 racts are easily distinguished from the lenticular. They 
 never present the stellated appearance frequently observed 
 when the texture of the opaque lens opens in the capsule, 
 as it does when macerated in water, nor the uniform horny 
 or the milky blue appearance of common lenticular cata- 
 ract. The opacity in capsular cataract exists in the shape 
 of irregular dots or patches, of an opaque paper-white ap-
 
 ON CATARACT. 17 
 
 pearance, and when touched with the needle are found 
 hard and elastic, like indurated cartilage, the spaces between 
 the specks of opacity frequently remaining perfectly trans- 
 parent. 
 
 It appears to be generally assumed by writers on anatomy 
 that a watery fluid is interposed between the body of the 
 lens and its capsule, from an incidental observation of 
 Morgagniwhen discussing the difference in density between 
 the surface and centre of the lens ; hence it has been called 
 the aqua Morgagni. The observation of this celebrated 
 anatomist, in his Adversaria Anatomica, which has led to 
 the universal adoption of this notion, is, however, merely 
 that upon opening the capsule he had frequently found a 
 fluid to escape. ' Deinde eadem tunica in vitulis etiam, 
 bobusque sive recens, sive non ita recens occisis perforata, 
 pluries animadverti, illico humorem quendam aqueum 
 prodire : quod et in homine observare visus sum, atque 
 adeo credidi, hujus humoris secretione prohibita, crystalli- 
 num siccum, et opacum fieri fere ut in extracto exsiccato- 
 que crystallino contingit. ' He does not, however, subse- 
 quently dwell upon or insist upon the point. I do not 
 believe that any such fluid exists in a natural state, but 
 that its accumulation is a consequence of loss of vitality ; 
 the water combined with the solid parts of the lens escap- 
 ing to the surface and being detained by the capsule, as 
 occurs in the pericardium and other parts of the body. In 
 the eyes of sheep and oxen, when examined a few hours 
 after death, not a trace of any such fluid can be detected, 
 but after about twenty- four hours it is found in considerable 
 quantity. In the human eye a fluid sometimes accumu- 
 lates in the capsule, constituting a particular form of cata- 
 ract, which presses against the iris, and almost touches 
 the cornea ; but such eyes are, I believe, always unsound. 
 From this erroneous notion of an interposed fluid between 
 the lens and its capsule has arisen the adoption of an un- 
 sustained and improbable conclusion, that the lens has no 
 vital connexion with its capsule, and consequently must 
 be produced and preserved by some process analogous to 
 secretion. Respecting this matter I have observed, in the 
 
 2 B
 
 iO ON CATARACT. 
 
 paper above alluded to : * The lens has been considered 
 by some as having no connexion with its capsule, and con- 
 sequently that its formation and growth is accomplished 
 without the assistance of vessels ; such a notion is so com- 
 pletely at variance with the known laws of the animal eco- 
 nomy, that we are justified in rejecting it, unless supported 
 by unquestionable proof. The only reasons which have 
 been advanced in support of this conclusion are, the failure 
 of attempts to inject its vessels, and the ease with which 
 it may be separated from its capsule when that membrane 
 is opened. These reasons are far from being satisfactory ; 
 it does not necessarily follow that parts do not contain ves- 
 sels, because we cannot inject them ; we frequently fail 
 when there can be no doubt of their existence, especially 
 where they do not carry red blood. I have not myself 
 succeeded in injecting the vessels of the lens, but I have 
 not repeated the trial so often as to make me despair of 
 accomplishing it, more especially as Albinus, an anatomist 
 whose accuracy is universally acknowledged, asserts, that 
 after a successful injection of the capsule of the lens, he 
 could see a vessel passing into the centre of the lens itself. 
 Lobe, who was his pupil, bears testimony to this. The 
 assertion that the lens is not connected with its capsule, I 
 think I can show to be incorrect ; it has been made from 
 want of care in pursuing the investigation, and from a 
 notion that a fluid exists throughout between the lens and 
 its capsule. "When the capsule is opened, its elasticity 
 causes it to separate from the lens ; especially if the eye 
 be examined some days after death, or has been kept in 
 water, as then the lens swells, and often even bursts the 
 capsule and protrudes through the opening, by which the 
 connexion is destroyed. I have, however, satisfied myself 
 that the lens is connected with its capsule (and that con- 
 nexion by no means slight) by the following method. I 
 remove the cornea and iris from an eye, within a few hours 
 after death, and place it in water, then with a pair of sharp- 
 pointed scissors I divide the capsule all round at the cir- 
 cumference of the lens, taking care that the division is 
 made behind the anterior convexitv, so that the lens can-
 
 ON CATARACT. 19 
 
 not be retained by any portion of the capsule supporting 
 it in front. I next invert the eye, holding it by the optic 
 nerve, when I find that the lens cannot be displaced by 
 agitation, if the eye be sufficiently fresh. In the eye of 
 a young man about six hours dead, I found that, on push- 
 ing a cataract needle into the lens, after the anterior part 
 of the capsule had been removed, I could raise the eye from 
 the bottom of the vessel, and even halfway out of the water, 
 by the connexion between the lens and its capsule. It 
 afterwards required considerable force to separate them, 
 by passing the needle beneath the lens, and raising it from 
 its situation. I believe those who have been in the habit 
 of performing the operation of extraction, have occasionally 
 encountered considerable difficulty in detaching the lens 
 from its situation after the capsule had been freely opened, 
 this difficulty I consider fairly referrible to the natural 
 connexion just noticed.' When the lens enclosed in its 
 capsule is detached from the hyaloid membrane, the con- 
 nexion between it and the capsule is destroyed by the 
 handling, and in consequence, it moves freely within that 
 covering, affording to those who believe that there is no 
 union between the two surfaces fallacious evidence in sup- 
 port of that opinion, which, if not sustained by better 
 proof, should be abandoned. Dr. Young insists upon the 
 existence of the natural connexion by vessels and even by 
 nerves between the lens and its capsule : he says — ' The 
 capsule adheres to the ciliary substance, and the lens to 
 the capsule, principally in two or three points ; but I con- 
 fess I have not been able to observe that these points are 
 exactly opposite to the trunks of nerves ; so that probably 
 the adhesion is chiefly caused by those vessels which are 
 sometimes seen passing to the capsule in injected eyes. 
 We may, however, discover ramifications from some of 
 these points upon and within the substance of the lens, 
 generally following a direction near to that of the fibres, 
 and sometimes proceeding from a point opposite to one of 
 the radiating lines of the same surface. But the principal 
 vessels of the lens appear to be derived from the central 
 artery, by two or three branches at some little distance
 
 '20 ox CATARACT. 
 
 from the posterior vortex, which I conceive to be the cause 
 of the frequent adhesion of a portion of a cataract to the 
 capsule about this point ; they follow nearly the course of 
 the radiations and then of the fibres j but there is often a 
 superficial subdivision of one of the radii at the spot where 
 one of them enters.' The great size of the vessels distri- 
 buted on the back of the capsule in the fcEtus strengthens 
 the conclusion that the lens is furnished with vessels as 
 the rest of the body. When the eye of a foetus of seven or 
 eight months is finely injected, a branch from the central 
 artery of the retina is filled and may be traced through the 
 centre of the vitreous humour to the back of the capsule, 
 where it ramifies in a remarkably beautiful manner, assum- 
 ing, according to Sommerring, a stellated or radiating ar- 
 rangement. Zinn declares that he found branches from 
 this vessel penetrating the lens : ' Optime autem placet 
 observatio arteriolae lentis, in oculo infantis, cujus vasa 
 cera optime erant repleta, summa voluptate mihi visas, 
 quam prope marginem ad convexitat^m posteriorem dila- 
 tam, duobus ramulis perforata capsula in ipsam substan- 
 tiam lentis profunde se immergentem cortissime conspexi.' 
 He also quotes the authority of Ruysch, Moeller, Albinus, 
 and Winslow, as favouring the same view. Against such 
 authority I find that of the French systematic writer 
 Bichat advanced j but on such a point his opinion is of 
 little value." 
 
 With respect to the nutrition of the lens and the nature 
 of its connexion with the capsule, it is necessary to state 
 that observers entitled to confidence deny the existence of 
 vessels in its structure, and consider that it grows by im- 
 bibing new matter from its capsule. Dr. Muller of Berlin 
 says that the capsule of the lens is its matrix, which seems 
 to secrete the layers of the lens from its inner surface, but 
 that this has not been ascertained with certainty. Mr. 
 Toynbee, in a valuable paper printed in the second part of 
 the Philosophical Transactions for 1841, says that " the
 
 ON CATARACT. 21 
 
 mode of nutrition of the crystalline lens may be explained 
 by supposing that the nutrient fluid is received by the 
 cells and conducted to the lens, through which it is dif- 
 fused ;" it being believed that cells are either interspersed, 
 among the fibres, or that the fibres are composed of them. 
 Notwithstanding this, I cannot admit that it is proved 
 that the lens, or the cornea and vitreous humour, are des- 
 titute of vessels. I do not mean to deny that nutrition 
 may be and is effected, as in the simpler forms of animal 
 and vegetable life, without the aid of tubular vessels, and 
 therefore cannot deny that the structures here alluded to 
 may be so nourished ; but the question is not yet settled. 
 Microscopic observations of fluids which are easily dif- 
 fused, separated, and diluted, may be relied upon ; but 
 those on organized solids not admitting of subdivision 
 without destruction, cannot be received with so much con- 
 fidence. Microscopic observers have, perhaps, been going 
 a little too fast, and must allow us a little breathing time 
 before we can accept all that is offered by them ; and the 
 more especially because the instrument has been laid hold 
 of, for the purpose of display, by ignorant persons totally 
 unacquainted with its use, and incapable of making correct 
 observations. The question, however, of the vascularity 
 of these structures, is not perhaps of so much practical 
 importance, seeing that, whether vascular or not, they 
 undergo the same changes, both in health and disease, as 
 vascular parts do. The cornea heals by first intention, 
 ulcerates, granulates, and cicatrizes, and the lens becomes 
 opaque, softens, hardens, and even is partially converted 
 into a calcareous structure. These changes I shall have to 
 notice presently, when I come to consider the great variety 
 of forms of cataract, and the other alterations of the lens 
 caused by age, inflammatory action, and injury.
 
 22 ON CATARACT. 
 
 ON CATARACT OR OPACITIES OF THE LENS. 
 
 Having endeavoured to explain the form, properties, 
 organization, and vitality of the lens, I have now to con- 
 sider the changes it undergoes from age, inflammation, im- 
 perfect or irregular nutrition, and injury. Writers on 
 diseases of the eye enumerate a great variety of cataracts, 
 applying different names to every different appearance 
 which these opacities assume, as they have done with re- 
 spect to opacities of the cornea. This, however, is of little 
 use, causes unnecessary trouble and confusion, and diverts 
 the mind from the investigation of the real cause of these 
 appearances. It is much better to consider the real nature 
 of these changes, and to explain the state of structure be- 
 longing to them. The crystalline lens does not become 
 opaque from a great number of different diseases affecting 
 it ; it is only the forms of opacity which are so numerous. 
 In the first place, it must be obvious that the lens being 
 composed of two structures so different in every respect as 
 the capsule and the body of it, and that both these being 
 liable to become opaque, there must, necessarily be at least 
 two very different forms of opacity, and hence the division 
 of cataracts into capsular and lenticular. The lenticular 
 is to be first noticed. From what has already been said 
 respecting the change which the lens undergoes in advanced 
 life, it is clear that it is liable to become still more changed 
 from the same cause, and experience has proved that such 
 is the case. In the great majority, it not only becomes 
 much more flat, and hence long sight requiring convex 
 glasses, but also coloured; acquiringanamber tint, although 
 previously clear as water. In still more advanced life it
 
 ON CATARACT. 23 
 
 also loses its perfect transparency, and becomes slightl}- 
 opaque or milky, although not so much so as to impair 
 vision materially. This I conclude from the appearance 
 it presents on dissection, and when seen in the living sub- 
 ject by causing the light to be reflected from it, especially 
 when the pupil is dilated with belladonna. When this 
 colour and loss of transparency increases still more, vision 
 becomes impaired and the opacity becomes visible in the 
 pupil, constituting the lenticular cataract of advanced life ; 
 one of the most common forms of the disease met with. 
 But the lens at this period becomes not only coloured and 
 milky or opaline, but also much firmer in consistence, and 
 hence the hardness of this species of cataract. The appear- 
 ance, however, of the hard lenticular cataract of advanced 
 life varies very much. It generally resembles a piece of 
 muddy amber, or still more, common horn, such as is used 
 for lanterns ; but is sometimes so brown that it cannot be 
 seen behind the pupil unless a strong light be thrown on it 
 obliquely, and hence probably the origin of the notion that 
 there is a black cataract. The hard lenticular cataract 
 frequently also presents the appearance which has been 
 denominated glaucoma, a greenish shining hue not easily 
 described, and scarcely to be represented on paper. This 
 semitransparent, amber, horny or opaline state of the 
 lens is not, however, by any means the uniform appear- 
 ance of the lenticular cataract of advanced life ; on the 
 contrary, the cataract of old persons is often of an opaque 
 white, or even a bluish white, like the lenticular cataract 
 of early life, or it may be irregularly clouded, stellated, or 
 combined with capsular cataract. 
 
 The stellated opacity of the lens which sometimes occurs 
 in the lenticular cataract of old age, but more frequently 
 in that of earlier life, it is necessary to consider distinctly, 
 because it is the result of additional disorganization, and
 
 24 ON CATARACT. 
 
 indicates a softer state of the lens, rendering it more easily 
 broken up and more fit to be absorbed. I have already 
 shown that from its fibrous structure, the lens splits up into 
 segments when immersed in water or other fluid, and from 
 whatever cause it may be, a similar change sometimes takes 
 place during life, constituting this stellated opacity or cata- 
 ract. There is no difficulty in recognizing this state, or of 
 perceiving that it depends upon a yielding of the natural 
 structure, and that it is accompanied by a corresponding 
 softness and looseness of texture favourable to division with 
 the needle. This splitting up of the lens into segments, 
 from the centre to the circumference, may be produced by 
 removing it from the eye of a sheep or other animal enclosed 
 in its capsule, and leaving it in water for a day or two. 
 Thus treated it becomes opaque, while the bars of the stel- 
 lated breach on its anterior surface are transparent, being 
 in fact filled with water. Now, if we are to give a name 
 to these different states, we may call the uniform amber or 
 horny opacity, the hard amber or horny cataract of advanced 
 life ; and if marked by bars radiating from the centre to 
 the circumference, we may add that it is stellated. 
 
 There is, however, another kind of opacity which occurs 
 at an advanced period of life which presents a more or less 
 stellated arrangement. This is produced by delicate slen- 
 der white streaks which run in the direction of the fibres, 
 and therefore from centre to circumference, the rest of the 
 lens retaining its transparency, or being only slightly 
 opaque ; so much so, that persons with this k«nd of cata- 
 ract often enjoy useful vision. These white streaks or 
 veins do not, however, always or even frequently assume 
 the stellated arrangement, but run as single streaks across 
 the whole face of the lens, with perhaps one or two other 
 streaks diverging from it about the centre. It is a remark- 
 able, distinct, and easily recognized opacity, although it
 
 ON CATARACT. 25 
 
 often escapes notice, especially where the pupil is small ; 
 and is obviously very different in its nature from the hard, 
 amber, or horny cataract just described. It is also remark- 
 able for the slowness of its progress to perfect opacity, often 
 existing for many years before it causes blindness and re- 
 quires operation. Such cataracts are not, perhaps, harder 
 than a healthy lens at the same period of life, and the 
 streaks of opacity are obviously not slits or spaces formed 
 by the receding of the fibres from each other, but an in. 
 duration and consequent opacity of a certain number of 
 them, the rest remaining transparent. I am surprised 
 that this form of cataract has not been more particularly 
 described and distinguished from the common hard stellated 
 cataract, especially considering the anxiety shown to mul- 
 tiply varieties and vary names, for there can be no doubt 
 of its being of a peculiar nature. It is it Mr. Mackenzie 
 alludes to when he says — " It is not an uncommon appear- 
 ance to see opaque strice stretching from the circumference 
 of the lens a short way into its substance ;" and Mr. Law- 
 rence notices it as a radiated cataract having the rays com- 
 mencing at the circumference instead of at the centre, as 
 in the more common or softer stellate cataract. *' Lenti- 
 cular cataracts (he says) are sometimes radiated, the opacity 
 appearing in streaks or radii, with the intervals compara- 
 tively transparent. Those radii generally begin in the cir- 
 cumference of the lens — a circumstance which forms a 
 striking contrast to the former species, in which the opacity 
 first appears in the centre. In the ordinary state of the 
 pupil we can hardly see the radiated opacity, because the 
 centre remains transparent ; perhaps a small white streak or 
 two may be distinguished : it is not, however, till we have 
 dilated the pupil by belladonna that we detect the opaque 
 streaks in the circumference of the lens." I sometimes, 
 however, find these opaque striae in the lens without the
 
 26 ox CATARACT. 
 
 marginal radii. It is probably to this form of cataract Mr, 
 Bowman alludes in the following passages* : — 
 
 "In the commencing cataract of middle or declining 
 age, we not uncommonly find the posterior surface of the 
 lens first affected, so that we look through the transparent 
 lens upon an obviously concave opacity. This opacity 
 sometimes, and indeed generally, encroaches from the mar- 
 gin in distinct streaks of irregular thickness, length, num- 
 ber, and distance apart ; and we usually find that, when 
 the pupil is widely dilated by belladonna, some at least of 
 these streaks are traceable round the margin for some way 
 over the anterior surface. So long as small portions of the 
 hinder surface of the lens remain clear, the body and front 
 being also clear, it is surprising how much visual power 
 may remain. At a subsequent period, the centre of the 
 lens begins to be cloudy, and then the progress towards 
 blindness is more rapid. Now I can entertain no doubt 
 that the streaks in these cases are sets or bundles of the 
 superficial layer of lenticular fibres, reduced to a state of 
 opacity by some nutritional change. There seems to be a 
 disposition in the fibres of the lens to become opaque in 
 their entire length when once they are morbidly altered at 
 a single point : and hence the linear figure of the opacity. 
 The opacity probably commences in the middle part of the 
 fibres near the margin of the lens ; and the arrangement 
 of the fibres would account for the different length of the 
 streaks, some approaching nearer than others to the central 
 point on the surface. 
 
 In another variety of opacity in adults, there are streaks 
 visible, either on the anterior or posterior surface, before 
 the nucleus manifests any tendency towards dulness, but 
 instead of converging from the border of the lens, they 
 rather diverge from the central point. These streaks are 
 also irregular in number and direction ; and it has never 
 occurred to me to distinguish in them any exact representa- 
 
 • Lectures on the Parts concerned in the Operations of the 
 Eye. By W. Bowman, F.B.S. London. 1849.
 
 ON CATARACT. 27 
 
 tion of the edges of the mesial planes as they are seen on the 
 surface of the prepared lens ; never, certainly, any trillnear 
 figure. But a glance at the representation above given of 
 the complex arrangement of the mesial planes in the adult 
 human lens, will suffice to explain why they are rarely 
 seen in such opacities. In the healthy lens they are in 
 reality too near together, and too irregular, to be detected 
 without a glass. The triple divergence from the axis can, 
 even then, only be recognized for a short distance, beyond 
 which the planes seem to diverge and branch without any 
 attempt at geometrical precision. We cannot, therefore, 
 wonder that an opacity, spreading from the centre of the 
 surface of the lens, and which consists of broad, ill-shapen 
 streaks, should fail to disclose the radiation of the mesial 
 planes : although it seems highly probable that its seat is, 
 primarily and essentially, rather in the edges of those planes 
 than in the fibres themselves. 
 
 In the lenticular cataract of adults, the glistening, silky, 
 fibrillation of the lens may be often seen ; but you will 
 fail, even in the best-marked of these cases, to discover, 
 with the naked eye, anything like regularity in the mode 
 in which the fibres pass off from the central region. Be- 
 fore becoming acquainted with the complex arrangement 
 of the planes of the human lens, I could not satisfy myself 
 why the triple line of the mammalian lens should be un- 
 seen ; but the actual complexity is a sufficient reason. It 
 explains, too, the appearances of many cases of opacity of 
 the body of the lens, where the fibrous texture is in general 
 obvious enough, but where, towards the centre, an amor- 
 phous, indefinable obscurity exists." 
 
 Of the hard lenticular cataracts of advanced life, we 
 have then the amber or horny, the stellate, and the 
 striated, but these are not the only varieties. Cataracts 
 in old persons are often white and very opaque with- 
 out any radii^ presenting a muddy cream-coloured or 
 even a bluish milky uniform surface, behind the pupil, and 
 such often have an opaline lustre from a hard amber cen-
 
 28 ox CATARACT, 
 
 tral nucleus reflecting the light through a semitransparent 
 superficial stratum. These cataracts appear so soft and 
 pulpy that they often tempt persons to operate on them 
 with the needle to cause their solution and absorption, but 
 they are almost always hard in the centre, leaving a small 
 nucleus undissolved for a very long time in the posterior 
 chamber after operation, moving up and down with the 
 motions of the eye. Besides these four distinct forms of 
 hard lenticular cataract of advanced life, the amber, stel- 
 lated, striated, and white or opaline, there are many inter- 
 mediate varieties which might be enumerated under differ- 
 ent names, and also many rarer varieties of the same species 
 presenting such peculiarities that they might be described 
 very properly as peculiar products of disease ; but my ob- 
 ject is to direct attention to the usual forms with a view to 
 ascertain their consistence and solubility for the purpose of 
 determining which operation should be chosen for their 
 removal. It should, however, be observed that all these 
 lenticular cataracts are more transparent and softer at the 
 circumference, because the lens in health is there thinner 
 and softer, and consequently, that when the pupil is dilated 
 with belladonna, they admit more light and appear less 
 opaque at the margin, except indeed it be the striated 
 cataracts which are often more opaque at the circumference. 
 Lenticular cataracts are not found in persons advanced 
 in life only, they occur at every period from infancy to 
 old age, but in early life they are very different in form, 
 consistence, and colour. As the hard amber cataract is 
 that which occurs most frequently in aged people, the 
 light -blue or milky one generally constitutes the disease in 
 younger persons. It is also much softer, frequently in- 
 deed softer than the lens is in its natural or healthy state 
 at the same period of life ; and instead of being shrunk 
 or flat, it is generally enlarged or swelled. Therefore, as
 
 ON CATARACT. 29 
 
 has been said, the hard amber- coloured shrunk lens most 
 commonly forms the cataract of advanced life, while the 
 soft milky-blue prominent one is found most frequently in 
 early life. There are, however, many varieties and modi- 
 fications of the disease at this period, as there are at the 
 other. Of these varieties, that which most frequently 
 occurs is the starred or stellated one already noticed as a 
 variety of the harder cataract of advanced life : the lens, 
 in fact, being not only opaque, but so disorganized or 
 changed in structure, that it has split up on its surface and 
 exhibits deep fissures radiating from the centre to the cir- 
 cumference. The colour, however, instead of being a 
 dirty-white, as in old age, is a milky-blue, and the fissures 
 are of a lighter tint, as if filled by water, which they pro- 
 bably really are, the whole being so soft and pulpy that 
 there is no diflSculty in completely mashing it up with the 
 needle in operation. A variety of the striated cataract 
 described as occurring in advanced life, is also often found 
 in early life, the striae commencing at the circumference 
 and converging to the centre, and not being open fissures 
 but opaque veins with transparent intervals between 
 them. Sometimes a defined circular white spot, very 
 opaque, is found occupying the centre of a transparent 
 lens, with one or more equally opaque thick bars or veins 
 radiating from it toward the circumference. In using the 
 term vein, I mean veins such as exist in minerals. This 
 central opacity with dense radiating striae, is generally, 
 but not always, accompanied by an equally dense defined 
 opacity of the capsule of smaller size, easily distinguished 
 by its chalky whiteness and cartilaginous appearance, con- 
 stituting a variety of capsulo-lenticular cataract. This 
 dense opacity of the lens has not, however, always the bars 
 or striae radiating to the edge, but exists alone in a lens 
 perfectly transparent to the circumference, admitting of 
 
 2 c
 
 30 ON CATARACT. 
 
 very useful vision when the pupil is dilated with belladonna. 
 Such are very slow in progress, sometimes, in fact, being 
 permanent, and undergoing little or no change for many 
 years, if not indeed for life, and they are often congenital, 
 but I think not always, for I have sometimes found them 
 in persons somewhat advanced in life who insisted upon it 
 that they had always had good sight until a comparatively 
 recent period. The late Mr. Tyrrel, in his book on Diseases 
 of the Eye, describes the striated cataract, but does not, I 
 think, appear to have distinguished it from the stellated. 
 He says, alluding to the distortion or multiplication of 
 objects in incipient cataract, " when these modifications of 
 symptoms have presented themselves, I have found that 
 the opacity of the lens has not been confined merely to the 
 centre, but that one or two, or several, opaque radii have 
 existed, passing from the centre to the circumference of the 
 body." (Vol. ii., p. 355.) And again (p. 363), '• In rare 
 instances, when cataract commences from the circumfer- 
 ence, and proceeds by radii toward the centre, these radii 
 are at first confined to the posterior hemisphere of the 
 lens. This opinion, however, is equally erroneous with 
 that before adverted to respecting the anterior portion of 
 the lens, as I have had opportunity of ascertaining by 
 watching the progress of such cases, and subsequently ex- 
 tracting the cataracts." Mr. Saunders in his treatise (p. 
 133., pi. iv., fig. 3,) says : — " There is a form of the con- 
 genital cataract in which the centre of the lens is opaque 
 and its circumference perfectly transparent. In these 
 cases the lens remains of its natural size as long as its cir- 
 cumference preserves its transparency, which, if undis- 
 turbed, it will do for many years." Fig. 3, referred to, 
 shows, he says, '• a lens of which the centre is opaque and 
 the circumference is transparent, with the exception of 
 three opaque radiated lines;' and it shows also a small
 
 ON CATARACT. 31 
 
 defined opacity of the capsule over that of the lens, but 
 smaller than it. I have now in this paragraph shown, that 
 of the lenticular cataract of earlier life there are four 
 varieties : the uniform light-blue or milky ; the stellated, 
 or split from centre to circumference j the radiated, with 
 veins from the edge toward the centre ; and that with an 
 opacity in the centre, with or without white bars or thick 
 veins running to the edge. But these are not all, for 
 sometimes the opacity is irregularly clouded, as if the 
 original fibrous structure of the lens was destroyed, and 
 the part converted into a grumous mass, as it appears some 
 weeks after having been freely broken up by the needle. 
 Mr. Wardrop, in his essays on the Morbid Anatomy of the 
 Eye (vol. ii., p. 81), says, alluding to this variety: — 
 *' Sometimes they are clouded in difierent parts, having 
 the appearance of a flake of snow ;" and Mr. Tyrrel (vol. 
 ii., p. 364) says: — " Sometimes the surface of the opaque 
 body appears flocculent, like the surface of a recently 
 broken piece of spermaceti." These cataracts are very 
 soft, and are speedily absorbed after breaking up. If they 
 are to have a name, they may be called flocculent. There 
 is yet another variety which I have often seen and operated 
 on. It is a very light-blue cataract, the colour of milk 
 and water, which evidently contains a quantity of fluid 
 between the lens and its capsule, for it is quite prominent, 
 pressing upon the iris so as to cause dilatation of the pupil, 
 and almost, if not all out, touching the back of the cornea. 
 This can be distinctly seen by looking at the eye in profile, 
 or sideways, the patient facing the light. Before I was 
 aware of the existence of this form of cataract, I was 
 much surprised to find that in operating on it I did not 
 break it up and scatter the pulp into the anterior chamber, 
 as I do in very soft cataracts, but that the more I worked 
 at it the less it moved. In fact, I had been all the time
 
 32 OS CATARACT. 
 
 moving the needle about within the capsule, bat when I 
 saw how it was circumstanced I brought (he instrument up 
 to the back of the cornea and tore open the capsule, when 
 it was immediately mixed up with the aqueous humour as 
 usual. Whether or not it is this variety which authors 
 allude to under the name of Morgagnian cataract I cannot 
 tell, because they seem to differ in their descriptions of it. 
 Mr. Mackenzie, in his work on Diseases of the Eye, ap- 
 pears to describe it under this title. He says: — "The 
 effusion of an opaque fluid between the lens and its cap- 
 sule forms one of the rarest kinds of cataract. It is gene* 
 rally followed by dissolution of the lens, and not unfre- 
 quently by capsular opacity. So long as the cataract con- 
 sists in a mere effusion between the capsule and lens, it 
 presents a cloudy appearance, as if formed of milk and 
 water imperfectly mixed. It is stated that if the eyeball is 
 repeatedly rubbed with the finger through the medium of 
 the eyelid, the clouds of opacity change their outline and 
 position ; and sometimes they do so merely on quick 
 motion of the eye from side to side. The capsule is dis- 
 tended in cases of Morgagnian cataract, and pressing 
 against the iris obliterates the posterior chamber and im- 
 pedes the motions of the pupil. When the disease is 
 purely Morgagnian vision is sometimes but slightly im- 
 paired, small objects escaping the observation of the pa- 
 tient, especially after the eye has been rubbed or moved, 
 but after the lens dissolves, the sight is limited to the per- 
 ception of light and shade." Mr. Lawrence says: — 
 •* Opacity of the fluid situated between the lens and its 
 capsule has been called cataracta Morgagniajia ; but I 
 doubt its separate existence. How can we determine that 
 the fluid is opaque and the lens transparent ? Can we 
 suppose that this fluid is opaque and the lens remains trans- 
 parent? I think, therefore, that in a practical consider-
 
 ON CATARACT. 33 
 
 ation of the subject this kind of cataract might be safely 
 omitted." Beer speaks of such a cataract occurring sud- 
 denly in consequence of exposure of the eye to acid va- 
 pours, and adds observations which render it doubtful 
 whether he understood the nature of the disease at all. 
 In the cataract to which I allude, I do not think that it is 
 the fluid which is opaque, but the lens behind it, which is, 
 I think, a common soft cataract. Mr. Mackenzie adds, 
 that a •' pure Morgagnian cataract is not to be touched in 
 the way of operation." The cataract I have been alluding 
 to I frequently operate on with success. 
 
 Notwithstanding the varieties of lenticular cataract, both 
 of advanced and early life, above enumerated, many other 
 forms of disorganization of this body might be described. 
 I have seen the lens of a beautiful pale opaque green after 
 general inflammation of the eye, and other curious appear- 
 ances of it are occasionally met with ; but the greatest 
 amount of disorganization is found in congenital cataracts, 
 and where the eye has been destroyed by the inflammation 
 commonly called iritis, but which should be called ophthal- 
 mia. When this happens the pupil is generally adherent 
 to a white, thickened, hard, opaque capsule, within which 
 is a shrunk, friable, white fragment, bearing no resem- 
 blance in structure to the original lens, and in congenital 
 cataract, as shall be noticed presently, similar or equally 
 great disorganization is observed. These shreds of lens 
 are, I believe, what are called siliquose cataracts. That 
 the lens sometimes, but very rarely, has earthy matter de- 
 posited in its structure, most probably phosphate of lime, 
 is an admitted fact, and one of interest in a physiological 
 point of view, when it is recollected that the nutrition of 
 this part has been attributed to a secreting process rather 
 than to the usual growth by vascular ramification. Mr. 
 Wardrop records an example of it, and I have myself seen
 
 34 ON CATARACT. 
 
 Streaks of white earthy material among the fibres of the 
 lens in horses' eyes destroyed by inflammation. Mr. 
 Wardrop describes it as "ossification of the lens," and 
 states that " on dividing the crystalline lens its central 
 portion was found converted into hard bone. The external 
 laminae of the lens were soft, but those nearer the centre 
 became more consolidated, the central portion itself being 
 of a deep brown colour, perfectly osseous, and exhibiting 
 a laminated structure." And again, in his description of a 
 plate of it : — " The ossification is seen commencing in the 
 centre of the lens, and extending towards its circumfer- 
 ence in the form of concentric bony laminae. The central 
 portion was a dark brown coloured and hard bone ; the 
 exterior laminae were of a paler colour, and more friable." 
 This example, thus authenticated, is of great value, be- 
 cause although ossifications of the capsule of the lens have 
 been met with occasionally, conversion of the body of the 
 lens into bone, or an earthy solid resembling it, is of extreme 
 rarity. The lens has been found sometimes, although 
 rarely, in congenital cataract converted into a white milky 
 fluid. Mr. Saunders records two, in which opaque cap- 
 sules were found filled with such material. In fact, there 
 seems to be no end to the variety in form, consistence, and 
 colour, observed in cataracts of long standing, especially 
 when congenital, or caused by inflammation or injury, but 
 it would be tedious and superfluous to enumerate all these 
 under different names. In alluding to the causes of cata- 
 ract and the possibility of its spontaneous cure, it will be 
 necessary to call attention to cataract from wounds or 
 other injuries of the eye. Here it is only necessary to 
 say, that such cataracts are of a bluish-white appearance, 
 and irregular flocculent composition ; sometimes, when the 
 wound in the capsule is very small, presenting the stellate 
 form ; sometimes, when the rent is larger, projecting in
 
 ON CATARACT. 35 
 
 the shape of a white fleecy mass through the pupil into the 
 anterior chamber ; and sometimes, when the whole face of 
 the capsule is torn open, swelling out so as to fill up the 
 whole anterior chamber up to the very back of the cornea. 
 
 OP CAPSULAR CATARACTS. 
 
 I HAVE said above that " the lens being composed of two 
 structures so different in every respect as its capsule and 
 body, and that both these being liable to become opaque, 
 there must necessarily be at least two very different forms 
 of opacity, and hence the division of cataracts into capsular 
 and lenticular." I have now to treat of the capsular. After 
 what has been stated respecting the nature and structure of 
 the capsule of the lens, it becomes obvious that opacities of 
 it must be very different from those of the lens itself I have 
 said the capsule is composed of a hard, elastic, solid mate- 
 rial, and have expressed my belief that it is nothing else but 
 transparent cartilage. Of this I entertain no doubt ; and 
 the examination of capsular cataracts has strengthened this 
 conviction. When the capsule has become opaque, it seems 
 in fact to have merely degenerated into cartilage of a coarser 
 structure, and consequently to have lost its characteristic 
 delicate and perfect transparency ; while it has at the 
 same time become thickened and harder. Such cataracts 
 necessarily present appearances totally different from those 
 observed in the lenticular form. There being no fibrous 
 structure arranged from centre to circumference, there is 
 therefore no stellated or striated opacity, but either one 
 patch, more or less uniform, or a number of small patches, 
 streaks, or dots, sometimes presenting a veined or marble 
 appearance, sometimes an arborescent or meandering out- 
 line. This remarkable irregularity in shape must at all
 
 36 ox CATARACT. 
 
 times serve to distinguish the capsular from the lenticular 
 cataract. 
 
 The whiteness or complete opacity of capsular cataracts 
 is as characteristic of the disease as the irregular mottled, 
 dotted, or marbled appearance. Sometimes, it is true, the 
 opacity is not so dense, but in general it is as white and 
 compact as paper, resembling the membrane within the 
 external shell of an egg, and being either a uniform patch 
 or an irregular one, with intervals or small spaces less 
 opaque pervading it. The surface sometimes, if not gene- 
 rally, loses that perfect smoothness and polish which dis- 
 tinguishes the capsule in its healthy state, and becomes 
 rugged or undulating ; while at the same time it is so hard 
 and tough that great force is required to tear it. It is 
 even sometimes converted into a calcareous layer, consti- 
 tuting what is called ossification of the capsule. All these 
 qualities of capsular cataracts are worthy of attention, be- 
 cause upon a knowledge of them depends the diagnosis pre- 
 vious to operation and the steps to be taken during its per- 
 formance. It is easy enough to determine beforehand the 
 consistence of a lenticular cataract and afterward to extract 
 or break it up according to its density, but it is often not 
 so easy to predict the amount of resistance to be expected 
 in capsular cataract, or during operation to overcome its 
 toughness or tenacity of attachment. 
 
 The varieties of capsular cataract are not at all so nu- 
 merous as those of the lens itself. No two of them, it is true, 
 are exactly the same in appearance, but there are fewer 
 species or varieties truly distinct in their nature. There 
 are, however, some perfectly so. The ossified or calcareous 
 degeneration must be held to be one, and that called 
 central cataract is another. This latter is a small defined 
 circumscribed dense, white, opacity, about the size of the 
 head of a pin, occupying the centre of a capsule otherwise
 
 ON CATARACT. 37 
 
 perfectly transparent. It sometimes Is prominent, pro- 
 jecting from the surface in the form of a cone, sometimes 
 is flat or nearly so. In general, the body of the lens is 
 perfectly transparent where these central opacities of the 
 capsule exist, but sometimes there is also a dense central 
 opacity in it somewhat larger than the other. This cen- 
 tral capsular cataract is sometimes probably congenital, 
 for we cannot ascertain from the patient that it was observed 
 at any particular period, or that it could be traced to any 
 particular cause ; sometimes, however, it exists in eyes 
 having dense and extensive opacities of the cornea from 
 purulent ophthalmia in infancy or from small-pox. I have 
 seen them very small in a lady of sixty, who said that she 
 never considered that her sight was worse than that of 
 other people, and it is probable that after having been once 
 formed they never increase. I have seen them remain un- 
 changed for many years, and when large with a small pupil, 
 I have afforded sufferers from them very useful vision by 
 the daily use of belladonna. 
 
 One of the most common forms of capsular cataract met 
 with is that which follows operations for cataract or injuries 
 of the eye in which the lens has been wounded. It ap- 
 pears in two very different shapes. In one, it is thick, 
 white, and very opaque ; in the other, a mere film, resem- 
 bling a broken cobweb. The thick, white, opaque capsule, 
 remaining after injury or operation followed by inflamma- 
 tion, either fills the whole pupil and adheres all round to 
 its margin ; or it hangs or projects from its edge in an 
 irregular flap or a rounded prominence. In either case it 
 is as hard and elastic as dry parchment, and if detached by 
 the needle remains undissolved and unabsorbed for a great 
 length of time, on which account I either work a hole in 
 the centre of it with the point of the needle, or detach it 
 from the margin of the pupil all round, except at one spot.
 
 38 ON CATARACT. 
 
 where I allow it to adhere, finding that in process of time 
 it shrinks and curls up into a white nodule, which, although 
 it projects a little into the pupil, does not obstruct vision. 
 Such may of course be extracted with a pair of forceps, 
 but if they adhere extensively, this is not so safe or so easy 
 of accomplishment as some think. The film resembling a 
 broken cobweb is very common, almost always remaining 
 after injury or operation where the capsule has not been 
 extensively torn, and where inflammation has followed. 
 This often exists in the shape of a few white strings, as 
 thin as fine threads, running from one side of the pupil to 
 the other, and having the intervals between them open and 
 transparent ; sometimes, however, it is a complete conti- 
 nuous film like an irregular cobweb. Such are very tough 
 and difficult to be detached with the needle, the iris not 
 affording sufficient resistance when they are pulled or 
 drawn from it by the instrument. I am often obliged to 
 twist them away by turning the curved needle round and 
 round upon them. In some cases they may be divided 
 with a sharp iris knife or cutting needle. The back of the 
 capsule sometimes, but not often, becomes opaque after 
 operation, and remains so after the lens has been completely 
 absorbed ; such opacities are very delicate, and being far 
 back, are not easily seen ; but with a dilated pupil become 
 visible, and may be torn asunder without much difficulty. 
 What has been called posterior capsular cataract, and de- 
 scribed as existing with a transparent lens is, I am con- 
 vinced, a radiated lenticular cataract in which the opaque 
 striaB are confined to the back and margin of the lens. 
 Capsular cataract never assumes the radiated or striated 
 arrangement. 
 
 It often happens that both the capsule and body of the 
 lens are opaque at the same time, constituting what are 
 called capsulo-lenticular cataracts. These are generally
 
 ON CATARACT. 39 
 
 either congenital, or the result of injury or severe inflam- 
 mation, but I have often seen opaque patches in the cap- 
 sule in common lenticular cataracts both of advanced and 
 early life. Sometimes, as has been already observed, the 
 central cataract of the capsule exists with a central opacity 
 of the lens itself. Such a one has been described and de- 
 lineated by Mr. Saunders, and Mr. Wardrop appears to 
 have observed similar examples. In capsular cataracts, 
 either congenital, or in consequence of injury or destruc- 
 tive inflammation, the lens is often found reduced to a 
 white and friable shred or fragment. This has been called 
 siliquose capsulo-lenticular cataract. 
 
 Congenital cataracts are so called because they exist at 
 birth. They are generally capsular, with a thin remnant 
 of white disorganized lens enclosed, but sometimes they 
 are firm lenticular cataracts with or without opaque cap- 
 sules ; or the lens is opaque in the centre with transparent 
 circumference and transparent capsule. Sometimes, but 
 rarely, the opaque capsule contains a white fluid, and some- 
 times the margin of the pupil is adherent. In fact, some 
 of these cataracts exhibit as great change of structure and 
 disorganization as those caused by severe injury or de- 
 structive inflammation, while others are simple lenticular 
 cataracts, like those which occur in early life generally. 
 As cataracts are not always observed in infants until they 
 are some months old, we cannot say with certainty that 
 they existed previous to birth, as they may have formed 
 subsequently, if merely lenticular and without opacity of 
 the capsule or much other alteration in structure ; but if 
 the capsule or centre be very opaque, or the lens shrunk 
 or otherwise disorganized, we may with safety pronounce 
 them congenital. I am inclined to believe that certain 
 striated or partial cataracts which are met with in growing 
 children commence before birth, because the subjects of
 
 40 ON CATARACT. 
 
 them exhibit symptoms of defective vision from the ear- 
 liest period, and the progress of the cataract is so gradual 
 that vision is not entirely lost until puberty or even later. 
 True congenital cataracts, however, rarely occur, at least 
 I can say that I have found them uncommon. Mr. Saun- 
 ders, it is true, met with sixty cases in three or four years, 
 but that arose from the success of his new method of oper- 
 ating, attracting patients to him who might have been 
 permitted to continue blind for many years according to 
 the old practice, and many of his cases may not have been 
 congenital at all. It is a remarkable fact that these con- 
 genital cataracts occasionally, if not frequently, occur in 
 more than one individual of the same family, as does con- 
 genital deafness. Mr. Saunders met with them in two 
 brothers in one family, and two others, twins, in another. 
 In a third family, a brother and two sisters were affected ; 
 and in a fourth, three brothers and a sister. I have met 
 with the disease in three children of the same parents, also in 
 two sisters and a brother, and in brother and sister. Mr. 
 Lawrence has observed similar examples. It should never 
 be forgotten that eyes affected with congenital cataract are 
 sometimes otherwise defective, rendering an operation of 
 no avail. In fact, there is congenital amaurosis as well 
 as congenital cataract, and when the retina is insensible 
 with opaque lens it is impossible in young subjects to as- 
 certain before an operation that it is so. The motions and 
 gestures of the child in search of light will afford some 
 guide to the state of the retina, but there may be percep- 
 tion of light without ability to distinguish objects. This 
 has sometimes caused great disappointment to the friends 
 of children operated on, and has brought discredit upon 
 the operator and the operation, but very unjustly, for the 
 operation when properly performed generally succeeds. I 
 think I can say that I never had an eye destroyed by in-
 
 ON CATARACT. 41 
 
 flammation following operation in young subjects, and I 
 have operated on many. 
 
 In order to avoid the danger of rendering the subject 
 confused or complicated, I do not enumerate among cata - 
 racts those opacities of the capsule which accompany ad- 
 hesions of the margin of the pupil to it ; but it must not 
 be forgotten that in inflammations of the membrane of the 
 aqueous humour and of the iris, the surface of the capsule, 
 and even the capsule itself, become opaque. Although the 
 membrane of the aqueous humour cannot be demonstrated 
 on the anterior half of the capsule of the lens in a state of 
 health, its presence there may be inferred from analogy 
 and the effects of inflammation. It is only reasonable to 
 conclude that if there be a membrane of the aqueous 
 humour at all, it must extend to all surfaces in contact 
 with that fluid, and the fact that adhesion does take place 
 rapidly and perfectly in iritis, seems conclusive as to the 
 existence of such a serous covering. In inflammation of 
 the membrane of the aqueous humour with or without 
 iritis, there can be no doubt that vision becomes slightly 
 cloudy or hazy from loss of transparency of that portion 
 of it which cbvers the back of the cornea. The speckled 
 opacity is distinctly visible in syphilitic iritis. Opacity 
 of that portion which covers the front of the capsule of the 
 lens is not, however, so unequivocal, although I believe it 
 often occurs, but whether or not permanent is doubtful. 
 Of the frequent occurrence of distinct and well-marked 
 opacities of the capsule where the margin of the pupil ad- 
 heres there can be no question, and when they are exten- 
 sive they must be called capsular cataracts. In almost all 
 cases of iritis which terminate in contraction of the pupil 
 and adhesion of its entire margin to the capsule, that part 
 becomes either entirely or partially opaque ; often with 
 opacity, disorganization, and shrinking of the lens itself. 
 
 2 D
 
 42 ON CATARACT. 
 
 In less destructive attacks the margin of the pupil adheres 
 only at certain points, but at these points distinct, well- 
 de6ned white spots are formed. Opacities from the above 
 causes, and of the above character, have been called 
 spurious cataracts, and the degrees and varieties of opacity 
 have been denominated fibrinous, flocculent fibrinous, 
 clotted fibrinous, and trabecular fibrinous cataract. The 
 term fibrinous, however, ceases to be applicable after some 
 time, as fibrine, if any exists, is either absorbed or con- 
 verted into permanently organized material. 
 
 THE SO'CALLED STNCHISIS ETINCELAMT. 
 
 There is a very remarkable and peculiar alteration of the 
 lens which, from its rarity, as well as from its value as an 
 example of extreme degeneration of organized animal struc- 
 ture, is well worthy of consideration ; and especially so, 
 because its nature has been mistaken by persons on the 
 continent who have undertaken to describe it in ignorance 
 of the accounts published in this country respecting its 
 true character. This peculiar alteration or degeneration I 
 described at a meeting of the Surgical Society on the 14th 
 of January, 1843, in the following terms: — 
 
 " Dr. Jacob called the attention of the society to an ap- 
 pearance which presented itself in the eye of a person upon 
 whom he lately operated for cataract in the City of Dublin 
 Hospital. The man, aged 33, was, he said, what is called 
 amaurotic, or in other words, his vision was very defective 
 even in the other eye which was free from cataract, and 
 therefore he was unwilling to operate from a conviction 
 that he had an unsound retina to deal with ; but at the 
 earnest solicitation of the patient, he consented to let him 
 have the chance which the experiment afibrded. The 
 cataract was lenticular, and although more of an amber
 
 ON CATARACT. 43 
 
 tint than is usual at this time of life, was otherwise not 
 uncommon. The lens was freely broken up with the 
 needle through the cornea, and was easily separated into 
 pulp and fragments, some of which fell into the anterior 
 chamber, and no inflammation requiring attention followed. 
 In a month the greater part was absorbed, and in six 
 weeks the whole, leaving a shred of opaque capsule attached 
 to the margin of the pupil, but not large enough to inter- 
 rupt the passage of light. As the cataract, however, dis- 
 appeared, the iris became studded with delicate brilliant 
 scales of metallic lustre, so numerous and large as to be 
 easily visible with the naked eye, and still more conspi- 
 cuous with the assistance of a lens. They were irregular 
 in form, but with surfaces so plane and polished that they 
 reflected the light freely, resembling, in a remarkable man- 
 ner, the particles of mica in granite. The appearance con- 
 tinued until the man was discharged, having been visible 
 for about a month, and may probably continue so for some 
 time. Sight, as had been predicted, was not restored, the 
 retina being unsound. Dr. Jacob reminded the society 
 that earthy, and perhaps crystalline deposits in the lens 
 and its capsule were not very uncommon, and that they 
 had been met of so dense a nature as to lead to the appli- 
 cation of the term ossification to them, although not to be 
 considered at all of the nature of real bone. They are 
 probably phosphate of lime, or perhaps ammonio-phosphate 
 of magnesia with phosphate of lime, but that he left to the 
 chemists to determine. He said that on another occasion, 
 in breaking up a cataract of somewhat the same appear- 
 ance, he was surprised to see a quantity of what appeared 
 to be delicate needle-shaped crystals difi'used among the 
 fragments, but these disappeared with the cataract as it 
 was dissolved. He also exhibited a drawing of a capsular 
 cataract, the consequence of injury, which he had removed 
 successfully, and which had presented on the surface an 
 appearance of such metallic lustre that he was obliged to 
 make the artist represent it with silver leaf, and added that 
 these brilliant cataracts, in a less marked form, were not 
 very uncommon, but in all of them the disease was of long
 
 44 ON CATARACT. 
 
 Standing. Earthy deposits, he observed, were frequently 
 found in the body of the lens in horses blind from cataract 
 consequent on inflammation. The shell of bone sometimes 
 found within the choroid of disorganized eyes, and gene- 
 rally called ossified retina, he observed, was probably of 
 the same nature as these lenticular deposits." 
 
 I again called the attention of the society to the same 
 subject on the 23rd of November, 1844, as follows : — 
 
 *• Dr. Jacob said he had some observations to make on a 
 peculiar appearance occurring in a cataract under his care 
 at the City of Dublin Hospital. It occurred in a boy on 
 whom he had operated about five weeks since. He had 
 received a blow on the eye some years before which had 
 cut the cornea and injured the iris, the black membrane of 
 the aqueous humour on the back of the iris being torn 
 from it and dragged in front. This led to cataract, with 
 irregular pupil ; it was evidently an unsound eye, and 
 was one of those cases to which he gave the chance of an 
 operation without any sanguine hopes as to the result. 
 He had broken up the lens, which was soft and pulpy, and 
 thrown the fragments into the anterior chamber in the 
 usual manner. In about a week a large portion of the 
 pulpy matter had been dissolved, but mixed up with the 
 remainder were a number of small brilliant scales, resem- 
 bling particles of gold leaf, perhaps not of so metallic a 
 lustre, but having more the appearance of mica. He called 
 the attention of the students to them at the time, and 
 though they had since then partially disappeared, they 
 were now, in the fifth week since the operation, distinctly 
 visible, moving about in the anterior chamber. They are 
 now fast dissolving, and in a week or ten days will pro- 
 bably have altogether disappeared. He would not offer 
 any conjecture as to the nature of these scales, if he had 
 not recollected a case which had formerly come under his 
 notice. It was an instance of cataract, produced, as well 
 as he recollected, by injury also. On breaking up the 
 lens, he was surprised to perceive it fall into a pulp in the
 
 ox CATARACT. 45 
 
 anterior chamber, having the appearance of oil altered by 
 cold. Some days afterwards on examining it with a lens of 
 2^ inch focus, a number of needle-shaped crystals or spiculae 
 appeared moving about in the anterior chamber, each about 
 a line in length. Knowing that the crystalline lens was 
 composed of delicate fibres, he at first imagined that these 
 might be some fragments of it, but all doubts on that 
 point were removed when he discovered that after some 
 days they were not dissolved, but remained even more dis- 
 tinctly visible as needle-form crystals than before, and he 
 was led to consider whether they might not have been 
 crystals of some of the phosphates of lime of the same na- 
 ture as the metallic scales he had been just describing. 
 He thought it very probable that these were crystals of 
 some phosphate of lime, as chemists, in speaking of that 
 substance, described both crystalline needles and crystalline 
 laminae. Some^persons might allege that these were merely 
 fibres of the crystalline lens, but his objection to that was, 
 that being so, they would have dissolved in a few days, 
 while both the scales and needles to which he had alluded 
 continued undissolved in the chamber for many weeks. It 
 might also be objected, that in natural or healthy animal 
 structure no crystalline deposits took place, unless the 
 enamel of the teeth and porcelanous shells might be 
 adduced as instances of such ; but whatever objections 
 might be urged against such an occurrence in health, he 
 would say that they were applicable to diseased conditions 
 of the body. [Dr. Jacob here exhibited a drawing of an- 
 other cataract upon which he had operated in 1839, the 
 surface of which presented a brilliant metallic lustre, and 
 the texture of which, it being capsular and free from in- 
 jury, was remarkabl)- tough and firm.] This he considered 
 somewhat of the same character, but not so crystalline or 
 calcareous. He was not aware that these appearances had 
 been described already, but he should not be surprised if 
 it was so ; for his engagements did rot permit him to 
 search for such a fact in the immense mass of medical mat- 
 ter delivered by the press to the profession in the last few 
 years ; it would be like seeking for a needle in a bundle of
 
 46 ON CATARACT. 
 
 straw. Other parts of the eye were subject to calcareous 
 deposits, even the cornea had been found with gritty par- 
 ticles in it, and those osseous cups, generally described as 
 ossifications of the retina, were not uncommon. Calcareous 
 deposits in the body of the lens had been described by Mr. 
 Wardrop and others, and such were frequently found in 
 the eyes of horses blind from cataract for many years. 
 Conversion of the capsule of the lens into a material resem- 
 bling egg-shell was not very rare ; all showing that there 
 was no difficulty in admitting that phosphate of lime, or 
 some similar deposit, was often made in the structures of 
 the eye." 
 
 Notwithstanding these circumstantial descriptions of this 
 very curious form of disorganization, recorded in the 212th 
 number of the Dublin Medical Press for January 25, 
 
 1843, and again in the 310th number for December 11, 
 
 1844, I find that it has been described and commented on 
 in the continental journals without the slightest reference to 
 my notices. In the Annales d' Oculistique, an ophthalmo- 
 logical journal, published in Brussels by Dr. Cunier of 
 that city, a communication appeared in the number for 
 November, 1845 (nearly two years after my first notice), 
 from Dr. Desmarres of Paris, describing an example of 
 the same disease. It occurred in a woman, aged 58, whose 
 sight began to fail from cataracts about eighteen years be- 
 fore, and who had the operation of depression performed 
 on her left eye seven years, and on the right three years, 
 before Dr. Desmarres saw her ; she then (September 22, 
 1845,) had dense capsular cataracts, dilated pupils, and 
 tremulous iris, with little sight. These capsular cataracts 
 were removed with a pair of nippers through an opening 
 made in the sclerotic, and good vision followed, but in 
 about a fortnight or three weeks after the following ap- 
 pearances were observed in the left eye : "Looking through 
 the pupil, which was widely dilated, to the bottom of the
 
 ON CATARACT. 47 
 
 eye, which was perfectly black, I saw (says Dr. Desmarres) 
 scales attached, brilliant as diamonds, moveable, and of a 
 size to be compared only to grains of sand. I'hey occupied 
 different planes in the posterior chamber, appearing gene- 
 rally twenty or thirty at a time ; becoming displaced from 
 below upward with the motions of the eye, and being re- 
 placed by others equally brilliant and numerous. All 
 these little luminous moveable points reflecting the light 
 with a vivid brilliancy, appeared to descend by degrees 
 to the lower part of the eye, when it remained immoveable, 
 and showing themselves in greater number as the motions 
 of the eye were more extensive and sudden. There was 
 no unusual appearance in the anterior chamber, and vision 
 was as good as could be desired after an operation for cata- 
 ract J the patient complaining of some muscce volitantes 
 only. 
 
 In the same Anndles d' Oculistique for April, 1846, Dr. 
 Sichel of Paris called attention to this subject, and relates 
 a case of the same kind which had occurred to him in 1841 . 
 The patient, a boy, aged 13, suffered from hydrophthalmia 
 of both eyes, the left being much larger than the right, but 
 still so free from disease as to enable the boy to read. In 
 the right, which was soft to the touch, and scarcely sensible 
 to light, was a yellow capsular cataract adhering to the 
 pupil. On tearing this capsule with the needle, a flow of 
 turbid, yellowish liquid took place, mingled with a quan- 
 tity of scales of a golden-yellow lustre, which fell into the 
 anterior chamber and filled it up completely. When this 
 subsided a second flow of semitransparent yellowish mate- 
 rial followed, resembling boiling water in its motion. These 
 appearances continued for several weeks, and some of the 
 brilliant scales were visible even in 1844, three years after. 
 Dr. Sichel adds significantly : " It is astonishing that Dr. 
 Desmarres, who, in 1841 and 1842, being my clinical clerk,
 
 48 ON CATARACT. 
 
 had seen with me this patient, should have lost all recollec- 
 tion of a fact so difficult to forget, and which gave peculiar 
 interest to that which he himself published." But it ap- 
 pears that neither E, Dr. Sichel, nor Dr. Desmarres first 
 noticed this curious disease, for it appears that M. Parfait- 
 Landrau, an oculist at Perigueux, described it in a com- 
 munication published in the Revue Medicale, t. iv., p. 203, 
 in 1828. The patient was a gentleman, aged 70, who, for 
 several years, had defective vision with muscce volitante^. 
 He says : "On looking into the depth of the posterior 
 chamber, I could perceive little bodies oscillating in the 
 bottom, shining with phosphorescent brilliancy. Notwith- 
 standing the attention I had paid in this examination, see- 
 ing the novelty of the phenomenon before me, which ap- 
 peared of high interest to science, I distrusted my own 
 judgment, and fearing that what I saw was the reflection 
 of some external object, I dilated the pupil with belladonna, 
 when M. Galy, of the hospital of Perigueux, also saw dis- 
 tinctly little bodies like fine powder of liquorice, and amongst 
 the number, which was very considerable, were seen some 
 having the brilliancy of filings of gold. These little bodies 
 oscillated throughout the entire extent of the posterior 
 chamber, and when the eye was at rest fell to the bottom, 
 but on the slightest motion rose and again fell. All this 
 took place at such a distance that no doubt exists that they 
 moved about in the vitreous humour. They were so nu- 
 merous that they were well seen with the naked eye, never- 
 theless we (examined them with a lens. Four days after 
 this, the eye was submitted to a second examination, in 
 presence of Dr. Vidal, a member of the medical jury of the 
 department, and first physician to the hospital, M. Galy, 
 surgeon of the same institution, and M. Renaud, another 
 surgeon : these gentlemen recognized the phenomena above 
 described, and consider it a duty they owe to the interests
 
 ON CATARACT. 49 
 
 of science to testify as to the correctness of the statements." 
 M. Parfait-Landrau goes on to argue that these appear- 
 ances serve to account for the muscce volitantes and luminous 
 spectra which so often disturb vision, but on this it is not 
 here necessary to dwell. After all this, it seems strange 
 that Dr. Desmarres should, in a work of considerable size 
 on Diseases of the Eye, published in 1847, say : " There is 
 not in science, to my knowledge, any observation similar to 
 this (made by him), not even that of M. Parfait-Landrau."* 
 The reader will perceive that while I described this curious 
 form of disease as occurring in the lens, subsequent writers 
 on the subject referred it to the vitreous humour, and 
 have actually named it accordingly. When the vitreous 
 humour is disorganized by inflammation, and the hyaloid 
 membrane loses its cohesion, the eyeball becomes soft to 
 the touch and the iris generally tremulous j this has been 
 named synckisis, and this supposed variety of it has been 
 dignified with the title of synchisis etincelant, or synchisis 
 scintillans. That the lens is the seat of the disease I enter- 
 tain no doubt whatever. In one case I saw the peculiar ma- 
 terial burst out of the capsule as I opened it with the needle 
 through the cornea, and in the others the scales and needle- 
 
 * Without wishing to detract from the merits of French 
 surgeons, it is only justice to those of other countries to re- 
 mind the reader that while an acquaintance with the French 
 language is so general elsewhere, that of German and English 
 is very limited in France. Hence the facility with which even 
 trivial communications made by Frenchmen obtain currency 
 in England and Ireland, while valuable information afforded 
 by us remains inaccessible to them ; or what is worse, the in- 
 formation is used without acknowledgment, so as to appear 
 original. This, however, is not perhaps so great an evil as 
 the wilful and obstinate ignorance, or something worse, osten- 
 tatiously displayed in other places, and from which some 
 London writers are not entirely free. 
 
 E
 
 50 ox CATARACT. 
 
 shaped crystals were so thoroughly embedded in the sub- 
 stance of the broken up lens, and were so obviously let loose 
 in the aqueous humour as these fragments dissolved, that 
 I could not be deceived. The description of M. Parfait- 
 Landrau, I admit, supports the other view, for he saw these 
 oscillating bodies in an eye which, although defective, was not 
 considered to suffer from cataract ; but as there are forms of 
 cataract in which the capsule of the lens is distended with 
 fluid, this may have been one of them, and in that fluid it 
 probably was that these bodies moved. In Dr. Desmarres' 
 case, the particles appeared upon extracting opaque cap- 
 sules, and had probably been discharged from the lens in 
 the previous operation of depression. Moreover, it does 
 not appear that Dr. Desmarres' patient had any sj/nchisis 
 at all, for he says, after describing the disorganized state 
 of the iris and its adhesions to the capsule, " touies les 
 autres membranes sont saines." And again, *' les yeux 
 avaient leur consistance normale." In Dr. Sichel's case 
 there was a capsular cataract, but there is no reason for 
 assuming that there was not a disorganized lens within it 
 when it was opened. In M. Parfait-Landrau's case there was 
 no softening of the eye, and therefore no syiichisis : in fact, 
 there is no evidence that the disease was in the vitreous 
 humour. As to the possibility of anything floating about 
 in a sound vitreous humour, it cannot be admitted for a 
 moment ; this structure, although a soft and delicate one, 
 is a solid, and in a solid such particles could not move. 
 As to the complete fluidity of this humour, even in soft- 
 ened eyes, much remains to be ascertained by careful dis- 
 section. It is much more probable that decomposition of 
 the crystalline lens would afford products such as these 
 described, than that a structure of such tenuity as the 
 vitreous humour could generate them. The lens of all 
 the structures in the body contains the elements of animal
 
 ON CATARACT. 51 
 
 organization in a state of the highest concentration, and 
 liable as it is to become detached from its capsule, although 
 still retained within it, presents a condition of parts in no 
 other place to be observed. It is, indeed, when so de- 
 tached, a lifeless material enclosed within living structure, 
 where, although it does not act as a foreign body, it under- 
 goes changes as peculiar as the extraordinary state in which 
 it exists. 
 
 Since this curious form of disease was noticed, much 
 discussion respecting its nature has been carried on in the 
 continental journals ; in which Dr. Stout of New York, 
 Dr. Blasius of Halle, Dr. Bouisson of Montpelier, M. 
 Petrequin of Lyons, and MM. Tavignot and Robert in 
 Paris, have taken part. I cannot, however, discover that 
 any material addition has been made to the descriptions 
 given of it by M. Parfait-Landrau in 1828, and by me in 
 1843 and 1844. It has been suggested that the crystalline 
 scales and needles are of the nature of cholesterine, but 
 no evidence of it has been afforded, and it seems impro- 
 bable that delicate and minute particles of such a material 
 could remain unchanged in the aqueous humour for months 
 or perhaps years. I have devoted more space to this in- 
 quiry than perhaps it is worth, but the circumstances 
 stated compelled me to do so. 
 
 OF THE CAUSES OF CATAKACT. 
 
 Cataracts, in the majority of cases, are the consequence 
 of the change which takes place in transparent parts from 
 age, or of inflammation, or accidental injury. We every 
 day, it is true, see cataracts which we cannot trace to any 
 cause, but that many are owing to either of these three 
 causes can scarcely be denied. It has already been shown 
 that the lens undergoes three obvious changes as we
 
 i»2 ON CATARACT. 
 
 advance in life. It becomes harder, acquires an amber 
 colour, and is flattened, or rendered less convex. In ad- 
 dition to this, it frequently, if not generally, loses its per- 
 fect transparency, and becomes slightly opaque, milky, or 
 clouded ; which, if increased, causes such obstruction to 
 the transmission of light, that it constitutes cataract, and 
 impairs or destroys vision. These changes, which the lens 
 undergoes in common with other structures, in some cases 
 proceed to still more remarkable alterations. StricB, or 
 veins of white opaque matter form, or the fibrous texture 
 separates, and it splits into segments, as has already been 
 stated. This being the case, it does not appear unreason- 
 able to attribute the various forms of cataract which are 
 seen in old persons to these organic changes where no evi- 
 dence exists of the operation of other causes. That cata- 
 ract, both capsular and lenticular, is often caused by in- 
 flammation cannot be denied. In general inflammation 
 of the whole eye, commonly called iritis, terminating in 
 contraction of the pupil, with close adhesion of its margin 
 to the capsule of the lens, not only is the capsule rendered 
 opaque, thick, and hard, but the lens itself is reduced to a 
 white, shrunk, disorganized mass ; and when the pupil is 
 not contracted or adherent, but dilated, the body of the 
 lens becomes opaque and of a greenish-amber tint, often 
 called glaucomatous. These effects of inflammation are 
 obvious, but opacity from less marked internal inflamma- 
 tion of the eye is not so unequivocal. I am, however, 
 satisfied that in those slow insidious forms of inflammation 
 which destroy the retina and cause what is called amauro- 
 sis, the lens is frequently rendered opaque ; and to this 
 cause are many of the soft blue lenticular cataracts of 
 earlier life to be attributed. Not only am I satisfied that 
 this is the case, but I am convinced that in many casein 
 this form of inflammation causes opacity of the lens with-
 
 ON CATARACT. 53 
 
 out destruction of the retina or amaurosis, and hence the 
 doubt which must exist as to the success of operations in 
 such cases. That central opacity of the capsule follows 
 penetrating ulcers of the cornea, or slough in the purulent 
 ophthalmia of infants, and the ulceration from pustules in 
 small-pox, has been already stated, and it appears only 
 reasonable to attribute such opacity to the inflammatory 
 action which accompanies these ulcerations. 
 
 That cataract is produced by injury, no one will, I 
 believe, deny. Puncture of the capsule by a sharp in- 
 strument, as often occurs from the accidental thrust of an 
 awl, a fork, or a needle, or from a thorn by a slap of a 
 bush in crossing a hedge, is immediately followed by 
 opacity or cataract. I think I have seen the lens quite 
 milky in ten minutes after the accident. In fact, the 
 moment the capsule is torn open, the soft fibrous lens 
 begins to imbibe the aqueous humour, and speedily ex- 
 pands, and becomes opened in its texture, at the same 
 time losing its delicate transparency and acquiring a milky 
 appearance. The capsule of the lens is sometimes, al- 
 though very rarely, burst by a blow, without any penetrat- 
 ing wound of the eye, causing opacity of the lens, and its 
 ultimate absorption. But not only is the lens rendered 
 opaque in this way, but it is a fact, that a blow on the eye 
 sometimes causes opacity without rupturing the capsule at 
 all. How this happens is not very certain, but it may be 
 caused by the detachment of the lens from its connexion 
 within the capsule by the shock of the blow ; or it may be, 
 that the cataract in such case is a consequence of inflam- 
 mation from the injury. 
 
 It has been said that cataract sometimes takes place sud- 
 denly, and this has been attributed to rupture of the cap- 
 sule in convulsions, but I very much doubi the truth of 
 these statements. I never yet met a patient who had
 
 54 ON CATARACT. 
 
 cataracts in both eyes and could prove that they took place 
 suddenly, although I have met many who asserted that 
 single cataracts had appeared on one particular day. The 
 real truth being, that blindness of one eye from cataract, or 
 any other cause, may exist for a long time without a person 
 being aware of it, until informed by attempting for the first 
 time to view an object with that eye, the. other being closed, 
 or until it is observed by another person. Every one con- 
 versant with diseases of the eye must have observed how 
 often very imperfect vision of one eye exists without the 
 patient knowing it ; so little are some persons in the habit 
 of observing or paying attention to occurrences which do 
 not materially affect them. 
 
 Of remote causes of cataract we have little evidence. 
 Hereditary predisposition is generally considered to exist, 
 and perhaps there may be some truth in the conclusion, but 
 I cannot say that 1 have been able to establish the fact in 
 a sufficient number of cases to justify a positive assertion 
 of its operation. Exposure to strong light and heat has 
 been enumerated among the remote causes ; and cooks, 
 glassblowers, workers in foundries, and smiths, have been 
 held more liable to the disease than others. Experience, 
 however, does not verify such statements, which have pro- 
 bably been repeated by successive writers upon some re- 
 mote authority not much to be relied on. Mr. Mackenzie 
 says he met with the disease at one time frequently among 
 stocking, weavers, and I, if I instituted an inquiry into the 
 matter, should probably say that the disease occurred most 
 frequently among labouring people. Chance may throw 
 more cases of particular trades into one man's way than 
 another. Constitutional disease, or derangement of im- 
 portant vital functions, might be supposed to be cal- 
 culated to induce this disease, but it does not appear to do 
 so. Neither scrofula, cancer, nor venereal, except so far
 
 ON CATARACT, 55 
 
 as they may cause it by leading to inflammation, seem to 
 produce it. Mr. Mackenzie says he met three instances in 
 cases of diabetes mellitus, and I think I have myself seen 
 two or three also. 
 
 OF THE SYMPTOMS AND PROGRESS OF CATARACT. 
 
 When sight becomes impaired, without opacity of the 
 cornea or contraction of the pupil, the defect is naturally 
 attributed either to opacity of the lens or loss of sensibility 
 of the retina; in other words, to cataract or amaurosis. 
 It is, therefore, necessary in such cases to ascertain how far 
 the disease is owing to the one or the other. The patient 
 in both cases complains of loss or imperfection of vision, 
 but in cataract he complains of a cloud, fog, or smoke in- 
 terposing between him and objects ; while in amaurosis he 
 rather thinks that he cannot see from want of light, or 
 some inexplicable inability to distinguish objects. In 
 cataract, I think that the patient when nearly blind can 
 judge better of the form, colour, and distance of objects, 
 than he can in amaurosis impairing vision to the same ex- 
 tent. In both, ocular spectra, muscae volitantes, floating 
 motes, smuts, and films, with or without luminous clouds 
 and scintillations, may be present, or they may not exist 
 in either, being I believe consequences of inflammatory 
 action. In incipient cataract there is generally a change 
 in the optical construction of the eye, causing indistinct- 
 ness of vision and loss of power of adaptation and adjust- 
 ment. So much so, that in many cases temporary relief is 
 derived from the use of lenses of short focus, and in near- 
 sighted persons concave glasses are abandoned, which is 
 not so much the case in amaurosis. In incipient cataract, 
 also, objects often appear distorted and multiplied ; the
 
 56 ox CATARACT. 
 
 print in a book appears thrown out of line, and the sashes 
 of the window appear doubled. The candle, also, often 
 appears as if with rays extending from it, and the circular 
 disc of the full moon appears broken at the edge, or the 
 candle and lamps in the street appear enlarged, and not 
 sharply defined ; while in amaurosis there is more of hazi- 
 ness, with spreading of the luminous point into a diflfused 
 patch. In cataract, patients generally see a little better 
 with the back to the light, or even in a weaker than in a 
 stronger light, because the pupil is then enlarged, and a 
 larger passage is formed for the transmission of the rays ; 
 while in amaurosis vision is improved in strong light, un- 
 less there be an irritable or excitable state of the retina 
 from inflammatory action. The admission or assertion of 
 a patient as to the existence of all or any of these symp. 
 toms, cannot, however, be considered conclusive of evi- 
 dence of incipient or advanced cataract, there must be 
 some visible opacity of the lens to justify us in pronounc- 
 ing positively that the disease is present. Yet even this 
 is not so easily ascertained as might at first sight appear. 
 On looking into the eye, an observer may perceive a degree 
 of cloudiness or milkiness of the lens which may lead him 
 to believe that cataract has commenced, but he must not 
 decide too hastily from this, because a perfectly transpa- 
 rent lens seen through a naturally large pupil, or through 
 one dilated by belladonna, with the light reflected from its 
 surface, appears milky ; and in aged persons the amber- 
 coloured lens, viewed under similar circumstances, appears 
 very opaque, although really not passing into the state of 
 cataract at all. If the defect of vision be but slight, and 
 the opacity but inconsiderable, it is not easy to determine 
 positively whether or not the defect is to be attributed to 
 the opacity or to the state of the retina, but when vision is 
 nearly lost from cataract, the opacity is so obvious that
 
 ON CATARACT. 57 
 
 there need be no doubt on the subject. In fact, if a 
 patient declares that he can only distinguish light from dark- 
 ness, or that he can merely perceive that the hand is passed 
 back and forward before his eyes, there must be visible 
 cataracts to account for such blindness ; and if there are 
 none, or if there is only a slight milklness of the lens, the 
 blindness must be referred to the retina. In other words, 
 if a man be blinded by cataracts, we have only to look into 
 his eyes and see them. It is in incipient cataract that any 
 difficulty exists of ascertaining the nature and amount of 
 the opacity, or of discovering that it is owing to this cause 
 and not to incipient amaurosis that the defective vision is 
 due ; and it Is therefore in such cases that dilatation of the 
 pupil by belladonna must be resorted to in order to obtain 
 a full view of the lens. With this most valuable aid, and 
 with the assistance of a good large convex lens of about 
 two and a half or three inches focus, I can with safety say 
 that I never fail to satisfy myself on the subject ; slight 
 opacities, whether general or partial, becoming thus dis- 
 tinctly visible, especially when a strong light is reflected 
 from the surface of the lens to the eye of the observer, or 
 when not so reflected, he looks deeply into its texture. I 
 must, however, warn those who have not acquired the art 
 of adjusting a lens so as to bring it to the proper place 
 between the eye of the patient and the observer, that they 
 must not expect satisfactory results from this method of 
 examination. I have also to warn beginners against re- 
 sorting to the dilatation of the pupil by belladonna without 
 some consideration, especially in aged persons ; because 
 the effect of such dilatation in a sound eye is to cause 
 great defect of vision while it lasts, and often in incipient 
 cataract the same result follows, and is immediately felt by 
 the patient, who ever after attributes his loss of vision to 
 this cause.
 
 58 ON CATARACT. 
 
 In endeavouring to arrive at a correct diagnosis of cata- 
 ract, the way in which the patient carries his head and 
 directs his eyes may be worth noticing. In cataract, 
 some vision always remaining, the patient continues to 
 direct his eyes in search of objects ; while in amaurosis, 
 especially if complete, there is a vacant stare which pro- 
 claims that he cannot see, and that he feels that there is no 
 use in attempting to do so. The state of the pupil and 
 power of contraction in the iris is also worth noticing, al- 
 though frequently aflfording little additional information. 
 If the pupil be permanently dilated, we may generally 
 conclude that the retina is insensible to light whether there 
 be cataract or not, but mere sluggishness in the action of 
 the iris, or even immobility of the pupil, should not be 
 considered conclusive evidence of amaurosis; because in 
 aged persons especially, the iris very often loses the power 
 of active dilatation and contraction without any corre- 
 sponding defect of vision. It seems to be very generally 
 assumed that if the retina becomes either partially or 
 entirely insensible to light, the pupil must of necessity be 
 dilated, because in the sound eye it is dilated when light 
 is diminished ; but experience teaches us that in the 
 majority of cases of amaurosis there is no dilatation of the 
 pupil. In the same way it is, or it may be, inferred that 
 when light is excluded by cataract the pupil is dilated, 
 but we know that it is not so. Consequently the state of 
 the pupil does not assist us much in our diagnosis of cata- 
 ract. If, however, in younger persons the pupil neither 
 dilates nor contracts under changes of light, with or without 
 cataract, insensibility of the retina may be inferred. 
 
 Much unnecessary doubt has been created with respect 
 to the diagnosis of cataract by giving to certain combina- 
 tions of cataract and amaurosis another name ; and de- 
 scribing under the title of glaucoma appearances which
 
 ON CATARACT. 59 
 
 depend upon the presence of an amber-coloured lens with 
 extensive alteration of structure in the other parts of the 
 eye. Glaucoma appears to me to bo merely that state 
 which follows general inflammation of the eyeball of chronic 
 character in persons more or less advanced in life. The 
 bloodvessels are permanently enlarged, the pure white of 
 the sclerotic is changed to a yellowish or dusky tinge, and 
 the cornea and lens, and perhaps sometimes the vitreous 
 humour, lose their perfect transparency and freedom from 
 colour ; the pupil being at the same time dilated, and the 
 eye soft from disorganization of the hyaloid membrane. 
 This is not progressive disease, but the consequence of dis- 
 ease ; in fact, the effect of inflammation, the existence of 
 which it is very important to ascertain where cataract is in 
 question, but which we need not seek to distinguish from 
 cataract, for frequently that disease is accompanied by this 
 very state of the eye. Opacity of the lens may properly 
 be called cataract, and loss of sensibility of the retina may 
 also be called amaurosis ; but I cannot see the necessity of 
 calling amaurosis with a yellow lens glaucoma. 
 
 Much has been said and written about another method 
 of detecting incipient cataract. It is called the catoptrical 
 test. A lighted taper is to be held a few inches from the 
 eye, and moved from side to side and up and down. If the 
 lens be perfectly transparent, one upright image of the 
 taper is seen reflected from the cornea ; a second, also 
 upright, supposed to be from the anterior face of the lens ; 
 and a third inverted, supposed to be from the back of the 
 lens. If the lens be opaque, the third or inverted image 
 is either|.indistinct or absent. To this method I have not in 
 my own practice attached much value, because I find that if 
 the sensibility of the retina is considerably impaired or 
 destroyed, or in other words, that the eye is amaurotic, 
 and that at the same time the lens is perfectly transparent,
 
 60 ON CATARACT. 
 
 I have only to look into the eye and see that it is so ; and 
 if, on the other hand, vision is much impaired, and the lens 
 so opaque as to obliterate the third inverted image, I have 
 also only to look and see it. Besides, I believe that in many 
 old persons the lens is so coloured and milky, although not 
 aflfected with cataract, that no inverted image is seen in 
 their eyes. 
 
 Many may, however, find the method useful, for it is 
 relied upon by Dr. Mackenzie and others as a valuable 
 means of diagnosis. My myopic eyes, too, which I find so 
 available in minute operations, may not admit of that ad- 
 justment which this experiment requires, and therefore 
 perhaps it is that I do not find it answer. Without ad- 
 vancing any claim to superior address in the investigation of 
 the state of the lens when supposed to be partially opaque, 
 I may observe that I have often felt surprise at the appa- 
 rent difliculty experienced by observers in determining the 
 question. With a glass of short focus and a strong light 
 reflected from the surface of the capsule, I seldom find it 
 necessary even to dilate the pupil in order to satisfy myself 
 as to the condition of the lens. Persons with presbyopic 
 eyes may not, however, find it so easy to accomplish the 
 same object, because they cannot so easily adjust the eye 
 to bring an exceedingly minute portion of an image to its 
 place on the retina. Whatever inconvenience may be expe- 
 rienced in early life by short-sighted persons, it is counter- 
 balanced by this state of vision at a more advanced period, 
 enabling them to pursue occupations which they should 
 otherwise be compelled to abandon.
 
 ON THE OPERATION 
 
 THE REMOVAL OF CATARACT, 
 
 AS PERFORMED 
 
 WITH A FINE SEWING NEEDLE 
 
 THROUGH 
 
 THE CORNEA. 
 
 ARTHUR JACOB, M.D., F.R.C.S. 
 
 PROFESSOR OF ANATOMY AND PHYSIOLOGY IN THE ROYAL 
 
 COLLEGE OF StlRGEiNS IN IRELAND, 
 
 AND SURGEON FOR DISEASES ^)F THE EYE TO THE 
 
 CITY OF DUBLIN H(SPITAL. 
 
 DUBLIN : 
 
 PRINTED AT THE MEDICAL PRESS OFFICE. 
 1850.
 
 DUBLIN : PRINTED AT THE MEDICAL PRESS OFFICE.
 
 CATARACT. 
 
 OPERATION THROUGH THE CORNEA 
 
 WITH THE 
 
 NEEDLE EMPLOYED BY DR. JACOB. 
 
 The following paper was published several years ago in 
 the Dublin Hospital Reports. I now republish it because 
 these valuable volumes have become scarce, and are con- 
 sequently out of reach of the majority of practitioners, and 
 because I have, within the last year, had frequent applica- 
 tions for information on this subject. I am also induced 
 to direct the attention of surgeons again to this method of 
 removing an opaque lens, in consequence of the want of 
 confidence reposed in it by many from an imperfect acquaint- 
 ance with its practice. My experience as to the use of 
 this needle, and the selection of the cornea as the place for 
 its introduction since the publication of this paper, leads 
 me to express still more strongly than I have done my con- 
 viction of the superiority of this operation. I think I can 
 with safety state that I have performed it more frequently, 
 and practised it for a greater length of time, than any man 
 now living, and therefore do I think that I have a right to 
 speak of its merits without hesitation or fear of contra- 
 diction. Many will probably think that I form a false 
 estimate of the value of my experience in this matter, or 
 perhaps that I am not aware of the amount of experience 
 which others have acquired respecting it ; but when I find,
 
 4 OX CATAKACT. 
 
 what I consider, the best method of repairing one of the 
 greatest losses which man sustains from disease or accident, 
 undervalued, I am compelled to advocate its adoption, re- 
 gardless of anything that may be said respecting my motives 
 for so doing, or the means I employ to accomplish my object : 
 
 "Without taking part in the protracted discussion re- 
 specting the comparative merits of the different operations 
 for cataract, I shall recapitulate the arguments which have 
 been urged in favour of that operation, to which I consider 
 the needle, which I have to describe, as particularly appli- 
 cable. The operation to which I allude is that of opening 
 the texture of the lens, to produce its absorption by expos- 
 ing it to the action of the aqueous humour.* 
 
 • Surgery is indebted to Mr. Pott for the important fact, 
 that cataract may be removed by absorption, if exposed to 
 the contact of the aqueous humour by opening the capsule; 
 and doubly indebted to Mr. Saunders for establishing by re- 
 peated operations the value of the suggestion. Attempts 
 have lately been made to transfer the credit of this improve- 
 ment to others. Mr. Guthrie first gives the merit to an old 
 lady, contemporary with Theodore Mayerne, and then, with 
 more reason, to Paul Barbette ; but as the works of these 
 authors have not been republished since 1690, and as the 
 copies e-xtant are not of frequent occurrence, it must be 
 allowed that it is probable they were not plundered by Mr. 
 Pott and Mr. Saunders. Frick, an American writer, attri- 
 butes the improvement to Gleize, who himself actually gives 
 Mr. Pott tlie credit of the discovery. 
 
 Among other technical terms in ophthalmic surgery intro- 
 duced from Germany, we have that of Keratonyxis applied to 
 this operation generally, although it can have reference to 
 the anterior operation only ; and with the word, we have the 
 claim of Dr. Buckhorn to the anterior operation, which Eng- 
 lish surgeons have been practising for nearly twenty years 
 at the suggestion of Mr. Saunders, and this on the grounds 
 that Dr. Buckhorn published an Inaugural Dissertation on 
 the subject in 1806,
 
 ON CATARACT. 5 
 
 The strongest argument in favour of this operation is, 
 that it is the most easily performed, affording a valuable 
 resource to the surgeon, who, unpractised in extraction, 
 wishes to avoid the evil consequences of depression. An- 
 other argument scarcely inferior in weight to the last is, 
 that the injury inflicted on the organ is much slighter than 
 in extraction, where so extensive a wound of the cornea is 
 made, or in depression, where the vitreous humour is neces- 
 sarily lacerated, and the retina frequently injured. If the 
 objections to depression be well founded, recourse must be 
 had to this operation in those cases where extraction is in- 
 eligible or impracticable. If after the operation has been 
 commenced the lens is found too firm to yield to the needle, 
 extraction may immediately be performed. It is, if not 
 the only operation applicable to capsular cataract in general 
 and congenital in particular, at least the preferable one : 
 where the eye cannot be fixed without subjecting it to 
 considerable pressure, it is obviously to be preferred. It 
 is urged as an objection to this operation, that it is appli- 
 cable to cases of soft cataract only. Whatever meaning 
 may be attached to the term soft cataract, my experience 
 leads me to the conclusion', that the operation, properly 
 modified, is applicable to the great majority of cases, per- 
 haps to nine in ten. It is said that it often requires to be 
 repeated ; but this is a minor evil to which we submit, in 
 preference to incurring the risk of either of the other oper- 
 ations. Extraction, if unsuccessful, cannot be repeated, 
 and a repetition of depression is not very desirable. It 
 has been said, without the least foundation in truth, that 
 vision is not as perfect after this as after other operations ; 
 the reverse is, I believe, generally speaking, the fact. 
 That more time elapses between the performance of the 
 operation and the recovery of sight than in the other oper- 
 ations must be admitted ; but this, which may be a very 
 
 2 A
 
 C ON CATARACT. 
 
 valid objection on the part of metropolitan oculists, many 
 of whose patients come from a distance, cannot be consi- 
 dered of great importance elsewhere, the disadvantage of 
 delay being counterbalanced by the greater security af- 
 forded by the mildness of the operation. From the cir- 
 cumstances above stated, it appears that this operation 
 must be, and is, very generally resorted to by surgeons, 
 and therefore any attempt to improve it should be treated 
 with indulgence. 
 
 It has been a subject of some controversy, whether this 
 operation should be performed by introducing the needle 
 anterior to the iris, through the cornea, or posterior to it, 
 through the sclerotic ; and hence the terms anterior and 
 posterior operations. The strongest argument in favour 
 of the anterior operation is, that the injury inflicted is 
 much less, the needle being passed through the cornea 
 only ; while in the other case it is passed through the scle- 
 rotic and choroid, wounding the ciliary processes, and pro- 
 bably often pricking one of the ciliary nerves. The scle- 
 rotic being a fibrous membrane, there is every reason to 
 apprehend the consequences which generally result from 
 injury of structure of that description ; added to which we 
 have the consequences of the injury sustained by the cho- 
 roid. On the other hand, there are few varieties of struc- 
 ture which bear injury so well as the cornea: it heals 
 rapidly when scratched or wounded : the extensive inci- 
 sion made by the extracting knife heals in a short time, 
 although exposed to the friction of the eyelids, and bathed 
 in tears : the wound of a cataract needle is closed in a few 
 hours : if a staphyloma, or a dropsical eye be opened, a 
 portion of the cornea must be removed, or a foreign body 
 introduced, to prevent the orifice from closing. Wound 
 of the iris may occur in either operation. That the lens 
 can be more effectually lacerated, and its texture opened,
 
 ox CATARACT. 7 
 
 by introducing the needle, of which I shall presently speak, 
 through the cornea, I am quite satisfied. 
 
 Some high authorities, among whom is Mr. Travers, are 
 inclined to think that the objections urged against the pos- 
 terior operation, on the ground of the injury sustained by 
 the sclerotic and choroid, exist in theory only. I am, 
 however, inclined to believe that those evils which we are 
 justified in apprehending from the nature of the parts in- 
 jured, actually do occur, and that the posterior operation 
 is more frequently followed by destructive inflammation 
 than the anterior. There can be no doubt that surgeons 
 become biassed in favour of the operation which circum- 
 stances have led them to adopt, but the opinion of Mr. 
 Saunders, who practised both operations, should have great 
 weight. He says (p. 149) : 'The surgeon has more power 
 in the posterior than the anterior operation ; but the latter 
 excites less pain and inflammation, and inflicts a slighter, 
 if any, injury on the vitreous humour.' 
 
 The surgeon who would succeed in restoring vision, by 
 exposing the lens to the contact of the aqueous humour, 
 should never forget that the most formidable impediment 
 to his success is the inflammation which follows the oper- 
 ation ; and that his aim should therefore be to accomplish 
 his object with the least possible injury to the organ. He 
 must also recollect that the lens displaced, whether whole 
 or in fragments, is equivalent to a foreign body in the eye, 
 and must therefore be so disposed that it shall not press on 
 the iris. A notion very generally prevails, which I cannot 
 but call a very mistaken one, that it is necessary to place 
 the fragments of the lens in the anterior chamber to accom- 
 plish their solution and absorption. The inexperienced 
 operator may rest assured that if he adopts such practice 
 indiscriminately he will have reason to repent of it. Sir 
 W. Adams, describing such a proceeding, says, after no-
 
 ON CATARACT. 
 
 ticing the method of introducing the instrument : * I then 
 turn the edge backwards, and with one stroke of the in- 
 strument, cut in halves both capsule and cataract. By 
 repeated cuts in different directions, the opaque lens and 
 its capsule are divided in many pieces, and at the same 
 time I take particular care to detach as much of the cap- 
 sule as possible from its ciliary connexion. As soon as 
 this is accomplished, I turn the instrument in the same 
 direction as when it entered the eye, and with its flat sur- 
 face, bring forward into the anterior chamber as many of 
 the fragments as I am able.'* It happens luckily for those 
 who attempt such an operation that it cannot often be 
 accomplished : a lens must be very soft indeed which could 
 be cut across, and chopped into fragments, upon a struc- 
 ture affording so little resistance as the vitreous humour ; 
 if it yielded so easily under the edge of the knife it must also 
 break under the needle in depression. Portions of cataract 
 will certainly dissolve more rapidly when placed in the 
 anterior chamber, because they are completely immersed 
 in the aqueous humour, while in the posterior they have 
 perhaps only one surface exposed ; but it is absurd, and 
 contrary to experience to suppose, that they cannot be 
 dissolved behind the iris. I quote one or two passages 
 from the work of Mr. Saunders to enable the reader to 
 contrast his mild, delicate, and successful operation with 
 the practice to which I allude : — 'As soon as the needle 
 has penetrated the tunics, he gently depresses its handle so 
 as to direct its point towards the capsule through the thin 
 edge of the lens, and steadily projecting its flat surface 
 between the capsule and lens, he arrives at the centre of 
 the capsule, which he opens, taking the same precaution 
 as in the anterior operation, not to rend it extensively, 
 
 * See his work on Cataract, p. 255.
 
 ON CATARACT. i) 
 
 lest he should dislocate the lens. He now cautiously opens 
 the texture of the lens, and withdraws the needle. In his 
 subsequent operations, he will complete the central aper- 
 ture in the capsule, and then loosen the texture of the 
 lens, suffering the flocculi to full into the anterior chamber, 
 but not projecting into it amj considerable portions of the 
 lens, for the process of its solution and absorption is best 
 accomplished in its natural position.'* 
 
 I must not, however, be understood to say that the 
 fragments of the lens are in no case to be brought into the 
 anterior chamber. A cataract is often soft and friable, 
 falling almost to a powder under the needle j in such case 
 the fragments necessarily fall into the anterior chamber, 
 so as to fill it half way up, and are afterwards rapidly ab- 
 sorbed without producing inflammation : such are certain 
 lenticular cataracts of a blue tint, not generally found in 
 old persons. If, however, the fragments be larger than 
 the head of a common pin they are liable to produce in- 
 flammation by pressing on the iris, which pressure can 
 only be obviated by keeping the pupil completely dilated 
 by belladonna, an object that cannot always be accom- 
 plished. I have frequently had an opportunity of witness- 
 ing the solution of cataract in situ after the capsule had 
 been opened, and I could with a magnifying glass observe 
 from day to day the change in form which occurred from 
 the removal of particles of cataract, until at last a portion 
 has disappeared, and left a passage for the light. In such a 
 case I observed three several times, that when a small frag- 
 ment fell out of the capsule into the anterior chamber, pain 
 and slight inflammation supervened, and continued until the 
 particle was absorbed. In cases of hard cataract I do not 
 attempt to break up the lens, because it would certainly be 
 
 * Treatise on Diseases of the Eye, p. 147.
 
 10 ON CATAllACT. 
 
 dislocated from its situation in the capsule in the attempt ; 
 I merely open the cataract, as directed by Mr. Saunders, 
 and as much of the lens as I can with safety, leaving it for 
 a future operation, when the lens shall be found softened, 
 and capable of being broken down into small fragments. 
 
 Another circumstance which has interfered with the 
 success of the surgeon in this operation, is his forgetting 
 that much time is required to accomplish the absorption of 
 a lens, and consequently neglecting to prepare his patient 
 for the delay. In cases of congenital cataract Mr. Saunders 
 says (p. 149) : ' The number of operations which may 
 be necessary to accomplish the cure of a congenital cata- 
 ract will very much depend on the texture of the capsule 
 and the size of the lens. It is frequently cured by a 
 single operation, more frequently it requires two, often 
 three, sometimes four, but very rarely five. This period 
 of cure will of course depend on the same circumstances. 
 Some are cured in a few days, the greater number in one 
 or two months, in many the process is protracted to three, 
 and in a few to four or even five months.' The common 
 period I have found to be from two to five months ; soft 
 cataracts are of course more rapidly dissolved. Occa- 
 sionally cataracts operated on in this way disappear in a 
 few days, not from being absorbed, but, as I conclude, 
 from falling down into a fluid vitreous humour ; as I have 
 observed to take place in eyes otherwise diseased, espe- 
 cially with a tremulous iris. I have learned to look upon 
 such an occurrence with apprehension, notwithstanding 
 that it is attended by an apparent cure. Surgeons fre- 
 quently in their anxiety to obtain a speedy cure, sacrifice 
 all prospect of success by too early a repetition of the 
 operation. While the broken lens lies well in the pos- 
 terior chamber, without pressing on the iris, the operator 
 has reason to congratulate himself, and it is only when he
 
 ON CATARACT. 1 1 
 
 has ascertained that no change is taking place in the cata- 
 ract, that he is called upon again to disturb it. He should 
 be particularly cautious not to repeat the operation while 
 any trace of inflammation exists. 
 
 If the surgeon determines to adopt this operation of open- 
 ing the texture of the lens through the cornea, he has next 
 to make choice of the instrument which will accomplish 
 this object most effectually, and with least injury to the 
 organ. I conceive that all that is required for this pur- 
 pose is a fine point ; a cutting edge or knife being only 
 required where the lens is to be cut in pieces. I also con- 
 sider that the needle should be curved at the point, to 
 enable the surgeon to open completely the texture of the 
 lens if it should prove soft or friable, and it should be so 
 constructed that the aqueous humour shall not escape. It 
 is obvious that these objects cannot be attained by the use 
 of the old spear-pointed couching needle, or by the smaller 
 needles of Hey or Scarpa, unless they are very much dimin- 
 ished in their proportions. The flat needle of Mr. Saun- 
 ders, however successfully used by him, is objectionable on 
 account of its straight form, and the impossibility of rolling 
 it between the fingers to produce the effect of a drill on 
 the lens. That the modifications of Scarpa's needle, re- 
 commended by Langenbeck and Guthrie, may be employed 
 with the best effect, there can be no doubt ; but I have to 
 object to every needle fabricated by a cutler, that, however 
 delicately the instrument may be formed, it is liable to 
 leave a mark in the cornea, and when made very small to 
 guard against this occurrence, can seldom be obtained of 
 the proper temper and finish : if too soft they bend, or if 
 too hard, break. To attain the desirable objects stated 
 above, and to avoid the difliculties to which I have just 
 alluded, I determined to try a fine sewing needle curved 
 at the point, and after about forty operations I do not feel
 
 12 ON CATAKACT. 
 
 in the least inclined to repent of ray choice. I am on the 
 contrary every day more and more satisfied that it affords 
 peculiar and unquestionable advantages. It rarely, if 
 ever, leaves even the slightest mark in the cornea. I could 
 produce examples where it has been three times introduced, 
 and where not the slightest speck can be detected ; and I 
 have introduced it through the very centre of the cornea 
 without any bad consequence. When fairly introduced 
 into the eye, it is capable of accomplishing any object to 
 be attained by a needle. The capsule can be opened to 
 any extent : a soft or friable lens can be actually broken 
 up into a pulp, by pushing the curved extremity of the 
 needle into its centre, and revolving the handle between 
 the fingers ; large fragments can be taken up on the point 
 of the needle from the anterior chamber, and forced back 
 out of the way of the iris, or if sufficiently soft, may be 
 divided by pressing them against the back of the cornea 
 with the convexity of the needle ; a method which I have 
 repeatedly adopted with advantage. When the lens has 
 been displaced from the capsule, in consequence of the 
 needle sticking in it in attempting to open its texture, I 
 have, without removing the needle, placed the lens in the 
 anterior chamber, and then extracted it ; and in other 
 cases have forced it back into the vitreous humour, out of 
 the reach of the iris. From the fineness of its point, and 
 the ease with which it can be turned and twisted in every 
 direction, it enables the surgeon to deal most effectually 
 with an opaque capsule ; he may pick it with the point from 
 any attachment it may have formed to the iris, or if it 
 hangs flaccid he may entangle and detach it by pulling or 
 twisting. In certain cases the pupil is found nearly closed, 
 and adhering to a small cataract of nearly cartilaginous 
 hardness ; in these I have introduced the needle, and with 
 the point picked up the adhesions between the margin of
 
 ON CATARACT. 13 
 
 the pupil and this hard mass, which I have then placed in 
 the anterior chamber, and removed through an opening in 
 the cornea, with a pair of forceps. It may be said that all 
 this might be accomplished by a diminutive needle on the 
 plan of Scarpa's ; but not, I conclude, with the same pro- 
 spect of success, on account of the much greater size of 
 even the smallest of such needles. 
 
 There is one difficulty attending the use of the round 
 needle : it requires very considerable force to pass it 
 through the cornea ; so much indeed as frequently to em- 
 barrass those who use it for the first time. I can, how- 
 ever, safely assert that very little practice enables the 
 surgeon to surmount this difficulty. It is only necessary 
 that he should be aware of the degree of force required, 
 that force he is perfectly safe In employing. The surgeon 
 who rejects an instrument which affi^rds peculiar advan- 
 tages, or refuses to adopt superior methods of operating, 
 because difficulties in execution stand in his way, can 
 never expect to obtain the character of a good operator. 
 The greatest advantage in the use of the needle results 
 from the very circumstance which causes the difficulty in 
 its introduction, it is from its conical form firmly wedged 
 in the cornea, prevents the aqueous humour from escaping, 
 and in consequence of being thus fixed, gives the surgeon 
 a power of holding the eye that defies every etCort on the 
 part of an unruly patient, unless he actually plucks out the 
 instrument with his hand. If the head be suddenly drawn 
 back the surgeon has only to let the instrument rest loosely 
 on his hand, and follow the motions of the patient. I have 
 seen the needle under such circumstances slip from the 
 hand of the surgeon, and hang from the eye without seri- 
 ous mischief, the handle being very light. 
 
 The size of the needle is known in the shops as number 
 seven, being the forty-fourth part of an inch in diameter,
 
 14 ON CATARACT. 
 
 about one-half the size of the finest Saunders's needle which 
 is made. The point can be turned to the requisite curve 
 by means of a pair of cutting forceps, or the ward of a 
 small key ; of course without heat, which would destroy 
 the temper. It must not, however, be expected that all 
 needles are so soft as to be bent thus cold : there may not 
 be ten in an hundred of this temper, but when once turned 
 they retain the curve without any danger of bending or 
 breaking, and certainly possess a degree of strength and 
 temper never observed in needles separately forged and 
 finished by the best cutlers. They should always be tried 
 before use by passing them repeatedly through thick calf- 
 skin leather. After they have received the requisite curve, 
 the point should be cut flat on each side, on a fine hone, 
 and carefully examined with a magnifying glass to ascer- 
 tain that it is perfect. The extent to which the point 
 should be curved may be left to the choice of the sur- 
 geon, reminding him that the greater the curve the 
 more efiectual the needle will be when introduced, but the 
 difficulty of introducing it through the cornea will also be 
 greater. I therefore recommend those who use it for the 
 first time to choose one slightly curved. After the point 
 has been turned, the needle, held in the jaws of a pair of 
 pliers or a vice, is to be run down into a cedar handle, 
 without cement, leaving only half an inch of blade, which 
 I have found to answer every purpose. If the blade be 
 left longer it will yield and spring when opposed to a re- 
 sistance. The handle should be about a fifth of an inch 
 in diameter, and four inches long. I use the handles made 
 for camel-hair pencils, and find that a metallic ferule, which 
 increases the weight, is unnecessary and objectionable. A 
 needle thus constructed, and preserved free from rust, will 
 retain its point for a great length of time : I have used the 
 same one a dozen times without sharpening.
 
 ON CATARACT. 15 
 
 The surgeon, provided with such a needle, places himself 
 in the usual position with respect to the patient, availing 
 himself of whatever assistance he may find necessary to 
 secure the lids.* He then brings the point of the needle 
 within a very short distance of the eye, and when the 
 cornea is brought into an advantageous position, he sud- 
 denly strikes the needle into it near its circumference. As 
 I do not apprehend any opacity from the wound, I am not 
 very particular with respect to the precise point where the 
 needle pierces ; I generally, however, enter it sufficiently 
 near the margin to obviate defect from this cause. The 
 point of the needle once fastened in the cornea, the sur- 
 geon has complete command of the eye ; no action of the 
 muscles can disengage It, and there Is no danger of the 
 needle slipping into the anterior chamber ; an elevator or 
 ophthalmostat is therefore altogether useless. The operator 
 now pushes the needle through the cornea, which frequently 
 yields like wet leather, and the eye often turns so much 
 toward the inner canthus that the pupil is hid, and he must 
 rely upon his knowledge of the course which the needle 
 necessarily takes, in order to conduct It to the lens. This 
 is the principal difficulty to be surmounted. If the sur- 
 geon does not now steadily push the needle forward, what- 
 ever resistance he may feel, he will find, when the eye re- 
 turns to Its proper position, that the point of the needle is 
 still merely entangled In the cornea. This also is the 
 period of danger to the iris : if the operator does not keep 
 the flat of the needle to that membrane, with the point 
 
 * Some ophthalmic surgeons recommend that the left hand 
 be employed to operate on the right eye, supposing the oper- 
 ator to sit in front of the patient. I operate on the left eye 
 sitting opposite to the patient, on the right standing behind 
 him with the head resting against my chest ; this latter posi- 
 tion I find by far the most favourable and convenient.
 
 16 ox CATARACT. 
 
 down and the convexity up, he will be very liable to injure 
 it. Should it happen that the point of the needle has 
 passed through the iris, it may be easily extricated by 
 gently drawing back the instrument without removing it 
 from the eye. After the needle has been fairly entered, 
 and that the operator sees its point at the opposite side of 
 the pupil, he brings the cornea forward merely by pulling 
 it upon the needle, to which it is completely secured, in 
 consequence of the blade being wedged into its texture. 
 He now turns the point directly back, and gently tears 
 open the capsule, picking and scratching the surface of the 
 lens with a rotatory or drilling motion of the instrument; 
 not with the lever or cutting movement, which is necessary 
 when Saunders's needle is used. If the lens be soft and 
 friable, the fragments fall like snow into the anterior cham- 
 ber, and the surgeon may deal very freely with it, pushing 
 the needle deep into its structure, and twirling the point 
 round so as to mash it into a pul^. If, however, it proves 
 hard, and that he attempts to deal thus with it, he fixes 
 his needle in its tough and glutinous structure, turns it 
 out of the capsule, drags it against the iris, and makes it 
 necessary either to extract it or force it back into the 
 vitreous humour. As I have already observed, if the 
 cataract be hard, the capsule should be opened, and the 
 centre of the lens cautiously scratched with the point of 
 the needle, so as to expose its texture to the contact of 
 the aqueous humour, by which it is softened and fitted for 
 breaking up on a future occasion. In withdrawing the 
 needle the surgeon has to encounter the same descrip- 
 tion of difficulty which attends its introduction ; it is 
 tightly held by the cornea, requiring to be turned on its 
 axis in order to extract it, as an awl is drawn from leather. 
 It must not, however, be forgotten that this wedging of 
 the instrument is attended with the great advantage of
 
 ON CATARACT. 1 ( 
 
 enabling the surgeon to operate on the most unsteady eye 
 without an ophthalmostat or elevator. 
 
 While advocating the merits of this instrument I am 
 not ignorant of the proposal of Buekhorn and others to 
 employ a round needle. I have not, however, been able 
 to ascertain from the books what is the precise form and 
 size of Dr. Buckhorn's instrument, and as I have not 
 seen his Essay I must be excused if I have been repeating 
 what he has already stated. Scarpa's needle is round in 
 the stem, but it is spear-pointed, and consequently allows 
 the aqueous humour to escape ; a disadvantage that must 
 attend the use of every needle so constructed. In the 
 needle which I have been describing we have combined 
 the advantages of a delicately small blade, of great strength 
 and fine temper, inflicting so minute a wound that no mark 
 remains in the cornea, capable of opening the texture of 
 the lens as effectually as any other needle, and from its 
 conical form, not permitting the aqueous humour to escape 
 during the operation." 
 
 Since this paper was published, I have continued to 
 practise this operation as described in it, and with the 
 needle proposed, without interruption ; scarcely deviating 
 from the directions given, or resorting to any modification 
 of the method laid down. Of the superior qualities of the 
 needle I have not the slightest reason to change my opinion. 
 It is, I am satisfied, by many degrees the best for the pur- 
 pose. Its small size, great strength, and matchless tem- 
 per, entitle It to a preference before all others as regards 
 these qualities ; while its cylindrical stem and the curvature 
 at the point, fit it for application to any peculiarity. But I 
 find all these advantages in the instrument overlooked, if 
 not despised, by some, because it has not the imposing ap- 
 pearance of a finely polished blade in an» ivory or ebony 
 
 2 B
 
 18 ON CATARACT. 
 
 handle with silver ferule ; so much so, that the cutlers 
 will not make it, or keep it for sale, and some of them 
 have actually forged a tool to resemble it, in proportions 
 more worthy of the trade, when called on for it by a cus- 
 tomer. Now the truth is, that no cutler could forge, 
 temper and finish such a blade with the slightest probabi- 
 lity of equalling this needle, which acquires its temper by 
 chance in the tempering of thousands of needles together. 
 I have stated in this paper that not ten, I might perhaps 
 have said five or six only, in a hundred of needles, are 
 found with the temper which admits of their being bent 
 without breaking, and enables them to preserve the set or 
 curve given to them by the pliers. As to the strength of 
 the blade, diminutive as it is, no fears need be entertained. 
 I never yet broke one or saw one break in an operation ; 
 and, as I have said, it may be passed without danger 
 through the stoutest leather. I should, however, remind 
 the surgeon, that the blade, before being finally pushed 
 into the handle, should be dipped in a solution of gum lac 
 or sealing wax, in spirit of wine, as otherwise it may rust 
 at the wood If laid aside wet, and may snap there in con- 
 sequence. I have also to warn those fond of " improving " 
 surgical instruments to suit their peculiar notions, that I 
 do not answer for the performance of any needle of this 
 description unless it has been constructed precisely as di- 
 rected. It must be the needle Ko. 7 (being the 44th of 
 an inch in diameter), half an inch long in the blade, 
 from the wood to the point, and in a cedar handle of the 
 specified proportions. If the blade be left longer it will 
 spring in using, and if shorter, it will not reach as far as 
 necessary. 
 
 With respect to the objection made to this operation on 
 the score of its endangering the cornea, and causing opacity 
 of that structure, I can with safety state that there is no-
 
 ox CATAUACT. 19 
 
 thing in it. I never yet saw vision impaired by any opacity 
 caused by the wound of the needle, and very seldom indeed 
 have I seen any opacity at all remain. In fact, as I have 
 said elsewhere, I know no structure in tl\e body which 
 bears simple injury, such as a clean cut or puncture, bet- 
 ter than the cornea. In the course of a long practice, I 
 have met but one case in which suppurative inflammation 
 took place in the puncture, and in that case the suppur- 
 ation and subsequent ulceration was confined to a circle 
 not an eighth of an inch in diameter, and left behind an 
 opacity not larger than the head of a pin, at a distance 
 from the pupil, and consequently not impairing sight. I 
 have also met with cases, but very rarely indeed, in Avhich 
 the whole cornea suppurated, and the entire eye partici- 
 pated in the destructive inflammation, as sometimes hap- 
 pens from any operation for cataract ; this, however, I 
 have never considered a consequence of the peculiar nature 
 of the puncture in this peculiar structure, but the result 
 of constitutional derangement operating on local inflamma- 
 tion following injury. In fact, I looked upon it as of the 
 same nature as the abscess of the cornea which follows 
 very slight injury or irritable ulcer, and which takes place, 
 not from the mere injury or ulcer, but from that state of 
 the animal economy, whatever it may be, which is attended 
 by these local destructive processes. But as I have said, 
 this is a very unusual consequence of this operation ; so 
 much so, that I have often wondered that it does not occur 
 more frequently, seeing that it so often follows slight 
 wounds of the cornea by particles of stone or steel in stone- 
 cutting or metal turning. I repeat therefore emphatically 
 that the surgeon need never be deterred from operating 
 through the cornea by any apprehension of the effects of 
 injury on this more than any other structure m the body 
 he may be called upon to divide.
 
 20 ON CATARACT. 
 
 In the preceding paper and elsewhere, I have asserted 
 the superiority of this the anterior operation through the 
 cornea to the posterior operation through the sclerotic, 
 and have not hesitated to say, what I now repeat, that 
 the latter method is a disgrace to surgery, notwithstand- 
 ing the preference given to it by many surgeons. No 
 anatomist, aware of the nature and number of the struc- 
 tures injured in the posterior operation, can for a moment 
 assume that such inj ury does not cause more risk of de- 
 structive inflammation than the injury inflicted on the 
 cornea in the anterior one ; and no surgeon who has com- 
 pared the effects and consequences of the two oj)erations 
 can for a moment maintain that the results of the puncture 
 through the sclerotic are not more injurious than those fol- 
 lowing the puncture of the cornea. No man who knows 
 what the penetrated structures are could venture to main- 
 tain that the conjunctiva, sclerotic, ciliary ligament and 
 ciliary processes, could be traversed by an instrument with 
 the same or less injury than is inflicted in traversing the 
 cornea ; and no man who has compared the dimensions and 
 relations of the anterior and posterior chambers of the 
 aqueous humour, could venture to maintain that the nar- 
 row space behind the iris affords a more accessible passage 
 for the needle than the comparatively capacious chamber 
 anterior to it. Neither can any man who has witnessed 
 the sufferings caused by this posterior operation, or the 
 destructive consequences of the inflammation which it pro- 
 duces, venture to assert that such mischief follows the an- 
 terior one. The truth in fact is, that this most valuable of 
 all the methods devised for the removal of an opaque lens 
 has been brought into discredit and almost into disuse by 
 this bigotted preference of a method handed down to us 
 from a remote antiquity, when surgery was in its infancy 
 and anatomy not yet cultivated. I have every day to
 
 ON CATARACT. 21 
 
 listen with wonder and no small vexation to the expres- 
 sions of want of confidence in the operation for cataract, 
 uttered, not only by patients, but by practitioners ; and 
 this I find is to be attributed to the experience people have 
 had of the consequences of this bad method. I know that 
 other causes operate to diffuse and perpetuate these pre- 
 judices and misconceptions ; that in fact they are fostered 
 by feelings of jealousy and that spirit which leads men to 
 decry what is successfully practised by rivals ; but the 
 foundation of these representations is the frequent failure 
 of this posterior operation and the sufferings patients have 
 undergone in consequence of it. 
 
 In the performance of this operation I have adopted 
 some modifications since this paper was published. In- 
 stead of operating on the left eye standing in front of the 
 patient, I now operate on both eyes standing behind him. 
 This position as regards the left eye may seem to some a 
 strange one, but I was induced to adopt it to enable the 
 hospital pupils to see all the steps of the operation, which 
 they could not if I stood in front, and I now find that it is 
 the preferable position. It gives the operator the most 
 perfect command over the patient's head and eyelids, and 
 enables him to bring his eye to bear on the needle and 
 cataract with the utmost precision. Moreover, it renders 
 him independent of an assistant who, in eye operations, 
 should, if possible, be dispensed with. I seat the pa- 
 tient in a chair and make him sit straight up or inclining, 
 according to his height. If very tall I raise myself by 
 standing on a large book or two, or on anything which an- 
 swers the purpose to be found at hand. In my own place 
 of business I find old medical folios answer the purpose 
 well : operating chairs, although very imposing and cal- 
 culated to produce effect, I have not adopted ; not finding 
 myself at ease with such things. When he is seated I lay
 
 22 ON CATARACT. 
 
 the patient's head against my chest, and placing the middle 
 finger of my left hand on his lower and the forefinger on his 
 upper eyelid, and gently holding the eye between them, I 
 strike the point of the needle suddenly into the cornea, 
 about a line from its margin, and there hold it until any 
 struggles of the patient, which may be made, cease. There 
 must be no hesitation here, for if the cornea be touched 
 without fixing the point of the needle in it, the eye will 
 turn rapidly and the surface will be scratched. I advise 
 the operator to pause here for a moment, holding the eye 
 firmly and steadily on the point of his needle, and if neces- 
 sary to say a word of encouragement or remonstrance to 
 the patient. After quietness becomes restored, the needle 
 is to be pushed on with a firm hand through the cornea 
 into the anterior chamber, directing its point downward 
 and backward to the centre of the surface of the lens. 
 This is the most difficult step in the operation, and that 
 part of it which requires most confidence in the instru- 
 ment. If the surgeon now hesitates from the feel of 
 resistance experienced he will not succeed. He must 
 push on, fearless of consequences, until the needle passes 
 through : in doing so, however, the eye will often turn 
 from him or yield before the pressure, even until the 
 pupil, iris, and the cornea itself are hidden under the eye- 
 lid ; still he must push on until he is satisfied that the 
 needle has fairly entered the anterior chamber, when he 
 relaxes the pressure and allows the eye to recover its na- 
 tural position. Here, again, he had better pause a moment 
 to allow the patient to recover his composure, which is 
 often disturbed in this the roughest step of the operation, 
 and also to ascertain the distance to which the needle has 
 passed, and how the point lies as to the margin of the 
 pupil. If it has passed so far that the point cannot be 
 brought into contact with the lens without touching the
 
 ON CATARACT. 23 
 
 iris, it must be gently pulled, and at the same time slightly 
 rotated, until the point is brought within the circumfer- 
 ence of the pupil ; and if it has passed through the iris, 
 which sometimes happens when the pupil has not been 
 fully dilated by belladonna, it must be gently pulled 
 and rotated in the same way until disentangled from that 
 structure. This, however, is a nice manoeuvre, requir- 
 ing great delicacy of manipulation ; for if too much force 
 be used, the needle is withdrawn entirely from the eye. 
 Whenever this accident has happened to me, and it has 
 been very seldom indeed, 1 have at once passed the 
 needle in again and finished the operation ; but beginners 
 may not be able to do all this, for the escape of some 
 aqueous humour leaves the cornea flaccid, and therefore 
 tough under the instrument. Some may think that this 
 danger of wounding the iris is a capital objection to the 
 operation, but it should not be so considered, for the ac- 
 cident seldom happens, and when it does there is no great 
 harm done. I have never found any mischief from it. 
 The needle, however, having been fairly introduced, is 
 now to be turned so as to bring the point to work on the 
 opaque lens. If the cataract be a hard one, the surgeon 
 must pick up the face of it by repeated delicate touches 
 over every part of the surface ; and keeping in view the 
 necessity of completely detaching the anterior portion 
 of the capsule, for fear of subsequent adhesions of it to 
 the iris and consequent capsular cataracts, he will use the 
 needle very freely for this purpose. Here, however, he 
 must be on his guard, for if he dips the point too deeply 
 into a hard lens, it will stick there, and with the next 
 motion of the instrument the cataract will be entirely 
 detached from its bed on the vitreous humour, twirled 
 round, and perhaps placed, through the pupil, in the an- 
 terior chamber. Should this, however, happen, the oper- 
 ator need not be dismayed. The same handling of the
 
 24 ON CATARACT. 
 
 needle which brought the lens into this position will bring 
 it back again. He has only to stick the needle in it, 
 and with a steady hand replace it in its original position : 
 the iris, with a fully dilated pupil, offers no obstacle. In 
 dealing with hard cataracts, I have frequently picked 
 up the face of the lens and then turned it round and 
 picked up the back. I know that many surgeons, and 
 perhaps the majority of oculists or ophthalmologists, 
 will think that all this roujrh work is a very dangerous 
 proceeding ; but the truth is, that if the lens be kept 
 away from the iris, so as not to press upon that highly 
 organized and exquisitely sensible structure, the eye will 
 bear a great deal without subsequent destructive inflam- 
 mation. This, however, suggests an inquiry as to the 
 final disposal of the remains of the hard lens, after all 
 that can be broken up has been detached. Since the 
 preceding paper was published, I have learned to dis- 
 pose of it more advantageously than 1 then did: I force 
 it down into the vitreous humour, and, in fact, depress or 
 recline it, thus combining the two operations of breaking 
 up and couching. I was for a long time adverse to the 
 operation of depression, from a consideration of the 
 amount of injury necessarily inflicted by tearing through 
 the vitreous humour, and of the amount of inflammation 
 liable to ensue from the presence of the lens, equivalent 
 to a foreign body in that structure ; but repeated trials 
 have convinced me that it can be done with much 
 less danger of bad consequences than may be sup- 
 posed. The operation of couching, notwithstanding its 
 antiquity, must I think now rank the last of the three 
 operations for cataract, judging from a comparison of re- 
 sults ; but this I am inclined to think has arisen from the 
 injudicious selection of the sclerotic as the place of punc- 
 ture, or in other words, from the preference given to the 
 posterior operation. Be this, however, as it may, I now
 
 ON CATARACT. 25 
 
 find that picking up, opening, and detaching, the soft sur- 
 face of the lens, and then completely depressing the re- 
 maining hard nucleus, is a safe and successful operation. 
 But some will very naturally ask how it is possible to de- 
 press a lens through the cornea with a needle half an inch 
 long and a forty-fourth of an inch in diameter? All the 
 reply I have to make is that it can be done very easily, and 
 that I am constantly in the habit of doing it. As soon as 
 the surface of a lens has been opened in texture and all the 
 soft part detached from it, I then lay the convexity of the 
 curve of the point of the needle upon it and force it down 
 through and into the vitreous humour. In doing so, how- 
 ever, this delicate needle gets entangled in it, and in with- 
 drawing the instrument the cataract is brought up again, 
 unless the surgeon, while the lens is down, rotates the 
 needle a little, inclines it here and there, and as it were 
 shakes it off the needle. But do what he will the lens 
 will often rise as it will in any operation of depression, 
 and must be sent down again by a repetition of the ma- 
 noeuvre, until it remains down. Should it, however, rise 
 after the operation has been finished, the case generally 
 does well, because a bed has been made for it in the 
 vitreous humour far from the iris, but recovery of sight 
 is delayed until the solution of the cataract, which thus 
 still, more or less, obstructs vision, takes place. I have 
 to add, that in operating on the right eye I generally re- 
 quire one finger of an assistant to hold down the lower lid. 
 
 The value of preparatory and after-treatment as part of 
 the surgeon's care in cataract operations has boon fully ap- 
 preciated, and, in practice, amply made available ; but the 
 value of a respectful consideration of all the functions of 
 the animal economy upon which health depends has not 
 been so well understood. It is assumed that a patient 
 should be prepared for an operation by taking physic and 
 
 c
 
 26 ON CATARACT. 
 
 abstaining from food, yet a rational man acquainted with 
 the consecutive operation of each apparatus provided for 
 the growth, repair, and preservation of the living being 
 may well doubt the correctness of such a view. The uni • 
 versal faith reposed in the practice of giving and taking 
 physic has led practitioners not only to place too much 
 reliance on that resource, but to resort to it sometimes to 
 the injury of the patient, as I find in the case under con- 
 sideration. In preparing a patient for operation, I do not 
 act on the belief that empty bowels are essential to health, 
 or that what are called faces should not be found in the 
 intestinal canal ; on the contrary, I proceed on a convic- 
 tion totally different. If a patient be in good health, not- 
 withstanding an habitual retention of the contents of the 
 bowels beyond the prescribed periods, I do not wish to 
 risk an interruption of health by disturbing the natural 
 functions of the stomach and bowels, and I therefore refrain 
 from giving physic. But if the patient be not in good 
 health, I of course endeavour to bring him into that con- 
 dition by every means in my power, and resolutely resist 
 every attempt to induce me to operate until I have accom- 
 plished that object. Above all things, the state of the 
 digestive organs should be carefully studied, and if found 
 defective, if possible, repaired. Nothing seems to require 
 more attention than the state of the tongue as indicative 
 of the state of the stomach and bowels. If it be white or 
 coated with discoloured adhesive mucus, the functions of 
 assimilation and nutrition are probably imperfectly per- 
 formed, and a resulting tendency to destructive inflamma- 
 tion from local injury Is engendered. This I see every day 
 exemplified in accidental Injuries of the cornea in stone- 
 cutting, and in chipping and turning metals. If the patient 
 has a clean tongue, and Is otherwise free from disease, little 
 inflammation, and still less of destructive inflammation,
 
 ON CATARACT, 27 
 
 follows the injury ; but if the tongue be coated with a thick 
 yellow adhesive layer, ulceration and formation of purulent 
 matter often ensues. In preparing a patient for operation 
 for cataract, this will therefore demand the first care of the 
 surgeon ; especially if he finds, as he often does, a deposi- 
 tion of lithates or other salts in the urine. He will also 
 make inquiry as to the state of the discharges from the 
 bowels, as to their colour, consistence, and proportion of 
 undigested materials, and also as to the frequency of dis- 
 charge ; not looking upon what is called costiveness, as 
 evidence of deranged digestion, but rather the reverse : 
 undigested food seldom remaining so long quiet in the 
 alimentary canal as the insoluble remains of thoroughly 
 digested aliment mixed with the excrementitious part of 
 the bile. This inquiry is not, however, so easily made as 
 those who are satisfied with loose statements suppose, and 
 many may think it unnecessary ; but convinced as I am 
 that attention to this matter is necessary for the success of 
 the operation, I dwell upon it. Every practitioner has his 
 own way of correcting this derangement of the digestive 
 organs ; it would therefore be superfluous to enter here 
 into details on the subject. I myself generally rely on a 
 moderate purgative pill with blue pill or calomel at night, 
 followed by some aromatic bitter infusion, containing a little 
 alkaline salt, in the morning and middle of the day ; at the 
 same time regulating the diet by restricting the quantity 
 and quality of the food, as well as the periods at which it 
 should be taken. It is usual in preparing for this and 
 other operations to make great alterations in diet, substi- 
 tuting liquid for solid, and vegetable for animal aliments. 
 This, however, must be done with caution, leading as it 
 inevitably does to disturbance of the digestive function and 
 interruption of the assimilating and nutritious processes, if 
 suddenly or exclusively adopted. Without digestible nu-
 
 28 ON CATARACT. 
 
 tritious food good chyle and blood cannot be produced, and 
 without good blood local injuries are liable to suffer from 
 destructive inflammation. Even in the case of old persons 
 habitually indulging in a glass of wine or other alcoholic 
 stimulant, the suspension of that supply of temporary aid 
 to the nervous system should not be suddenly adopted : in 
 fact, the substitution of " low living," and what are called 
 " slops," for generous diet, should be gradually and spar- 
 ingly practised, if practised at all. In my own practice, I 
 resort to it as little as possible, and from experience feel 
 inclined to resort to it less and less. 
 
 In particular cases, the surgeon may be called on to 
 prepare his patient for operation by special direction of 
 remedies to specific derangements of health. Persons of 
 languid circulation and feeble frame must be invigorated 
 by generous diet and tonic medicines, while those of ple- 
 thoric and bloated habit must be reduced to more suitable 
 condition. Scrofulous or rheumatic constitution or dia- 
 thesis must, if possible, be corrected ; and specific disease 
 of any kind, if present, removed. All this, however, is 
 more easily suggested than accomplished. Scrofula or 
 rheumatism are not so easily eradicated, but it is well, with 
 a view as much to general treatment as to prognosis of the 
 result, that this consideration should be kept in view. 
 When called on to operate on a truly scrofulous or rheu- 
 matic patient, the surgeon must be careful to warn the 
 parties concerned that the prospects of complete recovery 
 of sight are less favourable than in cases where the health 
 is good. The after-treatment must be conducted on the 
 same principles as those laid down for the preparatory 
 treatment. The tone of the stomach should be preserved, 
 assimilation and nutrition duly maintained, and the gene- 
 ral condition of the patient made comfortable. There is 
 no necessity for immuring a patient after this operation in
 
 ON CATARACT. 29 
 
 a close and darkened room. The less of bed the better, 
 and the sooner the drawing-room is made the place of con- 
 valesence the better also. "With elderly ladies, and espe- 
 cially those of weakly nervous system, this cannot per- 
 haps be so soon done ; but the sooner it is done the more 
 rapid and certain will be the recovery. Should inflamma- 
 tion arise, it must of course be arrested, if possible, by 
 the usual means, judiciously adjusted to the constitution 
 and condition of the patient. Indiscriminate purging, 
 bleeding, and mercurializing must not be permitted ; but 
 if depletion becomes necessary, it must be carried to the 
 requisite extent without undue severity. The surgeon 
 should not act on the assumption, that if pain and redness 
 be present, destructive inflammation must be in progress : 
 the pain is generally from the pressure of fragments of the 
 cataract on the iris, and the redness often from trivial in- 
 flammation of the conjunctiva. Whether it be from this 
 conviction respecting the harmless nature of slight inflam- 
 mation and pain, or from this operation through the cornea 
 being seldom followed by destructive inflammation, I do 
 not find that I am often called on to draw blood either by 
 lancet or leeches. I am now, however, alluding more to 
 the inflammation which may come on immediately after the 
 operation than to that which may come on at a more ad- 
 vanced period, and which is often of more destructive cha- 
 racter on account of its implicating the whole eyeball ; as- 
 suming a chronic, and sometimes an intermitting, and even 
 a neuralgic character. This inflammation must be treated 
 as other inflammations of the eyeball, and as I have laid 
 down in my treatise on that subject. A strange proposal 
 has been made, probably in consequence of the frequency 
 of destructive inflammation after the posterior operation. 
 It has been not only suggested, but actually practised, to 
 administer mercury to a patient previous to operation, so 
 
 2 c
 
 .■30 ON CATARACT. 
 
 as to have him in a state of salivation, or on the point of 
 salivation, at the time when inflammation is liable to come 
 on. It is not necessary to warn the surgeon against the 
 adoption of any such puerile application of theoretical as- 
 sumption. Every one knows that the presence of mercury 
 in the system does not prevent the occurrence of inflam- 
 mation ; and the sooner every one knows that mercury is 
 not so certain an antidote against destructive inflammation 
 as people believe, the better. While considering the after- 
 treatment in this operation for cataract, it is necessary to 
 allude to an occurrence which often takes place, and which 
 causes much distress and alarm both to patients and 
 friends. This is a distressing nausea and vomiting which 
 seizes the patient, generally in the middle of the night of 
 the day of the operation, and continues for many hours, 
 and even more or less during the next day. I attribute it 
 to the pressure of the fragments of the broken-up lens on 
 the iris, and find that it is not followed by destructive con- 
 sequences ; but causing, as it does, so much distress and 
 alarm, I generally order an opiate to be taken when it 
 commences, or direct the attendants to be prepared with 
 some effervescing draughts, and to assure the patient that 
 there is nothing unusual or dangerous in the occurrence. 
 I know not whether this remarkable effect has been ob- 
 served by others or not, or whether it has been recorded in 
 books, and I have not at this moment time to inquire ; 
 but I am sure that I have always noticed it in my lectures. 
 As to local applications, the great object of their use should 
 be to dilate, and keep dilated, the pupil, so as to place the 
 iris more out of the reach of the pressure of the fragments 
 of cataract. This is, of course, to be effected by the ap- 
 plication of extract of belladonna ; but as there seems to 
 be some mistaken notions prevalent respecting this most 
 valuable and remarkable agent, it may be desirable to cor-
 
 ON CATARACT. 31 
 
 rect them. The pupil is, of course, to be dilated previous 
 to the operation to expose the lens fully and to place the 
 iris out of reach of the needle. Some think it necessary 
 to daub the whole eyebrow, lids, and half the cheek with 
 the black extract, and to leave it adhering to the skin for 
 several hours : some even lay it on the night before. This 
 is a great waste of the medicine, and soils the skin and 
 linen. It is astonishing what a small quantity of this most 
 wonderful agent will dilate the pupil, especially in the eye 
 of a young person. One grain of nitrate of atropia, dis- 
 solved in an ounce of distilled water, will form a solution, 
 of which one drop from a camel-hair pencil will dilate the 
 pupil fully in fifteen, twenty, or thirty minutes : a drachm 
 of good extract of belladonna to an ounce of water will do 
 the same. I therefore always use these solutions in this 
 way, putting in the drop at any time most convenient in 
 the course of the day on which I operate. The application 
 is neither very painful nor irritating, perhaps about as 
 much as a weak solution of common salt, and leaves no 
 redness after half an hour. I should observe, that in 
 aged persons this application of the narcotic to the con- 
 junctiva is sometimes absolutely necessary to secure full 
 dilatation of the pupil. The smearing of the extract 
 on the harsh skin in such subjects will not always effect 
 the object. After the operation, however, the lids and 
 brow should be painted with the extract to dilate the 
 pupil and keep it dilated ; because it may not be desir- 
 able to cause any additional irritation by dropping the 
 solution on the conjunctiva. This is a very necessary 
 precaution, for the surgeon should know that, however 
 perfectly the pupil may be dilated before the operation, 
 it generally becomes contracted again during the revo- 
 lutions of the needle : in fact, mechanical irritation, such 
 as the pressure of the needle or the broken fragments on
 
 32 ON CATARACT. 
 
 the iris, causes that organ to act and the pupil to return 
 to its original dimensions. This is a remarkable physiolo- 
 gical fact, which I have not seen recorded, but which I 
 have for many years demonstrated in the operation theatre. 
 By way of dressing, I leave a lotion containing a couple of 
 drachms of good extract of belladonna in eight ounces of 
 water to be constantly applied as a water-dressing with a 
 small scrap of old linen as light as a feather, but I strictly 
 interdict all tying or bandaging, and direct the attendant to 
 allow the rag to fall off when the patient turns to sleep. 
 
 It may be considered that I should state in detail the 
 results of my practice of this operation, but as I have not 
 been much in the habit of keeping regular records of my 
 cases, I cannot do so. I can, however, with truth aver, 
 that when properly performed upon healthy subjects, 
 and patiently followed up by careful watching during the 
 process of solution and absorption, it is an eminently suc- 
 cessful operation. I know that the same is said of the 
 operations of extraction and depression, but from what I 
 have seen and heard of extraction as performed by the best 
 operators in Europe, I have no doubt that the needle thus 
 used will afford more cures than the knife. If it be true, 
 as is asserted, that the losses of eyes by extraction amount 
 to forty, thirty, or even twenty per cent., I have only to say 
 that there should be no such loss by the operation of break- 
 ing up through the cornea. The truth, perhaps, has never 
 been told with respect to the result of cataract operations, 
 and perhaps never may be told, so great is the temptation 
 to exaggerate where a man's fame and bread depends upon 
 his success ; but I repeat, that my experience of this oper- 
 ation fully justifies me in asserting that it is the best of 
 the three. As I have already said, the metropolitan oper- 
 ator must lean to the operation of extraction because he 
 cannot detain his patient in the city until cured by the
 
 ON CATARACT. 33 
 
 process of absorption ; but the surgeon who takes an honest 
 interest in the welfare of his patient will probably sacrifice 
 the chance of the eclat attending success to the greater 
 certainty of a cure. By way of example of the results of 
 this operation, I shall briefly enumerate a few cases which 
 I happen to have on hands this moment. A gentleman, 
 aged between 50 and 60 years, with a hard cataract fully 
 formed in the left eye, and one forming in the right, has 
 just gone to the country able to write a legible and fair 
 letter after the operation of breaking up and depressing. 
 He was operated on three months ago, and could see 
 imperfectly through an open pupil after three weeks or 
 a month, and after three weeks more could write with 
 cataract glasses, notwithstanding occasional interruptions 
 from a nebulous condition of the cornea caused by chronic 
 vascularity of the conjunctiva. This gentleman had never 
 an hour's inflammation requiring serious attention. An 
 unmarried lady, aged about 50, had both eyes operated on 
 ten weeks ago. The lenses were soft and were broken 
 into a complete pulp, which fell, partly, into the anterior, 
 and partly, into the posterior chamber of the aqueous 
 humour. There was severe nausea and vomiting the night 
 following the operation, and some pain occasionally as the 
 fragments fell against the iris, but no inflammation. She 
 is now able to read and write with a cataract glass to the 
 left eye, the pupil of which is entirely free from cataract. 
 In the right eye there is still as much broken up lens as 
 fills up the space behind the pupil, but it is rapidly dis- 
 solving, and I am satisfied that she will require no re- 
 petition of the operation. About eight weeks ago I oper- 
 ated on a young gentleman for capsular cataract, the result 
 of a penetrating wound of the eye Inflicted a long time 
 since. He is aged about 12, and sat in a common chair 
 while I operated with a shawl tied round his arms, body.
 
 34 ox CATAKACT. 
 
 and the back of the chair. The capsule, with some re- 
 maining portion of the lens, was freely torn and detached, 
 and the child sent home. He continued to attend daily, 
 not the slightest inflammation following, but was attacked 
 by scarlatina, which nearly terminated fatally. His pupil 
 is now nearly free from broken lens, and I consider him 
 safe as to his vision. In the hospital I operated on a deli- 
 cate boy, aged 1 4, and five years blind with soft lenticular 
 and partially opaque capsular cataracts. The operation 
 was performed two months ago, the capsules freely torn 
 and detached, and the lenses made into a pulp. He had 
 nausea and vomiting, but no inflammation after the opera- 
 tion. His pupils are now completely clear, and he is able 
 to walk about without glasses and to read with them. A 
 labouring man, aged 37, was operated on for soft lenticular 
 cataract of the right eye about twelve weeks since. He had 
 lost the left eye from a blow of a stone, and I suspect his 
 cataract in the other eye was caused by sympathetic in- 
 flammation. Notwithstanding the difficulties presented by 
 a small sunk eye, very difficult to be brought to a steady 
 state, the lens was freely opened and a hard nucleus of it 
 depressed. The pupil was soon clear, but the remainder 
 of the hard nucleus, still undissolved, rose with the mo- 
 tion of the head occasionally towards the axis of vision : 
 it, however, finally dissolved without any other opera- 
 tion, and he now sees well with it about twelve weeks 
 after the operation. A girl, aged 17, operated on 
 about three weeks ago for thick and tough capsular cat-a- 
 ract of the right eye, has now an open pupil, but she 
 cannot see. I was induced to give her the chance of an 
 operation by the importunities of her friends, which I 
 should not have done, because it was a case of opaque lenses 
 with adherent pupils and other proofs of previous destruc- 
 tive inflammation ; but I was tempted to do so from the
 
 ON CATARACT. 35 
 
 state of the eye, the pupil being closed by capsular cataract 
 only, remaining after an operation by another surgeon. 
 Notwithstanding, however, the disorganized state of this 
 eye from the previous destructive inflammation, no inflam- 
 mation followed the operation ; and if the retina had not 
 been rendered insensible, and the eye consequently amau- 
 rotic by the same disease which caused the cataracts, she 
 might now have good sight. The worst case I have on 
 hands is that of a man, aged about 35, who had lenticular 
 cataracts of the firm consistence (neither hard nor soft) 
 usually found at this period of life. The operation was 
 performed on both eyes about six months ago, and was 
 not followed by any untoward symptom, but some weeks 
 after he had a severe attack of acute rheumatism, fol- 
 lowed by severe rheumatic inflammation of the left eye, 
 which closed the pupil j and he subsequently suffered 
 severely from psoriasis, from which he is now scarcely 
 recovered. The pupil of the right eye is, however, free 
 from cataract, except some threads of opaque capsule, 
 which I propose to remove ; and the left eye looks so 
 well that I intend to give him the chance of an opera- 
 tion for artificial pupil on it. From these cases the 
 surgeon can form some opinion as to the practical re- 
 sults of this operation. They present the general effects 
 of the practice, and certainly do not afford more favour- 
 able examples than an average would supply. I have no 
 wish to indulge in any exaggeration respecting the success 
 of this method: I am writing for surgeons, who will, in the 
 sequel, pronounce a verdict upon it from their own ex- 
 perience, and thereby verify or disprove my statements. 
 Malicious persons will say that I advocate this operation 
 because I cannot perform that of extraction as easily ; 
 but I can perform extraction as well as other people, 
 and refrain from it only because it is in its nature
 
 36 ON CATARACT. 
 
 a most formidable operation, and in its results a most 
 hazardous one. In principle, too, it is not creditable to 
 surgery. To cut open a man's eye, in order to squeeze 
 out his crystalline lens through the incision, when that lens 
 can be removed by absorption, I hold to be contrary to 
 the rule which binds the surgeon to give his patient the 
 best chance of recovery regardless of present inconvenience 
 or delay. But whatever view may be entertained on this 
 subject, I am firmly convinced that the operation of extrac- . 
 tion should be restricted to hard cataracts in aged persons. 
 Under fifty years of age, the crystalline lens once broken 
 in pieces, must be sooner or later dissolved and absorbed. 
 There can be no question as to the result ; it is only a 
 question as to time. 
 
 DUBLIN: PRINTED AT THE MEDICAL PRESS OFFICE. 
 
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