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exceedingly difficult to determine between the first approaches of gutta serena, and of cataract. Shortly afterwards the pupil loses its beautiful jet black colour, and assumes a turbid appearance, which muddiness increases by degrees, until at last the lens becomes entirely opake, and of a white, yellow, or dark colour, constituting what is called a mature, or ripe cataract.
During the whole of the advance of the cataract, unless it be complicated with any other state of disease, the natural functions of the iris are preserved, and no pain whatever is felt in the eye, or head. So little conscious, indeed, is the patient of the existence of cataract, when it attacks but one eye at a time, that he is frequently ignorant of the loss of sight in it, until, by accidentally covering the other, he finds himself wholly dark; or, from being unable to judge accurately of distances, he spills his wine in attempting to pour it into a small glass, or cannot, with certainty, snuff a candle, and is hence induced to examine his eyes separately. In one instance which I saw at Exeter, where cataract was produced by a blow from a bush, the wife of the patient soon after observed a whiteness of the pupil, which she did not mention to her husband, lest it should alarm him; and it was upwards of three weeks before he knew himself to be blind, in one eye, by accidentally putting his hand over the other.
The disease generally commences at first in one eye, and, by the time it has made any considerable progress, the other eye becomes affected. This, however, is not always the case, as I have known ten, or fourteen years, to intervene between the production of cataract in one eye, and the subsequent formation of it in the other. There is an equal degree of uncertainty, in the period of time, required for the complete formation of cataracts. I have known them completely formed (and when not arising, apparently, from any particular exciting cause) in the short space of three months, whereas, in other instances, if I may credit the patients' statement, they had been gradually losing their sight for upwards of ten years. The usual length of time is between one and three years, which embraces the period when the obscurity of vision first commences, until the cataract is completely formed. When, however, the cataract is produced by accidents, or arises from the application of any particular exciting cause, it will sometimes form in an almost incredibly short space of time.
'Richter mentions the case of a forester, who, labouring under the gout, had his feet exposed to a great degree of cold during the night: the gout suddenly retroceded in consequence, and he was entirely deprived of his sight the same night. He adds, "I saw him next morning, and found a complete pearly-coloured cataract. Eschenbach relates a similar case."
Tartra, in his excellent Thesis on Cataract, mentions a case, related by Fabrice de Hilden, of a lady about fifty years of age, who, having wept a great deal for the loss of a relation, became blind from cataracts in one night, without pain or inflammation.
'He also mentions, that he was informed by Weidmann, a celebrated surgeon of Mayence, of a case of cataract, which suddenly
formed in the eye of a man on his quitting a feast very much intoxicated. Tenon states, that he had seen a lady with two cataracts, which were completely formed in one day. He also relates the case of a potter, who, going into his pottery while it was heated, came out with two perfect cataracts.'
All these cases import great irritative action, and suggest inflammation rather than atony as the cause. Indeed we can hardly conceive how the latter could produce so sudden an influence: and it is observed by our author himself immediately afterwards, that, 'when cataract results from age, or is produced by any other natural cause, the progress of the disease is much more slow.' We mean not, however, to say that local debility does not induce cataract, but only that it is not the sole inductive principle; and that cataract, like gangrene, and a variety of other diseases, may proceed from either extreme. It is very probable, indeed, as our author observes, that cataract in old persons, or those in whom the animal powers, according to the course of nature, are suffering by slow decay, is occasioned by an obliteration of the vessels that nourish the crystalline lens.'-p. 48.,
It is not very surprizing that a dexterous and successful operator should be forward in recommending, even from the first, a recourse to chirurgical rather than to medical treatment. We do not differ from our author in the main, but we think that he allows somewhat too little to the possibility of benefit from any plan of medical treatment that is either now known, or may be hit upon hereafter. The subject, however, is well put in the following passage:
By whatever process the disorder may be produced, it is obvious, that it is not likely to be easily within the reach of medical treatment; and the almost uniform failure of general, and local remedies, leaves no other resource for the patient than an operation.
It will be granted to me, without much hesitation, that no solid body, in any part of the system, admits of being removed by the absorbents, without first undergoing solution. A supposition to the contrary, involves the absurdity of believing, that the finest and most delicate series of vessels of the body, whose largest trunks are with difficulty made visible by dissection, and whose smaller tubes are not cognizable to the senses, and can only be proved to exist by analogical reasoning, should possess the mechanical power of abrading the solid substance of bone. The power of these vessels in absorbing fluids is undeniable; and it is equally certain, that portions of exfoliated bone are removed by them, and carried into the general system; but their structure shews the impossibility of their exercising a sufficient force, for this purpose, upon solid substances; it is, therefore, more than probable that solution takes place as a preliminary process to absorption. This reasoning applies with equal force to the absorption of solid cataracts, for, in proportion to the comparative size of the absorbent vessels, which the Jens and capsule possess, the resistance will be equal to that which is offered
offered by bone to absorbent vessels of a larger size, in other parts of the body. One necessary step, therefore, to the removal of a solid, lenticular cataract, is, first of all, to effect its solution.
To accomplish this, completely within its capsule, and without the solvent agency of the aqueous humour, must be admitted to be beyond the power of any internal, or external remedies.'-pp. 48, 49.
Now we cannot categorically consent to any such admission, although we are not, at present, acquainted with any medicine, or course of medicines which, whether generally or locally applied, will decidedly operate in removing the opacity. We object to the argument.
The cataract, or opaque lens, is here contemplated as a dead or inert body, surrounded by a living substance. It should first, however, have been proved that it is a dead or inert body. But granting that it is so, are we to suppose no other set of vessels at work to carry off this obstruction than the absorbents? We admit that in every case of this kind a solution of the dead matter, and consequently a solvent medium, is necessary: and in all common cases, even where a dead piece of bone is to be removed, we find this, or think we find it, in the new and correspondent action of the contiguous secernents thus keeping pace with the new action of the absorbents, and pouring forth a secretion that, being applied to the surface of the dead matter, dissolves, not indeed the whole substance at once, so as to convert it into a mass of pus, or of any other fluid, but only that part of it with which it is in immediate contact, and which hereby becomes fitted for absorption, and is absorbed accordingly. And as the same double and harmonious. action is continued upon every fresh surface of the dead matter that thus becomes exposed, the whole is at length carried off, and a cavity produced where before was solid substance.
This reasoning, which is meant to embrace and exemplify the doctrine of Mr. John Hunter upon the general subject before us, applies to the opaque lens contemplated as a dead or inert substance alone. But it is not necessary thus to contemplate it in every case of lenticular opacity; for it is possible, and indeed probable, that, in many instances, it becomes nebulous from the secretion of a morbid and non-transparent fluid by its own minute secernents; and, in such cases, a return of the diseased vessels to their wonted healthy action is all that is necessary to remove the opacity, and consequently to carry off the cataract.
Whether there actually exist, in the wide region of therapeutics, any description of medicines capable of exciting this return of healthy action, or of stimulating the surrounding systems of secernents and absorbents to a removal of the entire lens when absolutely dead or inert, is a question altogether distinct from
the present consideration, which is merely designed to shew, that the general principles of the animal economy, so far as we are acquainted with them, and as they apply to the subject before us, are in favour of curative trials by medicine, rather than adverse to them upon the ground of physiological absurdity. That the crystalline lens, in a state of health, is a living and active substance; and that a change in its organization is perpetually taking place will not be disputed by any physiologist in the present day. Internal agents, apparently of various kinds, which lie far beyond the prying power of the nicest research, have a considerable influence upon this change, and hereby, indeed, not only produce the opacity which we call cataract, but all the peculiar characters by which one species or variety is distinguished from another, and the cataract is rendered black or white, or ferrugineous, or green, or amber in respect to colour; or hard, horny, soft, or even fluid and milky, in respect to consistence. And if internal agents be possessed of these powers, it is possible, whether we be acquainted with them or not, that external agents may also exist, capable of producing effects as considerable. The specific medicines we are acquainted with are not many, and their course of action is entirely concealed from us: yet they are sufficiently numerous, and their influence upon particular organs is sufficiently direct and unequivocal, to induce a belief that other specifics may yet exist, possessing as clear and undeniable a power over other organs of the animal system. Nor can we, even at present, altogether discredit the benefits which are stated by writers of the first character, to have resulted occasionally from a judicious application of some of the remedies in common use.
We are nevertheless ready to admit, and even with a high degree of satisfaction, that the judicious and ingenious improvement given by Sir William Adams to most of the operations for cataract, in whatever way it be intended to remove it, renders all attempts at curing or relieving the disease by medicine of far less consequence than they have been in former times.
The ordinary operations employed for the removal of cataract are the three following:-that of couching, or depression; that of extraction; and that of absorption. Each of these is described at length, as well historically as practically, in the work before us; their respective advantages and disadvantages are very candidly brought together from the best practical writers on the subject: and the dangers and the difficulties, and the various inconveniences accompanying each, being forcibly and alarmingly detailed, not from writings hostile to the particular method investigated, but, for the most part, from the verbal admissions of its chief advocates and patrons, our author proceeds to point out the means by which
the greater part, and not unfrequently the whole of these evils may be avoided by his own method of operating, which he describes with a perspicuity and an ingenuousness that does equal credit to his head and his heart.
Of the three ordinary modes of attempting to remove the cataract, and which we have just adverted to, that of depression or couching, as it is colloquially called, is abandoned by our author altogether; and for reasons which we confess are sufficiently satisfactory to ourselves, and we have no doubt will prove sufficiently satisfactory to the profession at large. The operation for absorption appears to be Sir William's favourite mode of practice. It is in effect more extensively applicable than any other operation for cataract, and will probably hereafter be allowed, in every instance, to supersede the use of the depressing process, wherever the cataract is capable of division; as the process of extraction, with our author's new mode of placing the lens in the anterior chamber, and then drawing it away through an opening on the outer side, instead of the inferior part of the cornea, will, in like manner, be employed to supersede the same process, wherever the cataract is indivisible from its hardness. We were much pleased with the author's valuable improvement on Cheselden's operation for artificial pupil; it bids fair to be accompanied with very extensive suc
Hitherto most operators, having made their election of a particular mode of practice, have confined themselves to that mode alone, and rejected every other as of inferior value. It is to the credit of Sir William Adams that he employs, without prejudice, such mode as appears best adapted to the peculiarity of the case.
Those,' says he, who practise the older mode of extraction, in general confine themselves exclusively to that operation, whatever may be the age of the patient, the consistence of the cataract, or its complications. From the various species, varieties, and combinations of the disease, described in the first chapter of this book, it must appear evident that no one operation can be equally applicable to all. It is the duty, therefore, of the surgeon to investigate the causes of the difficulties and embarrassments, which give rise to the frequent failures which must necessarily result, when the same operation is indiscriminately employed, and to exert his ingenuity, in order to devise means by which the causes of failure may be avoided. Such has been my endeavour, and I trust that it will not be deemed presumptuous in me, to express the hope, that these objects are in a great measure accomplished, by the adoption of a series of operations, which vary in their nature according to the species of disease to be operated upon.
The leading principle of my practice is, that the operation effecting the solution and absorption of lenticular cataract, should be performed in all ages, and in every combination, of that species of disease, in preference to all other operations, when it can be done with safety. This, as already mentioned, is always practicable, when the consistence of the cataract