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conservative treatment. My paper discussed alone the study of mastoid operation as a method of cure in acute suppuration, but this case having been referred to I would say that I was present at that session and the discussion plainly showed that the consensus of opinion was that conservative methods would ordinarily, in the class of cases to which the one reported belonged, be followed by disastrous results, that to delay operation would ordinarily mean a fatal result.

Dr Thompson emphasized a point which I am very glad to have brought to your attention in this way, namely, that we may have intracranial perforation without any external swelling and with no mastoid tenderness whatever.

In regard to hearing, if this operation were not indicated for any other reason I think we would be justified in its performance in every severe case of suppuration for what it does in restoring good hearing. I do not know that we can all agree as to the function of the mastoid cells, but I think we ought to be satisfied with the results which we obtain by using it as a method of approach to the middle-ear cavity for securing drainage in suppuration and thus saving the function of this diseased cavity. If we are going to have a septic discharge flowing down over the walls of the tympanic cavity these parts will be damaged. This damage means more or less loss of hearing. In the great majority of cases in which the mastoid operation is performed in cases of recent middle-ear suppuration we have cessation of discharge, healing of the drum membrane and restoration of good hearing power. This being the case, why should we have so many cases of chronic suppurative otitis media? It is because as specialists and as general practicians we have not impressed upon our patients the importance of these cases of acute suppuration and insisted upon those measures which will prevent the later and serious sequels of the disease.

The radical operation for the cure of chronic suppuration is a much more extensive surgical procedure. We must treat these patients after operation constantly, almost daily, from six weeks to nine months or even a year after the operation has been performed. This period of after-treatment is a long and tedious one. The after-treatment of the Schwartze operation, which I am advocating in this paper as a procedure in cases of recent suppuration, is short and comparatively simple, and the operation usually leaves no deformity.

The Snellen Wet Dressing in the
After-Treatment of Cataract

BY C. F. CLARK, M. D., COLUMBUS

The method of dressing described below is very old but has long fallen into disuse. It is, in my opinion, well worthy of reconsideration.

In our endeavor to perfect the operation for the extraction of senile cataract and obtain in each case the best possible result, almost as much depends upon the nature of the after-treatment and the careful management of dressings as upon the original operation.

Holding in check the iritis, which sometimes accompanies the traumatism necessarily incident to such an operation, and, above all, maintaining the lips of the wound in accurate apposition and thus avoiding prolapse of the iris, are matters of the most vital importance, and any means which tend to aid us in accomplishing these objects are well worthy of our consideration.

It is doubtless true that excellent results may be obtained in a variety of ways, and almost every operator of large experience has some method of his own which he regards as of more or less importance in accounting for hist success. Some prefer as light a dressing as possible, even going to the extreme of using only a small strip of courtplaster applied over the closed lids, while others go to the opposite extreme and insist upon a large covering of gauze and cotton with a long roller-bandage applied as a binocular or figure-of-eight, and over this apply a mask.

In the course of the last 19 years I have employed with a good measure of success both of these, and a variety of what might be termed intermediate methods, generally preferring a dry dressing strapped down with isinglass plaster and covered with cotton and a Ring mask. I have at times been inclined to agree with some of my friends who have reasoned that, if good results may be obtained by such a

variety of dressings, it does not much matter which we adopt. But I am convinced, and I think all will agree, that in an operation such as the extraction of cataract every detail is worthy of the most careful study and we cannot afford to ignore any suggestion that adds to our assurance of success in avoiding those accidents which, after a carefully performed extraction and in spite of all of our precautions, sometimes lead to such unfortunate results as prolapse of the iris.

During the summer of 1902 I had an opportunity of visiting a number of well-known eye clinics, and endeavored to obtain some new ideas on this subject. I will not occupy your time with a recital of the various methods employed, but will state that with a large proportion of operators the binocular bandage seems to be the favorite and while in minor details they differ somewhat, at only one clinic did I find a method of dressing which may be said to mark a real and important step in advance in the after-treatment of

cataract.

A maximum of safety to the operated eye with a minimum of discomfort to the patient and early use of the unoperated eye are certainly objects worthy of consideration not only in cases of cataract but in other operations involving corneal section. With the additional advantage of a much higher degree of security against sepsis than is possible by the old method, these objects are attained by the dressing which is employed in Snellen's clinic at the Donders Hospital at Utrecht.

After the toilet is complete a small patch consisting of a single layer of gauze is laid over the closed lids of each eye and over this are carefully laid, one at a time, a large number of small pledgets of absorbent cotton thoroughly saturated with a one to five thousand solution of bichlorid of mercury. A sufficient number of these are employed to completely fill out the orbital fossa and over this wet mass is laid an oval patch of thin, rubber tissue of such size as to cover the cotton. This is held in place by two or three

strips of isinglass plaster and outside of it is placed a mass of absorbent cotton which is usually retained by one of Snellen's concave aluminum protective shields held in place by adhesive plaster.

This outer dressing, however, may be substituted by the ordinary roller bandage, a tail bandage or, as I prefer, by the Ring mask, which is easily removed and serves to give the patient confidence, as he realizes that extreme violence would be required to injure an eye so protected.

In case the patient's skin does not tolerate the bichlorid, a boric acid solution may be substituted, the important point being that a moist, aseptic, or mildly antiseptic dressing shall be so accurately moulded to the eye as to fix it in place and prevent movement of the lids, while serving to prevent sepsis from without.

In order to maintain the moisture the dressing is renewed every 24, and sometimes as often as every 12 hours.

On seeing this dressing applied for the first time I at once raised the objection which naturally arises in the mind of every one; namely, that by such a method we were practically poulticing the eye and by maceration favoring sepsis.

A moment's reflection will convince one that this reasoning is unsound and nine months' constant use of the dressing has convinced me that I must adapt my reasoning to the facts, all of which stand in favor of this method. It is true we may, to a slight degree, macerate the skin of the lids, but this has caused me no trouble, and after all it is not the skin we are treating, but the eye, and when closed, the eye, even without any dressing, is always moistened with the lachrymal secretion. There seems to be no reason why moisture on the outside of the lids should unfavorably influence the healing of a wound, and, indeed, the facts as developed by my own experience, prove that it does not.

Our fear of poultices in ophthalmic surgery is, no doubt, based largely upon our unfortunate experience with septic poultices as applied in domestic practice, but the almost constant freedom from deposits of mucopurulent secretion in

this form of dressing when removed convinces me that the constant presence of an antiseptic solution in contact with the lashes and the orifices of the glands in the lid-margins serves to powerfully inhibit the development of septic material from this, which is deemed one of the most fruitful and inaccessible sources of infection about the eye.

I have laid some stress upon this phase of the question because I realize that in advocating moist dressings after cataract extraction I am going counter to the general practice of ophthalmic surgeons, and in such an innovation the burden of proof must be borne by those who urge a departure from a generally accepted practice.

Even nine months of constant personal experience with this method of dressing in both private and hospital practice, and its uniformly successful use in more than 25 successive cases of cataract extraction, most of which were simple extractions and in not one of which there was prolapse of the iris, would not, perhaps, justify me in advocating it so strongly were I not merely repeating in my own work the experience of years in one of the best-known ophthalmic hospitals in Europe, that of Professor Snellen, of Utrecht. In the large service of this great hospital Professor Snellen and his assistants assured me that, in spite of the fact that, with rare exceptions, they perform simple extraction, they had had only one case of prolapse of the iris in the last two years.

To the patient, as well as to the operator, one of the great advantages of this dressing is that, if kept thoroughly wet, it forms so accurate a cast of the orbital fossa and holds the lid so securely in place that at the end of 24 hours the unoperated eye may be uncovered. This has been my practice and I have seen no reason to regret it. Indeed, in Professor Snellen's clinic they often remove the dressing from the unoperated eye within a few hours after the operation.

It is my belief that this is a real step in advance in our method of treating corneal sections and well worthy of a trial.

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