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SAUNDERS'
MEDICAL HAND-ATLASES.



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secnred in ^he English edition as in the originals. The translations have
been edited by the lemding Americmn specialists in the different sub-
jects. The volumes are of a uniform and convenient size (5 x 7^ inches),
and are substantially bound in cloth.

(For Lilt of Book% Prices, etc^ lee back cover and fly-leaf)
Pamphlet containing specimens of the Colored PUtea tent free
on application , c^r^aXo

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ATLAS AND EPITOME

OF

OPERATIVE
OPHTHALMOLOGY



BY

PROF. DR. O. HAAB

of Zurich



AUTHORIZED TRANSLATION FROM THE GERMAN
WITH EDITORIAL NOTES AND ADDITIONS



EDITED BY

G* E. deSCHVEINITZ, A.M, M.D.

Professor of Ophthalmology in the University of Pennsylvania ;

Ophthalmic Surgeon to the Philadelphia Hospital;

Ophthalmologist to the Orthopedic Hospital

and Infirmary for Nervous Diseases



With 30 Colored Lltiio^aphk Plates and ^ Tezt-cuts



PHILADELPHIA— NEW YORK— LONDON

W. B. SAUNDERS AND COMPANY

1905



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Cop>Tight, 1905, by W. B, Saunders & Company.



Registered at Stationers' Hall, London, England.




KLCOTROTYPEO BY
WI8TC0TT a THOMSON, PHILAOA.



PRESS OF
W. B. SAUNDERS & COMPANY.



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EDITOR'S PREFACE.



This volume forms a natural and admirable conclusion
of the series of Atlases which Professor Haab has pre-
pared and published. Beginning with a thorough discus-
sion of the proper construction of operation-rooms, narcosis
both general and local, sterilization as it is applied to
ophthalmic instruments, and the theory and practice of
disinfection, the main operations upon the eye and its
appendages are described with characteristic fidelity and
clearness. The thirty colored lithographic plates portray
in a far more satisfactory way than words can the steps
of an operation. Next to seeing an operation itself, these
are of value, and in most instances give a view of lifelike
accuracy. What is omitted in the colored plates is sup-
plied in the text illustrations, of which there are one hun-
dred and fifty.

As in the previous volumes of this series, one is im-
pressed with Dr. Haab's wide experience, admirable
technic, and sound judgment. The editor, as in the pre-
vious books of this series, has compared the translation
with the original, and believes that it conveys with faith-
fulness the author's meaning. Editorial comments are



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6 EDITOR'S PREFACE.

placed in brackets^ and a few operations not described by
Professor Haab have been inserted.

This book should prove useful not only to students of
ophthalmology who may not have the opportunity of
witnessing frequently operations upon the eye, but also to
those whose daily work is concerned with the operative
side of ophthalmic work.

jAliUABY, 1905.



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PREFACE



The great abundance of material made it necessary to
exercise a certain selection in this Atlas and Epitome of
Operative Ophthalmology. I was guided in my selection
chiefly by my own practical experience, which covers a
period of almost thirty years ; but let me say at once that
I am not familiar with all the methods of operations de-
scribed in this work from personal experience with them.
In the case of most of them, however, I have determined
their advantages by testing them myself. In doing so I
found out that it is not only necessary, but also most in-
teresting, for the operator to resort from time to time to
other methods besides those on which he was, so to speak,
brought up, and which have become a part of him.

I have, therefore, endeavored in this work to describe
the various operative interventions in such a way as to
enable my colleagues to vary their operative procedures as
I myself have done.

As a rule, mere verbal description does not suffice to
give a clear idea of operative procedures, and pictorial
illustration is therefore indispensable in this kind of work ;
for which reason a copiously illustrated Atlas is most desir-
able.

7



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8 PREFACE,

The text, which has been condensed until it contains
only what is indispensable, is intended as a guide to stu-
dents, practitioners, and ophthalmologists in the technic of
operations on the eye and their various modifications ; and
I imagine that assistants who have to prepare an operation
will welcome the book because it enables them, without
loss of time, to get a general idea of the plan of an opc^r-
ation and the instruments necessary for its performance.

In order to demonstrate the usefulness of a special
method of operation I have thought it advisable to give
the pictures of cases after recovery. On the other hand,
I have omitted many geometric drawings of plastic oper-
ations which usually embellish the chapter on Blepharo-
plastic Operations in movst of the current works and text-
books, but which are more likely to have seen the light
of day at the desk than on the operating-table, and are
therefore of questionable usefulness, especially sinc>e the
introduction of Thiersch's method of skin-grafting has
made so many changes in this bnmch of surgery.

The illustrations of the instruments in this work were
obtained by reproducing the photographs made under my
direction by Messrs. H. and E. Butcher, of Zurich, after
reducing them one-tenth ; except in two groups, those for
Kronlein's operation, for which, on account of the size of
the instruments, a reduction of one-half was found to be
necessary. The instruments which are here represented
were obtained in the course of years from the following



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PREFACE. 9

firms : Weiss & Son, 287 Oxford street, London, W. ; H.
Windier, Friedrichstrasse 133 a, Berlin ; H. Wulfing-
Liier, 6 Rue Antoine-Dubois, Paris; G. Tiemann & Co.,
New York ; and Chambers, Inskeep & Co., Cliieago ; but
I do not pretend to say tliat other instrument-makers do
not also furnish very good instruments of the kind.

I am indebted to the artist, Mr. J. Fink, for the prepa-
ration of the remaining pictures, many of which presented
considerable difficulties.

I am also indebted to the publisher, Mr. T^elimann, for
his efforts in connection with the preparation of this Atlas.

O. HAAB.



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LIST OF LITHOGRAPHIC PLATES.



Plate 1. — Introdnction of a Pencil of Iodoform into the Anterior

Chamber in a Case of Infection by a Foreign Body.
Plate 2.— Operation for Senile Cataract.
Plate 3. — Reposition of the Iris with the Spatula at the End of an

Operation for Senile Cataract.
Plate 4.— Operation for Secondary ('ataract, after Bowman, with Two

Needles.
Plate 5. — Operation for Secondary Cataract with Knapp*s knife in-
troduced through the Sclera.
Plate 6.— Iridectomy in Glaucoma.
Plate 7. — Inferior Sclerotomy.
Plate 8. — Advancement of the Right Intemns in Divergent Strabismos,

after Prince.
Plate 9. — Enucleation of the Eyeball.
Plate 10. — Opening of the Orbit after Kronlein.
Plate 11.— Oi)ening of the Orbit after Kronlein.
Plate 12. — Destruction of the Orbit by Carcinoma (Rodent Ulcer).
Plate 13. — Fig. 1.— Pagenstecher's Ptosis Operation.

Fig. 2. — Gaillard's Suture in Spastic Entropion.
Plate 14.— Fig. 1.— Blepharophimoeis.

Fig. 2.— Canthoplastic Operation.
Plate 15.— Fig. 1.— Ectropion due to Facial Paralysis in the Second Year
of Life.
Fig. 2.— The Same Eye after Six Months, after Median Tar-
sorrhaphy with Szymanowsky's Modification.
Plate 16.— Senile Ectropion with Senile Cataract (see Plate 17).
Plate 17. — Fig. 1.— Kuhnt's Ectropion Operation in Same Patient.

Fig. 2.— Same Eye Three Months after the Operation and
One Month after Cataract Operation without Iri-
dectomy.
Plate 18.— Fig. 1.— Senile Ectropion.

Fig. 2.— Same Eye Immediately after Kuhnt's Ectropion

Operation with L. Miiller's Modification.
Fig. 3.— Same Eye Three Weeks Later, after Recovery.

U



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12 LIST OF LITHOGRAPHIC PLATES.

Plate 19. — Fig. 1.— Severe Cicatricial Ectropion.

Fig. 2.— The Same Eye Six Months Later.
Plate 20.— Fig. 1.— Cicatricial Ectropion.

Fig. 2. — Showing the Wound before the Skin-grafting.
Plate 21.— The Same Eye Two Weeks Later, after Uninterrupted Ee-

covery.
Plate 22. — Enormous Cicatricial Ectropion.

Plate 23.— The Same Eye Three Months after the Last Operation.
Plate 24. — Fig. 1.— Cicatricial Ectropion after a Dog-bite.

Fig. 2. — Condition of the Eye Fifteen Months Later.
Plate 25.— Fig. 1.— Complete Symblepharon and almost Complete Ankyl-
oblepharon.
Fig. 2.— Recent Bum on the Lower Portion of the Conjunc-
tival Sac.
Plate 26. — Figs. 1, 2. — The Symblepharon which had Meanwhile Devel-
oped was Treated by Operation.
Plate 27. — Large Carcinoma.

Plate 28.— Shows the Patient's Condition when Disi-hargcd.
Plate 29. — The Same Patient after the Carcinoma bad Roi-urred and had

again been Removed.
Plate 30.— Fig. 1.— Extirpation of the Tear Sjvc.

Fig. 2.— The Extirpat^'d Tear Sac, which lia<l probably not
been Reached by the Incision and Curettage ICc-
ferred to.



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CONTENTS.



TAGB

General GonslderatloxiB 17

Hospital Wards and Operating Booms 18

Anesthetization 25

Local Anesthesia 28

Sterilization, Antiseptics, and Asepsis 33

Bandaging 45

Salivary Infection 59

Disinfection 68

Instruments 76

Operations on the Globe 81

Operation for Cataract 81

Indications 85

for Removal of Total Juvenile Cataract 102

for Total Soft Cataract of Adults 108

for Traumatic Cataract 108

for Partial Stationary Cataract '. . . 112

for Senile Cataract 118

Preparatory Treatment 124

with Iridectomy 136

without Iridectomy 142

Modifications 148

Accidents and Mistakes 154

Method of Applying? Dressing and After-treatment .... 162

Accidents Interfering with Healing of Wound After . . 163

for Secondary Oitaract 166

Treatment of Operation for Senile Cataract by Couching and

Deprei?sion 174

Operative Treatment of Dislocation of the Lens 175

Removal of the Lens in High Myopia 176

Iridectomy 179

Optical Iridectomy 180

For Relief of Increased Tension 186

Sclerotomy 196

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14 CONTENTS.

PAGE

Operations on the Cornea, Sclera, and Coiyunctiva 202

Removal of Foreign Bodies from Cornea 202

Puncturing the Cornea 206

Operation for Pterygium 208

The Utilization of the Coiyunctiva to Cover Defects in the

Cornea 210

Tattooing of the C'oruea 210

Removal of Dermoids 212

Staphyloma of Cornea 213

Operations in the Anterior Chamber 215

Separation of Anterior Syuechiae 215

Separation of Posterior Synechise 216

Removal of Foreign Bmlies from the Interior of the Eye .... 216
Removal of Spicules of Iron from the Eye (Magnet Opera-
tion) 216

Removal of Foreign Bodies not consisting of Iron ... 237

Operations Outside of tbe Eyeball 239

Operations on the Ocular Muscles . 239

Strabismus 239

Tenotomy after von Grafe 242

Tenotomy after Arlt 245

Tenotomy after Snellen 246

Operations on the Antagonist of the Squinting Muscle . . . 249

Knapp's Method 249

Weber's Method 249

de Wecker's Method 250

Landolt's Advancement 252

Prince's Operation 253

VerhoeflTs Operation 254

Worth's Method 255

Capsular Advancement after de Wecker 256

Knapp's Method 257

Todd's Method 258

Brand's Method 258

Schweigger's Method 258

KosteWs Method 259

Mailer's Method 259

Enucleation of the Globe 265

Resection of the Optic Nerve 274

Exenteration or Evisceration of the Globe 275

Artificial Glass Eyes 278



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coy TESTS. 15

PACK

Operations on the Orbit 279

Tlie Removal of Tumors from the Orbit 281

Kronlein's Operation 284

Exenteration of the Orbit 291

Operations on the LldB and In tbe GonjunctlTal Sac 295

Operation for Ptosis 295

Pagenstecher's 297

de Wecker^s 297

Dransart's 297

Hess' 298

Pana's 300

Motels' 300

Eversbnsch's 302

Snellen's 303

Woirs 304

Lapersonno's 305

Elschnig's 306

Gillett de Grandmont's 307

Operations for Entropion 308

GJaillard's Suture 309

Destroying Roots of Cilia by Electrolysis 309

Spencer Watsoti's 311

Hotz's 311

Entropion Operation with Advancement of the Levator

Tendon 314

Streatfield's 316

Snellen's 317

Hotz's Tarsus Excision for Trichiasis of Upper Lid . . . 317

Division of the Tarsus after Panas 318

Pfelz's 319

, Ablation of Ciliary Border after Flarer 320

Displacement of Ciliary Border after Jasche-Arlt .... 320

Operation for Blepharophimosis 321

Cauthoplastic Operations 321

Tarsorrhaphy 322

Operations for Ectropion 323

Snellen's Sutnre 324

Szymanowsky's 324

Kuhnt's Operation 325

Blepharoplastic Operations 328

Fricke's 329



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16 coy TEXTS,

PAGE

Dieffenbach's 331

Thiersch's Method of Skin-grafting 332

Operation for Symbiepharon 337

Operatious on the Conjunctiva 345

Oparations on tbe Lacrimal Organs 347

Simple Eversion of the Lower Lacrimal Punctum . . . 348

Dacryostenosis 350

Dilation of the Nasal Duct by Means of Soands .... 353

Extirpation of the Tear Sac 357



Literature 361



Index .



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OPERATIVE OPHTHALMOLOGY.



GENERAL CONSIDERATIONS.

Since upon the success of an ophthalmic opemtion,
especially an operation for cataract or glaucoma, depends
not only the sight of the aflTected eye, but also that of
its fellow, because any operation in which the globe is
opened may be followed by sympathetic disease of the
other eye — for these considerations an operation on the
organ of sight is fraught with great responsibility and
should not be lightly undertaken. For most people blind-
ness is as bad as death, and for many it is even worse.
As an operation on the eye may often be exceedingly
difficult and call for the greatest care and skill on the
part of the operator, I fully agree with Snellen when he
says : " Although it is true that the operative field in
ophthalmology is limite<l and most of the operations are not
formidable, it is nevertheless a mistake to regard operative
ophthalmology merely as a part of minor surgery and
within the scope of every practitioner, as there appears to
be a tendency to do from time to time. When an opera-
tion on the eye fails to realize the patient's hopes, the
effect is often more tragic than death itself."

In operations on the eye a surgeon must be cool, de-
liberate, and experienced, or an accident is very likely to
happen to him or, rather, to his patient. He must also
have well-drilled assistants of the right kind. The most
important operations on the eye, particularly those for
cataract and glaucoma, are peculiar in that they must
be performed in a short space of time; and if the

2 17



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18 GENERAL CONSIDERATIONS,

operator has made a slight mistake, as, for example, in
the size or position of his incision, it is often difficult for
him to rectify it. Besides, the surgeon is very much de-
pemlent on the patient's behavior, which frequently spoils
the most beautifully planned operation. In such cases
nothing but promptness on the part of the operator to do
the right thing and the greatest presence of mind will
avert disaster. At the same time the entire operative
field must be kept constantly in mind during the entire
operation — not only the spot where he happens to be busy
with his instruments. It may be asserted with confidence
and with entire honesty that an ophthalmic surgeon, be
he ever so experienced, never is certain when he b^ins
an uncomplicated operation for cataract how it will end.
This feature lends a special character to this operation,
which is one of the most important that can be performed
on the human subject.

Not only the operation itself, but the after-treatment,
the subsequent course, and the question of recovery are
very much influenced by the patient's behavior. In the
same way the nursing and medical treatment which he
receives are important features in bringing about the
ultimate result.



Hospital Wards ilnd Operating: Rooms.

The question of efficient nursing and treatment is much
simplified if the operating room and the wards in which
the patients spend their convalescence are properly ar-
ranged. By exercising great care and deliberation in the
treatment of the eye, from the time of operation until
re(M)very, excellent results may be achieved even under
unfavorable external conditions in hospitals and operating
rooms which fail to come up to the most modern require-
ments. Of course, the man who can give his patients the
benefit of the scrupulous cleanliness of a modern hospital
will have an easier conscience during the operation, and,
on the average, more satisfactory results afterward, pro-



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HOSPITAL WARDS AND OPERATING ROOMS 19

vided the nurses and assistants are thoroughly imbued
with the principles of modern hospital nursing and the
modern treatment of wounds and act according to these
principles. The condition of the walls and of the floors
has no special bearing in ophthalmic surgery ; but the
hands of the nurses who take care of the patients are of
the utmost importance. For that reason I should like to
mention — ^aside from the well-known architectural ad-
vances of the last decades, which ought to be found in
every hospital — the fitting up of every room with running
hot water as a chief requisite or at least a great advantage
for an eye dispensary of any considerable patronage. If
hot water and soap are readily aco>essible, the attendants
will have no objection to cleansing their hands at frequent
intervals, and this alone is of value.

It has also been found desirable in our clinic at the
University, which has now been in operation seven years,
to have two rooms adjoining the operating room for
patients that have just undergone operation, especially for
cataract, one for males and the otner for females. The
patient's bed is rolled into the operating room, the opera-
tion performed while he is in bed, and he is then taken
back to his room, so that there is no necessity of lift-
ing him from his bed to the operating table, and from
the latter back to his bed. I have no doubt that patients
who have been operated upon for cataract or glau-
coma may be allowed to walk about and go to their
rooms, as is the custom in some hospitals, without any
great danger of harm arising therefrom; but it is per-
fectly evident that complete rest in a recumbent posture
immediately after the operation is not only more agreeable
to the patient, but also better for the wound, and that in
any large hospital it is more convenient simply to transfer
the patient in his bed from the operating room to the
ward or private room. Since it is of the greatest im-
portance in the case of all wounds that involve division
of the capsule of the globe to get primary union, if pos-
sible, during the first twenty-four hours afi^er operation.



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20 GENERAL CONSIDERATIONS.

complete rest during the first day is desirable. The
})atient himself will realize the importance of such pre-
caution better if the rest begins inimtnliately after the
operation and he is not allowed to walk about for a time
before he begins his rest in bed. In my private clinic
cataract extraction and iridectomy are invariably per-
formed in the patient's own room, and subsequently the
latter remains quietly in his be<l. This was also tl^e*
practice of my esteemed master, Horner, both in his clinic
and private work. It is possible that this pmctice is in
part responsible for the fact, which has always been a
source of personal gratification, that during the twenty-
seven years of oj>erative exj>crience (including the time
when I was an assistant to Horner) I have had but 1
case — two years ago — of that frightful intra-ocular hem-
orrhage, w^hich so treacherously destroys the eye imme-
diately or soon after cataract ojK^rations.

[An operating chair or table, the height or inclination
of which can be altered to suit conditions, and the imme-
diate surroundings of which can be maintained in surgical
cleanliness, is preferred by the majority of surgeons.
From it the patient can be lifted readily to the ImkI he
afterward occupies without deleterious effort on his pirt.
—Ed.]

It is not necessary to darken the room of a patient
recently operated upon. All that is necessary is to arrange
the shutters so as to bar out any glaring light that would
be equally unpleasant to the normal eye. It is important,
however, to see that the ventilation in the rooms is ade-
quate, because the patients are often old and their respira-
tion is insufficient, so that oxygenation and metabolism
are incompletely performed.

The enforced rest during the first period should be
made more bearable to a [)atient who has l)een through an
o{>eration for cataract or glaucoma by giving him an
electric l)ell to hold in his hand ; in this w^ay we may
guanl against fright, which in many cases is, perhaps,
the precursor of post-operative delirium, especially when