THE LIBRARIES COLUMBIA UNIVERSITY Medical Library |E]| finJf]ifgfrin]|]ifOffijgfiijLl^ I 1 1 1 1 I 1 I 1 1 II u 1 1 1 1 1 1 I 1 i Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/practicaltreatiOOmaGk DISEASES OF THE EYE. PRACTICAL TREATISE t DISEASES OF THE EYE. By WILLIAM MACKENZIE, //> LECTURER ON THE EYE IN THE UNIVERSITY OF GLASGOW, AND ONE OF THE SUR- GEONS TO THE GLASGOW EYE INFIRMARY. FROM THE LAST LONDON EDITION. BOSTON: CARTER, HENDEE AND CO J. E. Hinckley & Co., Printers, 14 Water Street. ""i'833""" M 11 ' -^ - >. \ » •\ :'■*- \ V CONTENTS. Chapter I. Diseases of the Orbit, Section I. Injuries of the Orbit, 11. Ill IV. • • • . *^- 1. Contusions and Cuts upon the Edge of the Orbit, 2 9. Fractures of the Edge of the Orbit, . 3 y. Fractures of the Walls of the Orbit, attending Fractured Skull, ... 4 4. Counter-Fractures of the Orbit, . 5 5. Penetrating Wounds of the Walls of the Orbit, ib. 6. Incised Wounds of the Orbit, . . 16 7. Gunshot Wounds of the Orbit, . . 17 Periostitis, Ostitis, Caries, and Necrosis of the Orbit, 26 Periostosis, Hyperostosis, Exostosis, and Osteo-Sar- coma of the Orbit, .... 35 1. Periostosis of the Orbit, . • . ib. 2. Hyperostosis of the Orbit, . . 36 3. Exostosis of the Orbit, ... 37 4. Osteo-Sarcoma of the Orbit, . . 47 Dilatation, Deformation, and Absorption of the Orbit, from Pressure, .... 49 1. Pressure on the Orbit from within the Orbit, 51 2. Pressure on the Orbit from the JVostril, ib. 3. Pressure on the Orbit from the Frontal Sinus, 55 4. Pressure on the Orbit from the Maxillary Sinus, 62 5. Pressure on the Orbit from the Sphenoid Sinus, 69 6. Pressure on the Orbit from the Cavity of the Cra- nium, . . . . ' ib. Chapter II. Diseases of the Secretij^g Lacrymal Organs, 73 Section I. Injuries of the Lacrymal Gland and Ducts, . ib. II. Xeroma, . - . . .74 III. Epiphora, ..... 75 IV. Inflammation and Suppuration of the Lacrymal Gland, 76 V. Enlargement or Scirrhus of the Lacrymal Gland, 78 VI. Lacrymal Tumour in the Lacrymal Gland, . 86 VII. Lacrymal Tumour in the Subconjunctival Cellular Membrane, ..... 92 VIII . True Lacrymal Fistula, ... 94 IX. Morbid Tears, .... ib. X. Lacrymal Calculus, . * . . . 95 Chapter III. Diseases of the Eyebrow and Eyelids, . 97 Section I. Injuries of the Eyebrow and Eyelids, . ib^ 1. Contusion and Ecchymosis, . . ih. 2. Burns and Scalds, ... 98 3. Incised and Lacerated Wounds, . . 100 VI Section II. Phlegmonous Inflammation of the Eyelids, III. Erysipelatous Inflammation of the Eyelids, IV. Carbuncle of the Eyelids, V. (Edema of the Eyelids, VI. Emphysema of the Eyelids, VII. Inflammation of the Edges of tlie Eyelids, or Oph- thalmia Tarsi, .... VIII. Hordeolum and Grando, IX. Phlyctenula and Milium, X. Warts on the Eyelids, XI. Encysted Tumours of the Eyelids, and Eyebrow, XII. Callosity of the Eyelids, XIII. Cancer of the Eyelids, XIV. Syphilitic Ulceration of the Eyelids, . XV. Naevus Maternus, and Aneurism by Anastomosis of the Eyelids, .... XVI. Neuralgia, or Tic Douloureux, XVII. Twitching or Quivering of the Eyelids, XVIII. Morbid Nictitation, XIX. Photophobia, and Spasm of the Eyelids, XX. Palsy of the Orbicularis Palpebrarum, XXI. Ptosis, or Falling down of the Upper Eyelid, 1. Mechanical Ptosis, 2. .Atonic Ptosis, . • . . 3. Paralytic Ptosis, XXII. Lagophthalmos, and Retraction of the Eyelids, XXIII. Ectropium, or Eversion of the Eyelids, 1. Eversion of either Lid, from Inflammation and Strangulation .... 2. Eversion of Lower lAd, from Relaxation, 3. Eversion of Lower Lid, from Excoriation, 4. Eversion of Lower Lid, from Disunion at the Temporal Angle of the Lids, 5. Eversion of either Lid, from a Cicatrice, . 6. Eversion from Caries of the Orbit, XXIV. Trichiasis and Distichiasis, XXV. Entropium, or Inversion of the Eyelids, XXVI. Phtheiriasis, ..... XXVII. Madarosis, Chapter IV. Diseases or the Tu>"ica Co>'juxctiva, Section 1. Injuries of the Conjunctiva, and Foreign Sub- stances in its Folds, II. Subconjunctival Ecchymosis, III. Subconjunctival Emphysema, IV. Subconjunctival Phlegmon, V. Pterygium, VI. Conjunctiva Arida, VII. Fungus of the Conjunctiva, VIII. Warts of the Conjunctiva, IX. Tumours of the Conjunctiva, Chapter. V. Diseases of the'Semilunar Membrane and Carujs'- CULA LaCRYMALIS, Section I. Inflammation of the Semilunar Membrane and Caruncula Lacrymalis, II. Encanthis, ..... Chapter VI. Diseases of the Excreting Lacrymal, Organs, 171 Section I. Injuries of the Excreting Lacrymal Organs, 1. Injuries of the Lacrymal Canals, 2. Injuries of the hacrymal Sac, 3. Injuries of the JVasal Duct, II. Acute Inflammation cf the Excreting Lacry- mal Organs, III. Chronic Blenorrhoea of the Excreting Lacry- mal Organs, IV, Stillicidium Lacrymarum, V. Fistula of the Lacrymal Sac, VI. Caries of the Os Unguis, VII. Relaxation of the Lacrymal Sac, VIII. Mucocele of the Lacrymal Sac, IX. Obstruction of the Puncta Lacrymalia and Lacrymal Canals, X. Obstruction of the Nasal Duct, Chapter VII. Diseases oe the Muscles of the Eyeball. Section I. Injuries of the Muscles of the Eyeball, II. Palsy of the Muscles of the Eyeball, . III. Double Vision from want of Correspondence in the Action of the Muscles of the Eyeball, .... IV. Strabismus, .... V. Luscitas, -^r Immovable Distortion of the Eyeball, VI. Oscillation of the Eyeball, VII. Nystagmus, .... VIII. Tetanus Oculi, ib. ib. ib. 172 ib. 177 184 185 188 189 191 193 195 202 ib. 203 204 205 211 212 212 ib. Chapter VIII. Diseases in the Orbital Cellular Membrane, ib. Section I. Inflammation of the Orbital Cellular Mem- brane, . . . . . ib. II. Infiltration of the Orbital Cellular Membrane, 217 III. Scirrhus of the Orbital Cellular Membrane, . 219 IV. Steatomatous and Encysted Tumours in the Orbit,_ _ ib. 1. Extirpation of Steatomatous Tumours, . 221 2. Puncture of Encysted Tumours, . 229 3. Partial Extirpation of Encysted Tumours, 232 4. Total Extirpation of Encysted Tumours, 235 V. Orbital Aneurisms, .... 240 1. Orbital Aneurism by Anastomosis, . ib. 2. Aneurism of the Ophthalmic .Artery, . 247 Chapter IX. Injuries of the Eyeball, . . . 248 Section I. Injuries of the Cornea, . . . ib. 1. Contusion of the Cornea, . . . ib. 2. Foreign Substances adhering to the Cornea, ib. 3. Foreign Substances imbedded in the Cornea, ib. 4. Punctured Wounds of the Cornea, . 251 5. Penetrating Wounds in the Cornea — Loss of the Aqueous Humour — Prolapsus of the Ms, ..... 252 VIU 6. Burns of the Cornea, Section II. Injuries of the Iris, .... III. Injuries of the Crystalline Lens and Capsule, IV. Wounds of the Sclerotica and Choroidea, V. Pressure and Blows on the Eye, VI. Gunshot Wounds of the Eye, VII. Dislocation of the Eyeball, VIII. Evulsion of the Eyeball, Chapter X. The Ophthalmia, or I>'rLAMMATORY Diseases of the Eye, 261 Section I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. XVII. XVIII. XIX. XX. XXI. XXII. XXIII. XXIV. XXV. XXVI. XXVII. XXVIII. XXIX. The Ophthalmise in general, Remedies for the Ophthalmias, Conjunctivitis in general, Puro-mucous Conjunctivitis in general Catarrhal Ophthalmia, Contagious Ophthalmia, Ophthalmia of Xew-born Children, Gonorrhceal Ophthalmia, 1. From Inoculation, 2. From Metastasis, 3. Without Inoculation or Metastasis Scrofulous Ophthalmia, Erysipelatous Ophthalmia, Variolous Ophthalmia, Morbillous and Scarlatinous Ophthalmias, Rheumatic Ophthalmia, Catarrho-rheumatic Ophthalmia, Scrofulous Corneitis, Iritis in general. Rheumatic Iritis, Syphilitic Iritis, Pseudo-syphilitic Iritis, Scrofulous Iritis, Arthritic Iritis, Choroiditis, Retinitis, Aquo-capsulitis, Inflammation of the Crystalline Lens and Cap; Inflammation of the Hyaloid Membrane, Traumatic Ophthalmias, Compound Ophthalmise, Intermittent Ophthalmise, ;ule. Chapter XI. Diseases coxseque>t to the Ophthalmia, Section I. Onyx, or Abscess of the Cornea, II. Hypopium, III. Ulcers, Dimple, Hernia, and Fistula of the Cornea, and Hernia of the Iris, IV. Specks, or Opacities of the Cornea, 1. .Yebula, 2. Albugo, . 3. Leucoma, V. Granular Conjunctiva, VI. Anchylo-blepharon and Sym-blepharon, VII. Synechia, Vin. Obliteration of the Pupil, IX Section IX. Cataracts, or Specks of the Crystalline Capsule and Lens, ..... X. Dissolution of the Vitreous Humour, XI. Atrophy of the Eye, .... XII. Staphyloma, ..... 1. Staphyloma of the Iris, or Staphyloma Race- mosum, .... 2. Staphyloma of the Cornea and Iris, 3. Staphyloma of the Choroid and Sclerotica, XIII. Varicosity of the External and Internal Vessels of the Eye, XIV. Amaurosis, ..... XV. Ossification in different Parts of the Eye, 1. Ossification of the Cornea, 2 Osseous Deposite in the Anterior Chamber, 3. Ossification of the Choroid Coat, 4. Ossification of the Retina, 5. Ossification of the Hyaloid Membrane, Crystal- line Capsule, and Crystalline Lens, Chapter XII. Adaptation of an Artificial Eye, 421 422 ib. ib. ib, 423 42» ib. 430 ib. ib. ib. 431 432 ib. 433, Chapter XIII. Partial and General Enlargements of the Eye- ball ; Effusions and Tumours within its Coats, 437 Section I. Conical Cornea, .... ib.. II. Hydrophthalmia, or Dropsy of the Eye, . 440 1. Dropsy of the Aqueous Humour, . 441 2. Sub-sclerotic Dropsy, ^ . . 442 3. Suh-choroid Dropsy, . . . ib.^ 4. Dropsy of the Vitreous Humour, , 444 5. General Hydrophthalmia, . . 445 III. Sanguineous Effusion into the Eye, . . 446 IV. Fungous Excrescence of the Iris, . . 450 V. Scirrhus of the Eyeball, . . . 451 VI. Spongoid or Medullary Tumour of the Eyeball, 453 VII. Melanosis of the Eyeball, ... 459 Vm. Extirpation of the Eyeball, ... 469 Chapter XIV. Cataract, ..... 471 Section I. Definition and Diagnosis of Cataract; Method of Examining Cases of this Disease ; Causes and Prognosis, ..... i6, II. Genera and Species of Cataract, . . 480 Class I. True Cataracts, . . . 481 Genus I. Lenticular Cataract, . . ib. Genus II. Capsular Cataract, . . ib. Species 1. Anterior Capsular Cataract, . ib. Species 2. Posterior Capsular Cataract, . 482 Genus III. Morgagnian Cataract, . 483 Genus IV. Capsulo-Lenticular Cataract, ib. Species 1. Central Capsulo-Lenticular Cataract, ib. Species 2. Common Capsulo-Lenticular Cataract, 484 Species 3. Cystic Capsulo-Lenticular Cataract, 485 Species 4. Siliquose Capsulo-Lenticular Cataract, ib. Species 5. Bursal Capsulo-Lenticular Cataract 486 Class II. Spurious Cataracts, . . ib. Genus I. Fibrinous Cataract, . , ib. Species 1. Floccvlent Fihnnoua Cataract, 4t6 Species 2. Clotted Fibrinous Cataract, . 487 Species 3. Trabecular Fibrinous Cataract, i/*. Genus II. Purulent Cataract, . • ib. f Genus III. Sanguineus Cataract, . ib. Genus IV, Pigmentous Cataract, ._ 488 ill. Various additional Classifications and Distinctions of Cataract, .... i&. I 1. Consistence, . . . • ib- 2. Size, 489 3. Colour, . . . . ib. 4. Duration and Development, . . ib- 5. Curability, .... 490 IV. Complications of Cataract, . . • ib. V. Treatment of Cataract without Operation, • 492 VI. Prelimimary Questions regarding the Removal of Cataract by Operation, - . . 494 VII. Position of the Patient during Operations for Cataract, and Modes of fixing the Eye, . 496 VIII. General Account of the Operations for Cataract, 498 IX. Depression and Reclination, . . . 501 J . Depression and Reclination through the Cornea, .... 502 2. Depression and Reclination through the Sclerotica, .... ih. X. Extraction, ..... 511 1. Extraction through a semicircular incision of the Cornea, . . . . 511 2. Extraction through a Section of one-third of the circumference of the Cornea, . 524 3^ Extraction through the Sclerotica, . 527 XI. Division, . . ._ . . 528 1. Division through the Sclerotica, . . ib. 2. Division through the Cornea, . . 534 XII. Choice of an Operation for Cataract Indications and Contra-indications for the difierent Modes of Operating, .... 539 XIII. Secondary Cataract, . . . . 544 XIV. Cataract-Glasses, .... 546 Chapter XV. Artificial Pupil, .... 548 Section I. Introductory View of the Methods of forming an Artificial Pupil, .... ib. 11. Diseased States of the Eye requiring the Formation of an Artificial Pupil, . . . . 551 1. Partial Opacity of the Cornea, . . ib. % Partial Opacity of the Cornea, with partial Adhesion of the Iris to the Cornea, . 552 3. Closure of the Pupil, the Lens and Capsule being transparent, . . . 553 4. Closure of the Pupil, loith Adhesion of the Iris to the Crystalline Capsule, . . ib. 5. Closure of the Pupil after an Operation for Cataract, .... 554 6. Closure of the Pupil from Protrusion of Iris after Extraction, . . . ib. 7. Partial Opacity of the Cornea, Closure of the Pupil, Adhesion of the Iris to the Coimea, or to the Capsule, and Opacity of the Capsule, ib. XI Section III. General Rules regarding Artificial PupU, . 555 IV. Incision, Excision, and Separation compared ; Conditions necessary for these Operations, 557 V. Incision, ..... 561 1. Incision through the Sclerotica, . . 562 2. Incision through the Cornea, . . 563 ^ VI. Excision, ..... 566 1 . Lateral Excision, .... ib, 2. Central Excision . , . . 568 VII. Separation, . . , , . ih. 1. Separation through the Sclerotica, , ib. 2. Separation through the Cornea, . . ib, VIII. Compound Operations for the Formation of an * Artificial Pupil, .... 572 IX. Accidents occasionally attending the Formation of an Artificial Pupil ; After-Treatment, . 573 C HAPTEB XVI. Preternatural States of the Ibis independent OF Inflammation, . , . 575 Section I. Myosis, . . 11. Mydriasis, .... III. Tremulous Iris, . , Chapter XVII. Glaucoma and Cats-eye, Section I. Glaucoma, .... II. Cats-eye, . . , , Chapter XVIII. Various States op Defective Vision, Section I. Myopia, or Near-Sightedness, II. Presbyopia, or Far-Sightedness, III. Insensibility to certain Colours, IV. Chrupsia, or Coloured Vision, V. Photopsia, VI. Ocular Spectra, or Accidental Colours. VIL MuscBB Volitantes, VIII. Spectral Illusions, IX. Night-Blindness, X. Day-Blindness, XL Hemiopia, XII. Amblyopia, or Weakness of Sight, Chapter XIX. Amaurosis, Section I. General Account of Amaurosis, 1. Definition, 2. Seat, 3. Causes, 4. Symptoms, 5. Stages and Degrees, , 6. Diagnosis, 7. Prognosis, 8. Treatment, II. Classifications of the Amauroses, III. Illustrations of some of the Species of Amaurosis, 1. Amaurosis from Fractured Cranium with Depression, or from Sanguineous Extrava- sation in consequence of Injury, . ib, 576 579 580 ib, 591 593 16. 604 609 612 614 616 621 624 627 631 632 637 637 ib. ib. 638 641 643 649 ib, 650 ib. 655 658 ifi. Species 1. FloccvleTit Fibrinous Cataract, 4*6 Species 2. Clotted Fibrinous Cataract, . 487 Species 3. Trabecular Fibrinous Cataract, th. Genus II. Purulent Cataract, . . if>' Genus III. Sanguinous Cataract, . ib. Genus IV. Pigmentous Cataract, . 488 III. Various additional Classifications and Distinctions of Cataract, .... ib- 1. Consistence, .... ib. 2. Size, 489 3. Colour, .... lb. 4. Duration and Development, . . ib. 5. Curability, .... 490 IV. Complications of Cataract, ... ib. V. Treatment of Cataract without Operation, . 492 VI. Prelimimary Questions regarding the Removal of Cataract by Operation, - . . 494 VII. Position of the Patient during Operations for Cataract, and Modes of fixing the Eye, . 496 Vlll. General Account of the Operations for Cataract, 498 IX. Depression and Reclination, . . . 501 J. Depression and Reclination through the Cornea, .... 502 2. Depression and Reclination through the Sclerotica, .... ib. X' Extraction, . . . . . 511 1. Extraction through a semicircular incision of the Cornea, .... 511 2. Extraction through a Section of one-third of the circumference of the Cornea, . 524 3. Extraction through the Sclerotica, . 527 XL Division, . . ._ . . 528 1. Division through the Sclerotica, . . ib. 2. Division through the Cornea, . . 534 Xn. Choice of an Operation for Cataract Indications and Contra-indications for the different Modes of Operating, .... 539 Xin. Secondary Cataract, .... 544 XIV. Cataract-Glasses, .... 546 Chapter XV. Artificial Pupil, 548 ib. Section I. Introductory View of the Methods of forming an xA.rtificial Pupil, II. Diseased States of the Eye requiring the Formation of an Artificial Pupil, .... 551 1. Partial Opacity of the Cornea^ . . ib. 2^ Partial Opacity of the Cornea, with partial Adhesion of the fris to the Cornea, . 552 3. Closure of the Pupil, the Lens and Capsule being transparent, . . . 55.3 4. Closure of the Pupil, with Adhesion of the Iris to the Crystalline Capsule, . . ib, 5- Closure of the Pupil after an Operation for Cataract, .... 554 6. Closure of the Pupil from Protrusion of Iris after Extraction, ... ib, 7. Partial Opacity of the Cornea, Closure of the Pupil, Adhesion of the Iris to the Cornea, or to the Capsule, and Opacity of the Capsule, ib. XI Section III. General Rules regarding Artificial Pupil, . 555 IV. Incision, Excision, and Separation compared ; Conditions necessary for these Operations, 557 V. Incision, ..... 561 1. Incision through the Sclerotica, . . 562 2. Incision through the Cornea, . . 563 VI. Excision, ..... 566 1 . Lateral Excision, . . . , iff. 2. Central Excision .... 568 VII. Separation, . . , , , iff, 1. Separation through the Sclerotica, , ib. 2. Separation through the Cornea, . , iff, VIII. Compound Operations for the Formation of an Artificial Pupil, . , . . 572 IX. Accidents occasionally attending the Formation of an Artificial Pupil; After-Treatment, . 573 2 HAPTER XVI. Preternatural States of the Iris independent OF Inflammation, . , . 575 Section I. Myosis, . , . . II. Mydriasis, .... III. Tremulous Iris, . , Chapter XVII. Glaucoma and Cats-eye, Section I. Glaucoma, . . , . II. Cats-eye, . , , , CJhapter XVIII. Various States of Defective Vision, Section I. Myopia, or Near-Sightedness, II. Presbyopia, or Far-Sightedness, ni. Insensibility to certain Colours, IV. Chrupsia, or Coloured Vision, V. Photopsia, VI. Ocular Spectra, or Accidental Colours, VII. MuscsB Volitantes, VIII. Spectral Illusions, IX. Night-Blindness, X. Day-Blindness, XI. Hemiopia, XII. Amblyopia, or Weakness of Sight, IIJhapter XIX. Amaurosis, Section I. General Account of Amaurosis, 1. Definition, 2. Seat, 3. Causes, 4. Symptoms, 5. Stages and Degrees, , 6. Diagnosis, » * 7. Prognosis, 8. Treatment, II. Classifications of the Amauroses, III. Illustrations of some of the Species of Amaurosis, 1. Amaurosis from Fractured Cranium unth Depression, or from Sanguineous Extrava- sation in consequence of Injury, . ib. 576 579 580 ih, 591 593 ib, 604 609 612 614 616 621 624 627 631 632 637 637 ib. ib. 638 641 643 649 ib. 650 ib. 655 658 i6. xn 2. Amaurosis from Cerebral Plethora and Conges' tion, ..... 660 3. Amaurosis frovi Apoplexy, . . 664 4. Amaurosis from Aneurismal Dilatation of the Cerebral Aiieries, . . • ib» 5. Amaurosis from Ir^ammation, brought on by Exposure of the Eyes to Intense lAght, or by Over-action of the Sight, 6. Amaurosis from Concussion, or other Injury of the Head, .... 7. Amaurosis from Inflammation of the Brain, consequent to Scarlatina, 8. Amaurosis from Inflammation of the Brain , consequent to Suppression of the Menses, 9. Amaurosis from Inflammation of the Brain, consequent to Suppressed Purulent Dis- charge, .... 10. Amaurosis from Inflammation of the Brain, consequent to Suppressed Perspiration, . 11. Amaurosis from Morbid Changes in the Optic JVerve, .... 12. Amaurosis from Morbid Formations in the Brain, ..... 13. Amaurosis from Morbid Changes in the Mem- branes, or in the Bones of the Cranium, . 14. Amaurosis from Morbid Changes affecting the Fifth Pair ofJVerves, 15. Amaurosis from Poisons, . 16. Amaurosis from Inanition or Debility, 17. Amaurosis from Irritation of the Branches of the Fifth Pair of JVerves, 18. Amaurosis from Worms in the Intestines, . 15L Amaurosis from Acute or Chronic Disorders of the Digestive Organs, PRACTICAL TREATISE DISEASES OF THE EYE CHAPTER I. DISEASES OF THE ORBIT. Supposing my reader to be acquainted with the structure and con- tents of the orbit, and with its relations to the surrounding cavilies of the nostril, the frontal, maxillary, and sphenoid sinuses, and the cranium, I purpose in the following chapter to review the chief dis- eases to which the orbit is liable. SECTION I. INJURIES OF THE ORBIT. I Under the head of Injuries, I may mention, first of all. Contu- sion producing inflammation and caries of the bones forming the edge of this cavity, Fractures, and Penetrating Wounds of the Or- bit. Incised wounds, laying open the orbit, must from their nature be rare ; yet some interesting cases, even of this sort, are recorded. Many Gunshot wounds of the orbit are related. Indeed, numerous examples of the perforation of every part of the face and head Ijy balls, must present themselves after a battle to the notice of mihta- ry surgeons. It is not my intention at present to treat of injuries of the parts contained within the orbit. Yet it is impossible altogether to avoid noticing the effects produced on the contents of this cavity, while considering injuries of the orbit itself ; or, while treating of wounds penetrating the walls of the orbit, to pass over in silence the inju- ries which in this way, the brain and other surrounding organs may sustain. Cases occur, indeed, in which it is doubtful, to the injury of what particular part, without, within, or beyond the orbit, the con- sequences of an injury ought to be attributed. Amaurosis, for ex- ample, one of the chief consequences to be apprehended from wounds of the orbit, is sometimes owing to injury of the branches of the I fifth pair of nerves without the orbit : in other cases, to injury ol the optic or other nerves within the orbit, or of the e3'e itself; and in other cases, to injury of the brain. i. Contusions and Cuts upon the Edge of the Orbit May happen from a blow with the fist, with a stone, with a stick ; from a fall on the sharp corner of a table, from a feill on the! street; and from many similar accidents. It is only in scrofulous | children, and in the malar bone that I have seen the inflammation, arising from such accidents, run on into suppuration, and affect the periosteum and even the substance of the bone. But of course, the two other bones, which assist in forming the external aperture of the orbit, and especially the frontal, may be similarly injured, and I give rise to a long-continued ailment. ! After the abscess in such a case is opened, thin serous pus con-| tinues to be discharged for many weeks ; but at length, if the tex-| ture of the bone is not afiected, the matter diminishes in quantity, ! grows thick, and ceases entirely. If, on the other hand, caries has , begun, the discharge continues ; it sometimes becomes curdy ; the | opening turns fistulous ; the skin around the opening is dragged to- . wards the bone ; the edges of the opening throw out fungous gran- ulations ; and the eyelid, partaking in the dragging of the skin, is more or less everted. This is a state of matters which we have ver}^ little power of checking. Being a caries from an external cause, it may be re- garded, indeed, as less dangerous than one arising from constitu- tional disease : yet it must be more by improving the general health than by local means, that the bone is to be restored to a sound state. The youth of the subject leads to a favourable prognosis ; ' the scrofulous diathesis is unfavourable. In the inflammatory stage, before there is any suspicion of mat- ter being about to form, leeches ought to be liberally applied over the bruise. I am the more disposed to advise this, in all cases of bruise over the edge of the orbit, from having met with cases of this kind, vrhich having been thought too lightly of, and therefore not treated with leeches, ran the course which I have described ; but which, it is probable, might have been prevented from doing so. had proper antiphlogistic means been employed. If an abscess forms, it is to be opened as far from the edge of the eyelid as can be conveniently done, in order to avoid as much as possible the eversion which is apt to follow. If the probe, introduced to the bottom of the opening, comes in- to contact with diseased bone, an injection of a strong solution of lunar caustic may be imployed, or the pencil of lunar caustic may be filed down to the proper degree of slenderness, and introduced along the opening, till it touches the diseased bone. The applica- tions may be continued from time to time, till the disease of the bone is overcome. Change of air, nourishing diet, attention to the bowels, and the jse of tonics, are also to be recommended. The long-continued }mplo3anent of the decoction of sacsaparilla is likely to be benefit ^ial. After such a case has recovered, the integuments are generally :bund to remain immovably attached to the periosteum, where the istulous opening existed. From blows on the edge of the orbit, particularly its upper edge, ive must be prepared to meet with much more serious consequen- ces, than merety an affection of the bone or its periosteum. EfTu- ion of blood within the cranium, and inflammation of the brain or ts membranes maybe excited by such an injury ; and while our ears are perhaps confined to the state of the bone, or of the soft parts kvhich invest it, changes may be proceeding within, which shall juddenl}'^ prove fatal.* i Consequences not less serious have been known to result from [injuries of a similar sort, received at the lower edge of the orbit. Thus Petit relates a case of palsy of the left side, and death, from suppuration in the right hemisphere of the brain, consequent to a wound at the lower edge of the right orbit, close to the exit of the infra-orbitary nerve, which, however, did not appear to have been injured. t Contusion of the temporal edge of the orbit has been sometimes followed by the growth of encysted and other tumours within the Drbit. These, however, as well as inflammations of the vaiious parts contained within the orbit, and the formation of exostosis, excited by the same cause, will require separate consideration here- after. 2. Fractures of tJie Edge of the Orbit, The only instance which I recollect to have seen of this injury, was from a blow with the end of a long piece of wood, which struck the lower edge of the orbit, and separated a fragment, which I concluded to be the anterior angle of the malar bone. The frac- tured piece moved at first easily under the finger, in different direc- tions, but became united in the course of a few weeks. No bandage was apphed ; but cases may occur, in which, the eyelids being previously closed, a small linen compress, and a roller round the head, might be judiciously employee}, to press a fractured piece of the edge of the orbit into contact with the bone from which it had been separated, till the process of reunion be completed. Fracture of the upper edge of the orbit is apt to penetrate into the frontal sinus ; and the consequence sometimes is, that on blow- ing the nose, air, passing from the sinus, and through the fracture, * CEuvres d'Ambrose Pare ; Liv. s. Chap. 9. Dease's Observations on Wounds of the Head, p. 107. London, 1776. t Nouveau Systeme du Cerveau, par F. P. du Petit, contained in the CEuvres di- verses de Louis, Tome ii. p. 41. Paris, 1788. is introduced into the cellular membrane of the eyelids. In such a case, the integuments may be opened with the lancet, to let the air escape. 3. Fractures of the Walls of the Orbit, attending Frac- turtd Skull. Fractures of the skull not unfrequently extend to one or both of the orbits ; and it is worthy of particular observation, that fracture of the roof of the orbit in this way, is apt to be attended by lacera- tion of the dura mater, and injury of the anterior lobes of the cere- brum, which rests upon the orbits. Now, suppose that this is the case, while at the same time a fracture with depression is present, we shall say on the temple, and that this fractured piece of skull is raised into its place in the operation of trepan, the patient will, in all probability, not be relieved by this operation, the symptoms of pressure on the brain, or of inflammation within the skull, will most likely remain as before, and death follow, contrary, perhaps, to what might have been expected, if the fractured temple had been the sole iniur3^ It will probably be only on dissection, that in such a case the cause of death will he discovered. Dr. Ballingall has recorded a case of compound fracture of the OS frontis, in which, after the depressed pieces of bone were re- moved, the patient instantly recovered his senses, and answered questions rationally. He soon lapsed, however, into a comatose state, and died within 48 hours of the receipt of the injury. On dissection, the fracture was found to extend backwards, through both orbitary plates of the frontal bone, and to pass across the ethmoid behind the crista galli. Opposite to the fissures in the roof of each orbit, the dura mater was found lacerated to a con- siderable extent, and portions of brain protruding. The anterior lobes of the brain were disorganized and broken down ; and, what was remarkable, a distinct appearance of purulent matter was seen upon the tunica arachnoidea covering each hemisphere of the brain, although the patient had survived the accident for so short a time, lost a considerable quantity of blood from the wound, and manifes- ted no inflammatory symptoms.* In cases of fractured skull extending to the orbit, it sometimes happens, that portions of the walls of that cavity are so completely separated, that they easily come away, either in dressing the wound, or in raising and removing the depressed pieces of the skull. The mere circumstance of a portion of bone being loose, is not sufficient ground for removing it ; its surfaces being still attached to the membranes with which they are naturally in connexion, it may be susceptible of reunion ; but if the bone be extremely shattered, and pressed partly through the dura mater, we may be * Clinical Lecture in the Royal Infirmary of Edinburgh, March 1828, by George Ballingall, M. D., p. 5. J' warranted in removing the loose pieces. Cheselden has communi- I cated a remarkable case of this kind, which occurred in the practice of Mr. Cagua, a surgeon of Plymouth, in which five splinters of the cranium, which were depressed into the substance of the brain, were extracted, the largest piece comprehending part of the orbitary plate of the frontal, of the great wing, of the sphenoid, and of the i suture which connects the external angular process of the frontal to the superior angle of the malar bone. Pieces of the substance of the brain followed the removal of this splinter ; yet the patient, a boy of 10 years of age, perfectly recovered.* 4. Counter-Fractures of the Orhit. Fractures of the orbit sometimes take place, we are told, by what the French have called contrecoup, in consequence of falls on the forehead, or even on the occiput. It is seldom, if ever, that such fractures are discovered till after death. Indeed, it is of compara- tively little importance to know of their existence during life, as they do not admit of any particular treatment, and as our attention must be almost entirely directed to the concussion, and consequent inflammation of the brain, by which counter-fractures are invariably, or almost invariably, attended. 5. Penetrating Wounds of the Walls of the Orhit. The smallness of the eyeball, compared with the size of the cavi- ty in which it is placed, and its firm resistance, compared with the looseness of the parts interposed between it and the orbit, explain at once how pointed bodies, thrust against the eye, are very apt to leave the eyeball uninjured, and to penetrate deep into the cavity of the orbit, or even passing through its walls, to enter one or other of the neighbouring cavities. The sides of the orbit which are turned towards the nostril and cranium, from their situation and extreme thinness, are especially exposed to be thus injured. Per- foration of the orbitary plate of the frontal bone, in particular, is an accident to which the attention of the surgical student is early and forcibly drawn. The thinness and fragihty of that plate, the readi- ness with which the brain may be reached through it, and the in- stantaneousness with which death has been known to follow such an injury, make an indelible impression on the mind of the young anatomist. Thus Mr. John Bell, after attributing the thin- ness of the orbitary plate to " the continual rolling of the eye," with which that plate never comes into contact, and by which, therefore, it cannot be thinned, tells us, that " it is the aim of the fencer ; and w-e have known in this country," adds he, "a young man killed by the push of a foil, which had lost its guard.t * Philosophical Transactions for 1740. Vol. xli. Part II. p. 495. + Bell's Anatomy. Vol. i. p. 49. London, 1811. The thinness of the orbitary plate, like the thinness of the middle of the os illium, or the middle of the scapula, must be regarded as the natural constitution of the bone, and not at all as the effect of pressure of the brain, or rolling of the eye. 6 Various effects may follow a penetrating wound of the orbit, and we may find the patient in one or other of very different states ; for the weapon may have been immediately withdrawn after the injury was inflicted, or the foreign body may still be fixed in the wound, ; and is to be extracted, or it may have sunk so deep, that it cannot be laid hold of: and as for the effects of the injury, they may be slight and transient, or violent and immediately dangerous, or prolonged for a length of time. It is evident, that a dagger, or other weapon, directed outwards, so as to break through the suture between the malar and sphenoid bones into the temporal fossa, or directed downwards, so as to shatter the floor of the orbit, and enter the maxillary sinus, will not be productive of the same amount of dangerous consequences, as when the instrument of injury traverses the 03 planum of the ethmoid, or the orbitary plate of the frontal. I shall speak of gunshot wounds of the orbit separately ; but I may here remark, that their effects correspond so far at least with those of common penetrating wounds, that from both we may occasion- ally expect haemorrhage, extravasation of blood, blindness, strabis- mus, syncope, vomiting, coma, convulsions, palsy, death, as im- mediate effects ; and as remote effects, fever, delirium, suppura- tion, caries, exfoliation of bone, and the like. 1 . Trijling ajypearance of external v)oimd. A weapon pene- trating through the orbit, may strike deep into the brain, and yet so small an external wound be present, as shall be apt to excite lit- tle or no suspicion of danger. Ruysch relates the case of a man, who was wounded in the left orbit, with the end of a stick, not particularly sharp. The injury appeared of httle importance ; yet the patient died soon after re- ceiving the wound. The magistrates appointed Ruysch to exam- ine the body, in order to discover the cause of the sudden death. Externally, he observed a slight degree of ecchymosis at the upper part of the eye ; but on removing the calvarium, he found that the wound had penetrated to a considerable depth into the brain. This, he observes, may happen very easily, on account of the thinness of the upper part of the orbit, in many not thicker than writing paper, and so brittle as to be perforated with the finger. Wounds, there- fore, of the orbit, he concludes, are not to be considered as a matter of no moment, especially if the instrument by which they are in- flicted is not blunt, or if those who are wounded become sleepy, sick, feverish, giddy, or convulsed.* Peter Borel mentions a still more remarkable case, of a man who was wounded with a sword in the left orbit. Thinking that the wound had not penetrated deep, he merely covered it with a plas- ter ; after which he walked two leagues, and ate and drank heartilj- with his companions, exactly as if he had been well, being affected with no pain. Next morning he was found dead. The skull was * Ruyschii ObservationumCenturia. Obs. 54. Amstelodami, 1691. opened, when the wound was found to have penetrated to the cere- bellum.* These two cases are sufficient to show how cautiously our prog- nosis ought to be delivered, when a wound appears to have pene- trated to any depth towards the roof of the orbit. 2. Situation and extent of fractured orbit different in differ- ent cases. It is worthy of remark, that it is not the obitary plate of the frontal bone alone which is apt to be fractured when the weapon is directed towards the roof of the orbit ; and that we are sometimes enabled to judge of the degree of violence employed by the hand which held the weapon, even by the mere situation of the fracture, which in fatal cases is detected on dissection. The following case of fatal wound of the brain though the eth- moid bone, is quoted by Bonetus. A countryman, about 55 years of age, was asked by one who met him to step out of the way ; but as he was carrying a heavy burden at the time, he could not do so, and therefore refused. The other, provoked at this, struck the countryman violently over the shoulders with a whip ; and when the whip broke, thrust the sharp end of the broken stick of the whip in the countryman's face. Not apprehending any dangerous effects from the blows which he had received, the countryman, with his burden on his back, trudged along after his cart, which was loaded with wood, for nearly a quarter of a mile, till he arrived at the wood market, when he instantly dropped down dead. Schmid was appointed to inspect the body. On examining the head externally, he found that the sharp end of the stick had pen- etrated at the internal canthus of the right eye. He endeavored to ascertain with the probe whether the wound had reached the brain, but he could not, on account of the smallness of the wound. Having opened the cranium, the brain and its membranes at first view appeared sound ; but on raising the anterior part of the cere- brum, the nasal extremity of the falx was seen to be injured, and it was found that the wound had penetrated into the third ventri- cle, in which la}^ a considerable quantity of grumous blood.t Some years ago,+ I witnessed the examination of the body of a man, who, the evening before, had almost instantaneously dropped down dead, in a scuffle on the street, after receiving a penetrating wound of the orbit, with the pointed end of an umbrella. Con- siderable bleeding had taken place from the nose and mouth. The upper eyelid was swollen and livid, and the conjunctiva elevated by extravasated blood. Just over the tendon of the orbicularis palpebrarum, a penetrating wound easily admitted the little finger to the bottom of the orbit, between its nasal side and the eyeball. * Petri Borelli Historiarum et Observationum Centuria II. Obs. 19. Francofurti, 1676. t Joannis Schmidii Miscellanea ; quoted by Bonetus in his Sepulchretum. Tome I iii. p. 380. Lugduni, 1700. t 20th December, 1819- 8 The end of the finger felt a fracture of the orbit. On opening the head, much dark fluid blood was found eflused into the cavity of the tunica arachnoidea, and some between it and the pia mater. The dura mater was seen to be perforated by a lacerated wound, just under the edge of the boundary of the middle fossee of the ba- sis of the cranium, formed by the little wing of the sphenoid bone. The brain behind the wound of the dura mater was lacerated, and a small portion of it separated from the rest. On removing the dura mater, the fracture, which had been seen, indeed, imme- diately on hfting the brain, was displayed to view. The little wing of the sphenoid was separated by the fracture from the frontal bone, in the course of the sphenoidal suture. The fracture extended through the orbitary plate of the frontal from behind forward for about half its length ; but what was much more remarkable, the comparatively thick and strong portion of the sphenoid, which completes the posterior part of the roof of the orbit, was broken across at its inner extremity : proving, along with the state of the dura mater and brain, the great degree of force with v/hich the instrument of death had been driven against the hapless victim of a drunkard's fury. I may mention, that the optic nerve ^and eyeball were entire, the cornea lively, and the humors and retina uninjured. 3. Convulsions — Suppuration. Thecasewhichlam now about to quote, serves at once to confirm what is proven by the preceding cases, namely, that at the first there may be nothing alarming, ex- cept the suspicious situation of the wound ; exemplifies a symptom, which has ever been regarded as an exceedingly dangerous, if not fatal, one in injuries of the brain, name]}', convulsions ; and illus- trates in accidents of this kind, both the date and the effects of sup- puration. The earliness with which matter is formed by the tunica arachnoidea, in cases of wounded brain, is a remarkable circum- stance, and is strikingly proven by the case already quoted from Dr. BallingalPs Chnical Lecture. A soldier was brought to the hospital at Brest, at 11 o'clock in the evening, having been wounded with a pitchfork, at the middle of the left upper eyelid. The wound was obHque, about three hnes in length, and appeared to have injured only the skin and orbicul- aris palpebrarum ; there was very httle blood discharged ; the eye- lid was distended, and the conjunctivea inflamed. The apparent simplicity of the wound, the goodness of the pulse, and the free ex- ercise of all the functions, led to a favourable prognosis ; the pa- tient asserted that he experienced nothing particular at the moment of the injury ; scarcely had he been stupified by it. Compresses, dipped in brandy and water, were applied over the wound. The patient rested during the night ; next day, he was quite lively, walked about in the wards, complained only of slight pain in the region of the wound, and even ate with appetite. The same day, at 7 in the evening, he was seized with convulsions, which were supposed by his attendants to be epileptic. The day after, he was kept from food, and bled at the arm ; the convulsions returned, and he was bled at the foot. Vomiting, uneasiness, agitation, and delirium came on; the pulse became small and contracted; cold sweats succeeded, and the patient died at 2 o'clock next morning. On dissection, the eyelids were found oedematous, but the wound had already closed. On cutting through the upper eyelid and or- bicularis palpebrarum, a circumscribed collection of pus was found in the orljit, between its roof and the levator palpebree superioris. This collection of pus communicated with the cranium, through the orbitary plate of the frontal bone, which had been pierced through and through by one of the prongs of the fork. After removing the eyeball, the inferior wall of the orbit was found fractured, and depressed almost completely into the maxillary sinus. This fracture was without fragments, and is compared by M. Mas- sot, the relator of the case, to the depression which might be pro- produced on the surface of an egg, by pressing it inwards with the thumb. On removing the calvarium, the dura mater was seen to be penetrated over the hole made by the fork in the roof of the orbit. The dura mater appeared diseased at that place, the ante- rior fossae of the basis of the cranium were covered with pus, the anterior lobes of the cerebrum were in a state of suppuration, and the rest of the brain healthy. M. Massot thinks it probable, that when the fork was pushed through the orbit into the cranium, the eyeball being fixed and violently pressed between the fork and the floor of the orbit, the thin plate of the superior maxillary bone could not resist this pressure, but sunk by the continued action of the fork upon the eyeball." 4. Palsy. In those who survive wounds penetrating the sides of the orbit, we may expect occasionally to meet with paralytic affections. A case of this kind is recorded by Mr. Geach, a surgeon at Ply- mouth. He does not indeed say that the wound penetrated into Lhe brain, but merely that the instrument of injury struck against the inner side of the orbit ; leaving it a matter of doubt, whether Lhe paralytic symptoms which followed were attributable to effu- sion within the cranium, or to a still more direct injury of the brain. A midshipman was wounded in a riot by a small-sword, which, entering at the external angle of the left eye. and passing quite through the eye, struck against the inner part of the orbit. He fell down instantaneously senseless, with loss of speech, and hemi- plegia of the opposite side. Blood was immediately drawn. Next morning, he was found lying on his back, with the right eye widely opened, and the pupil (though in a light room) considerably di- lated. This eye was incapable of discerning objects, never winking I at the waving of the hand, or the close application of the finger, i * Journal de MeJecine, Tome iii. p. 530. Q,uoted in the Dictionnaire des Sciences ,Medicales; Tome xxxvii. p 558. il 2 10 though sometimes it was convulsed. The left eye was extruded from its orbit, and though destitute of all its humors, was enlarged to the size of a pullet's egg. The pulse beat at long intervals, with a lazy motion, and stopped upon gentle pressure ; the body was not feverish, but preserved a natural heat, the paralytic side, arm, and thigh excepted, which were livid, cold and rigid ; the lancet was employed without exciting any sensation, and blisters lay on sev- eral days without raising any vesications ; the benumbed parts were constant^ bedewed with clammy sweat. The patient was devoid of anxiety, or inquietude, and the powers of life seemed to be almost suspended ; purgatives produced no effect, and clysters, though repeatedly injected, were never repelled. The urine was in general emitted by drops only, but sometimes it would run off suddenly in a deluge; hearing was considerably impaired; the patient lay lethargic, and dead almost to every thing, though by pulling the arms and shaking the body, by loud and frequent cal- ling, and desiring him to extend his tongue, he would gape widely, and forgetting seemingly what had been said to him, keep his mouth wide open, when the tongue might be seen quivering and retracted. Five weeks elapsed in this state of insensibility ; every thing he took was with voracity, but without relish or distinction. About this time a new symptom began to threaten ; the jaw seemed to be moved with difficulty, and liquids only could be poured down ; the hypochondria were hard and distended, and every effort to procure an intestinal discharge ineffectual ; when very large eruptions of the miliary kind were suddenly diffused over the sound parts. From that critical moment he perspired freely, and had an easy motion of the jaw ; his urine was rendered in due quantity, and purgatives of the lenient kind easily operated ; the hypochondria became soft ; the discharge from the eye, which had hitherto been acrid, was now copious and laudable ; the sound eye had its motion, he could see distinctly, and seemed in other respects sensible, when roused from his stupefaction. Soon after, he could bear to be moved from the bed to the chair without fatigue ; the paralytic parts were rubbed with vinegar and mus- tard, and he took valerian and castoreum. A cataplasm of bread and milk had been daily applied to assuage the inflammation and swelling of the eye. Though several large sloughs had been thrown off from it, and though the suppuration was in large quan- tity, yet the bulk of the parts did not diminish, nor the inflamma- tion lessen, till an astringent fotus of red rose-leaves and port wine was applied, which so effectually braced up the relaxed parts, that the lids came to cover the deformity. A decoction of thyme and mustard was employed as a gargarisra, to remove the suppression of voice. As soon as he began visibly to mend, he had sometimes loud and sudden bursts of laughter, and at other times a long-con- tinued silent simpering, a species of convulsion not unlike that cal- led by the Greek physiciansj Kwim c^cto-fMi. When he attempt- 11 ed to walk, he had such gestures as accompany St. Vitus 's dance, and seemed a perfect idiot, throwing eagerly forward one leg, and dragging the other trembling after. At the time when Mr. Geach drew up his account of the case, the patient's appetite was natural, his sleep sound and refreshing, his hearing acute ; he spoke, but drawled out his words rather indistinctly than articu- lately ; the paralytic arm and thigh were again animated, and were recovering, but slowly, their power of flexion and extension. He remembered nothing from the moment he had received the in- jury to the time he recovered and sat up.* The only comment which I think it necessary to make on this interesting case is, that the instantaneousness with which the pa- tient fell on receiving the injury, looks very like the efTect of a wound of the brain ; while, on the other hand, the slowness of the pulse and the hemiplegia, are more the symptoms of pressure from effused blood. Even, however, on the supposition that the small- sword had not penetrated through the ethmoid bone into the brain, the case becomes only the more remarkable ; as on that supposi- tion, it would lead us to conclude, that a wound of the bones of the orbit, without perforation, might be attended by rupture of vessels within the cranium, and consequently with pressure on the brain, and paralysis. 5. Foreign body siill in the orbit. In all the instances which I have hitherto quoted, the weapon, whatever it was, was instantly withdrawn on the injury being inflicted ; but we must be prepared to meet with cases where the foreign body, which has been driven through the walls of the orbit, still remains in the wound. In such cases, we instantly proceed to its removal ; for there very soon follows such a degree of swelhng, as might prevent us from accomplishing the extraction without great difficulty, if at all j and if the weapon was left, what could we expect, but destructive inflammation of the eyeball, of the orbit, of the surrounding parts, and among these, of the brain ? A labourer thrust a long lath, with great violence, into the inner canthus of the left eye of another labourer. It broke off quite short, so that a piece, nearly two inches and a half long, half an inch w4de, and above a quarter of an inch thick, remained in his head, and was so deeply buried, that it could scarce be seen, or laid hold of. He rode with the piece of lath in him above a mile, to Barnet, where Mr. Morse, a surgeon, extracted it with difficulty ; it sticking so hard, that others had been baffled in attempting to remove it. The man continued dangerously ill for a long time ; at last he re- covered entirely, with the sight of the eye, and the use of its mus- cles ; but even after he seemed well, upon leaning forwards, he felt great pain in his head.t In the days when javelins and arrows formed principal weapons * Philosophical Transactions for 1763 ; Vol. liii. p. 234. t Philosophical Transactions for 1748; Vol. xlv. p. 520. 12 of war, many difficult cases of this sort must have occuiied. Albii- casis shortly relates two^ which had come under his care. In the one, the arrow entered at the nasal side of the orbit, and was ex- tracted under the ear. The patient recovered, without any per- manent injury of the eye. In the other case, a Jew was struck with a large un barbed arrow from a Turkish bow, under the lower eyelid. It had sunk so deep, that Albucasis could reach with diffi- culty the end of the iron, wiiere it stuck upon the shaft. This patient also recovered without any serious effect.* Yery great force may sometimes be necessary for extracting a foreign body, which has been driven through the walls of the orbit. Fare's successful case is well known, when he was obliged, with a pair of farrier's pincers, to tear away from the Duke of Guise, the broken end of an English lance, which had entered above the right 63^6, and towards the root of the nose, and had penetrated as far as the space between the ear and the nape of the neck, tearing and destroying vessels and nerves in its course, as well as fracturing the bones.t Percy had under his care a fencing-master, w^io, in an assault, received so furious a blow from a foil on the right eye, that the weapon penetrated nearly half a foot into the head, and broke short. The man fell down in a state of insensibility, and very soon the supervening swelUng was so great as to conceal the foreign body. In order to lay hold of it, Percy opened and evacuated the con- tents of the eyeball. His forceps not being strong enough, he sent to a clock-maker in the neighbourhood, and borrowed from him a pair of screw-pincers, with w^hich he laid hold as tightly as possible of the broken end of the foil, and thus succeeded in extracting it. The fencing-master died some weeks after, more from the conse- quences of intemperance than of the injury. Commenting on this case, Percy recommends that we should rather remove the eyeball, than leave large foreign bodies in such a situation ; and refers, in support of this practice, to a case related by Bidloo, in which a splinter of wood was left to come away from the orbit b)^ suppura- tion. The eye burst at last, after the most dreadful pain, and after the other eye had been threatened w4th destructive sympathetic in- flammation. + Sabatier notices a case of wound with a knife, through the upper eyelid, which also tore the neighbouring edge of the frontal bone. It was not, he says, till after four hours' work, that the surgeon succeeded, by means of a hand-vice, in tearing away the portion of the knife-blade, which remained in the orbit, on account of its projecting so little from the wound. The patient complained of severe pain, as if one had been tearing out his eye. No ill conse- * Albucasis Methodus Medendi; Lib. ii. cap. xciv. p. 166. Easileae, 1541. t Pare, Apologie et Voyages ; Voyage de Boulogne, 1545. t Percy, Manuel du Chirurgien-d'Armee, p. HI. Paris, 1792. 13 quetice followed ; the cure was speedy, and without any affection of sight.* 6. Dangers after the foreign body is removed. We must not ' imagine that on withdrawing the foreign body from the orbit, the danger is over. Inflammation, even fatal inflammation may fol- low, as in the case I have just quoted from Percy ; nay, the patient has been known suddenly to expire, immediately after the foreign body was removed. A girl, 10 years of age, playing along with other children, near a cotton-spinning machine, fell upon one of the pointed iron spikes, 5 or 6 inches long, on which the bobbin is placed. This instru- ment penetrated to the depth of about 2 inches into the orbit, be- tween the inner wall and the globe of the eye, and then broke across so that 2 or 3 lines' length of it projected above the level of the skin. Attempts were made to remove it, but so much diffi- culty was experienced that these attempts were not persisted in. Ten days afterwards, the piece of iron was found protruded for the length of 9 or 10 lines ; a month afterwards, it was still more protrud- ed : in fact, it now held apparently so shghtly, that it was laid hold of with the fingers, and extracted. Scarcely had this been done, when the child was seized with convulsions, and died in a quarter of an hour. The sight had not been affected during the residence of the foreign body in the orbit, nor had its presence there excited any very marked symptoms. The child had always been able to go about.t 7. Eyeball dislocated. It is important to observe, that mention is made bj?^ various surgical authors, of the eyeball being dislocated, or pushed out of its socket, by a foreign body thrust into the cavity, or traversing the sides of the orbit. Now, in such cases, it is necessary not only to remove the foreign body, but to reduce the eye. This has sometimes been done with complete restoration of vision. By being dislocated, or pushed out of its socket, is to be under- stood, that the eyeball is extruded beyond the fibrous layer of the eyelids ; that layer which is a continuation of the periosteum, and lies beneath the orbicularis palpebrarum. Of course, the optic nerve must be put very much on the stretch by such an accident, and the eyelids can no longer be made to close upon the protruded eyeball. Mr. B. Bell relates a case, in which the eye was almost com- pletely turned out of the socket, by a sharp pointed piece of iron pushed in beneath it. The iron passed through a portion of the orbit, and remained very firmly fixed for the space of a quarter of an hour, during which period the patient suffered exquisite pain. He saw none with the dislocated eye ; and the protrusion being so * Sabatier de la Medecine Operatoire. Tome. i. p. 409 Paris, 1822. t Demours, traite des Maladies des Yeux. Tome ii. p. 45. Paris, 1818. 14 great as to lead to the suspicion that the optic nerve was ruptured, Mr. Bell doubted whether it would answer any purpose to replace it. He found, however, on removing the wxdge of iron, which being driven to the head, was done with difficulty, that the power of vision instantly returned, even before the eye was replaced. The eye was now easily reduced to its original situation, inflam- mation was guarded against, and the patient enjoyed perfect vision.* 8. Foreign body not removed. The foreign body, by which a wound of the orbit has been inflicted, has in some cases been left unremoved, from the fact of its presence not having been sus- pected, or from the surgeon not having instituted a suflficiently strict examination of the wound with the probe ; while, in other cases, it has been left in the orbit or in the cranium, from an im- possibility of removing it v/ith safety. I do not recollect to have met, in the course of my reading, with any case of a foreign body thrust through the orbit by mere man- ual force, and left within the cranium. Numerous cases of gun- shot v/ounds, however, in which the ball or other foreign body was left within the cranium, are recorded ; and it is evident that the eflfects, so far as the mere presence of the foreign body is concerned, must be much the same, whether it has passed through the orbit into the brain by manual, or by gunshot force. Death, under such circumstances, is almost certain to be the result, either immediately or in the course of a few days ; although some remarkable cases have happened of extraneous bodies lying for years in the very brain itself, without producing death, or causing any apparent in- convenience.! As to foreign bodies, which have merely passed through one or other of the sides of the orbit, and are left without removal, they give rise to more or less irritation, destroy the bones more or less extensively, take different routes for their escape, but in most in- stances appear to pass either through the maxillary sinus, or by the spheno-raaxillary fissure into the fauces, and are discharged in very various spaces of time. Marchetti tells us, that he had under his care a beggar, who, asking charity rather importunately one summer day from a Pa- duan nobleman, this testy personage struck the beggar with the handle of his fan, in the inner angle of the eye, and with so much force, that a portion of the fan. three inches long, broke through the orbit, and sunk out of sight in the direction of the palate. When the man came to the hospital, Marchetti removed some * Bell's System of Surgery; Vol. iv. p. 162. Edinburgh. 1801.— The author of the Dictionaire Ophthalmologique has entirely misunderstood this case ; he tells us that the optic nerve was wounded (Ires blesse), which forms no partiof Mr. Bell's statement ; and very improperly throws doubts upon that gentleman's veracity. ' , t See GLuesnay's paper on Wounds of the Brain, in the Memoirs of the French i| Academy of Surgery. '" 15 small bits, which he found sticking in the angle of the eye, com- bated the inflammation, allowed the wound to close, and dismissed the patient as cured. In three months, he returned with a large sweUing in the palate, which, when Marchetti cut into, his knife struck upon the handle of the fan, which he immediately extracted with a pair of forceps. The patient speedily recovered.* Mr. White relates the case of a person, to whom it happened, that, as he sat in company, the small end of a tobacco-pipe was thrust through the middle of the lower eyelid. It passed between the globe of the eye and the inferior and external circumference of the orbit, and was forced through that portion of the os maxillare, which constitutes the lower and internal part of the orbit. The pipe was broken in the w^ound, and the part broken off, which, from the examination of the remainder, appeared to be above three inches, was quite out of sight or feeling, nor could the patient give any account of what had become of it. The eye was dislocated upwards, pressing the upper eyelid against the superior part of the orbit ; the pupil pointed perpendicularly upwards, the depressor ocuh was upon the full stretch, and the patient could see none with that eye. Mr. W. apphed one thumb above and the other below the eye, and after a few^ attempts at reduction, it suddenly slipped into its socket. The man instantly recovered perfect sight, and felt no other inconvenience than that of a constant smell of tobacco smoke in his nose for a long time after ; for, as he informed Mr. W., the pipe had just been used before the accident. About two years afterwards, he called on Mr. W. to acquaint him, that he had that morning, in a fit of coughing, thrown out of his throat a piece of tobacco-pipe, measuring two inches, which was discharged with such violence, as to be thrown seven yards from the place where he stood. In about six weeks, he threw out another piece measuring an inch, in the same manner, and never afterwards felt the least inconvenience.t In illustration of the great length of time which a foreign body may take in this way to escape, 1 may notice the following case, related in a letter to Horstius. A boy of 14 years of age was struck by an arrow, while amusing himself in his play-ground. It stuck fast in the orbit, but the boy pulled it out, and threw it on the ground. A surgeon arrived, to whom the playfellows of the boy who was wounded showed the arrow, deprived of its iron point. With a probe the surgeon attempted to examine the wound ; but on the ijoy fainting, he desisted, so that the iron point w^as left in the orbit. The external wound healed, and the boy recovered; the eye re- mained clear and movable, but deprived of sight. This happened in the beginning of August, 1594, and nothing more was heard of the iron point, till October, 1624, when after an attack of fever and catarrh, with a great deal of sneezing, it descended into the left • Petri de Marchettis Observationum Sylloge. Obs. 23. Londini, 1729. t Cases in Surgery, by Charles White ; p. 131. London, 1770. 16 nostril, whence, taking the way of the fauces, it came into the mouth and was discharged. During the whole 30 years and three months that it had remained in the head, it had not been produc- tive of any pain.* 6. Incised Wounds of the Orbit. Sabre-wounds of the head have sometimes been attended by a cleaving of the orbit ; and in some rare instances, the orbit has ac- tually been laid open, either by a very deep cut, or by an entire separation of part of its parietes. The following cases are sufficient illustrations of this class of injuries of the orbit. Marchetti shortly states the case of a German soldier, who was wounded in the forehead with a broad and heavy sword. The frontal bone and the brain were divided, down to the eyes, and the patient was immediately deprived of sight. In two months, he re- covered from the wound, but continued blind, with the pupils clear.t The following case shows the propriety of attempting union by the first intention, even when a piece of the osseous parietes of the orbit is completely separated by an incised wound. M. Ribes was called to a young man who had received a wound with a cutting instrument, extending obliquely from the upper part of the left temporal fossa across the root of the nose, to the right fossa canina. This wound had divided the skin, the temporal branches of the 7th pair of nerves, the anterior auricular muscle, a part of the temporal muscle, orbicularis palpebrarum, and corruga- tor supercilii. the frontal branch of the opthalmic nerve, and the superciliary artery. These parts hanging over on the cheek, formed a flap, in which were also present a portion of the orbitary arch of the frontal bone and its external angular process, so that a portion of the cavity of the cranium was laid open, as well as the cavity of the orbit, exposing to view the globe of the eye, and the motion of the brain. The nasal nerve and artery, the pyramidal muscles, and in a shght degree the bones of the nose, were divided ; from the nose to the right fossa canina, only the skin was divided. The portion of brain laid bare appeared unhurt: the eye also seemed perfectly sound, none of its parts had been touched, except the lev- ator palpebree superioris, which, having been cut across in the mid- dle, presented its anterior half in a state of relaxation, and dragged downwards and forwards by the flap which lay upon the cheek. The patient had neither experienced any concussion, nor become insensible ; but when M. R. saw him, was in a state of considera- ble depression. A surgeon, who had been called before M. R. arrived, had already dressed the wound. Perhaps, in imitation of Magatus, who directs in such cases that a plate of gold or lead, drilled through with holes, be applied over the dura mater, and that * Gregorii Horstii Observationum Lib. i. Operum Tom. ii. p. 225. rsorimbergEe, 1660. t Petri de Marchettis Observationum Sylloge. Obs. 17. Londini, 1729. 17 the edges of the wound be simply brought together, without sup- porting them by sutures, this surgeon had placed between the lips of the wound a bit of hnen spread with cerate on both sides, in or- fder to give vent to the suppuration, which no doubt would have followed ; he had then brought the flap into its place, and supported it by a roller. M. R. removed the piece of linen, and brought the edges of the wound exactly together, retaining them by strips of adhesive plaster. In six weeks, the patient was cured, without fever or suppuration. The eye, however, which had been exposed became blind, and the upper eyelid remained motionless. Ten years afterwards, the eye still preserved its form and transparency, but had shrunk in size. M. R. is of opinion, that the blindness in this case was a sympathetic effect, produced upon the retina by the division of the brandies of the 5th pair. He regards the retina, not ;is a mere expansion of the optic nerve, but as a nervous membrane into which enter branches of the great sympathetic, and of the cil- iary or iridal nerves, as well as the fibrils of the optic nerve ; whence injuries of the great sympathetic or of the 5th pair produce blind- ness, althoug-h in the first instance the optic nerve may not be at all affected.*' Although the separated piece of the orbit appears to have united ■ in this case, it sometimes happens that only the soft parts unite, while the bones continue divided. Of this, we have an example in the case related by Dr. Hennen, of an officer, who, at the battle of Waterloo, received a sabre-wound across the eyes, cutting obliquely inwards and downwards to such a depth as to admit of a view of the pharynx. One eye was destroyed, and the hiatus was so great, that the upper jaw was obliged to be supported by morsels of cork put into the mouth, in such a way as to act as fulcra, but admitting the passage of liquid nourishment. After the wound was dressed on the field, the patient was sent to Brussels, where he fell into the hands of a Belgian barber, who stupidly cut out the hgatures, re- moved the straps by which the lower portion of the face was kept in position, and stuffed the parts with charpie. This was not re- moved for several days, after which the parts v/ere again brought into apposition by straps and bandages, but with great pain, and consequent delirium. The patient recovered, granulations sprout- ing up at all points, and the soft parts uniting, but not the bones.t 7. Gunshot Wounds of ike Orbit "Present much greater variety in their direction than any other wounds of this part. They also vary much in the depth, extent, and effects of the injury which they produce. 1. Exterior parts of orbit injured. The superciliary ridge, * Meraoires de la Societe Medicale d'Emulation; Vol. vii. p. 86. Paris, 1811. t Hennen's Observations on some important points in Military Surgery; p. 370. Edinburgh, 1818. 18 and tlie other exterior parts of the orbit, are often the seat of gun- shot injuries. Sometimes a ball will traverse the outer wall of the orbit ; in other cases, it will pass through the superciliary ridge. When the latter is the case, the ball generally descends afterwards through the floor of the orbit into the maxillary sinus, or into the nostril, destroying the eyeball in its course. The frontal sinus, when much expanded, separates the two tables of the orbitary plate of the fron- tal bone, so as to form a cavity, in w^hich musket balls have fre- quently been known to lodge. This is generally attended by de- pression of the inner table, so as to render necessary the operation of trepan. The surgeons of former da3rs refrained from trepanning these sinuses, partly from fear of an incurable fistula following the operation, partly from the difficulty of sawing through two plates of bone placed obliquely in regard to one another, without wounding the dura mater ; but the fear of a fistula is now laid aside, and the second difficulty is in some degree removed, by employing two tre- phines, a large one for the external, and a small one for the internal table. In this way, a depression may be raised, or a ball, fixed perhaps in the internal table, or in the roof of the orbit, may be removed. 2. Bones of orbit susceptible of union. The bones of the or- bit, shattered by a ball, are still in some cases, susceptible of union, and ought not, therefore, to be too hastily removed, although they are felt to be loose after an injury of this kind. Poneyes had under his care a soldier, in whom a musket-ball had shattered the anterior part of the frontal sinuses, the upper part of the bones of the nose, and the right orbit towards the inner an- gle. He fell instantly on receiving the wound, vomited soon after, became insensible, and bled at the nose. Poneyes removed the portion of bone forming the frontal sinuses, leaving the bones of the nose and the injured portion of the orbit loose. The posterior part of the frontal sinuses was not fractured. Delirium came on with drowsiness ; but after the patient was repeatedly bled, these symp- toms ceased. The loose pieces of bone reunited, and the cure was completed in two months and a half.* 3. Different directions of balls through the orbit. Balls pass- ing directly backwards through the orbit, are generally fatal, from entering the brain ; whereas, those w^hich enter the orbit obliquely, though generally destructive of vision, either by striking the eyeball, or dividing the optic nerve, very frequently leave the brain un- touched. Dr. John Thomson, for example, mentions a case, in which the ball entered nearly in the middle between the frontal sinuses, passed across the left sinus, and seemed to lodge in the cavity of the orbit, producing bhndness, with great swelling of the eye, and of the parts * Memoires del'Academie de Chirurgie. Tome vi. p. 202. 12ino. Paris, 1787. 19 surrounding it. In another case, where the bullet had entered the face on the upper and left side of the nose, and passed out anterior to the right ear, the patient was affected with amaurosis of the right eye. The left eye was similarly affected, in a case where the ball had entered the right side of the nose, and had come out be- fore the left ear. In one case, the ball had entered at the inner angle of the left eye, and passed out before the left ear. In another, the ball had entered above the inner angle of the right eye, and passed out of the right ear. In both cases, the eye of the side on which the ball had passed was destroyed. In one case, in which the ball had entered the right eye, and had passed out midway be- tween the left eye and ear, the left eye was affected with amaurosis.* 4. Balls traversing both orbits. Many instances are recorded of balls passing through both orbits, from temple to temple. Heister relates a case of this soit. The person recovered ; only he became blind the very moment he received the shot, and re- mained so ever after. The entrance and exit of the ball were ex- actl}'^ in the angle which the zygoma makes with the process of the malar bone going up to join the frontal, and of course the ball must have passed through the posterior part of each orbit, probably di- viding both optic nerves, without wounding either the eyeball or the brain. The eyes appeared quite clear, and without inflamma- tion, but fixed, and totally deprived of sight.t Such a gunshot wound as this must be regarded as less danger- ous than one in which the ball does not pass so directly across from one side of the head to the other ; but either from being directed backwards in its course, enters the brain, or from its force being partially spent, lodges among the bones. Speaking of the wounded before Mons in 1709, Heister states, that for the most part, those who had received a wound only in one temple, died either imme- diately or soon after. Dr. Thomson tells us, that he saw from eight to ten patients, after the battle of Waterloo, in whom musket-balls had passed through behind the eyes from temple to temple. In all of them, there was great swelling, pain, and tension of the head and face. He mentions, that a careless examination would have led one to suppose, that in these cases the balls had entered the cranium ; and remarks, that cases of this kind are recorded, in which the blind- ness which followed is supposed to have been produced by the balls passing through the inferior part of the anterior lobes of the brain ; but that most probably in such cases, the brain is untouched. In one case observed by Dr. Thomson, where the ball had passed through behind the eyes from temple to temple, one eye was destroyed by inflammation, and the other affected by amauro- * Thomson's Report of Observations in the Military Hospitals, after the Battle of Waterloo ; p. 64. Edinburgh, 1816. t Heister's Medical, Chirurgical, and Anatomical Cases and Observations, transla- ited by Wirgnian. Obs. Ixxiv. p. 92. London, 1755. 20 sis. In another case, wliere the ball had taken precisel}^ the san direction, both eyes were affected with amaurosis, without ai:i} inflammation being produced. He remarks, that in some of the patients in whom amaurosis had followed, there was reason to be- lieve, from the course which the balls had taken, that the optic nerves were divided ; but that in a considerable proportion of those affected with amaurosis, it was obvious that the balls had not come into contact wnth these nerves. Various instances occurred, in which the bullet, penetrating through both eyeballs, had passed behind the bridge of the nose, and left it unbroken. In one of the cases, in which the ball had passed through below and behind the eyes, the patient was affected, at the end of some weeks, with pain- ful spasms in the face, which, in their severity, and in their mode of attack, bore a striking resemblance to those of tic douloureux.* 5. Balls sometimes extracted from, the orbit ; in other cases left unremoved. A ball which has penetrated through one or other of the sides of the orbit, may in some cases be detected and extracted. In other cases, it cannot be extracted, nor its course as- certained ; so that, if the individual survives, it must be left to make its waj^ out by the fauces, or by some other route. In those cases in which the ball is left, we must lay our account with caries, exfoliation of the bones, deep-seated formations of mat- ter, sloughing of the mucous membranes, puffy swellings on the surface towards which the ball is approaching, and a very tedious recovery. Sinuses form, in such cases, before the ball makes its exit, and continue after it has escaped ; and to dry these up is gen- erally attended with danger. We must wait till the parts within have become healthy, and then the sinuses will close of themselves Dr. Hennen mentions the case of a soldier, who was brought tc him some weeks after being wounded, for the purpose of having e ball extracted, which gave him excessive pain, impeded his respi ration and deglutition, prevented his speaking distinctly, and kejjl up an irritation in his fauces, attended with a constant flow of sal iva, and a very frequent inclination to vomit. On examination, i) was found to be lodged in the posterior part of the fauces, forming a tumour behind, and nearly in contact with the velum pendulum It had passed in at the internal canthus of the eye, fracturing the bone. Although blindness was the instant consequence, the globe of the eye was not destroyed ; and the remaining cicatrice, and the very inflamed state of the organ, were the only proofs that an ex traneous body had passed near it.*" One of the most remarkable cases of a ball which had penetratec through the orbit making its way out of the head, is that of Dr Fielding, who was shot at the battle of Newberry, in the time o the Civil Wars. The ball entered by the right orbit, and passec * Thomson's Report of Observations, &c. p. G5. t Hennen's Observations on some important points in Military Surgery ; p. 361' Edin. 1818. 21 nwards. After 30 years' residence in the parts, and a variety of I exfoliations from the wound, nose, and mouth, and the formation ;)f several swellings about the jaw, it was at last cut out near the jDomum Adami.* 6. Balls or other foreign bodies passing through the orhit, \eft within the crajiiuni. Although it generally happens that Tunshot wounds of the orbit, penetrating into the brain, prove im- mediately mortal, yet in some rare cases, the ball, or other foreign body, has been known to remain within the cranium for a length of time, without producing much disturbance. Petit related in his lectures, the case of a soldier, who received a musket-shot in the inner angle of the eye. It seemed a very sim- ple wound, and healed under the common hospital treatment. The man seeing himself cured, determined to leave the hospital, although advised by the surgeon to remain some time longer. Scarce had he reached the door, when he was seized with rigors, obliged to return, and died in two days. On dissection, the ball was found lodged under the sella turcica and optic foramina. An abscess was present in the brain.t Dr. Hennen mentions the case of a French soldier, wounded at Waterloo. The ball entered the right eye ; the left, though not in the slightest degree injured to appearance, was completely blind. Dr. H. felt under the zygoma, and all along the neighborhood of the wound, but in the puffy state of the parts could not detect the course of the ball. The patient himself was confident it had gone into his brain. He returned to France convalescent. + The following case of a gun-breech penetrating the orbit and cranium, and remaining in the brain for two months previously to the death of the patient, occurred to Mr. Waldon of Great Torring- ton, Devon, and was communicated by Mr. Abernethy to the Med- ical Society of London. A lad, of 19 years of age, about 5 o'clock in the afternoon, as he was shooting at a wood-dove, was knocked down in consequence of the bursting of the gun. No person being with him at the time, the first effects of the injury could not possi- bly be ascertained ; he was probably deprived of sensation and power by the accident, as he remained in the wood until the after- noon of the following day, comprising a space of 22 hours, during a very severe frost, and was found about 60 paces from the spot where the accident happened. On Mr. W.'s arrival, he found the patient in his perfect senses, notwithstanding that the os frontis and dura mater had been perforated a little on the right side and above the frontal sinus, and that a considerable quantity of the cerebrum was then upon his clothes, and exuding from the wound. From considering the nature of the injury, and the manner in which it * Philosophical Transactions, abridged by Jones. Vol. v. p. 203. t Garengeot, Traite des Operations de Chirurgie ; Tome iii. Obs. xx. p. 155, Paris, 17.31. t Hennen's Observations, &c. p. 361. 22 had been inflicted. 'Mi. "W. concluded that only the breech, as it i- called. which screws into the back part of the barrel of the gun. could have effected the mischief. On the gun being found, his conclusion was verified, the barrel being perfect, and the breech gone, having carried with it the whole of the wooden part of tl.e stock on a plane with itself. Notwithstanding he was at this time sensible. Mr. W. still doubted, from toe force with which the breech must have been dislodged from the barrel, to overcome the resist- ance of the OS frontis and dura mater, whether it might not be within the cavity of the cranium. In the most gentle manner possible, he introduced his finger as far as he judged it prudent, in order to detect whether any extraneous body was lodged there or not. but without efiect. The patient having lost a considerable quantity of blood, as appeared on examining the spot where he lay the preceding night. Mr. TT. judged it not expedient to open a vein, but contented himself, for that night, with wrapping the upper part^ of the face in a warm poultice, giving a laxative mixture, and or- dering a strict antiphlogistic regimen. Next morning, !Mr. W.. to ' his inexpressible surpiise. was informed that the lad had passed a good night- retained his senses, and was in good spirits. On re- moving the cataplasm, he found that an immense discharge'of bloody fluid had exuded from the cavity of the cranium. This continued for several days to be thrown out. to the quantity of at least a pint every 24 hours, by the pulsatory motion of the arteries. On re- moving, at the first dressing, some part of the cataplasm from the internal canthus of the left eye. 3lr. "W. discovered by the probe, the head of one of the screw pins which fastens the lock to the stock, almost buried beneath the inflamed integuments, and which had penetrated the roof of the orbit upwards and backwards, through the cerebrum, towards the right parietal bone. 3Ir. W. extracted the nail with some difiiculty. From the figure which he has given of it, it appears to have been the breech nail, an inch and three Cjuarters long, a quarter of an inch thick, bent at an angle of about 135°. For some days, few or no unfavorable symptoms occurred, but a temporary loss of the power of associating ideas. The pa- tient did not immediately recollect himself when awaking from sleep. The discharge continued profuse. On the morning of the 7th day from the time of the accident, Mr. W. was alarmed by the coming on of drowsiness, stertorous breathing, and sinking of the pulse from 70 to .5.5. Under these unfavorable circumstances, he ordered the fomentations to be renewed, and made large evacua- dous. ZS'ext morning, the patient was greath' better ; and from this period, his convalescence became apparent daily. The tension of the integuments subsided, the pain of the head, hitherto violent and almost insupportable, left him. and laudable pus was evacuated through the opening in the frontal bone. In this state, he visited Mr. T\ .'s house, about the distance of 2 miles, every day. or every other dav, sometimes on horseback, oftener on foot, to have his ' 2S ^i head dressed, without the least apparent fatigue or inconvenience. ; Precisely in this state he continued till the 20th of January, (the accident having happened on the 29th of November,) when he had ia severe rigor, and complained of great pain in the back part of his head and muscles of the neck, with total loss of appetite, and ina- ' bility to quit his bed. He had gone to a feast in the neighborhood, where he had indulged more in eating and drinking than Avas proper. Previously to this, nature appeared to be regenerating ■the lost cerebrum, throwing out from its substance granulations of a faint blush color. The symptoms of inflammation and formation of pus within the cranium continued to increase till the 28th, when ! he was taken sick. During the act of vomiting, the attendants I perceived on a sudden, a large projection on the right side of the : frontal bone, underneath the sound integuments, and about 2 inches from the wound. On examination, Mr. W. thought he [perceived a large portion of the frontal bone detached, and in a state of exfoliation ; and considered a free division of the integuments, and a total removal of the substance, whatever it might be, as af- fording his patient the only chance of recovery. As he was dividing the integuments, which, extraordinary as it may appear, were scarcely altered from a natural state, he perceived the knife to grate on a yielding body, which appeared very unlike bone ; and :he found not a little difficulty in effecting the division from the re- ceding of this hard body, which he had hitherto considered as de- tached bone. When the division was completed, he perceived a round black body, which he immediately recognized as the breech of the gun. It was laid hold of, first with a pair of forceps, and then with the fingers, and after some difficulty, extracted. It was three inches or more in length, and weighed three ounces and one irachm. It had lain in the brain, with one end pointing to the Dccipital, and the other to the frontal bone ; and consequently must have extended nearly to the centre of the brain. The patient im- mediately became paralytic, and on the 3d day after the extraction, died, under a complete subsultus tendinum. Mr. W. could not obtain leave to examine the head after death.* 7. Palatial loss of the substance of the brain, in gunshot wounds of the orbit. In some cases of gunshot wound of the orbit, recovery has taken place after partial loss of substance of the brain. The following is an interesting case of this sort, in several respects resembUng Mr. Cagua's case of fractured orbit, already referred to.t A young man, of 17 years of age, was wounded by a musket ball, which passing from below upwards, penetrated through the upper lip, the right nostril, and the roof of the orbit into the cranium, whence it escaped at the upper part of the frontal bone near to the * Memoirs of the Medical Society of London ; "Vol. v. p. 407; London, 1799. ^ t See page 5. 24 sagittal suture, where it made a large wound of the integumen|i with loss of substance. Such a degree of swelling came on as madi the head frightful. An incision was made over the wounded part of the orbit, whence at the first dressing there came out a portion of both substances of the brain, in bulk about the size of a small hen's-egg. The eye was exceedingly swollen, especially the upper eyelid, into which an incision was made, to give issue to the blood which was supposed to be there extra vasated ; but instead of blood, there came out a spUnter of bone and a portion of both substances of the brain, nearly equal to a third of the portion which had formerly come away. The wounds were dressed lightly, and the patient was repeatedly bled. Some sixiall portion of brain was again discharged. On the fourth day, the brain appeared to be in a state of suppuration ; and on the fifth, the discharge became very considerable. From the time that he had been bled, the patient had continued pretty well till the eleventh day. Next day, he was more feeble. On the 13th day, the matter from the brain, which had been discharged both from the wound above and from that below, was in part retained, and the patient fell into a state of drowsiness and general depression. M. Bagieu, who treated the case, having anevv examined the wounds witii minute attention, removed a large piece of loose bone from the upper part of the skull. The patient did not appear to be reheved by this, but became worse till the 15th day, when every one expected him to die. M. B. remarked, that, on pressing the skin where he had removed the piece of bone, pus oozed out, which made him suspect that there was an accumulation of matter at that place. Led by this idea, he removed the skin and some portions of dura mater, so as freely to re-estabhsh the discharge. The pulse rose, the patient was next day able to speak, and afterwards the suppuration slowly subsided. About the 19th day, the fleshy parts began to granulate, and the wound on the upper part of the head was soon covered over. It was otherwise ^vith that of the eyelid : for there supervened a con- siderable fungus, occasioned by the splinters separating from the neighboring bone. In spite of cutting and burning this fungus, it was found necessary to wait patientl}^ till all tiiese splinters had come away ; after which the excrescence was easily destroyed, the wound closed, and the patient recovered completely.* 8. Part of the orbit shot away. The temporal angle of the orbit is peculiariv exposed to this accident. Occasionally a consid- erable portion of the face, along with the floor of the orbit, is removed ; and yet recovery may follow. Larrey relates the case of a soldier, who was struck on the face with a cannon-ball, which took away almost the whole of the lower jaw and three-fourths of the upper: the two upper maxillary bones, the bones of the nose, the ethmoid bone, and the right malar * Memoires de r Academie de Cbirurgie; Tome i. Partie ii. p. 127. 12mo. Paris, 1780. bone, and zygoma, were broken to pieces ; the soft parts corres- ponding to those osseous portions, destroyed ; the right eye burst ; the tongue cut across ; the fauces, and posterior apertures of the nostrils completely exposed, as well as one of the glenoid cavities of the temporal bone, and the muscles and vessels of the neck. Such was the state of the wound, that the comrades of this soldier had laid him into a corner of one of the French hospitals at Alexandria, in the belief that he was dead. Indeed, when Larrey first saw him, the pulse was scarcely to be felt, and the body cold and with- out the appearance of motion. As he had taken nothing for two days, Larrey's first care was to administer to him, by means of an oesophagus tube, some soup and a little wine. His strength was re-animated ; he raised himself, and testified by signs the most lively gratitude. Larrey washed the wound, removed the foreign substances which adhered to it, cut away the soft parts which were in a state of disorganization, tied several vessels which he had opened in doing so, and brought the flaps together as much as pos- sible by stitches. He also united by stitches the two portions into which the tongue had been divided. He covered the whole exca- vation with a holed cloth dipped in warm wine, and then applied fine charpie, compresses, and a bandage. Every 3 hours, a little soup and some spoonfuls of wine were given with the gum-elastic tube and funnel. The dressings were frequently renewed, on account of the flow of saliva, and other fluids. Suppuration was estabUshed, the sloughs separated, the edges of the enormous wound approached one another, the parts which were brought together adhered ; 35 days after the injury the man was in a state to be moved, and ultimately cicatrization was completed. After having been supported during the first 15 days by means of the tube, he Vfas able to take food v/ith a spoon. He retm-ned to France, and 11 years afterwards, when Larrey published his work, was alive, and in good health, in the Hotel des Invalides. He could even speak so as to make him^self understood, especially when the large opening into his face was covered with a silver mask." I have thus attempted to classify and illustrate the various In- juries to which the orbit is hable, and the various effects which those Injuries are apt to produce. There remain only two topics, on .which I wish to say a few words. 1. Prognosis. It is evident from the cases which have passed in review before us, that although in general, immediate death is the consequence of an injury extending through the orbit to the brain, yet this is not always the case ; but that in some cases life has been prolonged for several days, and that in other cases the patient has completely recovered. It is probable, that it is not so much the absolute amount of in- * Larrey, Memoires de Chirurgie Militaire ; Tome ii. p. 140. Paris, 1812. 26 jury to the brain, as the suddenness with which it is inflicted, which renders wounds of the brain through the orbit so generally fatal. We have examples of disorganization of very considerable portions of the brain proceeding slowly, for years, and yet life prolonged ; while in perforation of the roof of the orbit, the smallest wound oif , the brain may prove immediately mortal. Pathologists have gene- rally attempted to explain the sudden and fatal effects of such ; wounds of the brain, by telling us. that thereby the heart, or the organs of respiration, are instantly deprived of the nervous energy necessary for continuing their functions,* But how it hap- pens that death takes place instantaneously in some cases of this sort, while others sufier so little from sudden injury of the brain, but linger, like Mr. Waldon's patient with the gun-breech in his brain, or recover like Mr, Cagua's and M. Bagieu's patients, we cannot tell, any more than we can explain how one man shall have a limb carried off, or shattered to pieces, by a cannon-ball, without exhibiting the slightest symptom of mental or corporeal agitation, while deadly paleness, violent vomiting, profuse perspira- tion, and universal tremor, will seize another on the receipt of a slight flesh wound. To say that all this depends on differences in nervous susceptibility, is only to repeat the fact in other words, not to explain it. 2. General Treatment. In regard to the general treatment of Injuries of the Orbit, it is very plain what that ought to be ; namely, quiet and rest ; a very spare diet ; blood-letting, if the re- action demands it ; opiates ; laxatives ; gentle diaphoretics ; a little blue pill occasionally, if the liver becomes irregular in its action, as from confinement it is very apt to do ; great cleanliness in regard to the injured parts ; emollient cataplasms, and soft light dressings, frequently renewed. We must beware of neglecting the use of blood-letting, and we must beware of employing this remedy too soon and too profusely. We must not omit to examine the injured parts frequently, in order, if there be any piece of exfoliated bone or foreign substance keeping up irritation, that it may be withdrawn ; and, on the other hand, we must beware of too much poking and intermeddling, and of attempting prematurely to close up the issues, by which matter and foreign substances may have still to escape. SECTION II. PERIOSTITIS, OSTITIS, CARIES, AND NECROSIS OF THE ORBIT. We have hitherto considered the orbit merely as a part exposed to a variety of external injuries. We must now ture our attention to it as a part subject to inflammation and its consequences. * Les playes du cerveau et des membranes sont mortelles le plus souvent, a cause que souventesfois s'en ensuit ablation de Paction des muscles du thorax, et des autres servants a la respiration : dont de necessite la mort s'ensuit. Pare, Liv. x. Chap. 10. 27 It is generally admitted that the bones are susceptible of the ame diseases, as the soft parts ; only, on account of the mineral 'natter which they contain in the proportion of about 2 to 1 of mimal matter, the whole of the processes, whether natural or norbid, which go on in the bones, take place with much less apidity, and with much fewer manifestations of vitality, than do imilar processes in the soft parts. Inflammation in particular, ilceration, and mortification, with all their concomitant phenomena, (roceed in general very slowly in bones. The periosteum, with Ivhich they are every where invested, possesses a much greater legree of vitality ; and as this membrane is not merely firmly ad- ; lerent to their surfaces, but sends innumerable vessels into their :ubstance, we find the bones very much aflfected in every case in vhich the periosteum is diseased. It is an old and a just notion, that the dura mater, making its ixit by the numerous foramina of the cranium, is continued into he periosteum. The dura-matral envelope for the optic nerve, [laving reached the point of origin of the recti muscles of the eye, j splits into two laminae, the external of which is lost in the perios- i.eum of the orbit, while the internal, which is whiter, denser, i md thicker, goes on closely to surround the nerve, and ultimately I )ecomes continuous with the sclerotica. Between these two laminae, 1 canal is formed for the transmission of the ophthalmic artery, [t is not by the optic foramen alone that the dura mater enters the Drbit. The dura mater closes in part the spheno-orbital fissure, and sends into the orbit by this opening a prolongation, which is also con- cinued into the periosteum of the orbit. This prolongation, allows the 3d, 4th, 1st division of the 5th, and 6th nerves to enter the 3rbit, and the ophthalmic vein to escape from it. Causes. Inflammation of the bones and periosteum (ostitis and periostitis of the orbit may be the result of several different kinds of causes ; for example, 1st, Syphilis, scrofula, and other internal diseases, of a constitutional nature, acting locally ; 2d, Injuries, perhaps attended with fracture ; and 3d, The spread of inflamma- tion from the neighbouring parts, and especially from the soft parts contained within the orbit. We should call the first two examples -primary, and the last secondary inflammation of the orbit. This last is by far the most common. Inflammation of the bones of the orbit, primarily or secondarily- excited, may terminate by resolution, merely an increased deposi- tion of osseous matter being left in the inflamed part, hyperostosis ;* it may terminate in the formation of pus, and ulcerative absorption of the substance of the bone, caries ; or in the death of the inflamed piece of bone, necrosis, t * I shall have occ*ion to quote an interesting case of hyperostosis of the orbit, in the next section. t See Dr. Cumin's Paper on the Diseases of Bones, in the Edinburgh Medical and Surgical Journal, Vol. xxiii. 28 . It will rarely be possible to decide at first sight, in cases of dis- eased orbit, whether the bone which is felt bare with the probe, is carious or necrosed, or whether both caries and necrosis are present. The exact nature of the disease will become evident only in the course of the cure, from the sensations communicated through the medium of the probe, the foetor emitted, the appearances of the discharge, and the texture and size of the pieces of bone which come away. I do not consider it necessary to describe, farther than I have done, the inflammatory effects of injuries of the orbit. In pene- trating wounds especially, and in gunshot wounds of the orbit, w^e must lay our account with inflammation of the bones and perios- teum, followed by suppurations, sloughings, sinuses, caries, necrosis, and tedious exfoliations. Demours speaks of primary inflammation of the orbital perioste- um as extremely common * ; but the symptom to which he refers, is evidently nothing more than the supj'a-orbitalpain, which return- ing every evening and relaxing every morning, is an invariable attendant on rheumatic ophthalmia. The most frequent cause of secondary inflammation of the bones of the orbit, is inflammation of the orbital cellular substance, or of the lachrymal gland, going on to suppuration, and the abscess from misapprehension or neglect not evacuated ; while in some cases, se- vere inflammation of the eyeball spreads not only to the surround- ing soft parts, but also to the periosteum and the bones. Inflammation of the orbital cellular substance, going on to sup- puration, may take place near the front of the orbit, between the levator palpebree superioris and the orbit, between that muscle and the rectus superior oculi, or below the eyeball, between the rectus inferior oculi and the floor of the orbit. Inflammation and suppu- ration in these situations are attended with pain and fever, immo- bihty and distortion of the eyeball, and much swelling of the eye- lids. If the disease be understood from the first, and treated on an active antiphlogistic plan, suppuration may often be prevented : if matter has actually formed, any very serious or extensive injury may still be obviated by opening the abscess sufficiently early ; but neglected or misundei-stood, an abscess even near the front of the orbit, perhaps pointing and fluctuating through one or other eyelid, may spread its mischief to the periosteum and bones, or insinuate itself into some of the neighboring cavities, into the nostril by the lachrymal passage, into the zygomatic fossa by the spheno-maxil- lary fissure, into the maxillary smus through the floor of the orbit, or even into the cavity of the cranium through the orbitary plate of the frontal bone. It will penetrate through the bones in the last two cases, by the process of progressive absorption, a process attend- ed by inflammation in the bones pressed upon, aftd leaving these • Traite des Maladies des Yeux. Tome i, p. 91. Paris, 1818. 29 )ones in a diseased state, but seldom, if ever, in the state either of ;aries or necrosis. It is where there is no perforation from the orbit nto the neighbouring cavities, but merely a sjDreading of inflamma- ion to the periosteum and bones, that caries or necrosis is most apt. take place. Of a still more dangerous character is inflammation in the back jart of the orbit, or in the cellular membrane immediately surround- ng the optic nerve. Vision is always more or less injured, and )ften destroyed by suppuration in these situations ; the eyeball i& )ushed more or less forwards from its natural situation ; not unfre- juently exophthalmia follows hard upon this state of exophthalmosy ,hat is to say, the eyeball is destroyed by inflammatory disorgani- sation as well as protruded ; nay, I have known deep-seated abscess )f the orbit to prove fatal, the patient having for a day or two shown symptons of pressure on the brain, and in fact dying apoplectic. 1 need scarcely say that in such cases, the periosteum and bones of the orbit will be very apt to suffer, especially if the disease is pro- longed, and no attempt made to evacuate the abscess which may have formed. I do not consider it necessary to describe these diseases of the orbital cellular membrane njore minutely for the present. Them, as well as inflammation of the eyeball spreading to the cellular membrane, periosteum, and bones of the orbit, and inflammation of the lachrj'mal gland running the same course, I shall take up separately hereafter. I mention them now, merely as the most common causes of caries and necrosis of the bones of the orbit. When the bones of the orbit inflame from syphilis, after pain io the seat of the disease, not in general acute, there forms a tumour of the eyelids, shghtly red at first, and but little painful to the touch, but which slowly advances in redness, pain, and size, till it is felt to fluctuate, and either bursts of itself or is opened with the lancet. It is but rarely that we have an opportunity of watching the invasion and progress of such a case. Much more frequently the patient applies for aid, only after the abscess has biu'st and discharged matter for a length of time. Local Sym'ptoms. Let caries or necrosis of the orbit have arisen from whatever cause it may, let it be primary or secondary, the re- sult of some constitutional disorder, as syphilis, or of an injury, as many of those injuries we have already described, or of inflamma- tion spreading from the contents of the orbit, the following are some of the appearances which may lead us to suspect the exis- tence of such an affection : — A fistulous opening through one or other eyelid, more frequently through the upper, sometimes just un- der the center of the superciliary arch, but generally nearer to the outer extremity of this arch ; the opening of the fistula callous, or perhaps fungous ; the skin around red, hard, depressed, and drawn back into the orbit ; the eyelid shortened, so that the eyeball cannot be completely covered by the lids when the patient attempts to close 30 them, a symptom called lagophthalmos ; eversion of the lid through which the fistula passes, sometimes to a very great degree ; a dis- charge of ichorous matter from the fistula, the quantity discharged being too great in general to be furnished by the small opening which is visible. These appearances, we learn from the patient, have been consequent to symptoms of inflammation of the orbit, with or without injury, ending in abscess, which had either been opened with the lancet, or allowed to burst of itself. If we take the probe, and pass it along such a fistula, it generally comes into contact with bare, rough bone. I believe it will rarely be the case, that the bone, under such circumstances, has been merely exposed, by the formation of an abscess in its neighbourhood, and by the evacuation of that abscess : but that, on the contrary, the bone is, in general. affected, either with necrosis, in which case a cure is likely to be sooner effected, or with caries, and then the cure is generally very slow. It sometimes happens that several different portions of the orbit are affected at the same time, ending in the formation of a number of sinuses, passing through the eyelids in the direction of the dis- eased pieces of bone. Such a state is commonly the result of se- vere and general inflammation of the orbital cellular membrane, running on into suppuration. When the floor or the inner wall of the orbit is the seat of caries or necrosis, excited in this way, we almost alwa^'S find that the whole thickness of the bones has in a greater or less extent been destroyed, permitting the matter to drain from the orbit into the nostiil or into the maxillary sinus. A case of this kind is related, ia a desultory aud tedious manner, by De- mours. The patient was a canon of Besancon, in whom it would appear that suppuration had entirely destroyed the cellular mem- brane of the orbit, and that a part of the upper lid had been lost by gangrene. The eyeball was destroyed, the upper lid was left evert- ed and shortened, and four fistulous openings existed into the orbit, two at the inner and two at the upper edge. FcEtid matter, mixed w"ith curdlike substance, was discharged, some pieces of bone came away, injections passed for a time from the orbit into the maxillary sinus and nostrils, at last the discharge ceased, the parts became quiet, the sinuses closed, and a glass eye was applied to cover as much as possible the deformity. The general health does not appear to have been affected. The chief local treatment consisted in mild injections, frequently repeated in the course of the day.* Saint-Yves mentions his having treated a lad of 15 years of age, who had had an abscess under the eyeball, which had burst through the middle of lower eyehd. On passing a probe through the open- ing, he found that the matter, lodging under the globe of the eye, had produced caries of the floor of the orbit. The matter had flowed into the maxillary sinus, and was discharged in part by the nostril. ♦ Demouis, Traite des Maladies des Yeux. Tome ii. p. 33, Paris, 1818. 31 Fearing that the presence of pus in the maxillary sinus might bring Dn caries of that cavity, Saint- Yves extracted one of the molares, the root of which he thought likely to penetrate into the sinus, and then employed injections, morning and evening, through the open- ing in the eyelid. The fluid injected ran through the maxillary 5inus, and through the alveolus, into the mouth. The injection employed was a decoction of aristolochia, gentian, and myrrh. In two months the patient was cured.* Although caries of the orbit is generally attended by abscess of the soft parts in its neighbourhood, (if it has not originated itself in such abscess,) the skin of one or other eyelid inflaming, and at length giving way, and an external flstula forming, yet cases may Dccur in which the disease shall be situated very deep in the orbit, in the sphenoid bone, for example, where it gives passage to the optic, or other orbital nerves, so that amaurosis may be brought on, any suppuration of the soft parts w4iich may form shall lie long concealed, or even death be the result before any, or almost any external marks of the disease be present. /State of the Constitution. We ought not to proceed to the treatment of any case of diseased bones of the orbit, till we have made ourselves acquainted with the state of the patient's general health, and as much as possible with the history of the local dis- ease. Children are not unfrequently the subjects of diseased bones of the orbit; strumous children, who have suffered inflammation of the lachrymal gland, and in whom the fossa lachryraalis of the frontal bone has become carious. In other cases, the subject is adult and syphilitic. I have seen both orbits affected in such an individual. T have seen caries of the roof of the orbit, in an elderly man, free from any venereal disease, and who could give no accoimt of the origin of his complaint. It is evidently impossible to decide from a mere examination of the diseased bone, what has been the nature of the inflammation in which the caries or necrosis has originated, whether syphilitic, or strumous, or scorbutic, or of what other kind. We must refer to the history of the case and the constitutional symptoms, in order to deteimine, if possible, this point. In syphilitic cases, we might be led to expect considerable pain, aggravated during the night ; although nothing of this kind ex- isted in the only case of syphilitic caries of the orbit which I have seen. Other bones, besides those of the orbit, are likely in such cases to be affected with similar disease. The bones of the nose, and the frontal bone where it forms the forehead, are much more apt to be affected with syphilitic inflammation, than are the walls of the orbit. Mr. Hawkins, in a paper on Syphihtic Pains and * Saint- Yves, Nouveau Traite des Maladies des Yeux, p. 80. Paris, 1722 32 Diseases of the Bones,* refers to a case iii which the orbits appear to have been the last parts afiected. He speaks of it as the most frightful example of syphilitic disease of the bone wihch he had wit- nessed. The skull is preserved in the museum of the London Royal College of Surgeons, along with a pi'eparation of the scalp, showing the great extent to which it also had been destroyed by ulceration. The disease of the bones reached (says Mr. H.) into the orbits, so as to produce complete and disgusting eversion of the eyelids, terminating in total blindness. The brain was little dis- turbed by the great extent of the disease, till the last two months of the patient's life, when frequent convulsions took place, with gradual loss of the mental faculties. In the case to which I have referred, in which both orbits were affected, it appeared that the patient had had a similar disease of the right acromion, a painful node on the left side of the forehead, and repeated chancres and buboes, during the 18 months preceding the disease of the orbits. Such a history naturally led to the conclusion that the disease of the orbits was syphilitic. Prognosis. It is evident that both the prognosis and the treat- ment will be different in different cases. In a healthy adult, in whom the affection of the bones is the result of an injury, the prognosis will be much more favourable, and the treatment more simple, than in a strumous child, or an individual whose constitu- tion is either imbued with the poison of syphilis or impaired by frequent courses of mercury. In respect to the prognosis, I may mention that the eye is in danger of being destroyed in cases of caries of the orbit, simply in consequence of the lagophthalmos, or incapabihty from shortening of the eyelid of closing the eye. In every case of caries of the orbit which I have seen, there was either eversion, or lagophthal- mos, or both, and in consequence of the eyeball being but partially covered when the patients attempted to shut the eyes, there was always inflammation of the conjunctiva, sometimes inflammation and nebula of the cornea ; and in one case in which the lagoph- thalmos was to a great extent, the upper eyelid being permanently drawn by the sinus upwards and backw^ards into the orbit, so that a ver\^ considerable portion of the eyeball was continually exposed to the contact of the air and of foreign particles floating through it, there were pustule of the cornea and onyx. I was consulted only once in this case, but I had no doubt that the cornea would soon after be so much affected as to give way, and the eye be ultimate- ly left staphylomatous or atropiiic. The caries affected the roof of the orbit, immediately behind the middle of the supra-orbilary arch. Local Treatment. In the local treatment, our object is, if the disease be caries, to arrest the ulcerative process going on in the * London Medical and Physical Journal. Vol. Ivii. p. 318. Lond. 1827. 33 bone ; if necrosis, to promote the exfoliation of the portion which is deprived of life. i We shall rarely be able to accomplish either of these, without di- llating' the fistulee which communicate with the diseased bone. ! This is to be done partly with the knife, partly with tents. The j opening of the fistula may first of all be enlarged, by means of a straight, narrow, probe-pointed bistoury. This instrument may then be introduced along the fistula, and directing its edge first [upwards and then downwards, it is to be pretty freely dilated. To ■ keep it open,' a dossil of lint, dipped in almond oil, is to be pushed i along until it comes into contact with the diseased bone. I In cases of children, or of adults who are afraid of the knife, we imay be induced to dilate the fistula by sponge-tent, although this s in fact the more painful method of the two ; so painful indeed ;chat it sometimes cannot be borne. If there are fungous granula- tions round the opening of the fistula, these first of all may be de- stroyed with lunar caustic. If there be no fungus, the pointed pencil of lunar caustic may at once be introduced into the fistula, and turned round two or three times, so as to enlarge it. A pencil of sponge-tent is then to be introduced, and kept in for ten or twelve hours. Thicker and thicker pieces of sponge-tent are then to be [employed, till the opening becomes large enough to admit a dossil of lint, dipped in oil or covered with digestive ointment, and pushed an into contact with the diseased bone. Various applications have been recommended in cases of caries and necrosis ; but perhaps nothing is deserving of so much confi- dence as lunar caustic, ^either solid or in solution. Every second or third day, a strong solution of this substance may be injected along the fistula, taking precautions against the solution being allowed to touch the eye ; or the caustic pencil may be conveyed into contact with the bone, and kept there for the space of about half a mirnite. In general, no cure takes place in such cases unless the diseased bone comes away ; but the coming away of the bone is not always svident. It sometimes separates in minute scales, sticking to the dossil of lint, or washed out by the injection ; while in other cases, a considerable portion is thrown off at once, is felt with the probe to be loose, and is to be extracted with the forceps. There is no stated time for the necessary exfoliation in such cases. It may take place in a month ; or many months may elapse before the diseased bone comes entirely away. As soon as we judge it probable that the whole diseased part has been removed, we lay aside the dossil of lint, and allow the opening to close. I do not imagine that in cases of caries or necrosis of the bones of the orbit," there ever is any considerable formation of new bone. All that nature effects in such cases, is, I believe, a healing up of the diseased part, without any attempt to restore what has been re- moved by ulcerative absorption, or by exfoliation. Fortunate in- deed must the case be regarded, when the former process ceases, or 5 34 the latter is completed, so that the diseased bone may heal, and the external wound be allowed to close, and this without any consid- erable deformity. The eversion of the eyelid, the impossibility of covering the eye, and the deformity caused by the retraction of the external aperture of the fistula, are events very annoying under any circumstances. Suppose the patient to be a young lady, naturally anxious about her appearance, I need scarcely say how meritorious the surgeon will be in her judgment and that of her friends, if the case is brought to a speedy and favorable termination, especially if they have ever witnessed the deformity and the destruction of the eye which may have been the result in less fortunate cases of the same disease. It may sometimes happen that we are deceived in regard to the state of the bone. The fistula may even close, and yet the bone continue diseased. Granulations may fill up the sinus, without its bottom being sound. Perhaps some trifling exfoliation has taken place, without the whole diseased piece of bone having come away ; and the surgeon, misled by appearances, and thinking that all is right, does his best to close up the sinus. Nothing, however, is gained, if the bone is still left in a state of disease. On the con- trary, we are only obliged to go over again the same process of di- latation, and to wait for renewed exfoliation. General Treatment. The exfoliation and healing up of dis- eased bone is throughout an organic process, and may unquestion- ably be assisted by whatever remedies tend to support or improve the general health. In syphilitic cases, mercury, sarsapariila, and other anti-venereal remedies, are to be employed. In strumous cases, sulphate of quina, other tonics, a nourishing diet, and country air, will be found ad- vantageous. 1 have no experience of the power of asafcetida, and a variety of other internal remedies, which have gained a reputation for pro- moting the exfohation and heahng up of bones. If they act at all, they probably do so merely as stimulants or tonics, without any of the specific power over diseased bone, which has been attributed to them. SequelcB. Unless when the separation of the diseased portion of bone and the healing up of the sinus have been more than com- monly prompt, it is rarely the case, that recovery takes place from caries or necrosis of the orbit, without a considerable degree of la- gopthalmos, or eversion, or both. 1 am afraid that the lagopthalrnos in such cases must be regard- ed as incurable ; or if it be at all relievable. it is so not by art, but by a loosening of the retracted eyelid effected slowly by the natural action of the orbicularis palpebrarum. In a patient who was under my care, at the Eye Infirmary, with caries of the roof of each orbit, and lagopthalmos of each upper eyelid, the eyelids came very grad- ually to close more and more upon the eyeballs. For a time, how- 3S ever, the lag-ophthalmos was to such a degree as to leave the con- junctiva constantly exposed to the irritation of the air and the par- ticles of dust floating through it. The conjunctivitis and corneitis, thereby excited, I treated chiefly by the apphcation of the lunar caustic solution, till the elongation of the eyelids, produced by the action of the orbiculares palpebrarum in winking, rendered the la- gophthalmos gradually less and less, and served at length to permit the eyeballs to be almost completely covered. When this patient was dismissed, the sinuses had long been healed. There still re- mained a slight speck on one of the cornese ; and an evident de- ficiency was felt at the part of each orbit which had been the site of the caries. The lunar caustic solution was of signal service in this case, moderating the external inflammation of the eyeballs, brought on from their state of exposure, and in fact saving the eyes, till the natural apparatus of protection was in a great measure restored to the exercise of its office. I had another patient at the Eye Infirmary, (a boy of li years of age), with a great degree of eversion of the right upper lid, at- tendant on caries of the fossa lachrymalis. I used the lunar caus- tic injection in this boy, who was of a decidedly strumous habit, and attempted dilatation by sponge-tents. This of course was at- tended with a considerable degree of pain ; and he ceased on this account to attend. I need scarcely say that it would be folly to attempt the cure of the eversion in such a case, if the fistula were still open, or the bone unsound. Were we to detach the eyelid from the edge of the orbit to which it is drawn up, replace it in its natural position, and endeavor to keep it so, perhaps by extirpating a portion of the exposed and thickened conjunctiva, or cutting out a triangular piece of the whole thickness of the eyelid, and then bringing the edges of this incision together by stitches, so as to make the lid sit close, as in the natural state, upon the eyeball, we should merely lose our labor ; for the disease of the bone not being removed, the eyelid would very soon leturn to its former malpo- sition. ! SECTION III. PEUIOSTOSIS, HYPEROSTOSIS, EXOSTOSIS, AND OSTEO-SARCOMA OF THE ORBIT. Periostosis signifies a thickening c f the perioste- ra ; hyperostosis an increase of the bulk or thickness of bones ; exostosis, a bony tu- mour ; osteo-sarcoma, a malignant degeneration of bone, in which it is converted into a soft mass, having numerous osseous spiculse radiating through it. 1. Periostosis. Venereal nodes on the tibia are examples of periostosis. Similar nodes are sometimes strumous.* They may take place on the * Periostosis of the tibia is occasionally met with as an attendant on stnamous cor- neitis. 36 face of any bone : on the external surface of the skull, or within the orbit. 2. Hyperostosis Is a consequence of inflammation of a bone ; this process having been arrested before the occurrence of disorganization or death of the part. It is hyperostosis which in some cases slowly thickens the iDones of the cranium, without perhaps exciting any suspicion of the existence of such a state, till epilepsy, or mania, and ultimate- ly death, are produced. The bones of the orbit are liable to the same process ; the cavity of the orbit will thereby be intruded up- on : its contents pressed upon : and the eyeball pushed forw^ards from its natural place, and ultimately destroyed. We are indebted to Mr. Howship for the case of a stout healthy- looking man, 59 years of age, who lost his eyes from hyperostosis of each orbit. He dated the origin of his complaint to a period 14 years before Mr. H. saw him, which was in 1811. He was in perfect health, and on a windy day was walking up Hampstead Hill. On the road he was suddenly attacked with a violent itch- ing and heat in both his eyes, w'hich induced him to rub them most veheixiently. Before he could reach home, the irritation had increased to that degree that he was unable to open his eyes in the light. Inflammation supervened, and a small tumour formed just below the inner angle of each eye, about the size of a hazel-nut. These swellings burst inwardly, discharging afterwards freely be- tween the eyelids. The inflammation, treated by fomentations with poppy heads, and other occasional medicines, went on for about 12 weeks. It had then so far subsided that he could open his eyes, and bear the hght tolerably well, so that he went to work again. About a fortnight after this, having been exposed all night to cold and rain, in the winter season, he had a fresh attack. He applied to Mr. Ware, who ordered a warm poultice over each e)^e. as the swellings were again returning on each side of the upper part of the nose. This treatment was continued for about six wrecks, when the abscess at the angle of the right eye burst, evac- uating its contents upon the cheek. Two weeks afterwards, that upon the left side broke, and a copious discharge followed. The formation of these abscesses, particularly that upon the left side, was attended with pains in the head, the severity of which he could compare to nothing but the sensation of his head splitting asunder. These pains spread also through the bones of his face. During this attack he could get no rest day or night for the space of three months. A considerable degree of projection or tumour, apparently osseous, was now observable below the inferior margin of each or- bit, and the eyes had become much more prominent than natural. He was at this time a patient in St. Bartholomew's Hospital, where his case excited much attention. One day, one of the pu- pils observing the right eye thrust out of the orbit, proceeded to examine it rather hastily, when, as he pressed the tumour, and 37 pushed back at the same time the eyehd, the globe of ttie eye sud- denly sprung out beyond the palpebree. With some difficulty it wa.s reduced again. At this time he had some power of perceiving light with the right, but more with the left eye. The pains in his head and face continued so severe, that he was frequently almost distracted. The inflammation upon the eyes was still violent, par- ticularly that upon the left. He was often delirious, and it was sometimes with difficulty that he was prevented from tearing his eyes out, in the rage of pain and delirium. At length the right eye burst, from the intensity of the inflammation. The contents of the eyeball having escaped, the excessive inflammation declined, and the patient became somewhat better. The osseous tumours, however, still continued to grow, although their increase was very slow. Although nothing seemed either to have arrested their pro- gress, or much relieved his complaint, he now found his general health much improved. Some time after this, he was putting down a turn-up bed, and not being able to see what he was about, the bedstead slipped from his hand and fell, one of the feet striking him with great force immediately upon the ball of the eye that was protruded, and lying upon the hard tumour in the cheek. By this accident the globe of the left eye was burst, but he suffered no par- ticular pain at the moment, beyond the mere confusion arising from so severe a blow upon the face. A good deal of inflammation, however, soon came on, but subsided again spontaneously. Sub- sequently to this period, he usually enjoyed very good health, and in 1815 remained well. He merely observed that whenever he took cold, it was particularly apt to affect his head with a transient return of his old inflammatory pains. On separating the palpebree, the tunicee conjunctivae still retained strong marks of the severe in- flammation they had long suffered. The tumours of the maxillary bones, feeling as hard as ivory, and not in the least painful when pressed, appeared to occupy very nearly the whole space of each orbit, as well as the cavities of the nostrils, which were almost, if not entirely, obliterated. In the integuments covering the tumours, were several enlarged and varicose veins. From the slow and uni- form growth of the swelUngs, and from the great pain that attended their production, as well as from other circumstances connected with the history, Mr. H. considers that there is every reason to be- lieve that the original affection was the means of exciting a copious secretion of osseous matter, of a more dense texture than is natural to the parts ; a change, he observes, which generally results from healthy ossific inflammation.* 3. Exostosis Is a circumscribed tumour, consisting of newly formed osseous matter. A preUminary step in the process by w'hich an exostosis * Howship's Practical Observations in Surgery and Morbid Anatomy, p. 26. London, 1816. 38 is formed, is the deposition of cartilage. Exostosis within the orbit has been met with wholly in the cartilaginous state; in other cases, the tumour is partly cartilaginous, partly osseous. The cartilagi- nous deposition gradually undergoes the change which converts it into bone. Three varieties of exostosis have been distinguished; the cellular, the craggy, and the ivory; the first presenting an ex- ternal crust, within which are numerous bony partitions, together with a quantity of soft substance, and occasionally hydatids ; the second consisting of a mixture of osseous laminae with cartilage, but without any shell; the third white and dense like ivory.* Syinptonis. Exostosis springs in some cases from the edge of the orbit; its nature is recognized by the touch ; and as it grows, it comes to cover in part and to confine the eye. Although, in general, the touch will serve to discriminate between exostosis in this situation, and any other kind of growth, I may mention that I have seen a case of scirrhous tumour attached to the edge of the orbit, and partly within its cavity, so very firm in its consistence, and unyielding in its attachment, as to have been taken for an exostosis, previously to dividing the skin for its extirpation. Exostosis from the edge of the orbit is sometimes combined with encysted tumour, of which 1 had an instance at the Eye Infirmary, in a middle aged female. The encysted tumour had existed from infancy, and was attended w^ith exostosis from the edge of the frontal bone, preventing the patient from raising the upper lid. After a gentle mercurial course, the exostosis diminished so much as to permit the lid freely to exercise its functions. Exostosis may spring from any side of the orbit. We might perhaps suppose it more likely to grow from the floor or from the temporal side of that cavity, than from the thin bones w'hich form its roof and nasal side ; but this does not appear to be the case. The most remarkable symptoms produced by an exostosis withia the orbit are the following : — 1. Exophthalmos, or protrusion of the eyeball. This is one of the earliest symptoms of any kind of growth within the orbit. Sometimes the eye is projected directly forwards, even when the osseous tuinour is afterwards found to arise not from the bottom of the orbit, but from one or other of its sides. More frequently the eyeball is pushed forwards and to one side, towards the nose or temple, upwards or downwards, according to the side of the orbit giving rise to the exostosis. 2. Pain. This is very various ; nor is it easy to explain how some suffer so severely, even from a small exostosis within the orbit, while others from large tumours of this sort suffer but little. 3. Amaurosis. The projection of the eye must be attended with traction of the optic nerve ; and this, along with the pressure on the nerve caused by the tumour, induces obscurity of sight, and at length blindness. * See Dr. Cumin's paper in the Edin. Med. and Surg. Journal, Vol. xsiii. 39 4. Change of form. Exostosis sometimes increases to such a lize as considerably to dilate the orbit, advancing so as to be felt »etween the edge of the orbit and eyeball. It may even intrude ipon the nostrils, upon the opposite orbit, or upon the cavity of the ;raniura, so as to prove fatal. Diagnosis. In cases of exostosis within the orbit, it is often nipossible to decide regarding the nature of the disease, before )roceeding to operate, or before the death of the patient; for ex- ophthalmos, pain, amaurosis, and deformity of the orbit, are found arise from several other diseased states of the parts besides an )sseous growth; as encysted and other tumours, fungus of the max- Uary sinus, &c. In advanced cases of fungus of the maxillary iinus, other symptoms, no doubt, attend those already enumerated, IS softening of the palate, distention of the cheek, and obstruction )f the nostril, which may serve to distinguish suf.h cases from any disease confined to the cavity of the orbit. But between an encys- :ed tumour, not yet advanced so as to press upon the eyelids, and 1 deep seated exostosis, it is often totally impossible to discriminate. The eyeball is merely extremely prominent, and the patient deprived of the sight of that eye, without any tumour being felt, or any other diagnostic symptom being present. Neither can we pretend to decide in cases of this dubious kind, whether thickening merely of the periosteum, thickening of the bones, or such a tumour IS we call exostosis, be the cause of the exophthalmos. Prognosis. The venereal and strumous periostosis may yield to remedies ; hyperostosis is not likely to be affected by any treat- ment. The cellular exostosis is said to be occasionally destroyed by suppuration and caries ; any such change can scarcely be expected to take place in the craggy, and much less in the ivory exostosis. Nor will the possibility of any exostosis being destroyed by inflammation, ever withhold us from removing such tumour by operation ; for its spontaneous destruction must be uncertain and tedious. The ivory exostosis is much slower in its progress than the others, and sometimes it entirely ceases enlarging. Causes. Besides venereal and strumous constitutional disease, blows and other injuries have been known to give rise to exostosis. Treatment. This must consist in antivenereal and antistru- mous remedies ; and in certain cases, an attempt should be made to remove exostosis of the orbit by operation. The tumour being exposed by an incision through the integuments, and between the fibres of the orbicularis palpebrarum, it may be removed with a strong scalpel, a small chisel, or a slender pair of bone forceps, such as those used by Mr. Lislon for the excision of diseased pieces of bone. This operation must of course be executed very cautiously, lest the thin bones of the orbit be fractured, or any injury done to the eyeball or its nerves, in the attempts to detach tlie exostosis. Although cases are recorded, in which, after the application of caus- tic to an exostosis of the orbit, the tumour has mortified, and been 40 thrown off like an exfoliation, we must regard this as a practice to be followed only when immediate detachment of the diseased growth appears impracticable. It is a practice attended with much more pain, and is much less manageable than the use of the chisel or forceps. Under certain circumstances, it may be advisable to remove the protruded eyeball in cases of exoslosis of the orbit ; namely, when vision is destroyed, the pain distressing, and the osseous tumour probably so far back in the orbit, that it could not be extirpated. * The extirpation of the protruded eyeball has also sometimes been resorted to, in cases of exostosis of the orbit, when the symptoms were too obscure to lead to any decided diagnosis. Cases. The cases of exostosis of the orbit, minutely related, are but few in number. I shall quote the most remarkable, as each will serve to illustrate one or more points of importance. 1. Exostosis of the orbit removed, while yet cartilaginous. Exostoses have sometimes been removed while in the cartilaginous state, lying under the periosteum. Mr. Travers mentions that he . had seen several cases of this description ; the tumour presenting at the nasal side and appearing to extend to the bottom of the or- bit, its anterior edge thin and bound down by the orbital circum- ference, but the tumour itself, from its compressing the eye to blindness and pushing it out of the orbit, probably possessing con- siderable bulk. He once removed, he tells us, a tumour of this kind, on the nasal side of the orbit, scraping it clean away from the bone. It was of the hardness of cartilage, and of great extent. He is unable to say whether the disease returned, having lost sight of the patient soon after the operation. The impression he had of the case was unfavourable, fi-ora the character as well as the ex- s tent and connexions of the tumour.* 2. Exostosis of the orbit destroyed by inflammation excited > by the tise of caustic. Brassant's case is often referred to. The patient was a woman, 30 years of age, who had fruitlessly under- j gone the operation for fistula lachrymalis. Fifteen years after- wards, the OS planum and the internal angular process of the fron- { tal bone presented an exostosis of the size of an egg. The globe of the eye, compressed laterally, was thrust out of the orbit, and hung in some measure on the cheek at the temporal angle. Brassant attacked this exostosis with caustic. It suppurated, and within the space of from 3 to 4 months, exfoliation separated a considera- ble portion of the bony growth. The eye returned to its natural' situation, and the cure v/as ultimately perfect. t Professor Sporing has recorded a case of osseous excrescence, which grew from the bone in the immediate vicinity of the inter- nal canthus. The patient was a man of 35 years of age. The excrescence grew to the size of a very large walnut, pushing the * Travers's Synopsis of the Diseases of the Eye, p. 227, London, 1820. t Memoires de I'Academie de Chirurgie; Tom. xiii. p. 277. 12mo. Paris, 1774. I 1 eye nearly out of its socket, and impan-ing vision. A surgeon tried to remove it, by promoting exfoliation ; but the wound bled so freely, that he was happy to close it up again. Some time after- wards, a peasant was allowed to try his skill upon it. He began with an incision round the bone, which caused a great effusion of blood. He afterwards applied to it some secret remedy, which pro- duced intolerable pain for 12 days, attended with faintings. Sev- eral months afterwards, however, the patient had the courage to undergo the operation again. In the following spring, the entire exostosis dropped out ; the eye returned to its situation in the orbit, and vision was restored.* 3. Exostosis loosened hy operation, atid, after 12 months, ex- tracted, carious, from the orbit. Mr. Lucas has related a case of bony tumour, arising after an injury, and successfully extracted from the orbit. The patient was a farmer's daughter, 28 years of age. On the 25th of February 1802, she received a blow from a cow's horn on the upper and inner angle of the left orbit, nearly on the transverse suture. As it inflicted no wound, and the pain soon subsided, it was considered merely as a slight contusion, and httle attention was paid to it. About the beginning of March, there was discovered on the spot where the blow had been received, a small hard tumour, which gradually increased in size, with very little pain and no interruption to her general state of health, so that she continued her usual laborious employments about her father's house. On the 1st of October, she consulted Mr. L., who found, covered by the upper eyelid, a very hard tumour, of an oval form, and rather flat, somewhat more than an inch in its perpendicular diameter, and extending horizontally, about an inch and a half in length, from the inner angle of the orbit towards the eyeball, which was displaced. The tumour seemed to occupy the greater part of the orbit, and had forced the eye forwards and outwards, so that it hung pendulous and loose, and apparently entirely beyond the ex- terior edge of the outer angle of the orbit. Mr. L. concluded that the optic nerve and muscles must have been elongated nearly an inch. She could still discover objects with the eye, although its sight was much impaired. She complained of little pain, even when the tumour was pressed or handled pretty freely. Mr. L. resolved to ascertain the nature of the tumour, which, although hard, appeared somewhat loose. With this view, he made a hori- zontal incision through the upper eyelid, about an inch in length, along the greater diameter of the tumour. On separating and rais- ing the edges of the wound, the tumour was discovered to be a solid piece of bone, covered only by the common integuments, and a thin membrane somewhat resembling periosteum, to which the tumour was but slightly attached. No part of the bones of the or- * Gluoted from Haller by Mr. B. Bell, in his Treatise on the Diseases of the Bones ; page 121. Edin. 1828. Referred to also by Acrel. I have not been able to find the original account of the case. 6 42 bit was denuded : and although the manner of the adhesion of the tumour to the surrounding parts could not be ascertained, it remained firm and immoveable, notwithstanding considerable efforts to loosen it and bring it away. The wound made by the incision did not heal up, but continued nearly of its original size, discharging a small cjuantity of thin matter. The bone continued to increase in size, and the eye was still more pushed out of its natural position, although some degree of sight still remained in it. The patient continued in perfect health. At length, towards the end of September, 1803, the bone becoming carious and evi- dently loose, and pushing somewhat forwards, Mr. L. endeavored to extract it, by making, wiih a small scalpel, an incision around the edges of the former wound, to detach it from any adhesion at its orifice, and then taking firm hold of the exostosis with a pair of strong forceps. The first attempt failed ; but a second, made sev- eral days afterwards, succeeded. Mr. L. extracted, without much exertion or difficulty, a piece of bone, of an oblong shape, weighing an ounce and two drachms, an inch and a half in length, and 2 inches f ths in circumference, hard, solid, and pretty smooth. The extraction of the bone was followed by no haemorrhage ; a few drops of blood only were discharged from the edges of the wound. The cavity from which it was extracted was found to be lined with a strong membrane, cjuite smooth on the upper and inner sides, but somewhat uneven on the side next the ball of the eye. No perforation or communication with any of tlie surrounding parts could be discovered in it : when examined both with a probe and the finger, little irritation or pain was produced, and the bone had evidently no connexion or adhesion with any bone adjoining to it. In March, 1805, when Mr. L. published his account of the case, the wound was still open, and the cavity still extended in a straight direction backwards to two inches in depth. A little lint, covered by a bit of silk, hid the deformity. Ever}^ time the dressing was removed, the inside of the cavity was found to be covered with a slight exudation. The eyeball had in a great measure recovered its natural situation, and the sight of the eye had been complete!)'' restored.* The bone extracted in this case was particularly ex- amined and analyzed by Dr. Duncan, junior, who hns also pub- lished two figures illustrating its external appearance and internal structure. Its shape he represents as extremely iiTegular, but somewhat resembling a wedge cut out of a sphere. The convex back of the wedge, which was turned towards the middle line as it lay in the orbit, although extremely irregular and studded with processes, was in general smooth and polished. The sides were concave and much less uneven, but in no part had a smooth cr polished surface. They resembled those points of bone to which cartilage, ligament, or membrane is firmly attached, being full of • Edinburgh Medical and Surgical Journal, Vol. i. p. 405. Edin. 1805. 43 ;mall pits or depressions, and rough, as if corroded by the action )f a caustic fluid. In no part, after the most careful examination, ltd it show any appearance of fracture, and therefore (conchides Dr. D.) could not have been an exostosis. Its colour was yellow- sh-white ; its saw-dust snow-white. It was extremely hard. When cut, its internal structure was found to be nearly uniform, ;om3what like that of ivoiy, being very slightly marked with the ippearance of radii, extending from the middle of the edge to the ;onvex back of the wedge. It admitted of being polished like vory. In specific gravity and chemical composition, it scarcely liffered froui a piece of adult os femoris.* That this was an osse- )U3 tumour formed without any connexion with the bones or peri- )steumofthe orbit, is extremely improbable. I have not hesi ated quote it as a case of exostosis, notwithstanding Dr. D.'s opinion the contrary. That it had before its extraction become loosened, lot altogether by fracture, but at least partly by absorption, from my connexion it might have had with the walls of the orbit, is 'ery evident. It must also be kept in mind, however, that when \Ir. L. first attempted to extract it, it was so immoveable, that he ;ould not loosen it, to bring it away. To what could its immobil- ty be owing, but to its adhesion to the walls of the orbit ? That idhesion might have been cartilaginous or even osseous ; and yet ifter being allowed to become carious and to grow loose, during he course of a whole year, the piece of bone might, on extraction, jresent no mark of fracture. Even at the end of a year after his irst operation, Mr. L. did not succeed in his first attempt to extract fc. At his second trial, he did succeed, and found the cavity in vhich the bone had been lodged smooth, except towards the eye- )all. Of course it is impossible to decide, with certainty, how his bone grew ; but I regard it as much more probable that it vas an exostosis separated from its point of growth, by the frequent ixarainations which bad been made of it by Mr. L. and others, uid by the attempt first made by that gentleman to extract it, ,han that it was a formation of bone in the cellular membrane of he orbit, entirely unconnected with the walls of that cavity. 4. Exostosis of the orbit 7iot discovered till after extirpation f the protruded eyeball. Dr. Anderson has related a case of ex- )phthalmos, arising from exostosis on the floor of the orbit. The jatient, Mrs. Craig, aged 24, was admitted into the Glasgow Royal [nfirmary, 5th January, 1828 ; at which time the right eyeball ,vas almost protruded out of the orbit. As I had occasion to see .his patient before she went to the Royal Infirmary, I may men- ion that the protrusion was directly forwards, so that, though the dea of the exophthalmos probably depending on exostosis of the Drbit, naturally occurred to my mind, I could not have been led to issign any one of the sides of that cavity more than another as * Edinburgh Medical and Surgical Journal, Vol. i. p. 407. Edin. 1805. 44 likely to be the seat of such a growth. Ectropium tirid cheraosis attended the protrusion. The cornea was ulcerated and muddy; the pupil imraoveably dilated, and vision lost. The patient had constant severe pain in the bones of the orbit, and right side of the head, rendered more acute by pressure. She had rheumatic pain of the knees. Her health was greatly impaired, but had im- proved since her delivery 8 weeks before her admission. The vis- ion of the eye had been dim for 18 months, and completely lost for 4. The pain of the head was of 12 months' standing, and the prominence of the eye of 8 weeks'. She had had some discharge of yellow fluid from the right ear. about the time when the sight was lost, but not afterwards. Her mouth was affected by pills which she had taken for five or six weeks. Dr. A. suspected syph- ilis, but she' denied it : and as the mercury seemed to have had little other effect tha.n that of increasing debihty. he suspended its use, and endeavoured to procure relief from other medicines and external applications, chiefly opiates and narcotics. These did not succeed. He then evacuated the humour.-? of the eye, but this also was ineffectual. He next extirpated the eye with the knife, after which, a tumour about the size of a hazel-nut was discovered on the floor of the orbit, solid, nodulated, and bony. The pressure of this exostosis had been the cause of the pain and protrusion, but as it was firmly fixed, and could not now exert any injurious pressure, it was not considered prudent to attempt its removal. From some inflammation and fulness in the right nostril. Dr. A. had been led to suppose it likely, that there might have been a fungous or other tumour pushing upwards from the antrum to the orbit. The relief from pain was remarkable after the extirpation of the eye. Plum- mer's pill, and a decoction of sarsaparilla, were now used for several weeks, during which time the patient got almost quite well ; but whether this proceeded from the removal of the eye, the discharge which succeeded it, or the medicine. Dr. A. does not decide. He believes that all of these were useful. It was his intention to have advised the insertion of a pea issue in the neck, and a continuance of the medicine, but ihe patient left the Infirmary on the 1st of March, without receiving these instructions. At that time, her health was good, and there was no appearance of increased growth in the orbit.* 5. Exostosis filling the orbit. Dr. Baillie, in his Series of En- gravings illustrative of Morbid Anatomy, has given a figure of a preparation of exostosis of the orbit belonging to Mr. Hunter's mu- seum. The figure represents an inner view of a section of the fore part of the cranium. The section had been made at such a level, as to include a small part of each orbit. A tuniour is represented as occupying the left orbit, which it has considerably dilated, and shcotiog for some way across into the other orbit, and backwards " Glasgow Medical Journal, Vol. i. p. 319. Glasgow, 1828. 45 into the cavity of the cranium. Dr. BailHe mentions that the tumour was nodulated, and presented a compactness of texture exactly like that of ivory. Unfortunately no history of the case ap- i pears to have been preserved. It bears a certain degree of resem- blance to the remarkable case of hyperostosis of the orbits already , quoted from Mr. Hovvship*. Dr. B. has hazarded a conjecture re- garding it, for which, 1 should think, there is scarcely any founda- tion, namely, that perhaps this tumour consisted of the eye convert- ed into bone.t 6. Extostosis 'proceeding from the Tnaxillary sinus into the orbit. Boyer relates the case of a man, who for more than ten 3'ears had an exostosis of the left maxillary sinus. The eye on that side was affected with stillicidium lachryrnarum. The eyeball was pushed forward, the nose twisted to the right, the nostril closed, and the palate somewhat swollen. The tumour was very prominent upwards and outwards, and the skin covering it red and shining. The visage was excessively deformed. The exostosis had appear- ed soon after a venereal infection, which had been followed by sec- ondary symptoms. It had increared slowly ; but for several years had made no progress. Painful at first, it had ceased to be so when it stopped growing. The patient, of his own accord, resolved to try fully the effect of the liquor of Van Swieten ; and after having taken, without any medical advice, and in less than three months, 128 grains of corrosive sublimate, he was entirely freed of the ex- ostosis. The eye returned into the orbit, the stillicidium ceased, and the nostril became free. A depression on the cheek, and an adhesion of the skin, marked what had been the situation of the tumour.t Sir Astley Cooper observes, that exostosis of the facial bones is of frequent occurrence. He mentions, that in the collection at St. Thomas's, there is the skull of a fish-woman, who died in that hos- pital, and who had long been remarkable, even at Billingsgate, for her hideous appearance- Two large sweUings had been formed under the orbits in the forepart of the cheeks, between which the nose appeared wedged, and the nostrils were closed. Each eye projected considerably from its socket. This person was seized with a fit, which seemed to be of an apoplectic nature, and in that state was brought to St. Thomas's hospital, where she died almost immedi- ately. Upon examination of the head, an exostosis was found growing from each antrum, and forming the large swellings upon the cheeks. The exostoses projected also into the orbits, so as to occasion the protrusion of the eyes. On the left side, the exostosis entered the cranium, projecting inwards through the orbitary pro- cess of the OS frontis, and occasioning such pressure on the brain, * See page 36. t Baillie's Series of Engravings, Fasciculus x. Plate I. Also his Morbid Anatomy, p. 446. London, 1812. X Boyer, Traite des Maladies Chirurgicales. Tome vi. p. 168. Paris, 1818. 46 as, under a considerable excitement of the vessels of that organ, to produce apoplexy, which proved fatal.* I recollect a very remarkable skull, which was presented by Pro- fessor Sue to the Museum of the Ecole de Medicine at Paris, where it is still preserved. It has been described t as an example of osteo- sarcoma, but 1 think there can be scarcely any doubt of its being an exostosis of the maxillary sinus. The osseous tumour, which is actually not much less than an ordinary cranium, is smooth and polished externally, very thin at its upper part, hard and covered with bosses posteriorly, and interiorly filled with osseous cysts. It springs from the right maxillary sinus and lower part of the frontal bone, and extends from the right mastoid process towards tlie left maxil- lary bone. No trace is to be seen of the right orbit ; the right nos- tril is entirely obliterated ; as well as a portion of the left orbit. The tumour proceeds downwards and forwards from its origin, to a level with the basis of the lower jaw, measuring from the mastoid process 12 inches in length, and in circunjference 16 inches. 7. Exostosis- from the facial hones shuttivg vp the orbits. Jourdain has related and figured a remarkable case of exostosis of the bones of the skull, and especially of those of the face. The patient was the son of a surgeon at Perpignan, At the age of 12 years, he was affected with a lachrymal tumour at the inner angle of the right eye, which his father opened, and which suppurated for a pretty long time. When the tumour was opened, an eminence was observed growing from the middle of the nasal process of the upper maxillary bone, about the size of a small almond. It resist- ed different local applications, and grew insensibly, so that in a short time it was a considerable tumour. By the time that the pa- tient was 15, his two upper niaxillory bones were equal, and pre- sented two eminences so considerable, that they served to bury be- tween them the cartilages of the nose, and so compressed the nos- trils, that the patient could breathe only by the mouth. His school- fellows could not endure the deformity of his face ; 3'et they loved him for his wit and talents. Every thing was done by his father which was likely to remove the disease ; but all was ineffect- ual. By the age of 20, his appearance was monstrous, so that his friends dissuaded him from thinking of the priesthood, to Avhich he had intended to attach himself His lower jaw was also affected with an enlargement, which augmented more and more. Although his appearance was such as to oblige those who met him to turn awa}^ from looking at him, he was very curious, and would visit every thing which excited attention. He ate and drank well, till having reached his 44!h year, he was attacked with fever ; during his convalescence from which he became blind. As he recovered strength, he began to see with the left eye, and to go about alone ; * Surgical Essays, by Cooper and Travers. Vol. i. p. 169. London, 1818. i Dictionaire des Sciences Medicales. Toinexxxv. p 25. Paris, 1819. 47 ! but inflammation of the chest supervening, with suppuration, and bloody expectoration, he died. On dissection, the left lung was found almost entirely destroyed by suppuration. With the greatest attention, it Avas impossible to discover any of the muscles of the I face. The skin was glued to the periosteum. The cranium and face were entirely exostosed. Tlie malar bones especially appear; from Jourdain's tigure, to have each given rise to a large exostosis, projecting so as to meet, covering the nose, and in a great measure the orbits. The lower jaw also is exceedingly enlarged. The exostoses were as hard as marble. The cranium and face weighed 5 French pounds; the lower jaw by itself weighed 3 pounds 3 ounces ; the whole together 8 pounds 3 ounces ; whereas, an ordi- nary adult skull, including the lower jaw, Aveighs generally about |1 pound 9 ounces, or at most 1 pound and 3 quarters, so that tak- ling the pound at 16 ounces, the exostoses had augmented the weight bf the head 6 pounds 7 ounces. This patient had never complain- ed of pain in his head nor in his lower jaw.* ■ 8. Caplike exostosis of t!ie edge of the orhit. Acrel relates a 'ase of this sort under the title of Spina Yentosa of the right orbit. The bones forming that cavity, especially the frontal and superior uaxillary, were so much protruded, as to present the appearance )f a blunt cone, four fingers' breadtli high, and about the same in liameter at its basis. He compares it to a small cup inverted, in he bottom of which, or end which w^as turned outwards, was the iye. It was not completely sound and clear, and was smaller than he left eye ; yet it had eyelids, which were moveable, and the other Darts belonging to it, and even served to distinguish large objects )retty well. Acrel considered the case incurable. He mentions hat he had seen another case of the same sort, for which also he egarded it as useless to attempt any operation.t 4. Osteosarcoma, By some cdXleA fibrous exostosis, and by Sir Astley Cooper /wn- jous exostosis of the medullar y metnhrane, sometimes attacks he skull, and may involve the bones of the orbit. This kind of umour takes its rise within the spongy tissue of the bones, consists »f a substance much softer than ordinary cartilage, containing nu- nerous slender spiculse, or thin plates of bone, radiating through it, lepends on a particular state of constitution, and appears invariably be malignant. Dr. Baillie has figured a skull affected with several tumours of his sort ; one of which had its seat close upon the right exter- lal angular process of the frontal bone.t ♦ Jourdairi, Traite des Maladies de la Bouche, Tome i. p. 289. Paris, 1778. t Acrel, Chirurgische Vorfalle, Uberselzt von Murray. Vol. i. p. 102. Gottingen, 777. t Baillie's Series of Engravings. Fasciculus x. Plate 1. 48 I Sir Astley Cooper has given a sketch of an osteo-sarcomatous tumour on the forehead, extending close to the edge of the orbit. Sir A. persuaded the subject of this tumour to submit to an opera- tion. On removal, it was found exactly of the character above mentioned, and although partly formed of osseous spiculae, was readily broken down with the finger. The patient became feverish and comatose, and died on the 6th day. On dissection, Sir A found that the swelling occupied the internal as well as the exter- nal table of the skull, that it extended through both, and affectet the dura mater, which had several fungous projections proceeding from it, and that the inflammation excited by the operation, hac extended to the membranes of the brain. The complaint seemec to have originated in the diploe of the os frontis, and to have pro i duced an effusion both between the pericranium and the skull, anc ; between the skull and the dura mater. The ewelUng upon th( outer part of the head, was, however, much larger than that whicl had arisen from the inner table. It was evident, too, that this case must have ultimately proved fatal, although no operation had beer performed. Sir A. concludes by observing, that an exostosis on thi external table of the skull, growing slowly, very little vascular, un attended with any considerable pain, may safely be rendered th( subject of an operation ; but that a swelUng of more rapid growth red upon its surface, showing signs of considerable vascularity, an( attended with great pain shooting through the brain, is one fo which he should hesitate again to perform an operation.* Thes' latter characters belong not to simple exostosis, but to osteo-sarcoma Mr. Crampton relates that he v.-as consulted by a lady of abou 55 years of age, on account of dimness of sight affecting the righ eye ; the eye felt exceedingly hard to the touch, was af!ected by stra bismus, and projected in some degree from the orbit ; the pupil wa immoveable, but vision was not altogether destroyed. She com plained of severe shooting pains in the head and in the right arm her general health v.^as much affected, and her aspect almost C8 daverous : her memory seemed much impaired, and there was general insensibility to external impressions ; she was depressed i; her spirits, yet she made but httle complaint. On an attentive ex amination it was plain that there was some fulness in the situatioj of the temporal fossa, but the tumour was perfect!}^ indolent an incompressible. Mr, C. did not see the lad}' again for 4 or 5 week: when he found her nearly comatose; the swelling on the tempi had increased to a considerable degree, and the eye was still furthe protruded from the orbit. She expired in a few days, and on th day following her death, the head was examined. On raising th aponeurosis of the temporal muscle, the temporal fossa was foun to be occupied by a grayish coloured substance of the consistence ( brain ; the muscle itself had completely disappeared : numerot • Surgical Essays, by Cooper and Travers. Vol. i. p. 212. Lend. 1818. 49 |)sseous spiculee proceeding from the frontal and temporal bones, )assed into the tumour, of which they constituted a considerable )art. On opening the head, a tumour of precisely the same de- icription, beset in the same manner by bony spiculee, was found edged between the dura mater and the internal orbital process cf J*; he frontal bone. On macerating the bone, it exhibited the most |i Perfect specimen Mr. C. had seen of the fibrous exostosis. The . ipiculee proceeding both from the outer and from the inner table of he cranium were each about as thick as a hog's bristle, and f ths )f an inch in length ; they were set as closely together as the hairs )f a brush, and extended in an undulating line over a space of I bout two square inches in extent. The tables of the skull were ilightly separated from each other in the part corresponding to the exostosis, and the diploe seemed to contain some of the same brain- ike matter which formed the bulk of the tumour. Mr. C. thinks t impossible to decide whether the disease commenced in the soft Darts, or in the bone ; although it seems to him probable that it i ;ommenced in the bone, because the spiculae were furnished by the 3one itself, and not by the periosteum or dura mater, which were separated by the tumour to the distance of nearly an inch from he outer and inner tables of the skull respectively. Mr. C. ob- serves that in malignant osteo-sarcoma, it is more usual to find a deficiency than an excess of bony matter, for although spiculee of jone are interspersed through the brain-like matter which forms iLhe bulk of the tumour, the bone itself is usually divested of its 3arthy basis, and is converted into a steatomatous or cartilaginous substance. Sometimes, however, the tendency to secrete phosphate bf lime is surprisingly increased, and then large and singulaily I shaped masses of bony matter are thrown out from the surface of Lhe diseased bone. The presence or absence of bony matter in an Dsteo-sarcomatous tumour will probably depend, Mr. C thinks, on , the relative activity of the secreting and absorbing systems in the diseased bone. He is also of opinion, that the varieties w^hich are met with in the character and nature of osseous tumours, depend greatly on the kind of constitution of the patient, whether that be ,healthy, cachectic, or scrofulous.* SECTION IV. DILATATION, DEFORMATION, AND ABSORPTION OF THE ORBIT, FROM PRESSURE. When an abscess or a tumour forms within any of the osseous cavities of the body, pressure slowly dilates even the bones, thins them, softens them, and forces them to give way. The bones of the cranium are not exempt from these changes, and have been * Dublin Hospital Reports. Vol. iv. p. 554. Dublin, 1827- 7 50 known to allow a tumour of the brain to protrude externally. Di Donald Monro has related a case of this kind, in which a tumou of the brain protruded through the os frontis ;* and Mr. Hunter ha noticed a case so exactly similar, that it is likely it was the ver same which was seen by Dr. Monro. Mr. H. thinks that the tu mour had probably formed in the pia mater. It was oblong, above an inch thick, and two or more inches long. It was sunk nearh i its whole length into the brain, seemingly by the simple effects o j pressure, but the outer end of it, by pressing against the dura matei j had produced the entire absorption of this membrane at the pari pressed upon. The same irritation had been communicated toth( skull, which was also absorbed ; after which, the same dispositior/ was continued on to the scalp. As these respective parts gave way. the tumour was pushed farther and farther out, so that its outer end came to be in this new passage which the absorbents were making for it in the scalp, by which it probably would have been discharged in time, if the man had lived ; but it was so connected with the vital parts, that the man died before the parts could relieve themselves. While all these exterior parts were in a state of ab- sorption, the internal parts which pressed upon the inner end of the tumour, and which pressure was sufficient to push it out, did not in the least ulcerate, nor did the tumour itself, which was pressed upon all sides, in the least give way in its substance. No matter was to be observed ; neither from the dura mater, the edge of the bones of the skull, nor that part of the scalp which had given way. The general effect, however, was similar to the progress of an abscess, insomuch that it was on the side nearest to the external surface of the body that the irritation for absorption had taken placet The process by which an abscess or a tumour is thus brought to the surface of the body, Mr. Hunter regarded as a combination of interstitial and progressive absorption — interstitial, because parti- cles, only from the interstics of the part, are for a time removed, the part still remaining — progressive, on account of the tending to the surface, till at length the surface gives way, and the abscess or the tumour finishes its progress by being exposed or evacuated. By the process in question, the internal parts of the body are to a cer- tain extent protected from the intrusion of such diseases, and in many cases a cure is effected by the discharge of the morbid accu- mulation or growth. Hence Mr. H. called interstitial and pro- gressive absorption, the Natural iSiirgeon.l If, then, the thick bones of the cranium are forced to yield, how much more readily will the bones of the orbit suffer from the same process, excited either from within that cavity, or without from the * Medical Transactions, Vol. ii. p. 353. London, 1772. t Hunter on the Blood, Inflammation, and Gun-shot Wounds, Vol. ii. p. 307. London, 1812. ± Ibid. Vol. ii. p. 287. 61 surrounding' cavities, the nostril, the frontal, maxillary, and sphe- noid sinuses, or the cranium. 1. Pressure on the Orbit from within the Orhit. Yarious causes within the orbit may, by pressure, produce dilata- tion and absorption of its walls. I have seen the orbit slowly en- larged by the growth and pressure of a diseased lachrymal gland, till it was of size sufficient to contain the fist, and at several points had given way. Effused blood, collections of matter, aneurisms, I enlargements of the eyeball, encysted and other tumours, are all ki' capable of producing such effects. If pressure from within the orbit is sudden, it will in some cases I produce inflammation of the bones, and caries ; but if carried on 1 slowly, perhaps during the course of many years, dilatation and f absorption, without any formation of matter, and even without in- ;flammation, will be the effect. It sometimes happens, however, [that after the orbit has been slowly dilated, and perhaps partly ab- [ sorbed in consequence of the pressure of a morbid growth within it, j the tumour begins to inflame and form matter, and this action I spreading to the surrounding parts brings on caries. If it is the i roof of the orbit which has become affected in this way, the dura j' mater inflames and throws out matter, the brain participates in the j disease, and death follows more or less speedily. ,. 2. Pressure on the Orhit from the Nostril. The nostril communicates with the orbit by the lachrymal pas- sage. The OS unguis and os planum of the ethmoid form a thin i partition between these cavities ; a partition, which, but for the i{ instinctive property of the body already referred to, by which mor- bid growths are always forced towards the external surface, should often be broken through by polypus of the nostril. This tumour, after filling the nostril in which it has originated, dilates it at its anterior opening, and presses the septum narium aside so as to amphfy the cavity of that nostril at the expense of the other. It is i not in general till the nostril is in this way greatly dilated, and of |Course the face much disfigured, that the polypus pushes itself iKirough the os unguis, and projects, covered by the inflamed inte- 'Jguments, in the situation of the lachrymal sac. Previously to this, 1 however, the passage for the tears has been obstructed, and a pain- I ful feeling of pressure experienced in the orbit and through the head. [i As the polypus advances, the orbit is still more intruded upon, the eyeball is displaced, vision is lost, and in some cases even the cavi- 1 ty of the cranium giving way, the morbid growth gains admittance into contact with the brain. Alibert relates the case of Louis Niacre, aged 22, who at the age ![ of 16 became affected with frequent bleeding from the nose, which returned upon the slightest touch. One day the epistaxis being much more severe than usual, dossils of charpie were introduced at 52 the anterior opening of the nostrils, not by a medical man, and per- haps not with sufficient caution and delicacy. The consequence was that the mucous membrane was excoriated. The patient felt some slight pain ; but paid little attention to this circumstance, being satisfied at seeing the bleeding stopped. A year elapsed, when one day having introduced his finger into one of his nostrils, he felt a small prominence ; which, unluckily, he fell into the halnt of rubbing and irritating incessantly, so that in a short time it was considerably increased in size. Respiration became impeded ; the air, in escaping by the nostrils, pushing the excrescence forwards and downwards. The polypus was evidently making progress. The inner angle of the left eye swelled, and became red, tense, and painful. This was attended with stillicidium lachrymarum. A lachrymal tumour formed, in consequence no doubt of the polypus compressing the passage for the tears and displacing the os unguis. The cheek of the same side inflamed, and presented to the touch the feeling of fluctuation. Alibert supposes that the fluid contained in the larchrymal tumour, having made its way into the lower part of the nasal duct, but being hindered by the polypus from entering the nostril, had flowed into the maxillary sinus. Not merely the cheek, but also the interior of the iTiouth w^as aflfected, and the last four grinding teeth of the upper jaw were bent inwards. At this period, the patient apphed to a surgeon, who made a deep incision into the most depending part of the tumour, and gave exit to a large quantit}'' of pus. The cheek fell in consequence of this, but a considerable swelling continued wathin the mouth. As the poly- pus seemed to be increasing from day to day, the surgeon tied the portion of it which protruded from the nostril. After this, it grew no more in length ; but it increased considerably in thickness. The prominence at the inner angle of the eye, began to grow im- mediately after the inferior portion of the polypus was tied. It soon reached the size of a walnut. Its growth pushed the cartilaginous septmn of the nostrils and the vomer to one side ; the ossa nasi were separated from one another ; the whole nose dilated and flat- tened ; one of the lateral portions of the ethmoid pushed outwards, so as to intrude upon the orbit, and force the eyeball forwards be- yond the level of the eyelids. The patient scarcely saw with thd protruded eye. Alibert has given a portrait of the patient at thil[ period ; and mentions that both eyes, but especially the left, seem- ed ready to start from their sockets ; the left eyelids w^ere inflamed ; and the lower everted, the fungous tumour which had sprouted up through the os unguis, preventing it from being applied to the eye- ball. The left nostril was obstructed by the polypus : the right by the vomer, pushed into it by the polypus. The mouth was dis- torted, and its mucous membrane much thickened. Bleeding still took place from the nose on the slightest eftbrt. The patient felt pain between the eyes ; but continued to eat and sleep.* » Alibert, Nosologic Naturelle. Tome i. p. 529. Paris, 1817. 53 The result of this case is not given ; perhaps it may even admit of doubt, whether this was really a case of nasal polypus, or of fun- gus of the maxillary sinus ; but various other cases are recorded, by which the farther progress of neglected nasal polypus, and its fatal termination, as well as its effects upon the orbits, are illus- trated. Mr. Cooper mentions, that in April 1817, a boy in St, Bartholo- mew's Hospital, 12 years old, fell a victim to the ravages of the larg- est and most disfiguring disease within the nose which he ever had had an opportunity of beholding. The tumour had expanded the upper part of the nose to an enormous size ; while below, the left nostril was immensely enlarged. The distance between the eyes^ was extraordinary, being more than four inches. The left eye was affected with amaurosis, brought on by the pressure of (he swelling ; the right retained to the last the faculty of seeing. The tumour nearly covered the mouth, so that food could be introduced only with a spoon, and an examination of the palate was impossi- ble. About a fortnight before death, the leg became paralytic, and during the last week of the boy's existence, an incontinence of the urine and faeces prevailed. On examination of the head after death, a good deal of the tumour was found to be of a cartilaginous con- sistence, and, what was most remarkable, a portion of it, as large as an orange, extended within the cranium, where it had annihi- lated the anterior lobe of the left hemisphere of the brain. Notwith- standing this, the boy was not comatose, nor insensible, till a few hours before his decease. All the surrounding bones had been more or less absorbed, and the place where the excrescence first grew could not be determined.* In 1817, I had an opportunity of examining a skull in the pos- session of Professor Prochaska, which had suffered an extraordinary change in structure and form from polypus. The patient was a young man, 18 years old when he died. During his apprentice- ship to a shoemaker, he had been ill-used by his master, knocked down by blows on the head, and kicked by him while on the ground, in consequence of which he began to be affected with weakness of sight, and prominence of the eyes. In 1786. he was brought to Prochaska, then at Prague. Both eyes were amaurotic, and pro- truding from the orbits, the bones both above the orbits, and at the sides of the nose tumified, and respiration through the nostrils ob- structed. He continued in this state till 1791, without pain, and almost without any other inconvenience than the amaurosis. Gradu- ally, however, the eyes protruded more and more ; the face above the orbits, at the root of the nose, and throughout the whole upper jaw, became enlarged, as did also the palate, which began to pro- ject into the cavity of the mouth. Ichorous discharge followed from the nostrils, with frequent and profuse bleeding. For four weeks * Cooper 's Dictionary of Practical Surgery. Article, Polypus. 54 before his death he was confined to bed from weakness, breathing- not at all through the nostrils, and with difficulty through the mouth ; his mind, however, not affected. On the morning of the 18th September, 1791, his mother found him insensible ; and in the evening of that day, respiration through the mouth and nose being completely impeded, he died. The head, examined external- ly, presented above the eyes two tumours into which the supra-or- bitary arches had degenerated, while the root of the nose, and the upper jaw on each side, were so much swollen that no part of the nose but the point and pinnae was visible. On dissection, the right nostril at its anterior part was found greatly dilated, the cartilagin- ous septum being pushed to the left side ; posteriorly, the osseous septum was destroyed, and both nostrils were converted into one ample cavity, filled by a tumour, remarkable for its spongy excres- cences, and which by its pressure had dilated and pushed down the palate. On opening the cranium, the anterior and middle lobes of the brain were found to be of an unnatural ash colour, and that portion which lies upon the cribriform plate of the ethmoid and or- bitary processes of the frontal bone dissolved, along with the dura mater, into a pulp of the same colour, and in contact with the tu- mour proceeding from the nostrils. On account of the morbid condition of the brain, none of the nerves fiom the olfactory to the auditory could be distinguished. The internal part of the basis of the skull, from the orbitary processes of the frontal to the basilar process of the occipital bone was tumified and softened. After this examination was made, the head was submitted to maceration,, which being finished, there fell out from the basis of the cranium, and from the nostrils, a ponderous mass, partly lardy, partly cartilagin- ous, but not at all osseous, which by means of its soft processes had penetrated into the osseous swellings above the orbits, filling all the interstices of the radiating laminae into which these swellings had degenerated, and emerging at these places under the common integ- uments. The following was the state of the cranium. The orbi- tary processes of the fiontal bone, the ethmoid, the vomer, the tur- binated bones, the httle wings of the sphenoid, and its middle part, except the anterior clinoid processes, which adhered by osseous'fila- ments to the remaining part of the sella turcica, the anterior part of the basilar process of the occipital bone, and the apices of the petrous portions of the temporal bones, as far as the carotid canals, were so completely consumed, that the vast cavity of (he nostrils, along with that of the mouth, opened into the cavity of the cranium. Forth from the cranium also, as well into the compressed and deformed orbits, as into the supra-orbitary swellings alieady described, there were many larger and smaller openings. The superior maxillary bones, with their nasal processes, and the proper bones of the nose, were much expanded, and so thinned away, that they presented va- rious gaps, opening into the cavity of the nostrils. The palatine processes of the superior maxillary bones had disappeared ; the 55 pterygoid process of the sphenoid bone, on the right side, had so receded in its superior part, that the spheno-pnlatine foramen much enlarged, opened into the zygomatic fossa. The left antrum High- morianura had disappeared from compression, and the right opened backwards by a large hiatus.* 3. Pressure on the Orhit from the Frontal Sinus. If we consider that when the frontal sinus is enlarged inde- pendently of disease, it separates the orbitary plate of the frontal bone into two laminae, as may not unfrequently be observed in the skulls of very old persons, it will not appear strange that the pres- sure of a diseased and dilated frontal sinus should deform the orbit, displace the eyeball, destroy vision, and ultimately disorgan- ize the bones upon which the pressure is exercised. The frontal sinus, like the maxillary, is liable to several differ- ent kinds of disease, namely, 1st, inflammation of its lining mem- brane, ending in a collection of matter, which may be either thin, or thick and curdy ; 2d, encysted tumours, or what some have chosen to call hydatids ; 3d, tumours, more or less solid, and which are usually considered to be of the nature of fungus or polypus. 1. Inflammation of the frontal sinuses, ending in a collection of matter. The frontal sinus, on each side, is lined by a thin mu- cous membrane, a continuation of that which lines the nostrils. The two sinuses are separated by a bony partition, which rarely runs in the course of the middle line ; so that, in general, the one sinus is larger, and, in many instances, much larger, than the other. Each sinus communicates with the middle meatus of the nostril, through the medium of the anterior ethmoid cells. The com- munication is narrow and circuitous. Whether the diseases of the frontal sinuses are mainly, or frequently, or at all, to be attributed to accidental closure of this communication, I shall not pretend to say. Beer has mentioned sudden suppression of severe catarrh, as a cause of matter collecting within the sinuses. It is known, that in cases of wounds penetrating into these cavities, their lining membrane inflames, and secretes a white puriform mucus, which has sometimes been mistaken for the substance of the brain. Cold, and the other causes which give rise to the inflamnnation of mu- cous surfaces, m.ay also affect the lining membrane of these cavi- ties ; and in strumous constitutions curdy pus will be apt to collect there, as it often does in the maxillary sinuses. I may here observe, that there appears to exist a sympathetic influence between the Schneiderian membrane and the retina, probably through the medium of the branches of the fifth pair, which must lead us to regard the diseases of the nostrils, and of Prochaska has given two engravings, exhibiting a front and a side view of this remarkable skull, in his Disquisitio Anatomico-Physiologica Organismi Corporis Hu- mani. Vienna, 1812. p. 172. 56 the frontal sinuses, as operating- not merely mechanically upon the orbit, but vitally on the organ of vision. Suppression of the natural discharge from that membrane, independently of any other alteration, seems occasionally to be the cause of amaurosis. It will scarcely be necessary for me to quote cases of simple suppuration of the frontal sinuses ; I shall refer the reader to the cases related by Runge* and Richter.t One of these recovered after the sinus was opened externally ; another, after bursting of the matter into the nostril ; while a third proved fatal after spon- taneous discharge of the matter through the external table of the frontal bone, and through the middle of the upper eyelid. In the early stage of inflammation of the frontal sinuses, the obscurity of the symptoms will rarely permit any decided judg- ment to be formed of the case, or any active treatment to be adoped. In ail the three cases to which I have referred, the dis- ease had advanced either to the formation of a considerable pro- trusion of the outer wall of the affected sinus, or even to the giving way of the cavity, and the evacuation of the contained matter, before any suspicion seems to have been excited. Leeches, and other antiphlogistic means would, of course, be adopted, were we early enough in being called in, and did the pain, and other symptoms, appear to indicate inflammation of the lining membrane of the sinus. Emollient, and afterwards stimulating vapours, drawn up into the nostrils, might be tried. Jf they should succeed in exciting a considerable discharge from the nostrils, this might tend to relieve the inflamed membrane of the sinuses. In the suppurative stage, perhaps counter-irritation and a variety of other measures, might prove useful. The last stage, in which the frontal bone becomes deformed, thinned, softened, so that it yields to external pressure like a piece of elastic cartilage, or even perforated by absorption, or by caries, cannot be mistaken ; nor can there exist any doubt about the propriety of opening the sinus, either with a small trephine, or with a strong curved knife, evacuating its contents, endeavouring to im- prove the sto-te of its lining membrane, by lunar caustic injections, and the like, and then allowing the parts to granulate and heal. In one case, in which Beer trepanned the sinus, not merely was that cavity restored completely to its natural state, but the eyeball returned to its proper place in the orbit, and vision was recovered. In a second case, in which the external appearances were not nearly so alarming as in the former, after opening the outer table, he found, on examining cautiously with the probe, that the inner table was softened, and even drilled through; in this case the e^^e was totally bhnd. and Beer endeavoured merely to check the pro- * Runge de Morbis Sinuum Ossis Frontis et Maxillae Superioris ; in Haller's Disputationes ChirurgicfE. Tom. i. p. 212. Lausannse, 1775. t Novi Commentarii Societatis Regies Gottingensis. Tom. iii. p. 85. Gottingae- 1773. 57 gress of the disease, by inaking a counter-opening through the conjunctiv^a, above the eyeball. lu a third case, the symptoms were decidedly those of a collection of puriform mucus in the sinus, but the patient would hear of no operation being attempted. Five weeks after Beer's first visit, the outer wall of the sinus gave way of itself; and in course of two weeks more, the eye was lost, and a great portion of the orbit and of the nose destroyed by caries. The other eye remained completely amaurotic* 2. Encysted tumours, or hydatids, of the frontal simises. Langenbeck has given an interesting narrative of a case of exoph- thalmos from diseased frontal sinus. He speaks of it as a case of hydatid ; a term much misapplied by the German pathologists ; Runge would have probably regarded it as a cystic tumour ; per- haps it was nothing more than a collection of thick matter. The situation of the protrusion is one of the most remarkable circum- stances of the case. A ploughboy, of 20 years of age, 11 years before his admission into the hospital, had, while playing at tennis, received a stroke with a racket on the left side of the nose, and on the left eye, the consequence of which was a great degree of swelling, which, after a time, completely disappeared. Two years afterwards, he began to feel pain in the part, and observed a protuberance at the inner angle of the eye. When the patient came to the hospital, Lang- enbeck found the eyeball natural in form, the power of vision not affected, and the pupil lively. The eyeball, however, was pressed outwards and downwards, by a considerable swelling at the inner angle of the eye. The swelling had exactly the appearance and the situation of a greatly distended lachrymal sac, but was con- siderably bigger than we almost ever find the sac, even in its state of greatest enlargement. That this swelling did not consist in an enlarged lachrymal sac, Langenbeck concluded from his not being able to empty it by pressure, no mucus or tears being evacuated from the puncta on pressure, and the tears being duly conveyed into the nostril without dropping upon the cheek. The patient's voice was similarly affected as that of one with polypus in the nose. The swelling communicated an obscure impression of fluctuation. At the inner side of the swelling, or towards the nose, it was bounded by a sharp edge of bone, which was felt exactly where the nasal process of the upper maxillary bone rises by the inner side of the orl3it. As the surface of the swelling was not covered by any layer of bone, but felt soft and fluctuating, it was not easy to form a proper judgment regarding its seat, and one might have readily fallen into the error of supposing it to be an enlarged lachrymal sac. Against such a supposition, no doubt, there was the remark- able displacement of the eye outwards and downwards. As the swelling also extended from the inner angle upwards and towards * Lehre von den Augenkrankheiten, Vol. ii. p. 570. Wien, 1817. 8 58 the frontal sinus, Langenbeck concladed that that cavity was the seat of the disease. Six months before, he had extracted a large hydatid from tlie frontal sinus of a young woman, in whom the external table had been very considerably pushed forwards, and the orbitary process of the frontal bone so much depressed, that the eyeball lay opposite to the point of the nose. In this case he had perforated the external table, and extracted what he teriiis the hydatid ; after which the sinus appeared 2^ inches deep. He was led then to suspect a similar disease in the ploughboy; that the swelling was contained in the frontal sinus, whence it had pressed itself downwards into the nostril, and at the same time had pressed the inner wall of the orbit outwards.* He proceeded to operate in the following manner. He made an incision from above down- wards, close to the sharp edge of bone which was felt at the inner side of the swelling, and in such a way as to avoid both the lachry- mal sac and lachrymal canals. After the soft parts were suffi- ciently divided, a white glistening sac came into view. On touch- ing this with the finger, it was evident that it contained a soft mass. He separated the swelling as much as possible ; but as he found that it extended deep into the nostril, he opened it, whereupon there issued from it a greyish white tenacious substance. He cut away with the scissors as much as he could of the sac, and introduced his finger into its cavity. Its depth amounted to 3 inches. With the point of his finger he reached as far as the floor of the nostril. He could not reach the orbit, nor touch the eyeball. He felt from the diseased cavity the inner wall of the orbit, formed by the os planum of the ethmoid, a part of the orbitary plate of the frontal, and the os unguis. This wall of the orbit, along with the lachry- mal sac, and nasal duct, was pressed outwards ; hence arose the displacement of the eyeball, while the passage of the tears into the nose continued uninterrupted. Langenbeck introduced his forefinger up into the frontal sinus. He decided, therefore, that the disease had originated there, and had descended by the side of the nostril. He could now see into a large cavity, filled with a grayish white tenacious mass, which he removed witli his finger and a pair of forceps. This substance was contained in a shut sac, distinct from the mucous membrane of the sinus ; and had it not been so, he thinks the substance in question would have made its way into the nostril. As has already been mentioned, the swelling was not covered by bone at the inner angle of the eye. It must therefore, he thinks, have made its way either between the os unguis and nasal process of the superior maxillary bone, or it must have pro- duced the absorption of the latter. This is the more probable con- jecture, as the edge of the nasal process felt so sharp. The tena- cious substance, which was extracted, was enough to fill a tea cup.t * Outwards, from the middle line of the bod^'. Langenbeck says inwards, but he must mean inwards in reference to the axis of the orbit. t Langenbeck's Neue Bibliothek fur die Chirurgie und Ophthalmologie. Vol. ii. p. 245. Hanover, 1819. 69 Mr. Keate has recorded a case of what he terms an enormous collection of hydatids, between the two tables of the frontal bone. He appears to be of opinion that they were not contained within the sinuses. I might therefore be blamed for quoting the case, in- teresting as it is, did I not consider the evidence adduced insufficient to prove that the sinuses were imconnected with the disease ; and did I not conceive these cavities liable to be affected in the very manner described by Mr. K. The patient, a girl of 18 years of age, consulted him about a large tumour, chiefly over the left orbit, but extending partially above the inner angle of the right orbit also, and occupying the greater part of the left portion of the frontal bone. She had first discovered a small hard tumour about the size of a hazel nut, 6 years before, towards the lower part of the bone over the left brow, which had at first increased slowl}^, but for 3 years more rapidly, so that it had attained the size and shape of fths of a large orange. She had felt uneasiness externally from the com- mencement of the swelUng, attended with a sense of throbbing round its base ; but till a short time before consulting Mr. K., there had been no symptoms of internal pressure. She then felt, how- ever, intense headachs, occasional vertigo, dimness of sight, nausea, and tinnitus aurium. Mr. K. concluded that the disease lay be- tween the two tables of the frontal bone, the external table being pushed forward so as to cause the convex protuberance, while the internal was probably depressed and was giving rise to the above- mentioned urgent symptoms. By a crucial incision through the integuments, Mr. K. exposed the bony covering of the tumour. It appeared extremely thin and vascular. He had divided about one- third of the circumference of the base of the tumour, with the met- acarpal saw, when one of the assistants thought he perceived, through the groove made by the saw, a pulsation, as if of the ves- sels of the dura mater. This led Mr. K. to detach a portion of the bones, in order to ascertain the nature of the tumour, before he proceeded farther in sawing through the base. This was effected by the elevator, when a thin transparent membrane was discovered closely lining the bony case ; but in breaking off this small piece of bone, the cyst was ruptured, and its contents, a thin colourless fluid, escaped ; the cyst at the same time collapsing into the cavity. On examining the cavity with the finger, it presented an irregular surface, or floor, hned by the membrane above described, but evi- dently depressed below the proper level of the internal table. No pulsation was now perceptible, and no orifice, leading through the internal table and communicating with the meninges, was discov- erable. Some more small pieces of bone were then removed, but the patient had by this time become so exhausted that it was thought prudent to discontinue the operation, leaving the remainder of the bony case to be subsequently detached, or destroyed. Severe pain, and violent fever followed the operation. The cavity of the tu- mour was at first tightly filled with coagula, which after a time 60 I separated, and the wound discharged freely. Pieces of bones were removed from daj^ to day, and kali puram was occasionally applied to promote exfoliation. At length, ou the left side of tlie wound, where the surface had healed very quickly after the operation, a small puffy tumour appeared, which Mr. K. considered to be a part of the original cyst filling again. An attack of fever and erysipe- las coming on, the kali purum was discontinued, and the wound allowed to heal. The puffy swelhng above-mentioned gradually increased in size to nearly that of the original tumour. Whenever it became tense, the membrane and thin cuticle gave way, and the contents (the same sort of limpid fluid that was originally dis- charged) were evacuated. The cyst then collapsed, the opening healed, the tumour filled again, and the same process was repeated. About 10 months after the first operation, the cyst had increased to a great extent, and protruded beyond the limits of its former bony covering ; even the circumference of the bony base was evidently enlarged. Mr. K. punctured the cyst, and about 4 oz. of a clear straw-coloured fluid escaped : the cyst collapsed, but under it there appeared to be a soft tumour filling the cavity within the bony prominence. When the cyst filled again, he applied kali purura to its tense surface ; four days after which, nearly 4 oz. were evacua- ted from it, through the opening made by the caustic, and a mem- branous bag came away with the discharge. Mr. K. considered this bag to be a hydatid. He repeated the kali purum till the whole covering of the tumour was destroyed. This disclosed a number of separate cysts lining the cavit}". To these the caustic was freely applied. They were slowly destroyed, and rapidly reproduced. Nitric acid, sulphas cupri, and the actual cautery heated 212°, vvere tried without any better effect than the kali purum. An arsenical caustic was next employed, and produced a very large and deep slough, which appeared to remove the greater part of the remaining hydatids. There were still, however, imperfect cysts, particularly at the outer part of the tumour near the left temple, and at the upper part of its base, to which Mr. K. reapplied the arsenic. Seven days after this application, a slough separated from nearl}'^ the whole internal surface of the cavity, leaving only two distinct cysts visible at the lower and anterior part, just over each frontal sinus. Mr. K. passed a probe into each ; the cavity was trifling, and did not ap- pear to communicate with the sinus : but on pressing the bottom of the left cavity, acute pain w^as produced in the eye of that side. For some days after this, the patient suffered severe pain in the bead, a sense of tightness across the forehead and pain in the globes of the eyes. These symptoms were removed by the free use of leeches. She had suffered so much from the repeated and severe escharotic applications, that Mr. K. now resolved again to expose the bone and to remove the whole of the remaining emi- nence by the saw. This was accordingly done. The largest di- ameter of the basis cut through by the saw was 4J inches : the 61 smallest, 4 inches. In the very hard and compact bony substance forming the base of the tumour, were found 5 or 6 cells containing h3a1atid cysts. These were carefully removed. The original large aav'ity, which had formed the centre and greater mass of the tu- mour, from whence there had been (to use Mr. K's expression) such i rapid and inveterate growth of hydatids, was also denuded of its :ysts and granulations, and the inner table of the cranium entirely exposed. Lint, impregnated with a strong solution of co[)per, was applied to the whole of the denuded surface. Granulations rap- idly filled up the exposed cavity ; till an inflammatory attack in ,he chest, requiring repeated blood-letting, appeared to check their progress. After this, some small exfoliations took place ; and as aer health and strength improved, the wound contracted, and ulti- mately healed completely ."* 3. Polypus of the frontal si7iuses. I know of no case upon •ecord, in which polypus was found in either of the frontal sinuses, kvithout the same disease existing in the neighbouring cavities at ,he same time. It is, however, quite conceivable that a polypus might occupy one or other of the frontal sinuses, without any tu- mour of the same sort existing in the nostrils, or maxillary sinuses ; md that slowly dilating the cavity in which it took its origin, it might displace the eyeball, and extenuate and soften the external able of the frontal bone. Under such circumstances, the sinus should be opened ; and as polypus generally arises, by a narrow leck, from the mucous membrane, which gives it birth, the tumour might be extirpated with success. In 172-5, there died at the HSpital de la Chariti, in Paris, a /oung man of 17 or 18 years of age, who consequent to his having lad sraall-pox, and for the space of three j'ears, had been alfected ,vith polypus. There were seven of them altogether : in the nose, hroat, maxillary, and frontal sinuses. His appearance was hideous ; lis face enormously enlarged ; his nose spread out to the usual ividth of the malar bone ; and the upper maxillary bones greatly lilated. He had a very considei"able protuberance at the root of the lose ; his eyes were almost entirely protruded from the orbits ; the iistance between them was at least thrice the natural distance ; and he tears ran over the cheeks, mixed with pus from tv/o iachry- iial fistulee. The palate was so much depressed that it lay upon he tongue ; the lower jaw was not changed in size or form, but it vvas continually depressed, so that the sahva flowed uninterruptedly, it the entrance to the nostrils, two polypi were seen, which com- iletely filled these cavities ; as was pioven by introducing a flexible 3robe, which could be passed around each of the polypi, without meeting with any obstacle. On dissection, the one superior max- llary bone was found to be at its middle as thin as the skin of an Miion ; while the other had already given way, so as to bring into * Medico-Chirurgical TransatetionSj Vol. x.p. 278. London, 1819* 62 ] view the thia and polished membrane enveloping a polypus, about 2 inches in diameter, reddish and very elastic, loose at all points except towards the nostril, where it was attached by a slender ped- icle. The two frontal sinuses were converted into a single cavity, occupied by two polypi which, united, might have equalled the bulk of the maxillary polypus just mentioned. Each of them was at- tached by a slender pedicle, close to the excretory passages from the sinuses. The lining membrane of these cavities was thickened. The orbits were found to be diminished in size by the intrusion of the polypi ; the eyeballs consequentl}^ displaced ; the ossa ungues completely separated from the other bones of the orbits, and so ! pressed upon as to have become convex instead of concave towards the cavities of the orbits ; and the bones of the nose separated from each other, to the extent of several lines.* 4. Pressure on the Orbit fro'in the Maxillary Sinus. The diseases of the maxillary sinus are upon the whole analo- gous to those of the frontal sinus. They are more frequent, more* variable, and generally more easily recognised. They dilate the cavity of the sinus, thin by pressure the bones which form its walls, and force them at last to give way. They disfigure the face, dis- place the eyeball, and if neglected may ultimately prove fatal. 1. Collections of quucus or of pus within the maxillary sinus. A thin continuation of the Schneiderian membrane passes from the upper part of the middle meatus of the nostril, through a narrow aperture, into the maxillary sinus, and forms its lining membrane. The fluid secreted by this membrane is apt to accumulate, consti- tuting what some have called dropsy of the sinus ; in other cases, this cavity is filled with thin puriform mucus, or with thick curdy pus. Obstruction of the communication between the sinus and the nostril, cold, blows, affections of the teeth, small-pox, and various other causes, have been mentioned as giving rise to these diseased accumulations, which have often been known to increase so much as to elevate the floor of the orbit, and force the eyeball forwards from its place, as well as to dilate and even perforate the outer wall of the sinus. For an example of apparently simple accumulation of mucus within the maxillary sinus, I may refer to a case which occurred to M. Dubois. The patient, when a boy of 7 years of age, was ob- served by his parents to have a hard round tumour, about the size of a filbert, near the root of the nasal process of the left upper max- illary bone. It gave no pain, and did not appear to be increasing. A blow, however, which he received about a year after by a fall, excited this tumour to grow, which it did by almost insensible de- grees till he was 15. It then began to enlarge more evidently, and to cause slight pain. By the time when he was 18, it was so consid- * Leviet, Observations sur la Cure de plueieurs PolypeSj p. 235. Paris, 1749. 63 arable in size as to raise the floor of the orbit, so that the eye was pressed upwards, and appeared less than the other, on account of the limited motion of the lids. The palate was depressed, so tliat it formed a swelling of about the size of an egg divided longitudi- nally ; the nostril was almost completely closed, and the nose was twisted to the right. The cheek was prominent ; and the skin below the lower eyelid, and covering the upper part of the tumour, was of a livid colour, and seemed ready to give way. The upper lip was pushed upwards, and the whole length of the gums on the left side had advanced beyond the level of those of the right. Breathing, speech, mastication, and sleep, were impeded. Sabatier, Pelletan, and Boyer, being called into consultation, the unanimous opinion appears to have been that this was a case of fungus of the maxillary sinus, requiring an operation. So much thinned was the bone behind the upper lip, that Dubois felt there a degree of fluc- tuation, and proceeded to open the sinus at that place, expecting merely to give issue to a small quantity of ichorous fluid, and then to encounter the fungous tumour. The opening, however, allowed a very considerable quantity of a ropy substance to escape, similar to what is found in ranula. The probe being passed into the opening, entered evidently a large cavity, quite free of any kind of fiingous or polypous growth. It is probable that the opening made at this first operation, if kept from closing, would have served for the complete cure of the disease ; but Dubois appears to have thought differently, and proceeded 5 days afterwards to ex- tract 3 teeth, and to remove the corresponding portion of the al- veolar process. This enabled him, on placing the patient in a favourable light, to see the whole interior of the dilated sinus, at the upper part of which, and near to the edge of the orbit, he dis- covered a canine tooth, which he extracted. After this, the cavity grfidually shrunk ; the tumour of the cheek, that of the palate, and the displacement of the nose, continued for some time ; but after 17 months, no deformity existed.* A collection of pus within the maxillary sinus, whether produced in consequence of primary inflammation of its lining membrane, or of inflammation excited by diseased teeth, which is more generally the case, is not unfrequently evacuated in part through the opening of the sinus into the nostril ; much oftener, however, that opening appears to be obstructed, so that the pus collects and distends the sinus, producing a series of symptoms similar to those which ex- isted in the case of simple mucocele just quoted. Some years ago, I had under my care a gentleman, in whom the left maxillary si- nus was affected with this disease, to such a degree that the face was strikingly deformed, the bone absorbed at the most prominent part of the cheek, and the eye beginning to be displaced. I directed the second molaris, which was in a decayed state, to be removed ; * Boyer, Traite des Maladies Chirurgicales. Tome vi. p. 140. Paris, 1818. 64 and through the alveohis, I perforated the sinus so as to give exit to a considerable quantity of purulent fluid. 1 then pushed up a lachrj'niiil style into the opening, removing it every day, and in- jecting the sinus with tepid water. Under this treatment the se- cretion of matter ceased, and the sinus shrunk to its natural size. In neglected cases of suppuration within the maxillary sinus, various parts of its walls are apt to be absorbed in consequence of the pressure of the accumulated pus, or rendered carious from ex- cited inflammation. The floor of the orbit sometimes suffers these changes, the matter issuing from the sinus infiltrates behind the lower eyelidj the eyelid swells and inflames, and at length there is formed through it a fistulous opening, by which matter is from day to day discharged. Perhaps the patient is brought to us in this state, when on passing a probe along the fistula, we readily ascertain that it enters a diseased maxillary sinus. In a case of this sort, in w^iich the e3^e was already lost and the floor of the or- bit fistulous, Bertrandi, having introduced the probe along the fistula into the maxillary sinus, directed it as perpendicularly as he could against the infetioi" wall of that cavity, and while with two fingers of his left hand he pressed against the roof of the mouth, he with the probe perforated the alveolar process from above, l^etween the last two molares. After this opei'ation, the pus ceased to flow by the flstula of the orbit, and the patient recovered.* This mode of operating may be adopted, when the jaws, as is sometimes the case, cannot be sufficiently separated to permit a similar opening into the sinus to be made from below. Wherever the opening is made,, whether at the fossa canina, or through one of the alveoh, it ought to be kept patent, either by a dossil of lint, or by a lachr}'mal style, which is to be withdrawn daily, and the sinus injected either with water or a weak solution of nitras argenli. 2. Polypus or fungus of the maxillary sinus. I cannot better illustrate the effects produced on the orbit by polypus or fun- gus of the maxillary sinus, than by relating the case of James M'Culloch, aged 53, who became a patient, under m}^ care, at the Eye Infirmary, in February 1S28. He stated that he had been sensible of a stuffing of the right nostril for some years ; that 6 months before his admission, he had been attacked with supra-or- bital pain, darting towards the right side of his head : and a short time after this, with pain in the region of the right maxillary sinus, stretching towards the floor of the orbit, and increased when he opened his mouth. This was soon followed by stillicidium lach- rymarum. a soft elastic sweUing, in the situation of the right lach- rymal sac. and protrusion of the eyeball forwards, outwards, and upwards, from the orbit. He complained of a want of the sense of taste in the right side of his mouth, and want of sleep from the pain above the eye. On examining the palate, it was found to be * Boyer, Traite des Maladies Chirurgicales. Tom. vi. p. 153. Paris, 1818. 65 yielding and elastic under the light maxillary sinus. For several weeks, the vision had been double, in consequence of the misplaced state of the right eye. The conjunctiva was inflamed, the eye- lids adherent in the morning, and in consequence of the exposed state of the protruded eye, a small ulcer existed at the lower edge of the cornea. The right nostril was found to be filled by a poly- pous excrescence, of a white colour, and medullary texture, which bled profusely on being touched. After clearing away this substance with the polypus-forceps, a carious opening, sufficient to admit the end of the little finger, was found to exist between the nostril and the maxillary sinus. With the finger, introduced through this opening, it was ascer- tained that the sinus was completely stuffed with the same kind of polypous excrescence which had occupied the nostril. The clearing of the nostril was performed on the 19th ; and it is re- markable, that this had so much reheved the pressure on the orbit, that 5 days after, when I proceeded to open the maxillary sinus, the ulcer of the cornea was already cicatrized, evidently in conse- quence of the eyeball having retreated somewhat into the orbit, so as to allow it to be better defended by the lids. On the 24th, I made an incision, obhque in its direction from above downwards, and from without inwards, through the cheek, down to the bone, with the intention of opening the sinus, and removing its contents. 1 found, however, that the polypus had ahead}' produced absorp- tion of the outer wall of the sinus, to the extent of half an inch in diameter. Through this opening, the polypus was broken down and extracted. The bony parietes of the sinus felt through- out diseased ; its nasal side much disorganized ; the os unguis gone ; the orbital side, and indeed the whole circumference of the sinus denuded of its lining membrane. A long dossil of lint was introduced into the sinus. In a few days, a profuse secretion of white foetid matter flowed from the whole of the internal surface of the sinus, on removing the dossil of lint. By the 4th of March, the nose and lachrymal region were much more natural in their appearance, and the e3'^e more in its place. A solution of chloride of lime, ( 9 i. to ibii.) was daily injected into the sinus, wnth the view of correcting the foetor of the discharge. The long dosssil of Unt was carefully introduced, so as to fill the cavity completely. By the 9th, all pain had ceased, the eye was still more in its place, the vision improved, and the shape of the face much more natural. The discharge had lost its foetor, and was less in quan- tity. By the 18th, the double vision was gone. By the 27th April, there was very little discharge, and the vision was much improved. On the 5th of August, the report runs thus ; — General health and local symptoms go on improving — On pressing the site of the lachrymal sac, thick white matter issues from the lower punctum, but is diminishing under the use of an injection of the nitras argenti solution — Antrum seems contracting, and dis- n 66 charges ver}'' little — Water injected by the opening, flows out hy the nostril. On the whole, this case proved much more satisfactory than, fr(nii the very disoiganized state of the sinus, I had expected. Vision and life were saved by the operation. More than a yeai after, he was in good health, the wound much contracted, the sinus still kept open with a bent wooden style, and no appearance of any tendency to reproduction of the polypus. The sinus might have been cleared, in this case, without making any incision through the integuments, namely, by detach- ing the cheek from the upper maxillary bone ; but in this way the discharge would of course have flowed into the mouth, which would have been very disagreeable to the patient, and he would have been exposed to foreign substances entering the sinus, When we are very anxious about the personal appearance of the patient, we will perhaps prefer this mode of operating ; but when that is less an object than a ready, effectual, and even less disa- greeable method of getting rid of the disease, the incision through the cheek will be adopted. The method of operating adopted bj Desault, in fungus of the maxillary sinus, consisted, not merely in opening that cavity, after detaching the cheek from the bone, bul in removing, with the gouge and mallet, a considerable portion ol the alveolar process.* I should regard this as unnecessary. Through the mouth, it may be somewhat difficult sufficiently tc lay open the sinus ; but by cutting through the cheek, the bone may be so completely exposed, and an opening made of such a size into the sinus, as shall easily permit the diseased mass to be removed. In the case which 1 have rekted, the bleeding w^as easily re- strained ; but in other cases, profuse haemorrhage has followed the cutting or tearing away of the tumour, so as to demand the appli- cation of the actual cautery. Mr. Howship has illustrated, by a beautiful engraving, the great extent to which the bones forming the parietes of the antrum may be dilated -by this disease. The patient, whose skull he has repre- sented, a woman about 30 years of age, was received into the Westminster Hospital, with an extraordinary swelling upon the right side of the face, producing great distortion of countenance, but not attended with any discoloration of the skin. The basis of the tumour extended upwards to the eye, which was almost^losed, and reached below to the chin ; the adjacent angle of the mouth being much depressed, and thrown out of its line, and the nose pressed aside towards the left cheek. In the most prominent part, the tu- mour projected about 4 inches beyond the general line of the bones of the face. On the inside of the mouth, the tumour was very large, having extended itself across the palate, nearly to the oppo- site teeth. The tumour was confined entirely to the bones about * CEuvresChirurgicales. Tome ii- p. 165. Paris, 1813- 67 Ithe upper jaw ; it was apparently fleshy, and where it extended across the roof of the mouth, it was of a florid red colour. The teeth of the upper jaw, thrown out of their natural situation, formed an angle with the remaining part of the alveolar circle. All those teeth involved in the extent of the tumour, were thus forced into the middle of the mouth, greatly impeding deglutition. The disease was of 5 years' standing, and had begun with a small soft swelling in the right nostril. In this state, it had produced no uneasiness. I On the presumption of its being a polypus, the tumour had been J partially extracted at different times. These operations seemed ionly to accelerate the progress of the disease, aggravating the de- Igree of uneasiness and pain she now suffered, and hastening the increase of the swelling. When the complaint had become more completely formed, there were two or three teeth, which from their I horizontal position were very much in the way, and troublesome (from their being loose. Although the operation of removing them (required no great effort, it was attended with such an heemorrhage ia« brought the patient very low, before it could be effectually I checked. A second violent bleeding took place about 3 weeks af- terwards, from a spontaneous breach in the softer part of the tu- jmour. This reduced her so much, that she languished only a 1 week longer. On dissecting the tumour, it proved to be a fleshy (mass, or excrescence, not contained merel]^ within the antrum, but I surrounding and enclosing all the bones of the upper jaw. These I bones had, from pressure, suffered a separation at their respective I points of union, with such a degree of extension and attenuation I of their substance, that in many places they were reduced to the thinness of paper. The os malae was detached from the rest of the bones, and though in its natural state a very solid bone, exhib- ited a cribriform appearance. The origin and nature of the dis- ease cannot be a matter of any doubt. The bones had most likely remained uninjured till the soft fungous vascular mass from with- in the cavity of the antrum began to operate, first by producing absorption of the membrane lining that cavity, and then by the [pressure of its pecuhar and partially organized texture, not exciting I regular absorption of the bone, but sufficiently loosening its struc- |ture to admit of considerable distention. In the progress of the dis» ! ease, as might naturally be expected, the circulation in the perios- I teum made some effort towards repairing the mischief by the se- cretion of new bone, as happens in cases of necrosis, although this effort, owing to the almost disorganized condition of that mem- brane, had proved irregular and abortive.* The most remarkable instance of succe^^tiful extirpation rf a max- illary fungus is that which occurred to Dr. Thomas White of Manchester. The bones of the orbit appear to have suffered more * Howship's Practical Observations in Surgery and Morbid Anatomy, p. 22. London, I8I61. 68 in this case than in any other on record. The patient was a fe- male. In two years' time, the tumour, situated betwixt the left zygomatic process and the nose, put on a frightful appearance ; having grown to such a bulk that it pressed the nostrils to one side, so as to stop the passage of the air through them, and thrust the eye out of its orbit, so that it lay on the left temple. Though thus distorted, the eye still performed its office. The swelling occupied the greatest part of the left side of the face, extending from the lower part of the upper jaw, to the top of ihe forehead, and from the farthest part of the left temple to the external catithus of the eye. Upon handling the tumour. Dr. W. found an unusual and unequal bony hardness. It was of a dusky livid colour, with va- ricose veins on the surface, and there was a soft tulaercle projecting near the nose, where nature had endeavoured in vain to relieve her- self Dr. W. began the operation with a serai-circular incision below the dislocated e5"e, in order to preserve that organ, and as much as possible of the orbicular muscle : then carrying the in- cision round the external part of the tumour, he brought it to the bottom of it, and then ascended to the place where he began, tak- ing care not to injure the left wing of the nose. After taking away the external part of the tumour, which was separated in the mid- dle by an in)perfect suppuration, there appeared a large quantity of a matter hke rotten cheese, in part covered by a bony substance, so carious as to be easily broken through. Abundance of this matter was scooped away, with a great many fragments of rotten bones. Upon cleansing the wound with a sponge, Dr. W. found the left bone of the nose, and the zygomatic process, carious, and removed them. He says there were no remains of the bones composing the orbit, they being plainly destroyed by the same disease. The optic nerve was denuded as far as the dura mater ; this membrane and the pulsation of the vessels of the brain were apparent to the eye and touch. The superior maxillary bone, in the sinus of which this disease had had its origin, w^as surprisingly distended, and in some places had become carious. The alveolar process was pro- bably in this state, as Dr. W. mentions that he removed it. He then applied the actual cautery to the rest of the bones, taking care not to injure the eye and neighbouring parts, which were sound. The patient drew her breath through the wound, and was so in- commoded by the foetid matter flowing into her throat, that she was obliged for several weeks to lie on her face, to prevent suffoca- tion. Notwithstanding her miserable condition, nature at length assisted, laudable pus appeared, sound flesh was generated, and the patient recovered. The eye returned to its place, and she enjoyed the perfect sight of it. The only inconvenience that remained was a constant discharge of mucus from the inner canthus of the eye.* Fungus of the maxillary sinus occasionally proves fatal ; and it * White's Cases in Surgery, p. 135. London, 1770. 69 appears to do so, like polypus of the other cavities of the face, by inducing pressure on the brain. "I have seen," says Bertraudi, "a polypous excrescence, so situated, that inferiorly it destroyed the bones of the palate ; it filled the mouth, and anteriorly consumed the maxillary bone ; superiorly it pushed the eye almost out of its socket, at length it destroyed the roof of the orbit, pressed upon the brain, and the patient died apoplectic."* This termination of the disease when left to itself, and the favourable result of extirpation in many cases now recorded, should lead us at once to propose the operation, and not to leave the tumour for a single day to proceed in its slow but certain work of destruction. 5. Pressure on the Orbit from the Sphenoid Sinus. The sphenoid sinuses are each, when fully developed, of size sufficient to admit the end of thehttle finger. They lie before and beneath the sella turcica, below and to the inner side of the fora- men opticum, and to the inner side of the spheno-orbital fissure. The partition which separates the one sinus from the other, rarely runs in the middle plane of the body. They communicate with the upper meatus of each nostril, and like the other sinuses of the face, are lined by a continuation of the Schneiderian membrane. From analogy, then, we should conclude that they are subject to the same diseases as the frontal and maxillary sinuses ; but I know of no instance on record in which the sphenoid sinuses were dilated by inflammation or polypus. The consequences of dilatation of these cavities on the orbit, and on the vessels and nerves of the or- bit, may readily be conceived. They could expand easily, neither downwards nor backwards ; and were they to press either upwards or outwards, they would deform the posterior part of the orbit, im- pede the circulation of blood to and from the eye, and destroy its sensitive power and motion. 6. Pressure on the Orbit from the Cavity of the Cranium. In some diseased states of the encephalon, the orbits are pressed forward, so that their apex approaches to their base, or, in other words, they become much shallower than natural, and the eyeballs protuberant. This takes place in chronic hydrocephalus. I have now before me the skull of an adult, so much dilated by a diseased state of the brain, which must have supervened in adult age, that the distance from the meatus auditorius to the crown of the head, which commonly measures 6 inches, amounts to 7^ inches ; while almost every part of its parietes is so much thinned in consequence of pressure, as to be diaphanous. The ordinary depth of the orbit is 1 inch and 7-lOths, whereas in this skull it strikes one at the first glance as unnaturally shallow, and on measurement is found only 1 inch and 1-iOth in depth. ♦ Traite des Operations de Chirurgie, traduit par Sollier, p. 303. Paris, 1794. 70 In another set of cases, one or other orbit, rarely iDoth at once, although often the one and then the other, are not merely deformed by the pressure arising from disease within the cranium, but some . part of their walls, and especially their roof, becomes involved by the disease of the brain or of its membranes, inflames, is partially absorbed, or is destroyed by caries or necrosis. Under such cir- cumstances, death is generally preceded by amaurosis, exophthal- mos, and sometimes exophthalmia.* Many cases might be quoted of diseased dura mater producing the destruction of the orbit by pressure and absoiption. Most of the cases of this kind on record appear to have succeeded to inju- ries of the head, by blows or falk. In some of them, the dura mater was diseased, without any remarkable morbid change of the brain ; in others, the brain was likewise affected. In some, the disease of the dura mater was fungous ; in others hydatiginous or encysted. Disease originating in the pia mater or in the brain, and de- stroying the orbit, must necessarily be rare: but the case already quoted from Mr. Hunter demonstrates the possibility of such an event. The following cases are interesting, and will serve to illustrate the influence of diseases within the cranium, over the orbit and its contents. 1. A case by Paaw, is recorded among the HistoricB Anato- miccB of Bartholin, of a child, 3 years of age. whose left eye was entirely protruded from its orbit., and enlarged to a great size. In a few months the child died, and, on dissection, a fungous tumour, adherent to the dura mater -which covered the roof of the orbit, was found to be the cause of the exophthalmia. The brain was sound. t 2. A man. 51 years of age, fell from his horse, and received a severe contusion on the head, followed by pain, which gradually subsided. Four years afterwards, his memorv began to fail : from day to day, this defect increased, till he could no longer recollect what he had uttered a moment before. Frequent and violent epileptic fits succeeded : but appeared to 5'ield to different remedies, employed during 6 months. Most severe and uninterrupted head- ach next supervened. No remedy was found to calm this symp- tom : and after 6 months, the patient died. For 6 weeks before his death, the left eye had been turned from its natural position in the orbit.+ On that side of the head, the pain had been com- * Louis on Fungous Tumours of the Dura Mater, in the Memoirs of the French Academy of Surgery. Lieutaud, Historia Anatomico-Medica. Tom. ii. p. 195, Parisiis, 1767. Beer, Lehre don den Aucrenkrankheiten. Vol. ii. p. 579. Wien, 1817. Abercrombie on Diseases of the Brain, pp. 194, 443. Ed in. 1828. Hooper's Morbid Anatomy of the Human Brain. London, 18-26. t Memoires de 1' Academic de Chirurgie. Tome xiii. p. 27G. Paris, 1774. 12mo. t Contourne par la force du spasme. 71 paratively slight. On dissection, the two tables of the middle an- terior part of the right parietal bone were found carious to the ex- tent of a denii-jiorin ; while various other places of smaller extent were similarly affected. A fungous tumour, adherent to the dura mater, had produced the absorption of the roof of the left orbit, and thus made its way into that cavity. The same tumour had de- stroyed the cribriform plate of the ethmoid bone ; and the corres- ponding portion of brain was also diseased.* Had the patient sur- ' vived for any considerable time longer, there can be no doubt that the existence of this fungous tumour, pressing through the orbit, would have been manifested still more distinctly, by external changes. 3. Marechal had under his care a young man, 20 years of age, whose left eye was prominent and turned outwards, in consequence, apparently, of a tumour at the inner angle of the eye, attended by headach, giddiness, watering of the eye, and dryness of the nos- tril. Marechal attacked the tumour with caustic, and then punc- tured the eschar, when there flowed out two or three table -spoonfuls of lymph, a little reddish in colour ; after wiiich the eye was re- stored almost to its natural place. On being appointed surgeon to Louis XIV., Marechal handed the patient over to Petit. When the eschar separated, something like a vesicle presented itself in the middle of the opening. On puncturing this vesicle with the lan- cet, a fluid escaped similar to what had previously been discharged, only less in quantity. Two days after, a third was opened in the same way, but discharged very little. The eye became again displaced outwards and forwards, as it had been at the first ; the head became heavy, fever supervened, and in a short time the pa- tient died lethargic. On opening the head, nothing remarkable was found in the brain ; the dura mater investing the lower part of the middle lobe of the cerebrum appeared considerably elevated, and on endeavouring to detach it from the squamous portion of the temporal bone, it was found united to the bone, and the bone changed into a cartilaginous or fleshy substance. The roof of the orbit was changed in like manner ; while three hydatids or vesi- cles, full of reddish fluid, and each about the size of a walnut, were found, one in the orbit, a second, half in the orbit half in the cranium, and the third, in the hollow formed by the union of the sphenoid with the petrous and squamous portions of the temporal bone. That hollow, as w^ell as the sphenoid, where it forms the optic foramen, was also softened. In fact, this altered state of bone extended from the petrous portion of the temporal to the inner angle of the eye, the os planum and the os unguis being likewise affected.1 * Gluoted from Jauchius, by Louis, in his paper on Fungous Tumours of the Dura Mater ; Meraoires de TAcademie de Chirurgie. Touse ziii. p. 62. Paris, 1774. 12mo. I t Petit, Traite des Maladies des Os. Tom. ii. p. 325, Paris, 1759. 72 4. A robust maa, aged 48 years, whose employment led him to the frequent lifting of heavy loads into and out of a cart, was in the act, along with another labourer, of lowering from his cart a pack- age of above oOOlbs. weight, when his foot slipping, he was struck by the package on the head. No bad effects appeared immediately to result, so that he not only carried this load away to its destina- tion, after placing it on his head, but continued for five weeks to pursue his ordinar}'' occupation. After that period, he began to complain of feelings of internal, obtuse, pressing pain, in that part of the head where the right parietal bones form, along with the frontal, the coronal suture : and the pulse became quick, full, and hard. To these symptoms, there followed epileptic fits, which were renewed several times in the course of the day. The fever and pain of head became mitigated, digestion and nutrition were unim- peded, but the patient continued for more than a year totally unfit for any employment, on account of the frequency of the epileptic attacks. About fifteen months after the accident, the pain of the head again increased, to such a degree, as to deprive him of rest both night and day, and to cause such suffering, that he could not help crying out. Violent fever and delirium accompanied the pain. These symptoms continued for several weeks, but the epilepsy ceased. The pain gradually descended to the right ear and eye, and in proportion as it became more severe in the orbit, it subsided in the upper part of the head. The eyeball became inflamed and swollen, and was protruded from the orbit. On raising the upper eyelid, the cornea was seen to be turbid, the pupil expanded and immoveable, the iris green, and vision very imperfect. Onyx fol- lowed, commencing at the lower edge of the cornea, and advancing till the w^hole cornea w3-s affected. Violent pain continued, pro- ceeding from the bottom of the orbit towards the external parts of the eye, and attended at length by a discharge of blood from the inner canthus and riglit nostril. After this the pain ceased, and the patient had onl}^ two fits of epilepsy. The left eye, with the ex- ception of a little redness at the inner canthus, was healthy ; memory failed, and the vital functions became enfeebled. About eighteen months after the accident, the epileptic fits returned, they were more frequent and more violent than before, and, some few short lucid intervals excepted, the}^ were attended with constant stupor, and absence of mind. Respiration became impeded, and the patient died in violent convulsions. On sav.'ing through the cranium, the bones of the right side were seen to be bent outwards^ they were harder than those of the left, their two tables thicker, and their diploe wanting. The vessels of the dura mater were dilated, and filled with blood. That membrane firmly adhered at every point to the inner surface of the skull, except over the roof of the orbit, where a considerable portion of it (ad incmi majoris niagnitudinem) was separated from the bone, thickened, and in a state of suppuration. The dura mater, tunica arachnoidea, and pia 73 mater, were at that spot united together, and firmly adherent to the brain. The corresponding part of the roof of the orbit was rough. The substance of the right hemisphere of tlie brain was softer than that of the left, and of a dirt}^ brownish white colour ; the right la- teral ventricle was enlarged, and filled with thin fluid ; the lower surface of the right anterior and middle lobes was occupied by a number of steatomata, from the size of a pea to that of a filbert, and corresponding to the destroyed portion of the dura mater, and the rough part of the roof of the orbit. The Gasserian ganglion, and its three branches, were surrounded by a firm cartilaginous mass ; the motor oculi was compressed and changed in colour. The ab- ducens was contracted to the size of a small thread, while within the cranium ; but both it and the motor oculi were of their ordinary thickness within the orbit. The internal surface of the right side of the cranium, upwards to the middle of the frontal bone, and backwards over the little and great wings of the sphenoid to the sella turcica, was rough. The cartilaginous mass surrounding the Gasserian ganglion was found to proceed through the spheno-or- bital fissure into the orbit, surrounding the optic nerve, and so fill- ing up the space between the superior, external, and inferior straight muscles, as to envelop their origin and vessels, the posterior part of the naso-ciUary nerve, the inferior branch of the motor oculi, the abducens nerve, and the opthalmic ganglion. The same cartila- ginous substance was traced through the spheno-maxillary fissure, into the zygomatic fossa.* CHAPTER 11. DISEASES OF THE SECRETING LACHRYMAL ORGANS. SECTION I. — -INJURIES OP THE LACHRYMAL GLAND AND DUCTS. It will be difficult to wound the lachrymal gland, with any ordi- nary instrument, penetrating into the cavity of the orbit ; but still it might be possible to reach it, for instance, with a penknife, driven upwards, backwards, and outwards, into the fossa lachrymalis ; and we can easily enough suppose the excretory ducts of the gland to be divided in such a penetrating wound. The effects of such a wound will be apt to resemble those of a wounded parotid gland or * Commentatio Pathologico-Anatomica exhibens Morbum Cerebri Oculique sin- gularem. Auctore F. A. Landmann. Lipsise, 1820. 74 duct ; thai, is to say, the frequent distiUment of tears, like that of saHva, will be likely to prevent the healing of the wound, and a fistula lachrymalis vera, as it is called, to follow. 1 know of no such case on record ; but the thing is possible. A penetrating wound, then, v/hich we suspect may have penetrated to the lach- rymal gland, or divided some of its ducts, w^e should endeavour tO' unite with more than common care ; employing, for that purpose, sutures, strips of adhesive plaster, and a compress and roller, and enjoining the patient to keep the eye as much as possible at rest;. till the cure be completed. SECTION II. XEROMA. ,1 Xeroma or dryness of the eye, from suppression of the secretion of the lachrymal gland, is not so much a disease existing by itself^ as a symptom of various other diseases. In some cases, it arises from a disordered state of the lachrymal gland ; in other cases^ this gland ceases to fulfil its ofiice, on account of its sympathy with the brain. We have an instance of xeroma, of the first kind, in the disease called lachrymal tumour in the lachrymal gland. I am not cer- tain that xeroma is a common, though it may be an occasional symptom, in inflammation of the gland. The assertion that it ac- companies scirrhus or enlargement of that body, is contradicted by the cases related by Mr. Todd, and Dr. O'Beirne. Yet we can scarcely suppose that the function of the lachrymal gland will go on without impediment, when its substance is either inflamed or indurated. We meet with xeroma as a frequent attendant on the incipient stage of amaurosis ; and we may hail as a favourable sign in such cases, the return of the lachiymal secretion, for we invariably find that after this change, the vision begins to improve. We may regard the xeroma which occasionally attends deep grief, as a purely nervous or sympathetic phenomenon. In all these cases, when we look at the eye, no appearance of dryness is to be observed ; for the mucous secretion of the con- junctiva is not affected. The eye looks as moist and shppery as ever, but the patient complains that it is never wet ; or if it be at times bedewed with tears, great rehef is experienced, evidently showing that the dryness depends on want of the lachrymal, not of the conjunctival, secretion. If xeroma seems to depend on inflammation of the lachrymal gland, or if we suspect any incipient affection of that body likely to lead to its enlargement or disorganization, local bleeding, and the antiphologistic regimen, will be practised. If the affection appears to be nervous, purgatives, tonics, and antispasmodics, may be had 75 ' urecourse to. The influence of music has sometimes been very re- markable in removing the xeroma attendant on grief.* SECTION III. EPIPHORA^ This is the reverse of the last disease ; for the tears are secreted and discharged too abundantly, and too frequently. Like xeroma, however, epiphora may be regarded rather as a symptom than as a disease in itself Diagnosis. Epiphora must not be confounded with stillicidium lachrymarum. The difference is, that the latter is merely a drop- ping of tears, from some incapability in the excreting parts of the lachrymal organs to remove the mucus of the conjunctiva and the tears, after they have done their duty ; while epiphora is a disease of the secreting lachrymal organs, or an over-discharge of tears. Causes. Any mechanical or chemical irritation, applied to the conjunctiva, instantly produces a discharge of tears, or epiphora, so that the foreign body may be forcibly washed away, or the chem- ical substance diluted. Inflammation of the eye, or eyelids, and especially strumous or pustular inflammation of the conjunctiva, is an extremely frequent cause of epiphora. We observe that children, who are the general subjects of that species of ophthalmia, if they attempt to open the eye, are affected with instant epiphora, and spasm of the orbicularis palpebrarum. We can be at no loss to explain this connexion between the eyelids, conjunctiva, and lachrymal gland, when we recall to mind that the lachrymal nerve, having passed through the lachrymal gland, spends its ultimate branches in the conjunctiva, orbicularis palpebrarum, and skin of the upper eyelid.* In many cases of strumous conjunctivitis, the redness is extremely slight, perhaps scarcely an enlarged vessel is to be seen, and as yet no pustules or minute pimples have made their appearance, but the epiphora, and intolerance of light, are extremely acute. Epiphora is occasionally a symptom of disordered digestion, especially in children, and of worms in the intestines. Indeed, even when connected with strumous ophthalmia, we may regard both the ophthalmia and the epiphora, as originating, in many cases at least, in improper food, and disorder of the digestive organs. Treatment. We scarcely require to prescribe for epiphora alone. I have seen it completely and permanently removed by an emetic. Purgatives, followed by tonics, and occasionally antacids, will be found highly useful in removing some of the more com- mon causes of the disease. A mixture of rhubarb and supercar- bonate of soda, repeated every day, or every second day, and fol- lowed up by a course of the sulphate of quina, is a plan of treatment which I have often found effectual. * Dictionaire des Sciences Medicales. Tome xxxv. p. 71; Paris, 1819. t Socmmerring, Abbildungen des Menschlichen Auges. p. 43. Frankfurt am 1 Main, 1801. 76 Of local remedies, the most useful are tlie vapour of laudanum, and the lunar caustic solution. Into a cup of boiling water, a tea- spoonful of laudanum is mixed, the cup held under the eye, the eyelids opened, and the vapour allowed to come into contact with the conjunctiva. This may be done twice or thrice a day. No- thing reheves more the irritability of the conjunctiva, on which epiphora so frequently depends, than a solution of two or three grains of lunar caustic in an ounce of distilled water, dropped on the eye with a camel hair pencil once a day. Blisters are useful in epiphora. They are more likely to be so, when applied before the. ear, or on the temple, as they will then act more directly on the branches of the deep temporal nerves, which anastomose with the lachrymal nerve. SECTION IV. INFLAMMATION AND SUPPURATION OF THE LACHRYMAL GLAND. The lachrymal gland is liable to become inflamed. Children of a strumous constitution are the general subjects of this affection, which is by no means a common one. The cellular membrane which connects the acini of the gland is probably the original seat of the inflammation. Symptoms. Pain in the seat of the gland, and growing fulness above the external angle of the eyelids, are the first symptoms which are remarked. The swelUng becomes red and tense ; the upper lid can be raised with difficulty, if at all : the conjunctiva is inflam- ed ; the eyeball is pushed forwards and inwards : and at last, when the inflamed gland is enlarged to the utmost, the sympathetic swell- ing of the neighbouring cellular substance advances so much in front of the globe of the eye, as completely to conceal it. The pain in the orbit and head becomes more and more severe. Unless the progress of the inflammation is arrested, fever, restlessness, and de- lirium, usher in the local symptoms of suppuration ; fluctuation becomes more and more distinct ; and at last the matter points, and bursts through the upper eyelid. Unfortunately, it but too frequently happens, that before this discharge is afforded to the matter by the spontaneous bursting of the abscess, the bone has become affected, probably fi'ora pressure : the case becomes a very tedious one, ectro- pium of the upper eyehd follows, and the fistula, as has already been explained, does not heal till the bone becomes healthy, or till the diseased portion of it is discharged, which may not be accom- plished for years. Causes. Blows over the external angular process of the frontal bone, and exposure to cold, are, 1 beheve, the common causes of in- flammation of the lachrymal gland. Mr. Todd, however, has stated, that the greater number of cases which had fallen under his observa- tion, were not idiopathic, but succeeded to inflammation of the con- junctiva, or some other form of ophthalmia. He had known inflam- 77 mation of the lachrymal gland to accompany the psorophthalmia of childien, when that disease was severe, or aggravated by neglect, exposure to cold, or by the incautious use of stimulating or astrin- gent applications. He is also of opinion, that in some cases, inflam- mation of this gland ushers in the ordinary forms of ophthalmia, and gives rise to symptoms generally attributed to inflammation of the eye alone.* Forms. Besides the acute form of this disease, Mr. Todd has described a chronic inflammation of the lachrymal gland, almost entirely confined to the early periods of life, and, in all probability, depending on a scrofulous predisposition. In this chronic affeciion, there is an obvious enlargement of the gland, with occasional oedema- tous tumefaction of the upper eyelid; the patient seldom complains Df pain, but generally of a sensation of fulness above the globe, and an inabihty to move the eye of that side as freely as the other. On making pressure between the globe of the eye and the temporal 3xtremity of the upper edge of the orbit, an immediate and copious discharge of tears is produced. Mr. T. appears inclined to attribute strumous or pustular conjunctivitis, to the morbid secretion of the lachrymal gland, during the course of chronic inflammation ; and mentions the case of a j'^oung lady, who, on one side had chronic nflam mation of the gland, with frequent attacks of pustular con- unctivitis, while on the other side, the gland was healthy, and no ophthalmia ever occurred. Besides chronic inflammation, the specific nature of which is pro- bably equivocal, Mr. T. represents the lachrymal gland as subject ;o an enlargement more decidedly scrofulous ; characterized by slowness of progress, although it sometimes acquires considerable nagnitude; absence of pain ; the tumour presenting a surface m.ore )r less lobulated ; and the constitution and age of the patient. He states that in some instances this affection, after a certain period, vvill continue stationary for many months, or even for years, while n others it will undergo that form of suppurative inflammation 3eculiar to scrofulous glands, and will thus prove a tedious and trou- blesome disease. It is probable that this scrofulous enlargement of ,he lachrymal gland has sometimes been mistaken for scirrhus, jspecially when both glands have been affected in the same in- iividual.t Treatment. In acute inflammation of the lachrymal gland, eeches are to be applied liberally to the upper eyelid, forehead, and emple ; purgatives, rest, cooling lotions, and the whole antiphlo- pstic plan are to be adopted ; venesection is to be employed, if the 'ever runs high. When the symptoms become indicative of the formation of mat- j;er, a warm emolUent poultice is to be applied over the swefling. • Dublin Hospital Reports, Vol. iii. p. 408. Dublin, 1822. t See Daviel's 2d and 3d Cases, in the London Medical Gazette, Vol. iii. pp. 523, )24. London, 1829. 78 When the matter has fairly formed, it must be evacuated. I doubt whether it will be possible to do this, under the upper eyelid, with a small knife, directed through the conjunctiva, towards the seat of the gland. If this plan is found possible, it ought to be followed. If not, the abscess must be opened througli the upper eyelid, the incision being made parallel to the superior edge of the orbit. Matter will continue to be discharged for some time, gradually di- minishing, and at length drying up ; but it occasiooally happens, that the opening contracts to a very small diameter, and continues to discharge tears, forming what is called a true lachrymal fistula. This is still more apt to be the case, if the abscess has been allowed to burst of itself. Should we be called to a case of this sort, only after the abscess has burst of itself, we ought to examine the sinus with a probe, to discover whether the bone is diseased, wash it out daily with a small syringe and some stimulating injection, keep it open with a tent if the bone be diseased, and especially if there be any suspicion that the diseased piece of bone is loose and likely to come away, and forewarn the patient, or his friends, of the ectropium and de- formity which will probaljly ensue, and which are very difficult of removal, even by operation. In cases of chronic inflammation of the lachrymal gland, or of slow strumous enlargement, the antistrumous regimen is to be pre- scribed : nourishing food, sea-air, tonics, &c. The occasional ap- plication of a few leeches to the neighbourhood of the gland : a succession of small blisters to the forehead, temple, and back of the ear ; small doses of calomel, or blue pill at night, with a saline or other laxative, next morning, will also prove beneficial. If stru- mous inflammation of the gland ends in suppuration, we must not allow the skin to become extensively diseased, but employ the lan- cet as soon as fluctuation is distinct. SECTION V. EXLARGE3IENT OR SCIRRHL'S OF THE LACHRY- MAL GLAXD. The lachrymal gland, like other glands of similar structure, is subject to a slow enlargement, which has generally been regarded as scirrhous. Symptoms. This disease is known, we are told, b}' dryness of the eye ; but this statement appears to be incorrect, for in the cases recorded by Mr. Todd and Dr. 0"Beirne, epiphora existed, not xeroma.'' The following symptoms are less equivocal ; namely, lancinating pain in the upper and external part of the orbit ; en- largement of the gland till it forms a projecting tumour, which, through the extended skin of the upper eyelid, is felt to be hard and * Dublin Hospital Reports. Vol. iii, pp. 420, 421, 427. Dublin, 1822. 79 lobulated ; projection of the eyeball downwards, inwards, and for- wards ; dimness of sight ; double vision, and at length blindness. If the disease be neglected, or the patient refuse to submit to pro- per treatment, the temporal side of the orbit in some cases begins to DC dilated, the eyeball actually resisting the pressure of the tumour Detter than the bones ; but more commonly, the eyeball inflames, md bursts, its contents are absorbed, the gland goes on to enlarge ;il] it completely fills and distends the orbit, the remains of the eye- Dall are seen lying on the front of the tumour, which, still continu- ng to grow, presses itself downwards through the spheno-maxillary issure, and even deforms the brain by pressure. The patient dies A'orn out by pain and fever. This disease of the lachrymal gland does not, as far as I know, iffect the lymphatic system, nor does it appear to undergo any hing like cancerous ulceration. It may therefore be doubted, if t be scirrhus. It is also worthy of observation, that the globe of he eye, and the other contents of the orbit, may be extensively Hseased, and the lachrymal gland remain unaffected. I have seen t somewhat enlarged and hardened in a case of disorganization of he eye from syphihtic inflammation ; but in cases of fungus of he retina, rendering extirpation of the contents of the orbit neces- ary, I have repeatedly found the gland perfectly sound. Scirrhus )f the lachrymal gland, like inflammation of the same part, occa- ionally brings on caries of the fossa lachrymahs. Fatal case. Some years ago, I inspected the body of Mrs. F. iged 60 years, a patient of the late Dr. G. C. Monteath. Some ^ears before her death, she became affected with protrusion of the ight eye downwards, inwards, and forwards. After some years, ;he eye burst. We found the empty sclerotica lying on the front fthe tumour, which was white and granular, the grains being vidently the enlarged acini of the lachrymal gland. It was as arge as a man's fist, occupying a much expanded orbit, and pres- ing itself down into the spheno-maxillary fissure. It had been he means of destroying by absorption, the roof of the orbit, which \vas still covered by dura mater, except in some few points, where :he tumour and the brain were in contact. It had deformed the ■rain in a remarkable degree, having pressed the lower surface of he anterior lobe of the right hemisphere upwards, and the anteri- r surface of the middle lobe backwards. The right motor oculi lerve was absorbed. Within the cranium, the right optic nerve 'ras smaller than the left ; within the orbit, merely its neurilema emained. The right nostril was obliterated by the pressure of the umour. The frontal and maxillary sinuses on the right side /ere full of puriform mucus. This patient had all along refused 3 submit to any operation. ' Treatment. In the early stage, leeching may be tried, on the ame principle which we follow when we endeavour to reduce a uspected scirrhus of the mamma. A succession of blisters mav be 80 applied to the forehead and temple. Iodine, and other solvents and sorbefacients, may be used. If such means are ineffectual in I'educing the swelling, extirpa- tion of the gland is our only other resource, and ought to be em- ployed. It will be in vain to think of extirpating an enlarged lachrymal gland from beneath the upper eyehd, unless the eyelids are first of all disjoined at their outer angle, by an incision car- ried outwards through the skin and orbicularis palpebrarum, towards the temple. If this be done, the upper lid may be raised, and the conjunctiva exposed and divided, so as to bring the en- larged gland into view\ The mode of extirpation, however, which has generally been adopted, is to cut down directly over the tumour, through the upper eyelid, and parallel to the edge of the orbit. The gland is then to be laid hold of vrith a hook, dragged out of its situation, separated cautiously from its connex- ions, and removed. After the bleeding has ceased, the edges ol the wound are to be brought together with two or three stitches, and a few strips of court-j)laster. Neither is the vision nor the position of the eye restored immediately after extirpating the gland. Weeks, or even months, may be requisite before these objects are accomphshed ; and although the malposition of the eye is always lessened in time, if not entirely removed, vision may never be re- stored. The moisture and lubricity of the conjunctiva remaining unaffected after extirpation of the lachrymal gland, has, it is prob- able, given rise to the statement of some, that the patient continues capable of weeping. Cases of extirpation. Guerin,* Warner,t and TraverS;+ ap- pear to have performed this operation ; but the details which thej have given on the subject, are comparatively few, and hence ar additional degree of interest which has attached itself to the twc cases recorded by Mr. Todd, and Dr. O'Beirne. These, therefore I shall quote, along with a case by Mr. Lawrence, and anothei by Daviel. Case 1. Mr, Todd's patient was a woman of 70 years of age The lachrymal gland formed a large irregular tumour, occupying the upper part of the orbit, projecting more than half an inch be yond the superciliary ridge, and covered by the upper eyelid which was so stretched upon it as to render the knotty eminence: on its surface very conspicuous. The tumour was extremely hard It w^as moveable to a slight extent, in a transverse direction only The globe of the eye was not enlarged, but it had been protrudec by the tumour, and was so low upon the cheek that the corne; was nearly on a line with the edge of the ala nasi. The lowe eyelid was everted, and appeared dragged down with the globe the conjunctiva much thickened, and cheraosed. The transparen * Richerand, Xosographie Chirurgicale. Tome ii. p. 31. Paris, 1808. t Cases in Surgen-, p. 1C8. London, 1784. t Synopsis of the Diseases of the Eye, p. 2"28. London, 1320. 81 cy of the cornea was slightl}'' obscured. There was no apparent disease of the interior of the eye. Vision was destroyed by the pressure of the tumour. The pains were severe and lancinating, extending from the tumour to the globe of the eye, and were ac- companied with a sensation of heat, and a frequent discharge of scalding tears. The sufferings of the patient were most severe at night, and she was almost entirely deprived of sleep ; notwith- standing which, her general health was not much impaired, and her appetite for food was good. She attributed the disease to a blow wliich she had received on the eye about 7 years before; from which period she had been subject to frequent discharges of tears from that eye, but had suffered no other inconvenience until a year before coming under Mr. T.'s care, when the tumour began to project under the temporal extremity of the eyebrow. At first she had no pain or headach ; but as the tumour increased these symptoms set in, and had ultimately become so severe that she was anxious to undergo any operation which held out a prospect of relief. In consultation with Mr. Carmichael, Mr. T. determined that an attempt should be made to extirpate the diseased gland alone, and in the event of that being found impracticable, either from extent of attachments, or deep-seated disease, the expediency of removing all the contents of the orbit was fully acceded to ; the intense sufferings of the patient, the probable nature of the disease, and the useless state of the eye, appearing to render this an indispensable alternative. The patient having been placed on her back on a table, with her head a little elevated and secured by the assistants, a transverse incision was made through the integuments, nearly parallel to the superior margin of the orbit, from one extremity of the tumour to the other. Having cut through the orbicularis palpebrarum and the ligamenlum tarsi, Mr. T. exposed, by a careful dissection, the entire anterior surface of the gland. Being firmly wedged into the orbit, it was not without difficulty that the handle of the scalpel was introduced between the gland and the superciliary ridge in or- der to detach it from the orbitary process of the frontal bone. The surface of ihe gland next the eye was irregularly lobulated, and the lobes had insinuated themselves amongst the muscles and other contents of the orbit, so as to render their disentanglement extremely difficult and hazardous. By cautiously tearing their cellular at- tachments with the end of the finger, the handle of the knife, and the blunt extremity of a director, and by cutting on the finger with a probe-pointed bistoury some firm membranous bands, which could not be easily broken, Mr. T. succeeded in extracting the en- tire tumour. On a careful examination no farther disease could be detected in the orbit, and as no bleeding occurred, (he globe of the eye was gently pressed towards its natural situation, the wound dressed, the parts supported with a compress and bandage, and the i patient laid in bed, with strong injunctions to observe the strictest 82 quiet. The extirpated gland was much larger than a walnut. On the surface which had been towards the eye, it presented three con- siderable eminences or lobes, with deep fissures between them. It was almost as firm as cartilage, and more elastic. A section ex- posed several small cartilaginous cysts, which contained a glairy fluid, the interspaces consisting of a firm fatty substance, traversed by a few membranous bands. Two hours after the operation, an alarming hccmorvhage took place, which, from the great depth at which the wounded vessel was situated, and the extensive extrava- sation of blood into the loose cellular tissue of the orbit, was with difficulty suppressed by pressure with the finger. Dossils of lint were then introd'iced into the wound, and the bleeding did not re- cur. The pafienr paesed a tranquil night, and for tbe first time during many Vvceks enjoyed refreshing sleep. On the following da}-, the appearance cf the eye and surrounding parts was by no means encouraging. The globe was protruded from the orbit as liiuch as before the operation, by large coagula, which occupied the situation of the tumour ; the lids were affected with extensive ecchy- mosis ; tlev were livid and cold, as if in the state of gangrene ; and the cellular tissue of the conjunctiva was distended with effused blood. ^Notwithstanding these unfavourable appearances, the pa- tient had experienced inuch relief from the operation ; she was free from acute pain, and the constitutional excitement was inconsider- c. jle. In the course of a few days, the coagulated blood contained in the orbit began to dissolve, and suppuration was soon established. The globe of the eye began slowly to return into its natural situa- tion, and the conjunctiva and skin of the eyelids to assume their health}- appearance. On the 12(.h day after the operation, the im- provement in the position of the eye was quite evident ; but it was found impossible to prevent the eversion of the lower eyelid, in con- sequence of a thickened fold of the conjunctiva, which extended between it and the globe. To this fold the nitrate of silver had been frequently applied without any benefit ; 3Ir. T. therefore re- moved it by excision, and was immediately enabled to replace the lid, which showed no farther tendency to become everted. From this period the patient's recovery was uninterrupted, and she was discharged without any return of disease. Yision remained totally lost, the pupil greatly contracted, the position of the eyeball almost natural.* Case 2. A man, a.ged 22 years, strong and athletic, came under the care of Dr. O'Beirne, with considerable deformity and imperfect vision of the right eye. The globe projected more by its semi-diameter than the sound eye, yet it was covered almost entirely by the upper eyehd which hung loosely over it, as if paralyzed ; the pupil was dilated and insensible to light, the cornea was turned towards tha nose, and the puncta lachrymalia were patulous. The * Dublin Hospital Reports. Vol. iii. p. 419, Dublin, 1822- 83 upper and outer part of the orbit was occupied by a tumour, the outline of which could not be distinctly traced, but to its growth were attributed the protrusion of the eye and impaired vision. The patient suffered considerable pain of the right side of the head and face, and much irritation and watering of the eye were pro- duced by cold air, or particles of dust. All objects appeared to him double ; and in endeavouring to reach any object, his hand, or foot generally fell short of it, so much as to prevent him from working even as a labourer. About two years before coming under Dr. O'B.'s care, he perceived first of all sparks, and occasionally mists, before his eyes, with sharp intermitting pains in the right side of his head and face ; in about a year, a slight prominence and inver- sion of the globe were observed ; and from that period, the symp- toms gradually proceeded to the state already described. It was decided in consultation, that the tumour should be removed, but it was not even suspected that the lachrymal gland was the part affected. The operation was begun by an incision through the integuments of the upper eyelid, extending from the inner to the outer angle. The obicularis palpebrarum being next divided, some portions of adipose substance which presented were removed. Dr. O'B. then introduced his finger, and at once discovered that the disease was an enlarged and indurated lachrymal gland. The anterior surface of the tumour was exposed by dissection, and it was finally removed by cautiously working with the nail of the little finger, for it was not considered safe to introduce a knife into t'a back of the orbit. The surface of the extirpated gland was gran- ular, and of a pink colour. It was enlarged to at least six times its natural size. When cut into, it presented a hard, membranous, or rather cartilaginous centre, from v^hich septa passed to the cir- cumference. No sanies could be perceived. On the tumour being removed, the pupil instantly recovered its contractile power, and the globe retired nearly to its natural situation. Yision too was iiVi- proved, but not perfectl}^ restored. Scarcely any hseniorrhage ensued, and the wound was dressed simply.^ With the exception. of a slight erysipelas of the scalp, which yielded to ihe usual reme- dies, the patient's recovery was uninterrupted; and the wound was completely healed on the fourteenth day after ibe operation. At that time, vision was perfect, all uneasiness had subsided, and the eye occupied its proper place. The upper eyelid, however, having continued so much relaxed as to obscure a great part of the cornea, a camel's hair pencil, dipped in sulphuric acid diluted with three parts of water, was drawn in the line of the cicatrice. In a few days a slough separated, and the subsetjuent cicatrization of the ulcer contracted the lid to its natural state. The patient continued per- fectly well, and suffered no inconvenience from the loss of the gland.* * Dublin Hospital Reports. Vol. iii. p. 426. Dublin, 1832. 84 Case 3. The following report of a case of extirpation of the lachrymal gland, by Mr. Lawrence, appeared in the Lancet.* John Clifton, aged 24, seven years before his admission to the London Ophthalmic Infirmary, received a violent blow on the left upper lid, near the external angle of the orbit. This was followed by considerable swelling, which gradually subsided. Two months afterwards the lid again swelled, with considerable pain, which lasted for about a month. The pain then went off entirely, but the swelling continued. There was a constant profuse watery dis- charge, considerably increased by exposure to the air. The globe of the eye became gradually protruded from the orbit, with loss of all useful vision. A fortnight before his admission, the eye inflamed, and became very painful. There was general fulness of the upper lid, which was more particularly swelled, and broader than natural, near the external angle. The globe and the lower lid were pushed downwards and inwards to about half way between the orbit and the nose ; but although the globe was quite out of its socket, the lids were so extended as to cover it completely. There was con- siderable inflammation of the external tunics, a broad red zone in the sclerotic round the cornea, with general dulness, and a small ulcer of the latter. A hard unyielding tumour, tuberculated on its surface, projected a little beyond the margin of the orbit, at its upper and outer part. Mr. L. thought it doubtful whether or not this tumour "was moveable upon the bone. Mr. Tyrrell considered it not moveable, and therefore did not recommend its extirpation. The patient was cupped, bled with leeches, and purged. Mr. Wardrop was consulted, and after convincing himself that the tumour had not any immediate connexion with the bone, he strongly advised its removal by an operation, which 3Ir. L. accord- ingl}' peiformed. As the swelling obviously filled a large portion of the orbit, and probably extended deeply into that cavity, it was desirable to have ample room, and the external incisions were therefore free. The first, of about 3 inches in length, extended from the temple, along the fold of the upper lid, to the root of the nose ; the second of 2 inches, passed perpendicularly over the upper and outer part of the orbit and forehead, to meet the first at right angles. It was found necessary to moke a third incision, from the first towards the anterior root of the zygoma. By turning aside the flaps produced by this crucial incision, the seat of the tumour was completely exposed. No other difficulty was experienced, except that inseparable from the size and hardness of the swelling, its deep extent backw"ards, and close contact with the orbit and its con- tents : its surrounding connexions were, however, merely cellular. The tumour consisted of the lachrymal gland, increased to the size of a large walnut, and of the most compact homogeneous structure ; having a firmness of texture approaching to that of cartilage, a light • Vol. X. p. 159. Locdon, 1826. 85 rellow tint, and at one part an appearance of white radiating fibres. Altogether it much resembled the firmest part of a scirrhous breast. During the operation, a large quanti'iy of blood was lost, and, as it illed the deep cavity left by removing the tumour, its source could lot be discovered. The patient w^^as left quiet, in the hope that he bleeding would cease ; it continued, however, fieely, for more han half an hour, rendering the patient very faint. An artery ,vas then secured. The incisions were approximated by 5 small ;ilk ligatures, and 3 narrow slips of adhesive plaster ; and the parts vere constantly covered wnth a wet rag. By the following day, he wounds having united by adhesion, the stitches and straps vere removed. The eye (says the report) had receded to its natu- al position, and the inflammation of the sclerotic had ceased, i^ourteen days afterwards, the cornea had nearly recovered its ransparency, vision was much improved, the eye moved freely, and ts surface, with that of the lids, was as moist as usual. Case 4. A Medical Journal published at Bourdeaux in January 1829, contains an account of some cases of extirpation of the lach- •ymal gland, performed many years before, by Daviel. One of hese cases is that of a peasant, 63 years of age, who, eleven years oefore he consulted Daviel, had received a blow on the upper part )f the right orbit, for which fomentations and other remedies were employed ; notwithstanding which the eye became projected from :he orbit so as to produce considerable deformity, and to impede its "unctions. On careful examination, Daviel discovered a fistulous Dpening, about a line in width, which penetrated the orbit. By introducing a probe, an extremely hard body was felt between the ^lobe of the eye and the bone, which was likewise discovered to be carious at the upper part of the orbit. A director was introduced into the sinus, and an incision made tiirough the upper eyelid, from the outer and upper angle of the orbit to within the 8th of an inch of the inner and upper angle. By this incision the ball of the eye and the caries of the orbit were exposed, and several pieces of dis- eased bone removed. Nearly an ounce of grumous matter escaped, which had been contained in a strong cyst, and which, as well as the lachrymal gland, was removed. The gland was nearly as large as a pigeon's egg. A small fatty tumour was also removed ; after which the eye was easily restored to its natural situation ; and the strabismus, which had been present before the operation, dis- appeared. The wound was simply dressed, except that little dos- sils of charpie dipped in tincture of myrrh and aloes were applied to those points of bone which were exposed. In less than a month the patient was radically cured ; the eye being as moist as the other, and, (if the narrator of the case can be credited), capable of weeping, as if the lachrymal gland had been present.* * London Medical Gazette. Vol. iii. p. 523. London, 1829. 86 SECTION VI.— LACHRYMAL TUMOUR IN THE LACHRYMAL GLAND. This disease appears lo have been for the first time accurately described by Professor Schmidt. It consists in a collection of thin fluid in the situation of the lach- rymal gland. This fluid is supposed to be tears, and the cyst in which it collects to be originally nothing more than one of the cells of the cellular membrane, serving to hold together the acini oi grains of which the lachrymal gland is composed. Whether this is really a lachrymal tumour, or merely a common encysted tumour situated in the lachrymal gland, or at least closely connected with it, is a matter of little consequence. Were we certain that it was the latter, we should not, of course, make it the subject of a sepa- rate section, but class it under the head of orbital tumours. That this is a rare disease may be concluded from the fact that Schmidt relates only two cases of it ; and that Beer had seen only three cases. In one of Beer's cases, the diagnosis became com- pletely^ evident only after death. In the tumour, Beer found a small quantity of fluid, which he does not hesitate to call tears, and whicl; was thin, clear, sharp, and saltish to the taste. In the second case. Beer opened the tumour during life ; the fluid discharged was yel- lowish like serum, but so acrid that it immediately caused a small vesicle when applied to the tongue. In Beer's third case, he was merely consulted in the commencement of the disease. Schmidt called this disease hydatid of the lachrymal gland ; but as there is not the least reason to suppose the C3^st in the present case to be alive, it is less ambiguous to name this disease, lachrymal tumour in the lachrymal gland. Indeed, Schmidt's own hypothesis of the origin of the cyst is quite inconsistent with the assumption, that this disease is at all analogous to those parasitical zoophytes, which are well known under the name of hydatids. He supposes that a single cell of the cellular membrane connesiing the acini of the lachrymal gland becomes distended, and filled with tears, and that this is the origin of this disease. It is not easy to explain how this cell should afterwards become detached, so as to form a cyst, which anay be sometimes extracted, as if quite unadherent to the surrounding parts ; for to tell us, as Schmidt has done, that the distended cell presses aside the surrounding cellular membrane, so as to form a sort of capsule for itself, and that between this capsule and the proper membrane of the cell an interstitial fluid is after- wards effused, is to indulge entirely in conjecture. Symptoms. The development of lachrymal tumour in the lach- rymal gland is, in some cases at least, very rapid ; and its conse- quences are not merel}^ distressing, but dangerous. One of the most striking symptoms attended this tumour is protrusion of the eye. It is pushed forward fioni the orbit, and inward, toward the nose. I have already had occasion to mention that protrusion of the eye is called exophthalmos, if there is no other change than 87 merely the change of place, but that if there be inflammatory dis- organization of the whole globe of the eye along with the protrusion, this state is called exophthalmia. When this disease is attended with exophthalmos, the following are the symptoms. The patient, perhaps perfectly well in every other respect, complains of obtuse, deep-seated pain in the orbit. The pain is as if something behind the eyeball were pushing it out of its socket. It is felt m.ost when the patient moves his eye in difl'erent directions, and especially when he turns it towards the temple. It daily increases. Nothing unnatural in the form nor in the texture of the eye nor eyelids is as yet discernible. By and by, there is added to the pain behind the eye, a feeling of tension both in the orbit and over the side of the head ; and the eyeball is now observed to be somewhat protruded from the orbit and towards the nose. Some few individual blood-vessels excepted, it is not red. The patient has a feehng of dryness in the eye. He cannot move the eye without great aggravation of the pain, and a sensation of sudden flashes of light in the eye. At last, he is totally deprived of the power of moving it. When he regards objects with the pro- truded eye, he sees them disfigured. If he looks with both eyes, he sees objects double, as the protruded eye stands no longer in the natural axis of vision. The more that the lachrymal tumour pushes the eyeball out of the orbit, vision becomes the weaker and more disturbed. In proportion as the disease advances, the patient loses his appetite, and is deprived more and more of sleep. The hemi- crania becomes uninterrupted, by day and night. Vision is entirely lost. The eye is so much protruded, that it rests in some measure upon the cheek. The eyelids lose all power of motion, the upper one being firmly extended over the protruded eye. The patient betrays a constant incUnation to cover the eye with the eyelids, and at every attempt to do so the eyeball is rolled by the action of the obliqui towards the nose. A resisting hardness is felt with the fin- ger at the temporal angle of the eye, between the protruded eyeball, and the external edge of the orbit. The eye becomes sullied and dusky. If nothing is done to relieve the symptoms, coma and death are the consequences. Should this disease be combined with exophthalmia, besides ob- tuse, deep-seated, and constantly increasing pain in the orbit, there is pain in the eyeball itself ; and whereas, in the former case, the eye, though protruded by the growing tumour, preserves its ordina- ry size, in the present case it is rapidly enlarged, and destroyed by inflammation. It goes on to suppuration, and unless opened by the knife, bursts, discharging blood, and ichorous matter. The membranes do not collapse after this evacuation, but the eyeball I continues to project from the orbit, a fleshy formless mass, proving [how much its organization had suffered by the processes of inflam- ' mation and suppuration. The pain in the burst eye, and in the half of the head, continues, the patient is deprived of sleep and ap- 88 petite, and the lymphatic glands about the face become enlarged. Should a patient present himself with such symptoms, we shall na- turally be led to suspect the existence either of this disease, or of some other disease of the lachrymal gland, and our suspicions will be confirmed if we find a resisting hardness between the destroyed eyeball and the external edge of the orbit. This symptom, how- ever, may be detected, it is likely, at a much earlier period of the disease. Could we dare to draw a conclusion upoa this point from the few cases of lachrymal tumour on record, we should say that; this disease is more apt to terminate fatally when attended by ex- ophthalmos, than when accompanied by exophthalmia. In neg- lected cases, however, of lachrymal tumour with exophthalmia, the disorganization spreads to the bones of the orbit, and at last the brain itself l>ecoming affected, death puts an end to the patient's sufferings. This was the termination of one of the three cases ob- served by Beer. Treatment. The radical cure of lachrymal tumour in the lach- rymal gland, would consist, no doubt, in extirpating the tumour before the eye became protruded, at least lo any considerable ex- tent, from the orbit ; but at ihh period, we cannot distinguish the disease with sufScient certainty. Even had we the means of de- termining that the commencing exophthalmos arose from this dis- ease, could we extirpate this vesicular sweUing without removing also the gland in which it was situated? A palliative treatment will generally be adopted, by the employ- ment of which we may,^ on the one hand, save the life,^ and, on the other, the eye of the patient. It may even happen that by the early employment of this palliative cure, we may be fortunate enough to cure the disease completely. No hope of this, however, need be entertained, if the eyeball be already protruded from the orbit, the power of vision lost, the eyeball beginning to appear dusky and lifeless^ or if it be violently inflamed, and in part disor- ganized. The palliative cure consists in puncturing the tumour, and evac- uating the accumulated fluid. This should be done, if practicable, from under the upper eyelid, with a lancet or delicate histouri radtc directed towards the seat of the lachrymal gland. Should the tU' mour return after the healing of the wound, the operation must be repeated. I should think any attempt to keep the wound open, and the tumour perpetually empty, by the introduction of a bougie or other foreign body, out of the question, if the incision were made from under the upper eyelid. But if the protrusion of the eye were such that the upper eyelid was firmly stretched over the eyeball, and that no instrument could be passed between them, the tumoui would require to be opened through the upper eyelid, and the wounc might be afterwards kept open by a bit of catgut,, so as to give exit to any reaccumulating fiuicf, and perhaps cause a radical cure. That through the openings wherever it be made, the cyst of the 89 umour shall be extracted, cannot certainly be regarded, a 'priori, IS likely to happen ; yet this actually took place in one of Schmidt's )ases. Cases. As the present is a rare and interesting disease, I am nduced to lay before the reader the particulars of the two following :ases related by Schmidt. Case 1. A private soldier, aged 26 years, of a firm and corpu- ent make, from fatigue and exposure to cold, became ill with fever, n the end of November, 1800. According the history of the case, le had a slight typhus, which yielded to the use of the proper neans, so that he left the hospital in the beginning of January 801, and set off for his regiment. Already, some days before he left he hospital, he had an obtuse, deep-seated feeling of pressure in his ye ; but he set himself out against it, and said nothing of it to his oedical attendant. He was about 8 days with his regiment, when le observed that this obtuse, deep-seated pain grew more constant nd more troublesome. But as he could discover nothing wrong bout his eye, and saw perfectly well, he let matters rest as they i^ere. In the beginning of the third week the feeling of pressure lecame violent, he felt pain with tension in the eye itself, and in tie corresponding half of the head ; the eye became red and dry, nd began to project; he frequently had the sensation of fiery pectra, and at times his sight failed him. About this time, he be- an to sleep but little. With these symptoms, he was unable to erform his duty as a soldier. The medical officer to whom he f/as presented, ordered the application of a moist warm poultice, l^he case became evidently worse from day to day. With the be- inning of the fourth week, the hemicrania and pain in the eye ecame furious, day and night, so that he could not get a moment's eep ; the eye protruded completely from its socket, so that it was- ien from the other side over the root of the nose ; it was shghtly ;d, but not swollen, moist and slippery, but deprived of sight, ^he appetite for food, which had continued till now, was lost, ^he patient's restlessness rose to the extreme. In this state, he ■as brought to the Military Hospital of Vienna, on the 4th Febru- ry. Early on the 5th, Schmidt saw him for the first time. Be- ;des the above-mentioned symptoms, he found the patient affected 'ith spasm of the superior oblique muscle, whereby the eye was Very instant drawn more out of the orbit and towards the nose, ["■he eyelids were not in the least swollen, but quite pushed aside lom the eye. Schmidt felt distinctly a resisting hardness in the j mporal angle of the orbit. He declared before those who attended |ie visit, that the disease was seated in the orbit, and that it was fobably a steatomatous tumour for which nothing decisive could [i undertaken. Opium internally and externally, warm poultices jVer the eye and head, nothing could check the fury of the pain. 1 arly on the 6th, Schmidt found the patient in the same state, only lat the eye was no longer lively, but dusky and somewhat hke 12 90 the eye of a ^ying person, while the appearance of the sonnd eye was still very lively. The pulse, the respiration, and all the other functions, were not in the least altered. Schmidt determined t( evacuate the eye, next day, by an incision. Towards evening, the patient fell into a state of sopor, became insensible, discharged his urine and fseces involuntarily, and died towards midnight. Or dissection, the veins and sinuses of the brain were found distendec with blood. There was no accumulation of fluid in the ventricles On removing the orbitary process'of the frontal bone without injuring the periosteum, a fluctuating tumour pressed itself upwards fron the temporal angle of the orbit. On continuing the dissection, th muscles of the eye, optic nerve, and other nerves of the orbit, wer< observed to be evidently stretched and elongated, and the opthalmi vein appeared varicose. The lachrymal gland was smaller thai usual, and in connexion with it lay the fluctuating tumour. Thi individual acini which were more remote from the tumour, an were dii'ected towards the upper eyelid, were larger and more cc herent : v/hilst those acini which lay upon the tumour were smal and both appeared and felt more loosely scattered than natura The tumour was in diameter, from behind foiivards, the length c an inch ; in transverse and perpendicular diameters somewhat lei than an inch. It pressed itself close upon the external segment ( the eyeball, and even after death held the eyeball out of the orb and towards the nose. It had an external and an internal cove ing. The external consisted of thick cellular membrane. Betwee this and the internal covering was a quantity of interstitial fluic The internal covering w^as very fine, semitransparent, and coi fcained a limpid fluid. The external membrane could not be easil separated from the scattered acini of the lachrymal gland. Th internal could be freel}^ extracted from the external covering.* Case 2. A young country-woman came to Yienna in Mb 1802, and sought Schmidt's assistance. Two months before, si had weaned her child ; and immediately after, upon being e; posed to cold, felt violent hemicrania and pain in the eye. Aft some da3^s the eyeball inflamed severely, became swollen, at pressed itself forwards from the orbit. When the woman came Schmidt, the inflamed eye had the size of a man's fist, the cornc was completely destroyed from suppuration, and burst, and the ir was covered by a new and wart-like production, so that it was wii difficulty that an eye could be recognised in this formless mass flesh. Together with a constant pressing pain in the orbit, ar continual hemicrania, Schmidt found all the symptoms detailed the former case, with the exception of the spasmodic motions of tl eyeball. He mentions that the parotid gland, upon the same sid was swollen towards the bi'anch of the lower jaw, but more pr bably the sweUing affected one of the lymphatic glands l5'ing ov * Schmidt Qber die Krankheiten des Thranenorgans, p. 90. Wein, 1803. 91 ihe parotid. The patient was admitted into the hospital, under Lhe care of Mr. Ruttorffer, who passed a stnall flat trocar under the upper eyelid, directing' its point towards the fosi-a kichryniahs, where the resistance and hardness were felt. More than an ounce Df extremely clear fluid was immediately discharged through the 3anula. The canula was removed, and for several days this clear luid issued from the wound. Some hours after the operation, the lemicrania suddenly and considerably diminished, and from day .0 day the exophthalmia became less. On the 14th day after the operation, a whitish streak was observed in the wound, resembling )us, but which could not be removed with a httle lint. Mr. R. laid lold of this with a pair of forceps, and drew forth the cyst, or as 5chmidt chooses to call it, the hydatid, which, as represented in lis work, must have measured more than an inch in diameter. \.fter other 14 days, the woman left the hospital, the exophthalmia jiaving diminished to a small stump of an eye.* ) From the state to which the eyeball is reduced in exophthalmia jiroceeding from this disease, it is not unlikely that cases of this sort lave sometimes been taken for cancerous affections, and the eyeball )i'ith the cyst extirpated. An instance of this kind we find in the i^hilosophical Transactions for 1755, related by Mr. Spry, surgeon ) t Plymouth. [; The patient, a mariner's wife, complained of violent pain in her (ift eye, and sometimes of very acute pain in the temple of the ^ame side, with some defect in her sight. She also imagined that I er eye was bigger than ordinary ; but, upon inspection, it appeared 1 bigger than the other. The cornea, however, became less trans- jarent, and the pupil greatly dilated. The vessels of the conjunc- [I va and sclerotica were no way enlarged. Bleeding, blistering, and urging, proved of no effect. On the contrary, the cornea became liore opaque, great inflammation of the conjunctiva and sclerotica psued, and an apparent prominence of the whole eye. She was ^^ain purged, and a seton put in the neck ; but the symptoms in- ■eased. She became still more miserable. The conjunctivabecame greatly inflamed, wath eversion of the upper lid, attended with great j ;iin. Mr. S. often scarified the conjunctiva, which bled plentifully, liQd gave her eo^se for a day or two. He also took blood from the tem- pral artery. But the eye being greatly enlarged, and of so terrible Q appearance, after all his endeavours for eight or ten months, he idged the disease to be carcinoma, and therefore proposed cutting jt the eye as the only remedy. The operation, however, was de- rred ; till, at length, the eye becoming much larger, and the pain icreasing, extirpation was had recourse to, lest the bones of the •bit might become caiious. Mr. S. having begun his incision )und the upper part of the tumour, had not cut deep, when a reat quantity of fluid, hke lymph, poured out upon him with great :irce, like a fountain. The tumour subsided a good deal ; but pur- * Schmidt, D. 94. 92 suing the operation, he found a large cyst, which filled the whole orbit behind the eye. A part of this cyst was left to slough off with j the dressings. The whole eye being cut out, he filled the wound with lint. The cure went on with success, and was complete in a month. On examining the tumour which had been removed, the eye appeared a little bigger than natural, the aqueous humour not so clear as usual, the crystalline less sohd and transparent, the vitreous almost reduced to a liquid state, the cyst very strong and elastic, with a cavity sufficient to contain a large hen's-egg.* There can be little doubt that this was a misunderstood case o1 lachrymal tumour in the lachrymal gland, or, at any rate, of en- cysted orbital tumour, and not at all a carcinoma. SECTION VII. LACHRYMAL TUMOUR IN THE SUBCONJUNCTI VAL CELLULAR MEMBRANE. This disease resembles considerably in its nature that which we have last considered. Its seat seems to be the principal difference for the tumour described in the last section, is seated in the sub stance of the lachrymal gland, and is supposed to derive the fluic which it contains from the gland immediately ; while the presen disease, seated more superficially, is, in fact, almost immediatel; behind the conjunctiva, and derives its fluid, according to Schmidt from one or more of the lachrymal ducts. Benedict describes it a a mere dilatation of one of these ducts. The tumour in the disea& which we have been considering, produces a series of the most dan gerous symptoms, long before it comes into view itself, if ever i comes into view ; whereas, the present disease, from its superficia situation, is neither productive of so destructive effects, nor can i remain so long concealed. Symptoons. As soon as it has reached any considerable exteni the present disease manifests itself by the following symptoms. 1 circumscribed, very elastic swelling, void of pain, is felt immediatel; behind the upper eyelid, towards the temporal side of the orbit. 1 the tumour has already reached such a degree, as to present througl the eyelid the size of a hazel nut, and if we press upon it prett forcibly, the patient feels the pressure in the eyeball, and observe fiery spectra before the eye. If, at the same time, that we pres the tumour from without, we raise the upper eyelid, and, in sora measure, evert it, we see the conjunctiva project in the form of distended sac, in which we discover fluctuation. When the ti mour has reached the size of a pigeon's egg, the motions of th eyeball upwards and outwards are impeded ; yet, when we rais the upper eyehd in the manner just now mentioned, the patient i immediately able to move his eye, without difficulty, towards th temple, the eyeball retiring behind the tumour, pushing it and th conjunctiva still more forwards, while at the same tune the fluctuf * Philosophical Transactions, Vol. xlix. Part 1. p. 18. London, 1756. 93 tion becomes more distinct. From extreme distention, the conjunc- tiva, and the cyst in which the fluid is contained, are so thin, that the pressure we employ in examining the disease, seems ahiaost sufficient to cause the rupture of the tumour. In no other disease of the orbit, or of the eyelids, do we observe any similar symptoms. One of the most characteristic marks of this disease, we are told, is its momentary increase when the patient weeps. Causes. It is supposed that the proximate cause of this disease, is the termination of one or more of the excreting ducts of the lach- rymal gland in the loose cellular substance under the conjunctiva ; that one of the cells is gradually distended by the accumulating tears, and at last forms the thin sac, the projection of which gives rise to the symptoms described. That this is the real nature of the case, is concluded from the alleged fact, that if the tumour be opened through the eyelid, a considerable quantity of pure tears flows through the incision, every time the patient weeps. Beer met with this disease six times in individuals who were between 4 and 14 years of age. In two of these cases, an appa- rent exciting cause had preceded the disease. In the one, the cause was a violent bruise on the upper edge of the orbit, from the spring- ing of a biUiard ball. In the other, this disease arose after the in- complete extirpation of an encysted tumour, which had its seat at the same place. Treatment. The plan of cure which appears the most rational for this disease, is to evert the upper eyelid, or if that cannot be done to a sufficient extent, to separate the eyelids by an incision, carried outwards from the external angle towards the temple, and then, raising the upper lid, to expose the tumour, divide the con- junctiva very cautiously, lay hold of the cyst with a pair of forceps, and extirpate as much of it as possible. Beer's treatment of this disease consisted in laying bare the tumour by dividing the conjunctiva, and then passing a thick silk thread through the cyst, and through the upper eyelid, by means of a, curved needle, knotting together the ends of this seton, and drawing it backwards and forwards till such a degree of inflammation should be excited as was likely to obliterate the cavity of the cyst. If after 24 hours, this seemed insufficient to cause the necessary degree of inflammation, he moistened that part of the seton which issued from the eyelid with a solution of lunar caustic, or even of pure pot- ash. Still, if no sufficient adhesive inflammation followed, nor any suppuration sufficient to destroy the cyst, or even to destroy the excretory duct supposed to be in fault, he contented himself with having in this way obtained a palliative cure. He still retained the seton for a time, till the internal and external openings became callous, in the hope, that after the thread was withdrawn, the patient might be able to empty the cyst by gentle pressure, when- ever it should become filled. He mentions, that if the evacuation takes place through the external opening, the collected fluid is 94 squirted out in a scarcely visible stream, through the minute fistulous opening, to the distance of several feet, till the tumour be emptied. It strikes me, that rather than form in this way a troublesome fistulous opening through the upper eyelid, the simple palliative cure should be had recourse to, of puncturing the tumour through the conjunctiva ; but that it would be preferable, to endeavour radically to remove the disease, by extirpating the cyst in the manner already mentioned. SECTION VIII. TRUE LACHRYMAL FISTULA. This disease consists in a callous opening, so small as scarcely to be visible to the naked e5^e, situated in the upper eyelid, towards its temporal extremity, and from which there trickles from time to time, a quantity of tears. If we pass an Anelian probe into this minute fistula, we find that the probe is led directly towards the lachrymal gland, but we neither perceive any hardness of the gland, feel any portion of bone laid bare, nor give the patient any pain. True lachrymal fistula may arise from a wound of the gland, or of its ducts. More frequently it is the eflfect of a neglected or mis' treated abscess of the upper eyelid, or of inflammation which had passed into suppuration, of the cellular substance surrounding the lachrymal gland. It may also be the result of an otherwise fruit- less attempt to cure a lachrymal cyst, by means of the seton, as has been described in the last section. This almost capillary fistula will require the finest Anelian syr- inge, to inject any fluid into it. It has been advised to widen the fistula, by repeated introductions of the Anelian probe, followed by the use of a piece of catgut ; and after this is accomplished, to in- troduce into the fistula a small bougie armed with lunar caustic. By passing this bougie backwards and forwards several times with a rotatory motion, through the fistula, we may expect to excite such a degree of inflammation as shall end in its closure. Beer relates the case of a stout country lad, who had a fistula of this kind, 3^ lines deep, and completely callous. He quickly passed into the opening, and to the bottom of the fistula, a red hot knitting needle, turning it round several times upon its axis. Five days afterwards, the fistula was completely closed. 1 SECTION IX. MORBID TEARS. The tears are at all times an irritating secretion. The con^ junctiva is instantly reddened when they flow, and if they are sc profuse as to run over on the cheek, the skin, with v/hich thej come into frequent contact, becomes inflamed and excoriated. Ii soiTie cases, the extraordinary degree of inflammation which thi, tears have excited, has led to the supposition, that their chemica^ properties were changed by disease, so that they had acquired ai 95 unusual degree of acrid ness. In a supposed case of this kind, which some years ago attracted a considerable share of attention in this town, it was discovered, that the deep lines of excoriation which ran down the cheeks of the patient, who was a child, were not the work of the tears, but the effects of a deliberate applica- tion of sulphuric acid. The author of this extraordinary piece of cruelty, was the woman who kept the child. SECTION X. LACHRYMAL CALCULUS. The tears, like the saliva, occasionally become the source of calcareous depositions. Lachrymal calculus does not appear to have been met with ob- structing the lachrymal ducts ; but Professor Walther has recorded a case, in which a copious deposition of calcareous matter, from the tears, was continued for a period of nearly ten weeks, the concretions being formed in the folds of the conjunctiva. The patient was a healthy young woman, to whom it happened, in 1811, that a small bit of lime fell from the ceiling of a room into the left eye. Walther removed it, and the eye appeared to have sustained no injury. In February, 1813, she was first at- tacked with severe toothach, both in the upper and lower jaw. Several decayed molares, in which the pain was particularly vio- lent, were extracted, but with merely temporary relief. Soon after this, she had an attack of rather obstinate constipation, with other symptoms of colic ; but by clysters, fomentations, (fee. it was removed. Towards the end of July, of the same year, she be- gan to complain of a burning, stinging sensation in the left eye, most severe when the eye or eyelids were moved, or when she was exposed to bright sunshine. On closely examining the organ, a white angular concretion was discovered between the eyeball and the lower eyelid, towards the external angle of the eye. It was about the size of a pea, and, when removed from the eye, was readily rubbed down between the fingers into a greasy sandy pow- der. Although the patient firmly denied that any foreign body had fallen into her eye, Walther at first supposed, that the sub- stance removed was a piece of lime which had just got into it. He was not a little surprised, however, when the patient returned to him, three days afterwards, with a calculus exactly like the first, lying in the very same place. The eye was now considerably in- flamed, the pain not being confined to the eyeball, but extending in the direction of the supra-orbitary nerve. There was a propor- tionate sensibility to light, and increased flow of tears. The in- flammation of the eye had commenced the preceding evening, accompanied by a violent paroxysm of fever, vv^ith shivering, suc- ceeded by heat. Although the newly formed calculus was imme- diately and easily removed, still, on the following nmorning, after a restless and distressful night, the violence of the inflammation was 96 much increased, and in the lower fold of the conjunctiva another white crumbling concretion was perceived, which, by the succeed- ing day, had attained as large a size as the former. The upper eyehd was inflamed, and the margins of both swollen. The in- flammation was so violent as to require blood-letting, and other antiphlogistic remedies. By these, some alleviation was effected, but four days afterwards another bleeding was necessary, from an increase of the inflami^iatory symptoms. In the meantime, the formation of calculi, at the same place in the affected eye, not only proceeded, but larger concretions were produced, and with greater rapidity. The calcuh were now removed twice a day, and at length three times a day from the eye. Reasoning from the good effects of potash in calculous affections of the kidney, Wal- ther prescribed a solution of a drachm and a half of carbonate of potash in four ounces of cinnamon water, with half an ounce of syrup. Of this solution, half a tablespoonful was taken four times a day ; and along with this, the patient drank copiously of an in- fusion of the herb jacea. After using these remedies for six days, during which time the urine was muddy and foetid, and deposited a copious sediment, the activity of the disposition to form calculi greatly diminished. In the course of twenty-four hours, there was but one, and that a smaller concretion, formed, and at length merely a white crumbling powder, no longer consolidated into a mass, and which required ta be removed only every second day. But while the disease in the left eye decreased and disappeared, it attacked the right, and at the same part of the conjunctiva, between the eyeball^ and lower eyelid. Its course here was exactly the same as before ; at first,, the calculi formed in fewer numbers, and more slow)}', afterwards more rapidly, and in greater numbers ; the inflammation of the right eye was at first moderate, and afterwards more severe, ren- dering venesection twice necessary. Nevertheless, the disease never attained the same height, and was of shorter duration in the right eye. It gradually decreased as it had increased ; the concretions appearing at greater intervals, iDecoming smaller, and at length en- tirely ceasing. The whole course of the disease occupied nearly ten weeks. The patient's chest seemed to have suffered in some degree, from the repeated blood-lettings, altered manner of life, and perhaps from the continued use of alkaline medicine ; she had a troublesome cough, with considerable expectoration, particularly in the morning, and an altered appearance. Walther, therefore, or- dered her an infusion of lichen Islandicus, and better diet. In three weeks, she had perfectly recovered. Some years after this, however, she was again attacked with the same disease. Concre- tions of the former colour, size, and other properties, formed in the left eye ; at first, they lay between the eyeball and under eyelid, and afterwards between the eyeball and upper eyelid. In the course of a few days, the formation of calculi began in the right eye. On this occasion, both eyes were less severely inflamed, and 97 the disease was likewise of shorter duration. Walther immediately ordered her the solution of potash. The number of calculi which were daily generated soon diminished, and the whole jarocess ceased in shorter time. These concretions Walther proposes to call dacryolites. On analysis, they were found to be composed of car- bonate of lime, which formed the greatest part of their weight ; traces of phosphate of lime ; and coagulable lymph or albumen.* CHAPTER III. DISEASES OF THE EYEBROW AND EYELIDS. J SECTION I. INJURIES OF THE EYEBROW AND EYELIDS. Contusions, wounds, and burns of the eyebrow and eyelids, even when they may have at first appeared trifling, are often pro- ductive of very serious consequences. I have already had occasion to mention inflammation of the periosteum, and of the bones, as an effect which is sometimes unexpectedly produced by blows over the edge of the orbit. Lagophthalmos and eversion are apt to be the disagreeable consequences of neglected burns and abscesses of the eyelids ; while incised and lacerated w^ounds of the eyebrow, and of the neighbouring integuments, even of very small extent, are oc- casionally followed by complete, and but too often incurable, de- privation of sight. 1. Contusion and Ecchyvnosis. Even slight blows over the edge of the orbit are apt to be follow- ed by extravasation of blood into the loose cellular membrane of the eyelids. The extravasation or ecchymosis does not make its ap- pearance immediately after the blow. Five or six hours generally elapse before the sv^^ollen eyelid assumes the livid colour denoting the rupture of blood vessels and the subcutaneous effusion of blood. In some instances, however, the ecchymosis is sudden ; and the quantity of blood being considerable, a degree of fluctuation is felt in the swollen lid. It very rarely happens that the blood effused into the eyelids operates as a foreign substance, or excites inflammation. It is generally absorbed in the course of from fourteen to twenty days, the swelhng subsiding, and the skin gradually losing its livid colour as the absorption goes on, becoming first brownish, and then yellow. * Graefe und Walther's Journal der Chirurgie und Augen-Heilkunde. Vol. i. p. 163. Berlin, 1820. 13 98 The indications in cases of bruises and ecchymosis of the eyelids are to abate the inflammation, which is apt to attend this sort of accident, and to promote the absorption of the effused blood. The first of these objects is to he obtained by the appHcation of leeches, followed by the continued use of evaporating and slightly astringent lotions. More powerful astringents, and gentle pressure are employed to accomplish the second. To remove a black eye, as it is termed, quickly, is the great desid- eratum with the patient, who often visits us late in the evening, with a woful dread of what his appearance must be next morning, un- less we have some a])plication which can prevent or remove the discoloration. If the blow has been severe, there can be no ques- tion that leeching is the proper mode of treatment. "When the pa- tient is a strumous child, the application of leeches is imperatively called for, not indeed so much for the removal of the ecchymosis, as for preventing inflammation of the periosteum and bones. If the blow has been slight, and the patient is a robust adult, compresses wet with a solution of acetas plumbi, or murias ammo- niee, may be appUed, and kept in close contact with the skin, by means of a roller going round the head. A popular remedy is a cataplasm of the bruised roots of the convallaria multiflora or Solo- mon's seal. The roots are beat into a pultaceous mass in a mortar, and are reapplied every half hour for three or four hours, or longer, if necessary. They cause a degree of redness and oedematous swelling, and have been supposed to act by means of the oedema which they excite, diluting the effused blood, and thus promoting its absorption. If long continued, they produce too much inflam- mation ; and if the skin be abraded, they are too irritating to be applied at all. Whatever application we make choice of, whether an astringent solution, or the convallaria roots, the patient ought to be directed to keep the eyelids at rest, and to maintain a certain degree of pres- sure on them by means of wet folds of linen, or the cataplasm. Motion of the lids appears to throw the effused blood more into their loose cellular substance, while rest and gentle pressure tend both to prevent this, and to promote absoi*ption. Those who are obliged to appear in public, sometimes contrive to paint the discoloured skin from day to day, till the natural colour is restored. 2. Burns and scalds Of the eyelids require to be treated with particular care, for in neglected cases, there is, on the one hand, the danger of anchylo- blepharon, or union of the edges of the lids, and on the other, of ectropium and lagophthalmos. It is chiefly in cases of scalds from boiling water, and other hot or caustic fluids, as sulphuric acid, in which the cuticle covering the edges of the lids, has been detached, and the patient afterwards 99 allowed, from carelessness, to lie for a length of time with the lids shut, that anchylo-blepharon follows. It may always be prevented, by obliging the patient to open his e3'es frequently, and introducing, along their edges, a little unguentum oxidi zinci, or other mild salve, melted on the point of the finger. Sym-blepharon, or union of the lids to the eyeball, is sometimes produced, when the conjunc- tiva has been injured by the burn or scald, and is to be obviated in a similar way. Burns and scalds of the external surface of the lids, which have not been sufficiently severe to produce a separation of the cuticle, much less to destroy the texture of the cutis, require merely to be kept constantly wet, for 24 hours, by means of a fold of linen dip- ped in a mixture of vinegar and tepid water. The same applica- tion is also, I conceive, the best, in cases in which the skin is blis- tered, only, that as soon as the blister has fairly formed, it ought to be punctured with a needle, to let its contents escape. After the first 24 hours, a piece of soft linen, spread with the ceratum simplex is to be applied. Burns so severe as to destroy the texture of the cutis, heal only by a slow process of granulation and cicatrization. The granula- tions upon which the new skin is formed, are afterwards absorbed, 30 that a great degree of contraction is produced ; and if the eyelids are involved in the cicatrice, they are shortened or everted. This happens more frequently to the lower, but occasionally to the upper lid, while in some cases of destruction of the skin stretching from the outer angle of the eye towards the temple, we find after the burn has healed, that both lids are dragged outwards, and their in ternal surface exposed. The worst case of eversion of the lids, from a burn, which I have seen, was consequent to total destruction of a large portion of the skin of the temple and face, occasioned by a child falling against the fire. The lolie of the ear was lost, the cica- trice was very extensive, and both lids were everted. In such a case, it is impossible to prevent altogether the displacement of the lids, attendant on tiie contraction of the cicatrice ; but, in ordinary cases, much may be done by careful dressing and bandaging. The lids must be kept, as much as possible, on the stretch, during the progress of cicatrization ; for if this is not done, little or no new skin will be formed, but the ulcer will be covered at the expense of the loose integuments around, in the same way as an ulcer of the scrotum will sometimes heal up without almost any formation of new skin at all. The patient then, in whom the cicatrization of a burn in the neighbourhood of the eyelids is going on, ought not to be allowed to use his eyea, but ought to keep the lids constantly shut, except when the dressings are changed ; pledgets, spread with the ceratum simplex, ought to be laid upon the hds, and round the head a roller ought to be applied so as to press gently on the lids, and keep them on the stretch. This will appear, no doubt, a very tedious and annoying mode of treatment. To be allow^ed to use 100 the eyes, would be much more agreeable to the patient, till he found, as soon as the process of healing was finished, that he had lost the power of closing the lids, or that a portion of their inner surface was permanently exposed by eversion. Burns by gunpowder are to be treated in the same way as other burns, except when the grains of powder have been forced into the skin of the eyelids. When this is the case, the grains are to be carefully picked out. one by one, with the point of a needle, an ope- ration which sometimes requires several houi-s to accomplish. We should not trust much to the application of a poultice under such circumstances, which is recommended with the view of dissolvhig and bringing away the grains of the powder. If the skin is ailow- ed to heal over them, they will remain indelible. 3. Incised and Lacerated Wounds. Punctured wounds of the eyebrow and eyelids, are in general, not attended by any particular had consequences. We must l)e on our guard, of course, lest a punctured wound of the upper lid has gone deeper than its Vnere external appearance might denote, and the instrument with which the wound was inflicted perhaps pene- trated deep into the orbit, or through the orbitary plate of the fron- tal bone. The edges of incised wounds of the eyebrow are to be brought accurately together, and retained by shps of adhesive plaster ; or if these seem insuliicient, the interrupted suture is to be employed, with slips of court-plaster between the stitches. The same practice is to be followed in incised wounds of the eyelids. Even when they are parallel to the fibres of the orbicularis palpebrarum, and impli- cate only the integuments, we shall find the interrupted suture the best means of maintaining the edges of the wound in exact apposi- tion, and thereby preventing any unsightly cicatrice. Still more necessary are stitches, where the whole thickness of the hd has been divided, either traversel}' or perpendicularly. When the wound is transverse, we may content ourselves with including the integu- ments only in the suture ; but in perpendicular wounds, the needle ought to pass through the whole thickness of the divided hd. After the stitches are inserted, and the shps of plaster applied, the eyelids are to be closed, and covered with a pledget spread with simple ce- rate. A folded piece of hnen is to be laid also over the sound e3^e, and a roller, going round the head, is to press gently upon both eyes, so as at once to keep the dressings in their place, and to re- strain the lids from moving. Generally, by the third day, union is effected, so that the threads may be cut out. the slips of plaster being then replaced, as well as the compresses and roller. A perpendicular wound of the upper eyehd, passing through its whole thickness, so as to divide it into two flaps, somewhat hke the two portions of a hare-lip, has received the name of coloboma. If neglected, the edges of such a wound are apt to cicatrize separately. 101 A pitnilar deformity is said to occur con^enitally. An operation^ analogous to that for the cure of hare-lip, is to be had recourse to under such circumstances. The edges of the coloboma are to be pared, and then accurately brought and kept in contact, by one or two stitches and slips of court plaster, till reimion is completed. It occasionally happens, that through a wound of either eyelid, the eyeball is also wounded. This does not alter the mode of pro- [ ceeding with regard to the lid ; nor need we be very apprehensivcj that in consequence of such an injury, union shall take place be- : tween the eyelid and eyeball. Such an injury will generally be inflicted by the point of some sharp instrument suddenly directed against the eye, while the lids are open ; but as soon as the lids close, the wounded eyeball will roll upwards, so that the wound of the lid and that of ihe ball will no longer correspond. j Lacerated wounds of the eyebrow and eyelids do not so readily admit of union as incised wounds. The swelling, inflammation, i and suppuration, which are apt to ensue, often prevent immediate union. Still, we ought to treat lacerated wounds of these parts i almost exactly as we should do incised wounds. Having carefully '. cleansed the wound, and removed any foreign substances which may , have been forced into the cellular membrane, we bring the edges j accurately together. If the means of reunion succeed, we have ; gained our object. If they fail, or if they seem to produce addi- itional irritation, they must be removed, and the cure must be ef- 1 fected by the second intention. When the contusion and laceration [ attending a v/ounded eyehd, are very great, of course no attempt at I union need be made, till by leeching, and poulticing with bread i and water, the irritation and tumefaction shall have subsided. By ; guarding against motion, and by the careful use of compresses and ; adhesive plasters, after the parts have become quiet, we shall often be able to accomplish reunion, without any considerable deformit}^, or displacement of the injured parts. , Wounds of the upper eyelid are occasionally followed by palsy, I in consequence of the injury done to the levator palpebrae, or to the 'nervous branch with which it is supplied by the third pair or motor i ocuh. This branch, however, cannot be reached, unless the wound peneti-ates pretty deep into the orbit, and traverses the levator mus- cle. The patient, when he wishes to see, is obhged, as Ambrose Pare observes,* to raise the eyelid with his finger. Pare attributes ;this consequence of a wound of the upper eyehd, to unskilfulness, lor inadvertence, on the part of the surgeon, inasmuch as he must have omitted sewing the wound properly, and applying the neces- sary compresses and bandage. M. Ribes mentions the case of a soldier, who had received a cut from a sabre in the upper eyelid, towards the superior edge of the tarsus. The wound liealed readily ; but the patient, even while he retained the faculty of vision, saw * CEuvres. Liv. x. Chap. 24. 102 none, on accouot of the impossibility of raising the upper eyelid, which continued constantly depressed.* Such facts, while iliey must injpress us with the importance of leaving nothing undone which is likely to procure a complete reunion of the divided parts, may serve also to warn against pronouncing a prognosis too decidedly favourable, in those cases in which we have reason to suspect that the levator of the upper eyelid, or its nerve, has been materially injured. Even slight wounds of the eyebrow and eyelids have sometimes been followed by very important effects. 1 have already referredt to the cases recorded by Dease and Petit, in which injuries of this sort were followed by inflammation within the cranium, and death. The loss of vision is another consequence arising from apparently trifling injuries of the eyebrows and eyelids, which has attracted attention from the time of Hippocrates. Thus, Camerarius relates the case of a young man, who had received a slight wound at the inner angle of the left eye, close to the upper eyelid. The wound, though small, penetrated to the bone, and the patient inmiediately felt a severe pain, which was attended by sweUing of the part, and by palsy of the right side of his body. The vision of the right eye became dim, and that of the left, was totally lost, although nothing appeared diseased about the eye, except a slight dilatation of the pupil. The left upper eyelid was also paralyzed. The use of hot mineral waters seemed to restore the motion of the lid, and also of the right leg and arm. The sight of the right eye was in some degree recovered, but that of the left was irremediably lost. Mor- gagni was consulted by a lady, who had been wounded close to the left eye, in two places, by the fragments of the glass of a carriage window. She had seen none during the four days which followed the accident. One of the wounds was near the outer angle, and the other, which was smaller, was under the commencement of the eyebrow. Sabatier quotes these facts as illustrative of the effects of injuries done to the branches of the fifth pair of nerves. + He supposes, and the same supposition has been adopted by Beer and others, that in such cases the injury of the supra-orbitary nerve, or of some other of the branches of the fifth pair, operates sympathetically on the eye, through the medium of the nasal branch o^ that nerve, which assists in the formation of the lenticular ganglion. Admitting this supposition to be true, the question naturally arises, how an injury of the fifth pair, operating through the medium of the lenticular ganglion, should produce blindness. This question has been taken up by M. Ribes, who contends, that the ciliary or iridal nerves, the branches given off by the lenticular ganglion, do not terminate altogether in the iris, but that several of them, having reached the * Memoires de la Societe Aledicale d'Emulation. Vol. vii. p. 92. Paris, 1811. t See page 3. t Traite d'Anatomie. Tome III. p. 2-2-3. Paris, 1791. 103 anterior part of the eye, pierce the choroid, and having penetrated into the corpus ciliare, bend towards the retina.* Beer has discussed the subject of amaurosis from wounds of the branches of the fifth pair, at great length.! The substance of his observations is, that, in severe cases, the bhndness may be in- stantaneous ; in less severe cases slow ; sometimes not till after the process of cicatrization has begun, or is completed ; that it may be a consequence of tension of the nerve, or pressure upon it, produced by the cicatrice ; that the pupil is sometimes expanded, sometimes contracted, in such cases ; that we must beware of confounding amaurosis from wounds of the branches of the fifth pair, with amaurosis from concussion of the eyeball, and perhaps laceration of the retina, and bear in mind, that along with a wound of the eyebrow or eyelids, there may have been a severe blow on the eye- ball ; that in cases in which the amaurosis is really sympathetic, vision may often be completely restored by dividing the lacerated nerve. He insists particularly on this last point, telhng us not to be afraid of paralyzing the orbicularis palpebrarum by dividing the' supra-orbitary nerve. Chopart,t Boyer,§ and others, have adopted a different view from that of Sabatier and Beer, upon the subject of amaurosis con- sequent to wounds of the eyebrow and eyehds. They have ob- served that blindness is not the only attendant on such injuries; but that convulsions, palsies, dehrium, coma, and even death, have lot unfrequently been known to result, apparently from such wounds, but, in fact, from disease of the brain, either concomitant i«^ith, or produced by, the external injury. They have, therefore, concluded, that we ought not to account the amaurosis a mere liervous, or sympathetic effect, propagated from the injured nerve :)f the foce to the nerves of the iris or retina ; but that the irritation uising from the wound is propagated to the brain, that the nervous lymptoms which follow, are to be ascribed to disease arising in that )rgan ; and that the affection of the brain, or of its membranes, in liuch cases, generally partakes of the nature of inflammation, bllowed by effusion or by suppuration. In many cases of this sort, he result has been fatal, and dissection has demonstrated the truth ;>f these views ; while in cases that have recovered, we should be I ed to suspect, that the amaurosis, and other nervous symptoms, jiave disappeared, not in consequence of dividing the injured nerve, )Ut in consequence of the diseased state of the brain having sub- ided. The instances on record which show that very serious, or even ital, disease of the brain may arise in connexion with apparently * Memoires dela Societc Medicale d' Emulation, Tome. vii. p. 99. Paris, 1811. t Lehre von den Angenkrakheiten. Vol. i. pp. 176, 185, 189. Wien. 1833. t Treatise on Chirurgical Diseases, translated by Turnbull. Vol. L p. 267. Lon- on, 1797. § Traite des Maladies Chirurgicales. Tome v. pp. 245, 248. Paris, 1816. 104 slight wounds of the eyebrow or eyelids, are sufficiently numerousv Morgagni has narrated several highly interesting cases of this sort in his 51st epistle. The conclusion to be drawn from such cases is evidently this, that we must watch the effects 'of such injuries, keep the patient quiet, and on low diet, and have recourse freely to the use of blood-letting, if there appear the slightest symptoina of any affection of the brain, or its membranes, as convulsions, sopor, bUndness, or the like. Similar practice must be followed if we have reason to conclude that the amaurosis, concomitant with a wound of the eyebrow or eyelids, is the result not of the injury done to the branches of the fifth pair, but of concussion of the eye- ball. I have seen numerous examples of a blow on the eye in- ducing amaurosis, without in the least affecting the vascularity, or the transparency, of its different textures ; and I can easily con- ceive, that had any wound of the integuments in the neighbor- hood of the eye accompanied such blows, I might have been led into the erroneous supposition, that the amaurosis was not direct, but sympathetic. Jt is proper also, to mention, before quitting this subject, that the section of the injured nerve, proposed by Beer,, and which he expressly states to be a means which had never failed him, has been repeated in several instances by others, without producing any effect upon the amaurosis. " I have met," says Dr. Hennen. " with one or two cases of amaurosis from wounds of the supra- orbitary nerve ; the perfect division of the nerve produced no alle- viation of the complaint, but after some time, the eye partially recovered."* " When the defective vision follows a wound on tb€ forehead," says Mr. Guthrie, " the only hope of relief that we are at present acquainted with, lies in a free incision made down tc the bone in the direction of the original wound ; and even of tlu efficacy of this, 1 am sorry I cannot offer testimony from my owi practice, having failed in every case in which I tried it."t It is well known that every w^ound of the branches of the fiftl pair does not produce amaurosis. Magendie has even endeavourec to show by experiment that pricking these branches, especially tb« supra-orbitary, infra-orbitary, and lachrymal, has no bad effec on vision. He has been led to propose galvanising the eye, b; touching these nerves directly with the Avires communicating witi the opposite poles of a galvanic trough. + The consideration c these facts naturally leads us to regard with still greater doubt, th alleged occurrence of purel}^ sympathetic amaurosis from sligb injuries of the fifth pair, and to suspect that in all the suppose^ cases of this sort there has been either concussion of the eyeball, c disease excited within the cranium. * Observations on Some Important Points in Military Surgery, p. 366. Edin. 181i t Lectures on the Operative Surgery of the Eye, p. 102. London, 1823. t Journal de Physiologic. Tome vi 156. Paris, 1826.. i 105 SECTION II. PHLEGMONOUS INFLAMMATION OF THE EYELIDS. Phlegmonous inflammation of the eyeUds occurs more frequent- ly in children than in adults, and oftener in the upper than in the lower lid. Symptoms. The affected lid is of a deep-red colour, very painful on being touched, hot, and swollen. The swelling spreads from the edge of the lid, but is generally limited in its progress [by the edge of the orbit. It is soon so considerable as to prevent !ihe eye from being opened ; the pain is much increased by the east attempt to move the eye. If the inflammation is unchecked, ;he pain becomes pulsative, the sweUing increases, assumes a livid red colour, and begins to point, generally about the middle of the lid. The pain is now attended by a pricking sensation. The lardness of the swelUng diminishes, and at its most prominent Dart it becomes less sensitive to the touch. The lid has suppura- ed, and the fluctuation of the matter is now distinct. Causes. Abrasion, and other injuries of the skin covering the iyelids, appear to bring on phlegmonous inflammation ; but not , infrequently the cause is obscure, especially when children are the subjects. Prognosis. This disease being neglected or mistreated, a por- ion of the integuments of the eyelids may be lost, from ulceration, Dr from the inflammation going on to gangrene; the consequence ivill be contraction of the lid, and ectropium. Treatment. Leeches to the swollen lid, followed by the con- stant application of an evaporating lotion, constitute the local treat- ment during the first or purely inflammatory stage. The patient s also to be purged, to keep at rest, and live low. If these means ire found insufficient to procure the resolution of the inflammation, 1 warm bread and water poultice is to be applied, and as soon as fluctuation is distinct, the abscess is to be opened with the lancet, '.he incision being made transversely, or parallel to the natural folds of the skin of the eyelids. The matter is generally found immediately under the skin. The poultice is to be continued till the swelling subside, and the abscess cease discharging. SECTION III. ERYSIPELATOUS INFLAMMATION OF THE EYE- LIDS. In erysipelas of the face, the eyelids are always much affected, especially the upper. This disease may also arise in the lids, and be confined to them. Local iSymptom,s. The lids are much swollen, so that the eye is shut up. The sweUing is of a pale red colour, but sometimes of a bright scarlet, or even of a deep and livid red. The redness dis- appears on pressure, but instantly returns when the pressure is re- 14 106 moved. The pain is in general not considerable, nor pulsative. The swelling feels hot, and the patient complains of a stinging and burning sensation in the part. A serous effusion frequently takes place on the inflamed surface, tlie cuticle being elevated by vesicles, which bursting, allow the fluid they contain to escape, and forra crusts. These falling off, the skin is generally left in a sounc state, the sweUing has by this time subsided, and the eyelids have recovered their power of motion. In more severe cases, the inflammation runs on into suppuratioi and sloughing of the subcutaneous cellular membrane. In sucl cases, the redness has more of the livid hue, the swelhng is mon considerable, and soon becomes tense and firm, the sensation o heat and pain is much aggravated, and is attended by throbbing At first the cellular texture contains a v/hey-like serum. Mr. Law rence mentions his having seen this effusion into the eyelids almos of milky whiteness. It gradually becomes yellow and purulent, i is diffused through the swollen cellular membrane, which become so disorganized that it comes away, after the abscess is opened o gives way, in shreds soaked with matter. This erysipelatous ab scess differs from a phlegmonous abscess in this respect, that it i not bounded by a sphere of adhesive inflammation, but extend extremely irregularly in different directions, producing extensiv sloughings of the cellular membrane. An abscess of this sort com municates a peculiar boggy impression to the finger. If neglectec suppuration may take place as well below as exterior to tlie orbic ularis palpebrarum, and even destroy the ligamentous layer of th eyelids. At length, the integuments give way in one or mor points, a small quantity of matter is discharged, and shreds of dee troyed cellular membrane may be extracted. Left, in this way, t run its course, severe erysipelas leaves the lids so altered, and thei several textures so agglutinated from the loss of the connecting ce. lular membrane, that they are long before they recover, if ever the . recover, their natural pliancy and mobility. The conjunctiva. Meibomian follicles, and excreting lachrynic organs, always suffer more or less in erysipelas of the eyelids, j. mucous secretion accumulates, during the night, along the edges ( the lids, and in the nasal angle of the eye. The absorption of th tears is impeded, and there is a slight afcumulation of mucus i the lachrymal sac. In some cases, a stillicidium lachrymarum n mains after all the other s3niaptoms have disappeared. In sever cases, ending in diffuse suppuration, the matter occasionally pene trates into contact with the lachrymal sac, which is already di; tended by the presence of an inordinate quantity of mucus. Afte the. integuments in such a ca^e give way, the appearance of th parts is apt to impose upon a superficial observer. He probabl pronounces the case to be a fistula lachrymalis; and forthwith open the sac. It may happen, however, that the purulent matter of a erysipelatous abscess actually penetrates into the lachrymal sa< 107 which ihns comes to be filled with pus received from withont, in the production of which i(s lining membrane has had no share. SThe latter case, which, for the sake of distinction, may be called spurious fistula of the lachrymtii sac, must be carefully distin- Iguished both from the former, in which the sac is entire though distended with mucus, and from those diseases hereafter to be des- icribed, in which the purulent matter, which fills the sac, is the re- |3ult of inflammation of the lining membrane of the sac itself. The !3ac, and the lachrymal canals, may suffer so much by being in- ivolved in the erysipelatous abscess, as to be rendered unfit ever af- jterwards to execute their functions. Constitutional symptoTns. Erysipelas of the eyelids is gene- 1 rally preceded by rigors, and attended by considerable febrile irrita- ;.ion. The tongue is loaded, and the digestive organs much de^ ji;anged. |l Causes. As this disease frequently arises suddenly, without any iocal injury, it probably owes its origin to some peculiar state of the ktmosphere, or to contagion. It is certainly much more apt to at- lack those whose stomach and bowels are in bad order. Local i'auses, as slight blows, the stings of wasps and other insects, leech- )ites, exposure of the eyes suddenly to cold after much exposure to neat or after long-continued weeping, and the like, frequently ope- ;iate in its production. Treatment. An emeto-cathartic is the best of all general rem^ :die3 in erysipelas ; for example, one or two grains of tartras anti- nonii, with an ounce or two of sulphas magnesiee, dissolved in two lints of water, and a tea-cupful given every two hours. In robust 'ubjects, blood-letting maybe practised with good effects; but in !ged or debilitated patients, this remedy is not be ventured om ; after the stomach and bowels have been freely evacuated, gentle diaphoretics are to be employed. I A prejudice exists among the vulgar against every sort of wet pplication in erysipelas ; but I have witnessed much advantage (lom the use of saturnine lotions in this complaint, and have never leen them do harm. [\ In severe cases, threatening to go into suppuration, the practice ijiy incisions ought to be adopted. A transverse incision through i be skin and subcutaneous substance of the affected lid, if employed ijkrly, may prevent suppuration and sloughing ; if later, it will af^ i; prd the readiest outlet for the matter and disorganized cellular i'lembrane. A warm bread and water poultice is to be applied i fter the incision. f If a spurious fistula of the lachrymal sac has already formed, it ; ; to be washed out once a day with tepid water, mixed with a lit- i c of the vinous tincture of opium. A small quantity of lint dipped J a the same tincture is then to be introduced into the abscess, but )|||ot pushed so deep as to enter the lachrymal sac. If after the fis- litpila has healed, a blenorrhoea of the sac should continue, it will 108 require to be treated as explained under that head, in a following chapter. Mr. Lawrence, in his valuable paper on the nature and treatment of erysipelas, in the fourteenth volume of the Medico-Chirurgical Transactions, has related two cases in which this disease attacked the eyelids. These I shall quote, as they serve to illustrate both the progress of the complaint, and the mode of treatjnent by in- cisions. Case 1. Mr. R., a medical student, about 24 years of age, had a violent attack of erysipelas of the face, apparently from exposure to cold air, after being in a very crowded and hot room. The red- ness was vivid, with considerable tumefaction, particularly of the eyelids and forehead. There was great pain, headach, restlessness at night, and fever. He was bled to 20 ounces. The blood was buffed. He was freely purged, had salines with antimony, and low diet. He was much relieved by the loss of blood, and felt his head so much better, that he wished the bleeding repeated the same evening, but the friend who attended hira would not comply with his desire. On the next and following days, he was better ; the swelling and inflammation were nearly gone. The symptoms, although still inflammatory, did not absolutely require the repetition of venesection, and he was averse to it from a groundless notion that his constitution could not bear bleeding. He ought, however, (says Mr. L.) to have been bled again. He took on the second day, four doses of calomel, each containing three grains, at intervals oi four hours, and then a draught of infusion of senna with sulphate of magnesia, which operated very freely. In two more days, he indulged himself wdth some mutton broth, under the supposed ne- cessity of supporting his strength after the evacuations he had un- dergone, and this brought on a relapse. The inflammation was now nearly confined to the right upper eyelid, which was much swollen, of a deep red, without fluctuation, and acutely painful, He was freely purged with calomel, followed by the same draught. Next day, the swelling and pain had greatly increased, but nc fluctuation could be perceived. He urgently requested that the pari should be opened, to relieve him from the severe suffering. Mr. L accordingly made a transverse incision through the skin and tumic cellular substance, extending the entire breadth of the hd. About i. teaspoonful of white and almost milky fluid escaped. The cellulai substance was swollen, condensed, and had a whitish appearance This incision produced complete relief; the swelling lessened, th( inflammation stopped, suppuration ensued, and some disorganizec cellular structure was separated. A large ulcerated surface was thus left, which healed rapidly, without leaving any trace of th( mischief that had occurred. Case 2. A girl of the town, about 25, robust, and of full habit came under Mr. L.'s care in St. Bartholomew's hospital, in th( summer of 1825. The whole face was aflfected with erysipelas 109 but the palpebrae were enormously swollen, deep-red, and shining. There was high indammatory fever, with violent delirium at night. She was twice largely bled, (the blood having the most iniiamma- itory character); with great relief of the general symptoms, but wilh- I out diminishing the inflammation and pain of the eyelids. On I the second day after her admission, an incision was made along the whole breadth of each eyelid, and through the entire depth of the inflamed and swollen cellular structure, which had begun to slough, and contained matter diffused through its cells. Considerable por- i tions of cellular membrane were subsequently detached, and there was some sloughing of the integuments, leaving a large ulcerated : and ragged surface of the swollen lids, from which subsequent de- formity might have been apprehended. The parts, however, gran- ulated, and healed rapidly, and so completely, that not a vestige of the extensive mischief remained. I SECTION IV. CARBUNCLE OF THE EYELIDS. ' This circumscribed, gangrenous inflammation of the cellular I membrane is occasionally met with in the upper eyelid. The swell- 1 itig is of a dark red, or purple colour, extremely hard, and attended : by severe burning pain. Vesicles rise on its surface, occasioning : intolerable itching. Ichorous matter is discharged, and the cellular ! membrane and skin affected, become black and sloughy, and at ; length fall out. The cavity left by the separation of the slough gran- I ulates and heals up. Carbuncle occurs principally in old persons, whose constitutions have suffered from irregularities in diet. Opium to reheve the pain ; bark and wine, to support the strength ; laxatives, and gentle diaphoretics, make up the general ! treatment. ' An early and free incision into the tumour, most effectually re- ! lieves the pain, allows the matter to escape, and furthers the separ- ; ation of the slough. An emollient poultice is to be apphed after i the incision has been made, and continued till the cavity left by the I slough has filled up by granulation. The sore is then to be dressed jl with simple cerate. SECTION V. CEDEMA OF THE EYELIDS. This may depend either on local or on general causes. The loose cellular membrane of the eyelids, being destitute of fat, permits them readily, and to a great extent, to become oedematous. "We see this, sometimes from wounds and bruises of the lids, from ery- sipelas, or from the application of pressure to the lower parts of the face, as after the operation for harelip. In other cases, oedema of 110 the lids is part of a general dropsy ; or it exists without any othei* part of the body being dropsical, in adults of leuco-phlegnialic consti" tution, or in strLinioiis children. It rarely happens that this affection occurs spontaneous!)^, or without any known cause, in an individual not labouring under some other disease. The eyeUds affected with 03dema are swollen, smooth, pale, semi- transparent, and soft ; yielding easily to the pressure of the finger, and in some cases retaining the mark of pressure for a time. Their motions are impeded, and llie eyes cannot be completely opened. After scarlatinous ophthalmia, and after the too frequent use of emollient fomentations and poultices during different inflammatory affections of the e3^es, particularly where poidtices are allowed to be* come cold, and to he long without being changed or removed, we not frequently find the lids, especially the upper hd, to have be- come puffy and oedematons. (Edema of the eyelids succeeding to a wound or bruise, to an attack of erysipelas, or to the pressure of a bandage on the lower parts of the face, is gradually and completel}'^ removed as the cause ceases to operate which had produced it. That which appears in the morning in persons of a leuco-phlegmatic habit, diminishes dur- ing the course of the day, and is not dangerous. That which arises in strumous children, or in adults, without any evident cause, con- tinues long, or comes and goes at uncertain intervals of time. It is only when this affection is part of a general dropsy, that it seems at all influenced by diuretic medicines. In other cases, gentle stimulants externally, and tonics internally, may be used with advantage. Bathing the hds wtih rose water, or with hme- water, sharpened with a little brand}^, will be found useful. Bags of dried aromatic herbs, as chamomile flowers, sage, or rosemar}'', with a little powdered camphor, suspended from the brow, so as to cover the hds, are highly recommended. The bags should be made of old linen, quilted, so as to keep the herbs equally spread out. When the oedema is periodic, and without any evident cause, a blister to the nape of the neck will be found advantageous. In strumous and debiUtated subjects, chalybeates, and the preparations of cinchona, are indicated. SECTION VI. — 'EMPHYSEMA OF THE EYELIDS. A swelling of the eyelids, produced by the presence of air in their cellular membrane, may either be part of a general emphysema, arising from an injury of the organs of respiration, in which case the air, escaping from the limgs, spreads through the whole body, and accumulates chiefly where the cellular substance is loose : or it may be the consequence of a fiactured frontal bone, the air pass- ing through the frontal sinus, and through the fracture, into the eyelids. Ill The following is an instance of the latter variety of emphysema of the eyelids. A lad, of 16 years of age, as he was going along the street, with a load, ran inadvertently against a person passing in the opposite direction ; a scuffle ensued, in which he received a severe blow immediately over the right frontal sinus. About an hour after, having occasion to blow his nose, the eyelids and parts adjacent became immediately inflated, so as completely to close the eye ; and he felt the air rush, he said, into those parts. On being admitted into Guy's Hospital, under the care of Mr. Morgan, the eyelids were much distended, and so closely approximated, that they could not be separated by any voluntary effort of the patient ; the eyebrow was also puffed up, and the cellular membrane be- tween the ear and the orbit was in the same state of emphysema. The parts were not at all painful on pressure ; they yielded a crack- ling sensation to the touch, and were free from discoloration. The supposed seat of the fracture was at a small distance above the su- percilliary ridge, where a flight depression, but no crepitus, could be felt. The globe of the eye was perfectly natural. The treat- ment adopted was very simple. Two small incisions were made through the integuments, about the eighth of an inch behind the external angle of the frontal bone, which allowed the air to escape. The swelling subsided in 24 hours, leaving the eye and surround- ing soft parts in a perfectly healthy condition.* The same plan of incision through the integuments is adopted when the eyelids are greatly disteiided, in cases of universal em- physema. It is merely, of course, a palliative remedy ; the com- plete removal of the disease depending on the healing up of the injured part of the lungs, or windpipe. Even in cases of fractured frontal bone, the evacuation of the diflfused air is merely palliative ; and till the consolidation of the bone, the emphysema will be lia- ble to return. SECTION VII. INFLAMMATION OF THE EDGES OF THE EYELIDS, OR OPHTHALMIA TARSI. The edges of the eyelids and roots of the eyelashes are subject to a peculiar inflammation, of a very tedious character. It is this disease which produces bleared eyes, and so often destroys entirely the eyelashes. If long neglected, it becomes inveterate, and almost incurable. The seat of this disease appears to be the Meibomian follicles, their apertures running along the edge of the lid, the neighbouring portion of conjunctiva, and the glands at the roots of the cilia. The disease has received various names, and different views have been entertained of its nature. As itchiness is one of its symp- toms, it has been called scabies palpebrarum, and psorophthalmia ; * Lancetj Vol. x. p. 31. London, 1826. 112 and some have even supposed, that in certain cases, at least, it con- sists in an eruption of itch, caused either by inoculation or by re- percussion. Comparing it to eruptions of the hairy scalp, it has been called by some, tinea ciliorum ; Avhile others have regarded it as herpetic or porriginous. Mr. Lawrence denies that this com- plaint ever partakes of the nature of psora. '^I am in the habit," says he, "of seeing numerous cases of itch in its most aggravated form, but I have not seen inflan)mation either of the eye or lids in these instances ; neither during nor subsequent to the itchy erup- tion. Where the body has been covered with itch to the greatest degree, I never saw any kind of ophthalmic disease attributable to this specific cause ; indeed, it is well known that the head and face are peculiarly exempt from this loathsome disorder, and that they very rarely suffer, even when all the rest of the body is thickly be- set with vesicles and pustules of scabies. Nor has the rapid cure of the itch by suitable treatment, in instances of its most extensive prevalence, had any injurious effect, within my experience. I have neither seen ophthalmia, nor other affections of the organ, from the reti-opulsion of scabies." * Local symptoms. The most striking symptom of this disease, is the gluing together of the edges of the eyelids in the morning, by means of a glutinous and superabundant secretion from the Meibomian follicles and neighbouring portion of the conjunctiva. This gummy matter, incrusting during sleep,^ binds the eyelashes together, so that the patient is obliged either to soften it before opening his eyes in the morning, or to use considerable, and even painful effort, for their separation. This is not accomphshed without tearing out some of the eye-lashes, which is followed by little abscesses and ulcers at their roots. Frequently removed in this way, and their bulbs injured or destroyed, they are apt ta cease from being reproduced, or to become feeble and dw^arfish. In this disease, the Meibomian secretion, which is naturally bland, and very small in quantit)^, serving merely to smear the edges of the eyelids, so as to conduct the mucus of the conjunctiva and the tears towards the puncta lachrymalia, becomes profuse, and is changed into a puriform matter. This matter of itseli causes constant irritation, and frequent itchiness of the eye and eyelids, and adhering to the eyelashes, prevents the little ulcers from heaHng which arise at their roots. The tears, excited bj the irritation, are discharged more frequently than natural, and being no longer conducted along the edges of the lids towards the puncta lachrymalia, as they are in health, but dropping over upon the cheek, chafe and excoriate the integuments. The consequence is, that we frequently find this disease attended wMth much swefl- ing and redness of the eyelids, and the skin of the cheeks inflamed, ulcerated, or covered with scabs. Not unfrequently, the conjunc- ♦ Lectures in the Lancet, Vol. x. p. 322. London, 1826. j 113 tiva lining the lids is inflamed; one or more of the Meibomian follicles greatly distended, so as to form a kind of hordeolum ; or ;the whole substance of the eyelids much thickened, hard, and callous. I The local symptoms of inflammation of the edges of the eyelids, •vary considerably in different instances ; they vary in severity, in obstinacy, in the appearances of the matter discharged, and even !in the seat of the principal morbid changes, for in some the Mei- bomian follicles, in others the ciliary glands, or bulbs of the eye- lashes, are the parts chiefly affected. ; There are two events which are apt to take place, when this 'disease has continued long, and been neglected. The one is a ipartial or total obliteration of the Meibomian apertures, along the inner margin of one or both eyelids. In this case, which may be regarded as incurable, the edge of the affected lid becomes rounded loff, instead of being angular, and generally the eyelashes are al- iinost altogether wanting. The other event is eversion of the lower lid, from the contracted state of the skin, consequent to the ! healing up of the excoriated cheek. Not unfrequently these two sequelee go together. , Trichiasis, or inversion of the eyelashes, distichiasis, or mis- , placed eyelashes, and even inversion of the lids, must also be enu- inierated among the effects of long continued ophthalmia tarsi. Those who, being affected with this disease, get into the habit of iDpening their eyes but very partially, or in whom the edges of the 'Ms have suffered from repeated ulcerations, are most subject to in- iP'ersion. I Constitutional si/mj)tom,s. Inflammation of the edges of the •jyelids is much more frequent in children than in adults. In al- inost every case, the patient presents undoubted marks of a stru- nous constitution ; the functions of the skin, and of the digestive )igans are disordered, and the general health impaired. Not un- i'requently we find this disease associated with strumous conjuncti- ;ritis, enlarged lymphatic glands, swollen upper hp, sore ears, ucalled head, tumid abdomen, paleness and looseness of the skin, estlessness during the night, and morning perspirations. i Causes, Ophthalmia tarsi is rarely a primary disease. It much Inore frequently takes its origin from measles, small-pox, scarlatina, catarrhal ophthalmia, ophthalmia neonatorum, strumous oph- ; halmia, or porrigo. In all these diseases, the Meibomian follicles \re apt to become affected with inflammation, and while the other symptoms which attend them subside, or totally disappear, the )phthahnia tarsi is exceedingly apt to remain. When this dis- i;ase appears to be primary, cold, impure air, smoke, and filthi- less, operating directly on the eyelids, are among the most fre- i^uent exciting causes ; while the strumous constitution aflfords its I lid in perpetuating the complaint, or at least in favouring relapses, [n adults, we frequently find the habitual use of wine and spirits keep up this affection of the eyelids. 15 114 Treatment. The treatment of this disease cousists, 1st, Iii such remedies as are hkely to abate the inflammation, upon which the whole train of symptoms depends, to sooth the pain and itching", and prevent the bad eflects of the gluing together of the lids: 2dly, In the use of stimulants, with the view either of deadening the excoriated and ulcerated parts, or of strengthening the debiU- tated eyelids : and, 3dly, In constitutional remedies. 1. The first direction to be given to the patient, or to his attend- ant, is never to attempt to open the eyes in the morning, till the gluey matter is completely softened, so that the eyelids may sepa- rate without pain, and without injuring the eyelashes. For this purpose, a teaspoonful of milk, with a bit of fresb butter melted in it, may be employed for smearing the lids, rubbing it with the fingei gently along the agglutinated e3^elashe3. A piece of soft sponge, wrung out of hot water, is then to be held upon the eyelids for some minutes ; after which the patient will find the eyelids yield without pain, to the least effort he makes lo open them. With the finger nail, the whole of the gummy matter is immediately to be removed ; and should it happen, that during the day, or towards evening, there is any reappearance of it, the same plan must be adopted for its entire removal. This is absolutely necessarj^, be- cause as long as the gummy matter is allowed to remain, no appli- cation of eye-water or salve can be of any use, as it never gets into contact with the seat of the complaint. 2. The first indication is further to be promoted by the use of a warm decoction of chamomile flowers as a fomentation, after the lids have been thus completely freed from their morbid secretion. 3. Scarification of the palpebral conjunctiva, the apphcation o; leeches to the external surface of the lids, and to the neighbouring skin, blisters behind the ears, and to the nape of the neck, and laxa- tives, are also to be occasionally employed, for the purpose of sub- duing the inflammation. 4. Cataplasms of bread and water, enclosed in a small liner bag, and laid over the eyelids^ during the night, are often useful ir aggravated cases. 5. A caustic issue in the neck, or arm, is often attend with bene- fit. Indeed, it rarely happens that much good can be effected without this remedy, in those cases in which the lids, from long neglect, have become greatly thickened and callous, a state whict is sometimes termed tylosis. 6. Next in importance to the careful removal of the morbic secretion, and the use of hot fomentations in the morning, is the application of a stimulating salve to the edges of the eyelids at bed- time. The salves which have been found most useful, are the rec precipitate, and the mild nitrate of mercury. The latter is prepared according to the formula in the Pharmacopoeia, but is usually stiL farther reduced in strength. The former consists of 12 grains o: red precipitate, carefully levigated into an impalpable orange powder 115 ' lud mixed with one ounce of fresh butter, or of soft cerate. Abotit ; he bulk of a hemp seed, of one or other of these salves is to be nelted at the end of the finger, and rubbed into the roots of the eyelashes, and along the Meibomian apertures, every night, or svery second night, according to the severity of the symptoms, ind the effects produced. If much irritation follows the application >f the salve, once every second night will be sufficiently often, a ittle simple cerate, softened by an addition of axunge, being used on :he alternate nights. In some cases we are obliged to reduce the trength of the red precipitate salve, while in other instances, 20 grains to the ounce will be borne with advantage. Salves are often employed for the cure of ophthalmia tarsi, with- »ut almost any effect, from these two necessary particulars not :)eing known or attended to, namely, that the salve is not to be } meared over the diseased crust, but applied only after the lids are reed of every particle of the morbid secretion, and that it is not to ie pencilled softly on, but pressed, by repeated friction, into the iiiseased roots of eyelashes, and into the mouths of the Meibo- nian follicles. Unless it smarts considerabl}^, it, in general, does ittle good. Other salves besides those above mentioned, are sometimes em- ployed for the cure of this disease ; especially Janin's, which consists )f 30 grains of the white precipitate of mercury to an ounce of unc- Lious substance. In old people and in those incurable cases in which he Meibomian apertures are obliterated, this salve answers better, lerhaps, than any other. The ointment of oxide of zinc, that of arbonate of lead, and various others, have also been used. In lorriginous cases, a mixture of sulphur with the mild nitrate of iaercury ointment, will be found very effectual. ; Not unfrequently we meet with slight, but very irritable cases of iphthalmia tarsi, in which not even the mildest salve can be borne. ■ ''omentations, with poppy decoction, or simply with warm water, fford most relief in such cases. ■ 7. During the course of the day, it is proper to bathe the eyelids ; arefuUy with a solution of from one to tv/o grains of corrosive sub- imate in eight ounces of distilled water. This colly rium is to be : sed tepid ; and after the outside and edges of the hds are well paked with it, by means of a bit of hnen, it may be allowed to run 1 upon the eye, so as to get into contact with the inner surface of le lids, which in this disease is always more or less inflamed. : Other coUyria may also be employed, as weak brandy and water, I solution of sulphate of zinc, or of sub-borate of soda. I 8. Should little ulcers be present along the edges of the lids, they ;re to be touched with the lunar caustic solution, or with the solid uitras argenti. 1 When the lids are greatly thickened and indurated, their edges liuch incrusted, and the roots of the eyelashes ulcerated, it has ■een recommended to extract all the eyelashes, and then touch the 116 whole diseased surface lightly with a pencil of lunar caustic. This has a great effect in heaUng the ulcers, and diminishing the swell- ing. In a few days the caustic may be repeated. Three or four repetitions are generally sufficient. Mr. Lawrence, who recom- mends this practice, states, that there is another inducement to ex- tract the cilia. Those which fall out by ulceration are never re- placed, because the bulb which secretes the hair is destroyed, but when they are plucked out, they are afterwards restored. 9. As the obstinacy of ophthalmia tarsi almost invariably depends on a faulty constitution, tonics and alteratives are always necessary. The tonics chiefly to be depended on are the sulphate of quina, other preparations of bark, the mineral acids, the carbonas ferri preecipitatus, and chalybeates in general. These are to be given in appropriate doses, and continued for a length of time. The prin- cipal alterative employed in the cure of this disease, is mercury, and perhaps the form, which on the whole is the best, is Plummer's pill. l\hether alteratives or tonics are employed, a dose of laxative medi- cine, as sulphate of magnesia, infusion of senna, or powdered rhu- barb and jalap, ought to be occasionally interposed. 10. The regulation of the patient's diet is essential for the cure of this disease. Care is to be taken lest the stomach be overloaded at bedtime, or disturbed by indigestible or improper food during the day ; for if this be permitted, the morbid secretion becomes more copious, and a greater degree of irritation and inflammation is in- duced. 11. The warm bath, with sea-water, if it can be had, is an ex- cellent remedy in this disease. 12. Pure air, and regular exercise, are to be recommended. 13. The clothing of those affected with this disease, ought to b€ particularly attended to. A delicate child is easily chilled. The skin, stomach, liver, and bowels, are thereby disordered ; and an attack of this disease, or of strumous conjunctivitis, is a frequent concomitant. These diseases are always difficult of cure when the weather is damp and cold. 14. Sleep at early hours is of great consequence. Hardly anj thing tends more to confirm this affection of the lids, than sitting up late at night. Prognosis. So obstinate is ophthalmia tarsi in many instances that we are frequently asked, if it will ever be cured. The answei depends on the state of the Meibomian apertures, and on the per- severance of the patient, or his friends, in the means of cure. If from neglect, the mouths of the Meibomian follicles, in numbei about 30 on the edge of each eyelid, are partially, or totally obliter ated, so that the skin covering them is smooth and shining, and no thing can be pressed out from them, the case is incurable. Thf patient, for life, must pay attention that the hds do not get worse. He must use Janin's or some other salve, every night; and follow the general directions regarding diet, clothing, and exposure, alrea- 117 dy laid down. If the Meibomian apertures are patent, however niuch inflamed and disfigured the eyelids are by the disease, the case is perfectly curable by perseverance ; but even after the symp- toms appear completely gone, the remedies will require to be con- tinued for months at least. The approach of puberty exercises its influence over this, as over other strumous diseases. SequelcB. As important effects of ophthalmia tarsi, may be men- tioned, tylosis, or chronic thickening of the whole substance of the lid ; lippitudo, excoriation of the edges of the lids, or bleared-eyes ; obhteration of the Meibomian follicles, the cause of incurable lippi- tudo ; madarosis, loss of the eyelashes ; ectropium, from the con- tracted state of the skin, consequent to the healing up of the excor- iated lids ; trichiasis, or inversion of the eyelashes ; distichiasis, or misplaced eyelashes ; entropium. from repeated ulcerations of the edges of the lids, and contraction of the cartilages. Several of these sequelae I shall take up separately. The disease described by Cel- sus under the name of lippitudo, appears to have been catarrhal conjunctivitis. SECTION VIII. HORDEOLUM AND GRANDO. A hordeolum, or stye, is nothing more than a little bile, about the size of a barley-corn, projecting from the edge of the eyelid. Symptoms. The swelling is of a dark red colour, very hard, attended at first by itching, and afterwards by a great degree of pain in proporton to its small size. The tension and exquisite sensibility of the skin which covers the edge of the eyelids, serve to explain the vehemence of the pain. The inflammation spreads, in some degree, to the conjunctiva, and the motions of the lids are impeded. In delicate irritable subjects, fever and restlessness are excited. The swelling suppurates slowly, and at last points and bursts. After discharging a small quantity of curdy pus, and dis- organized cellular membrane, it subsides and disappears. If it heals up with any of the matter remaining within it, the disease is apt to return, or to degenerate into a hard white tumour, called grando, from its resemblance to a hailstone, which having once formed, shows no disposition to undergo any farther change. Grando also lesults occasionally from an indurated hordeolum which has not advanced to suppuration. Causes. Hordeolum is most frequent in strumous subjects. It frequently depends on late hours, the use of spirituous liquors, and disordered bowels. Treatment. In the incipient stage, cold applications are to be used, as vinegar and water, solution of acetas plumbi, or an iced poultice. If suppuratiun appears to be advancing, a warm bread and water poultice, enclosed in a httle bag of linen, or a roasted ap- ple poultice, is to be applied. If slow of bursting, the abscess may 118 be opened with the point of a lancet. The pus and destroyed cel- lular membrane are to be pressed out, and the poultice continued. It sometimes happens, that the sloughy cellular membrane is slow of coming away, in which case the cavity may be touched with a sharp pencil of lunar caustic, or with a probe dipped in sulphuric acid, after which the cavit)^ soon closes. In the commencement of hordeolum, an emetic, followed next day b}^ a purge, will be found useful. In those who are liable to frequent attacks of hordeolum, we must recommend temperance, and early going to bed. Grando is commonly single ; in other cases, there are several tumours of this sort even on the same eyelid. Attem.pts to discuss them by promoting absorption, are generally fruitless ; but occasion- ally by friction, or by the application of stimulating salves, they are induced to suppurate. The best plan of treatment, is to lay the grando open with the lancet, press out its contents, and touch the interior of the cyst with the pencil of lunar caustic. SECTIOX IS. PHLYCTENULA AXD MILIUM. Semitransparent vesicles, or phh'ctenulae. filled with watery fluid, are frequently observed on the edges of the eyelids, especially at the inner canthus, sometimes single, often in groups, varying in size from that of a mustard seed, to that of a pea. They are to be laid hold of with a pair of hooked forceps, and snipped off with the scis- sors. Small white tumours, like millet seeds, containing a suet-like substance, are often observed between the Meibomian apertures and the cilia. They are to be opened with the point of a lancet, and their contents pressed out. SECTION X. "WARTS OX THE EYELIDS. "W"arts are not uncommon to the external surface of the eyelids, and sometimes grow from their edges. They are to be removed by ligature, or the application of caustic, according to the breadth of their attachment. I have known the removal of a wart on one of the lids blamed for bringing on a warty or fungous state of the conjunctiva. t SECTION XI. ENCYSTED TU3I0URS OF THE EYELIDS, AND EYE- BROW. There are two kinds of encysted tumours of the eyelids, which we meet with not unfrequently. 1. The first, which is an extremely common disease, contains a 119 gelatinous matter, and is often spoken of by the name of chalazion, although this word is merely the Greek term for grando. This gelatinous encysted tumour bears considerable resemblance to a hordeolum, only it is not situated on the edge of the lid, but gene- rally at some considerable distance from it. The skin covering the tumour is red and elevated ; the tumour is at first perfectly moveable, but after a time becomes more fixed to the cartilage of the lid ; on everting the lid, we find its inner surface inflamed, and often depressed, even in the early stage ; and after the disease has continued for a considerable time, we find a small fungus-like pro- jection through the cartilage, and through the conjunctiva lining the lid, corresponding to the point which previously had been de- pressed. This sort of tumour is met with most frequently in the upper lid, sometimes in the lower, or in both at the same time. In some cases more than one such tumour are situated in the same lid. The digestive organs of those who are troubled with this disease are almost uniformly out of order ; the stomach acid and flatulent ; the bowels slow, and the stools morbid. In incipient cases, the farther progress of the tumour may often be checked by alterative doses of blue pill, laxatives, and tonics, especially steel and bark. Under this treatment, I have seen many such tumours disperse entirely. Friction over the tumour with camphorated mercurial- ointment is also useful. When the tumour still continues, or advances, it is necessary to remove it by operation. Scarpa strongly recommends this to be done on the inside of the lid. I was in the way of extirpating such tumours by an incision through the integuments, and orbicu- laris palpebrarum ; but I have for some time satisfied myself with a simpler, but not less effectual mode of cure. I evert the affected lid, puncture the tumour freely with the lancet pushed through the cartilage, and' press out the gelatinous contents. For some days the cyst continues to keep up an appearance as if the tumour were still present, although lessened in size : but gradually the sweUing, redness, and other signs of the disease, go off entirely. 2. The other sort of tumour of the eyelids is steatomatous. It is more distinctly circumscribed than the former, and the integu- ments covering it, instead of being red, are whiter than natural. It is firmer to the touch, not at all painful, and does not appear to be connected with any disordered state of the digestive organs. If dependent on any constitutional cause, steatomatous tumours of the eyelids are of strumous origin. I have seen a crop of them disap- pear from the eyelids of a strumous child, during the use of the sulphate of quina. In general, howevei', we are obliged to extir- pate such tumours, by a transverse incision through the integu- ments. They appear to lie exterior to the orbicularis palpebrarum, so that in several instances, after dividing the skin, I have been able, by pressure, to bring away the tumour enclosed in its cyst, without any farther dissection. 120 In extirpating a sarcomatous, or any other tumour from the eyelid?, care must be taken, lest the cyst, being adlierent to the car- tilage, we remove part of the latter, or in any way materially injure it. Leaving the adherent part of the cyst behind is to be preferred to injuring the cartilage. The eyebrow, and especially its temporal extremity, is a frequent seat of encysted tumours. These are generally melicerous, or stea- tomatous. A firm scirrhus-like tumour, which is very apt to return, unless completely extirpated, is also met with under the integuments of the eyebrow. All these tumours are to be removed in the usual manner, and the edges of the wound brought together by stitches and adhesive plaster. SECTION XII. CALLOSITY OF THE EYELIDS. Tylosis is a kind of callosity, arising, as has heen already ex- plained, from neglected opthalmia tarsi. There are two other varieties, however, of thickening and indu- ration &f the eyelids, which merit attention. The one is attended with redness, attacks generally the upper eyeUd, and seems to have its chief seat external to the cartilage. The whole length of the eyelid is commonly affected ; but in some cases, merely a part, and not unhequently the neighbourhood of the papilla lachrymahs. I have never seen this variet}^ of callosity end in suppuration nor ulceration. It slowly increases, and then becomes stationary, and is little, if at all, affected by any remedies. The application of leeches, friction with camphorated mercurial oint- ment, laxatives^ and alteratives internally, I have generaUy found fruitless in this complaint. The other variety of callosity attacks the lower lid more fre- quently than the upper, is seated more on the inner surface of the affected lid, is of a white, or slightly yellow colour, rriore or less tu- berculaied, and apt to end in ulceration. From its appearance, its occurring generally in old people, its intractable nature, and its ending in ulceration, we are apt to confound it with scirrhus, with which, however^ it is by no means identical. I have watched some cases of this variety of callosity for a number of years, and although the indiiration and swelling did not subside, yet, by care to avoid injuring the part, by soothing applications to the edges of the lids, and the use of the red precipitate ointment, and lunar caustic solu- tion, to the ulcerated points, the complaint has been kept at bay, and the operation of removing the affected lid, which could not have been done without sacrificing the eye, prevented. Fowler's solution, internally, has appeared to me to assist in checking the progress of this complaint. Although hitherto successful in warding off the progress of this disease, yet I can easily conceive, that both it and the other variety of callosity^ may be brought, by neglect, to such a state, as shall 121 warrant the removal of the affected lid. There is one thing, how- ever, regarding the removal of either eyelid for this disease, or for any disease, which must be attended to. If either lid is removed, the eyeball is necessarily left exposed, and is very apt to become irritated and inflamed. We ought to state this to the patient. Such an event wiU, of course, much more readily follow, if it be the upper lid which is removed ; and, perhaps, it would be the best plan, if the patient would submit to it, to remove the eyeball along with that lid. When both eyelids are removed, this ought always to be done, even although the eyeball is as yet not at all affected. SECTION XIII. CANCER OF THE EYELIDS. ' The disease, vulgarly called Eating Cancer of the Face, is not m unfrequent one. It often begins on the lower eyelid. It slowly consumes the skin and the muscles, till it destroys not merely the id, but a great part of the cheek, enters the orbit, attacks the eye, md at length proves fatal. Dr. Jacob, in some excellent observa- ions which he has published* on this disease, remarks, that its •characteristic features are the extraordinary slowness of its progress, he peculiar condition of the edges and surface of the ulcer, the ;omparatively inconsiderable suffering produced by it, its being ncurable unless by extirpation, and its not affecting the neighbour- ng lymphatic glands. Symptoms and Progress. We sometimes meet with this dis- ;ase while yet confined to the lower lid. We find it thickened, md more or less of its edge ulcerated. In some instances, the »uter angle of the lids is the seat of the disease. It appears not mfrequently to commence in the form of a wart, or, perhaps, more orrectly, it is nothing else than a wart, which, being picked off Is^ith the finger, leaves a raw surface, exposed to the irritation of be tears, and apt to spread by ulceration. In other cases, the rigin of this disease appears to be an encysted tumour, which, llowed to burst on the inside, or, it may be, on the outside, of the yelid, becomes irritated, and is thus induced to assume the ulcerous r cancerous action. An encysted tumour, immediately under the kin, picked with the finger, sometimes a mere scratch of the edge j f the eyelid, a blow, or the irritation of an old cicatrice, such as hat which results from small-pox, may give rise to cancer of the yelids. The irritation of the tears has, in every case, much to do with le production of this disease. They are excited to flow by the isistenceof the ruffled wart, or burst encysted tumour, and again, in leir turn, they prevent the sore (simple, probably, in the first in- Icance,) from healing ; till at length it assumes what we term a jpecific, or malignant character. ij ' * Dublin Hospital Reports. Vol. iv. p. 233. Dublin, 1827. 16 122 The progress of the ulceration in this disease is generally very slow. I have known it for years confined to the lower eyelid, without making almost any advance ; nay, occasionally contract- ing, and partially, or even totally, cicatrizing : again to commence, and spread for a certain space, and again to heal. It has been known to remain for ten, nay, for 20 years, without making much progress. In other cases, hov/ever. the eyelids are entirely destroyed, the eyeball exposed, so as to become inflamed, and at last to burst, the lachrymal passages laid open, the bones of the orbit deprived ol their periosteum, and rendered carious, while the ulcer, spreading down tlie face, eats away the cheek, lays bare the teeth, and at last forms one common and hideous opening along with the mouih Yet, even after it has produced the most shocking deformity, its progress is sometimes stayed for months or for years, so that thf individual lives with his eyelids entirely gone, the eyeball dissectet from almost all its connexions, and perhaps half of the face de- stroyed. The appearances of the disease are different at different times Sometimes it presents a scab, which, on being removed, is sue ceeded by another ; but generally, the sore exposed, on removinc these successive scabs, is found to be slowly enlarging, growing deeper, and becoming more painful. When the sore becomes ai open ulcer, too large, too irregular, and too active, to be covered b} a scab, we observe that it eats away all parts indiscriminately which may be in the direction in which it is spreading. In on( of the cases which have fallen under my care, the ulceration o the skin appeared, after a time, entirely to cease, while the disease proceeded deep into the oibit by the inner side of the eyeball Not unfrequently, we find that the progress of the ulceration i. checked at one part of the circumference of the sore, while it i still advancing at another ; or that the whole sore assumes, for i time, a healing action. When this is the case, the pain become less, the edges become smooth and glossy, and even the part \\nth in the edges becomes smooth, or is gradually covered with florid healthy-looking granulations. These are occasionally firm ii texture, and remain unchanged in size and form for a length o time. Veins of considerable size are seen ramifjing over the sur face of the sore. If it heals up, it does so in patches, which ar< hard and smooth, and marked with the same venous ramifications When it again begins to ulcerate, it loses its florid hue, and glis tening and granulating appearance. Often there is present in thi disease, a tendency to actual reparation, as well as to cicatrization there is a deposition of new material, and a fiiUing up in certaii places, which gives an uniformity to the surface, which otherwis' would be very irregular. The healing which occurs in this dis ease may take place on any part of the surface, whatever be th original structure. In a case which Dr. Jacob had under his care the eyeball itself^ denuded as it was by ulceration, became partially cicatrized. 123 The skin in the vicinity of the sore is not, in general, much thickened, or discoloured, differing in these respects from the dis- ease called lupus, or noli me tangere, which we see attack the point of the nose, and sometimes spread to the face. The edges of the sore in cancer of the eyelids, are occasionally formed into a range of elevations or tubercles. The veins which ramify over the surface of the sore are apt to- give way, when considerable bleeding sometimes takes place. From the surface itself of the ulcer, there is no considerable bleed- ing. When haemorrhage does occur, it arises from the superficial veins giving way and not from sloughing or ulceration opening the vessels. Sometimes the surface of the sore assumes a dark gangrenous appearance, arising from effusion of blood beneath. The discharge from the surface of the sore, is not, in general, of the description called unhealthy, or sanious, but yellow, and of proper consistence ; neither is there more foetor than from the healthiest sore, if the parts be kept perfectly clean, and dressed frequently. Mr. Travers, however, whose short notice of this disease differs in several particulars from the more elaborate de- scription of Dr. Jacob, mentions, that it is attended by an unhealthy discharge.* There is, in general, httle or no fungous growth, nor indeed any elevation, except at the edges, and even this is sometimes very inconsiderable. Dr. Jacob has represented the sufferings of persons labouring under this disease as not very acute. He says, there is no lanci- nating pain, and that the principal distress appears to arise from the exposure, by ulceration, of nerves, and other highly sensible parts. In the instances which he had met with, the disease, at the worst period, did not incapacitate the patients from following their usual occupations. One gentleman, who laboured under this disease for nine years, and who died from a different cause, was cheerful, says Dr. J., and enjoyed the comforts of social life after the ulceration had made the most deplorable ravages. These statements of Dr. J. may be received with implicit confidence. Yet it must be noticed, that when the ulceration affects the infra- orbitary and supra-orbitary nerves, very severe suffering is experi- enced. I have also witnessed the most excruciating pain when the eyeball was attacked with inflammation, in consequence of ex- posure from destruction of the lids. The eyeball, in these circum- stances, ulcerates and bursts, the lens and vitreous humour are evacuated, and sometimes, till this emptying of the eye is effected, the pain is agonizing. I have known the lens hang in view for several days, producing great irritation, which ceased after it fell out. In such a case, it is probable that the iridal nerves convey the impressions which are so painful. * Synopsis of the Diseases of the Eye, p. 100. London, 1820. 124 When this disease extends to the periosteum, the bones of the orbit are laid bare, and become carious. They sometimes exfoU- ate in small scales, but more generally they are destroyed, as the soft parts are, by an ulcerative process. This may proceed to such a length, as to expose the cavity of the nostril through the de- stroyed orbit, or even to lay open the cavity of the cranium through the orbitary plate of the frontal bone. Inflammation of the dura mater and of the brain will, in this case, soon put an end to the patient's sufferings ; although more commonly he dies worn out by fever, and sometimes by diarrhcea. Diagnosis. Modern researches into the nature of malignant tu- mours and ulcers, and especially those carried on by Professor Burns, Mr. Hey, Mr. Abernethy, Mr. Wardrop, M. Breschet, Mr. Fawdington, and others, have established at least this fact, that there are essential differences between a number of diseases formerly confounded under the appellation of cancer. The improbability that structures so extremely different as the mamma, the uterus, the glans penis, the lip, the eyelids, and the eyeball, should fall into the same kind of degeneration, had formerly entirely escaped atten- tion. It is probable that a still more accurate discrimination may be made between the various malignant disorders of these parts. We are now at no loss in distinguishing cancer from spongoid tumour, or spongoid tumour from melanosis, but with regard to the malignant ulcerations which attack different parts of the face, there still exists a considerable degree of confusion. Dr. Bateman, Mr. S. Cooper, and others, seem to consider this dis- ease of the eyelids as noli me tangere, which, according to Sir A. Cooper, is an ulceration of the cutaneous follicles. Dr. Jacob, how- ever, ol3serves, that this disease is evidently pecuhar in its nature, and is to be confounded neither with genuine carcinoma, nor with the disease called lupus or noli me tangere. From the former, it is distinguished by the absence of lancinating pain, fungous growth, foetor, slough, haemorrhage, and contamination of lymphatics ; from the latter, by the absence of the furfuraceous scabs, and in- flamed margins, as well as by the general appearance of the ulcer, its history, and progress. It is equally distinct from the ulcer with cauliflower-like fungous growth, which occasionally attacks old cicatrices. We sometimes see syphilitic chancre on the eyelids ; but from this the present disease may generally be distinguished by its slow progress, by its not causing so much swelling of the integuments round the ulcer, and by the history of its origin. Treatment. — 1. Alterative and other medicines. It is a ques- tion of great importance, whether this disease can be removed by any other means than the knife, or powerful escharotics. Dr. Jacob's opinion is, that it bids defiance to all remedies short of extirpation. '•' I have tried," says he, " internally, alterative mercurials, antimony, sarsaparilla, acids, cicuta, arsenic, iron, and 125 other remedies : and locally, simple and compound poultices, oint- ments, and washes, containing mercury, lead, zinc, copper, arsenic, sulphur, tar, cicuta, opium, belladonna, nitrate of silver, and acids, without arresting for a moment the progress of the disease. I have indeed observed, " adds he," that one of those cases which is completely neglected, and left without any other dressing than a piece of rag, is slower in its progress than another which has had all the resources of surgery exhausted upon it." Now, although these remarks of Dr. Jacob are perhaps rather too sweeping, yet it cannot be denied, that both internal and ex- ternal remedies have extremely little control over this disease, : and that though it may for a time seen to mend under their in- Ifluence, it has rarely if ever been known to be thoroughly cured, 1 except by destroying the part with caustic, or removing it by the } knife. Arsenic internally, and carbonate of iron, sprinkled on th» sore, are the means which, I believe, do most good. I have known I them to operate as paUiatives, but never to produce a radical I cure ; and therefore I should never trust to them. 2. Caustics and cautery. These are certainly not much to be recommended. They are more painful, and not so sure as the knife. They do occasionally succeed when the disease is lim- ited to the outer surface of the eyelid, never when the whole thickness is aflfected. Dr. Jacob mentions, that a woman in the incurable Hospital at Dublin, had had a burning cancer plaster applied several times, and 17 years after, the arsenical composition called Plunkett's powder, without any good effect. A gentleman, to whose case he repeatedly refers, had the sore healed, when it was very small, by the free application of lunar caustic, under the care of Mr. Travers. It broke out again, however, and spread, without inter- ruption, until it destroyed the lids and globe of the eye. Under these circumstances, he in despair, submitted himself to a quack, who, bold from ignorance, gave a full trial to escharotics. He repeatedly applied what was understood to be a solution of muriate of mercury, in strong nitric acid, and in a short time excavated a hideous cavern, extending from the orbitary plate of the frontal bone above, to the floor of the maxillary sinus below, and from the ear on the outside, to the septum narium within. The unfor- tunate gentleman survived, the disease continuing to preserve, in every respect, its original charactei-, 3. Extirpation hy the knife. That when the disease exists in a situation which admits of extirpation, the sooner this is done the better, and that this can be effected best by the knife, admits of no doubt. The effects of removing one or both lids, have already been ex- plained. The upper lid will, to a certain extent, and much more than, a priori, we could expect, supply the loss of the lower lid ; 126 but if the upper is removed, the eyeball also requires to be taken away, else it will speedily be destroyed by inflammation. The incisions ought to be made into the sound parts. If both lids are affected, the lower ought first to be extirpated, then the up- per, and last the eyeball. SECTION SIV. SYPHILITIC ULCERATION OF THE EYELIDS. I have seen only two cases of this sort. The one was a.priraary sore on the edge of the lower lid, in a girl of the town ; the other, a secondary sore, also on the lower lid, of an old man, a patient at the Eye Infirmary. He acknowledged having been treated, some time before, for a primaiy affection, else I should have probably experi- enced some difficulty in deciding lespecting the nature of the case. The lid was much swollen and everted, its conjunctiva greatly in- flamed, and on the external surface of the lid there was a deep ul- cer, painful, and spreading towards the inner canthus. The skin round the ulcer w^as of a dark red colour. I ordered him two grains of calomel, and one of opium, night and morning. Not- withstanding which, he returned in five days with another smaller ulcer near the punctum lachrymale of the same lid. The conjunc- tiva, covering the inner edge of the cornea, was also in a state of ulceration. The first ulcer of the lid was extending upwards and inwards, but at other parts its edge appeared inclined to skin. The ulcer of the cornea was touched with the lunar caustic solution, and a carrot poultice ordered to the lid. Nine days after this, the ever- sion and thickening of the lid had become considerably less ; the first ulcer had coalesced with that near the punctum, but was gran- ulating and filling up. Soon after this, the mouth became soi'e, and the ulcer contracted and healed. The mercury was stopped and resumed according to the state of the mouth, and a decoction of elm-bark was given. As the lid continued to be everted after the ulcer had cicatrized, the thickened and inflamed conjunctiva was scarified, and the red precipitate salve was applied every even- ing ; after which, the lid completely resumed its place, scarcely any deformity being caused by the cicatrice, and no opacity left on the cornea. Syphilitic ulceration of the eyelids generally occurs either on the edge, going on to destroy at once the skin, the cartilage, and the conjunc- tiva; or on the integuments, proceeding rapidly to form a deep and foul excavation ; but in some cases the ulcer commences on the in- side of the lid, spreading over a considerable extent of the conjunc- tiva. Mr. Lawrence mentions his having seen some cases, in which foul ulcers of this kind, having been developed in the upper lid, spread over the whole of its inner surface, without appearing exter- nally. In one case, the sore, he believes, would not have been discovered, if he had not been directing his attention some time be- 127 fore to the subject, so that he was led to evert the eyeUd, when he discovered a syphilitic ulcer as large as a sixpence.* I remember M. Cullerier mentioning in his lectures at the Hopi-' tal des VinerienSy that chancres of the eyelids were sometimes brought on by a kiss from an infected person, and in other cases by the virus being conveyed on the finger. Secondary sores on the eyelids are generally attended by other secondary symptoms, and particularly by ulcerations of the throat. Both the primary and the secondary cases will be most effectually relieved by the use of mercury. Either to mistake the nature of the ulceration, or to trifle with it in the non-mercurial way, would be to expose the patient to the loss of the hd, and even of the eye. SECTION XV. N^VUS MATERNUS, AND ANEURISM BY ANASTO- MOSIS, OF THE EYELIDS. Neevus maternus, or mother's mark, occurs not unfrequently on the eyelids, and especially on the upper. It is sometimes but little raised above the level of the integuments, through which there ap- pears a collection of dilated blood-vessels. In other cases, the nee- vus is prominent, of a deep red colour, smooth like a cherry, or granulated like a raspberry. Some nsevi, though vivid at birth, gradually fade and disappear ; some remain stationary through life, although varying in intensity of colour at different seasons, and according to the different degrees of activity in the circulation ; while a third set begin to grow, sometimes immediately after birth, and sometimes from incidental causes at a subsequent period, and from small beginnings, -become large and formidable vascular tu- mours, partaking of the nature of the disease first accurately de- scribed by Mr. John Bell, under the name of aneurism by anastomo- sis, readily bursting, and giving rise to impetuous and alarming haemorrhages, which, if they do not prove suddenly fatal, materially injure the health by frequent depletion of the system.! There appears sufficient ground for believing, that tumours of this sort are, in some cases, venous, and in others arterial. The latter are characterised by their vivid colour, high temperature, rapid and dangerous course, continual and distinct pulsation, and the great dilatation, sudden bendings, and violent throbbing of the arteries which feed them ; while the former are livid, cold, without pulsa- tion, and slow in their progress. Both, however, are subject to be- come suddenly tense, as if ready to burst, when the patient is ex- posed to much heat, indulges in violent exercise, or is under the influence of mental excitement. Both, but especially the arterial, communicate a peculiar dough-like impression when laid hold of * Lectures in the Lancet, Vol. x. p. 324. London, 1826. _ t See Bell's Principles of Surgery, Vol. i. p. 456. Edin. 1801. Bateman's Synop- sis of Cutaneous -Diseases, p. 329. London, 1819. 128 with the fingers, yielding slowly to pressure, till they seem empty and flaccid, then filling up almost immediately to their former size. Another distinction of some importance is, that of cutaneous and subcutaneous nsevi. In the former, the tumour appears to be seated entirely in the skin ; while in the latter, the integuments can be pinched up from off the tumour, and do not seem to be in them- selves affected. It is not to be denied, that aneurisms by anastomosis, after hav- ing increased to a certain degree, sometimes cease to enlarge, and thenceforth continue stationary, or gradually shrink till scarcely a vestige remains. In some cases, ulceration and sloughing occur spontaneously in these growths, destroying them in part, consoli- dating the remainder, and preventing them from increasing. In other cases, some very shght cause of irritation, as a trifling bruise, will excite a mere stain-like speck, or a minute livid tubercle, into an uncontrollable state of diseased action. It is fortunate, then, that a method of cure for nsevus maternus, in its early stage, has been discovered, which seems to be equally sure and simple. The principle upon v/hich this method of cure depends, is the destruction, by suppuration, of the cellular substance surrounding the anastomosing vessels, thereby insuring the obliter- ation of the vessels themselves. The means by which inflamma- tion of the neevus is excited is the vaccine lymph, and the sooner after birth the cure is attempted the better. With a lancet already charged with the recent lymph, slight scratches are to be made upon the surface, and into the circumference of the neevus, at reg- ular distances from each other. As soon as the bleeding has ceased, additional lymph is to be introduced ; and then over the whole surface of the tumour, a bit of linen, saturated with the same fluid, is to be applied, and retained for several hours. In the usual time the vesicles appear, and in general the nsevus gradually subsides, leaving scarcely any mark behind. Each vesicle produces a de- gree of adhesive inflammation, which induces an occlusion of the nseval cells and vessels only to a certain distance around it ; and therefore it is necessary to inoculate the surface of the tumour at such distances that the inflammation of one shall coalesce with that of another, and thus produce the cure of the whole. If the child has been vaccinated in the common way, previously, perhaps, to the nsevus attracting much notice, this plan of cure will rarely suc- ceed ; but ought still to be tried. If the child has not been vaccin- ated, this operation, besides curing the nsevus, will affect the con- stitution as inoculation in the common way. We owe, it appears, this method of removing nsevus, to Mr. Hodgson, of Birmingham.* It has now been adopted by a num- ber of other practitioners, and among these by Dr. Young, of Glas- gow, who has published a short account of two cases in which he * Medico-Chirurgical Review, Vol. vii. p. 280. London, 1827. Lancet, "Vol, xi-L p. 760. London, 1827. 129 tried it. His first patient was a child, three months old, who pre- sented a roundish tumour, nearly as large as a sixpence, on the right side of the chin. It was considerably elevated above the sur- rounding skin, and had a purplish colour. At birth it was no bigger than a split pea. Around the border of the tumour, as well as all over its surface, minute punctures were made, and vaccine lymph freely applied. In ten days the whole disease was involved in one pustule, but when this became incrusted, and was thrown off, there still remained a dark coloured, prominent, and diseased surface. Another suppuration succeeded, and a third ; when at the 3nd of five weeks, a complete cure was effected, no trace of the djs- 3ase remaining, nor mark, farther than what follows vaccination on .1 healthy part. This cure was hardly completed, when another little child was brought to Dr. Y., with a nsevus advancing rapidly, and occupying the middle and edge of the upper eyelid. The same process was followed with very similar results. A cure was effected, Dut after a very tedious festering and ulceration.* When vaccination has failed, or when vaccine lymph cannot be procured, some other stimulating fluid may be tried, inserting it into the nsevus in the same way as we do the lymph. A strong solution of tartrate of antimony may be used for this purpose ; or a pustular eruption, affecting the nsevus to a sufficient depth, might probably be excited by rubbing it with the tartrate of antimony ointment, or covering it with an antimonial plaster. It is likely that the vaccine lymph produces no specific effect upon this sort of lumour, but operates merely by the inflammation which it excites, and that any other stimulant, of proportionate strength, and ap- plied with equal care, would be followed by nearly the same result. Mr. Wardrop has repeatedly employed pure potash for this purpose, applying it to the neevus so as to produce an eschar. In some in- stances, the eschar, on falling out, has been found to comprehend the whole diseased mass ; while, at other times, the separation of the eschar has been followed by ulceration, v/hich destroyed the remainder of the tumour. t It is evident, that we cannot expect large neevi to be cured in this way. If they have readied, perhaps, three quarters of an inch diameter, and are prominent and active, the hgature or the knife must be emplo)^ed for their cure. The former will generally be preferred in cases in which the eyelids are the seat of the dis- ease. The tumour being laid hold of with the flnger and thumb, or with a pair of forceps, so as to raise it as much as possible from the proper substance of the lid, a curved needle, armed with two strong waxed linen threads, is to be passed through its base from above downwards, so as to divide the tumour into two portions, «ach of which is to be grasped by its own ligature. The ligatures * Glasgow Medical Journal, Vol. i. p. 93. Glasgow, 1828. t Lancet, Vol. xi. p. 653. London, 1827. 17 130 being drav/n tight, and secured by a double knot, in the course of 48 hours the tumour will have entirely lost its vitality, so that it may be sliced off, and the ligatures removed. A poultice is then to be applied, and continued till the exposed surface granulates and heals. Some very extensive and irregular nsevi, stretching partly over the eyelids, may require more than two ligatures. Nsevi. going on into the state of aneurisms by anastomosis, have occasionally been removed by excision. This is an effectual, but by no means a very safe mode of cure. The bleeding attendant on the removal, by the knife, of even small naevi, is profuse, and dangerous in the young patients, who are the most frequent sub- jects of the operation. When the morbid growth itself is cut, a powerful gush of arterial blood takes place, which can hardly be restrained, and is not exphcable by any thing hitherto ascertained respecting the nature of these structures. Although the knife keeps clear of the tumour, there is, in general, very serious haemorrhage. so that in removing even small nsevi in this way, alarm has justl} been excited for the life of the patient, and the recovery of strength and colour has been very tedious. Mr. John Bell relates the case of a gentleman, of about 25 years of age, who had an aneurism by anastomosis upon his forehead where it had been grov/ing for some years. It began with a smal spot like a pimple, of the size of a pea, and was, when he consultec Mr. B., of the size of an egg. It was seated close upon the eye brow, and at its commencement was so small, and so little trouble- some, that it was believed to be a pimple, brought on by a tight hat. When it had attained the size of a sparrow's egg, the patien thought he felt occasional pulsation in it. He consulted a surgeon who found the pulsation distinct, pronounced it to be an aneurism and advised that it should be cut out. The patient delayed, auc was recommended by some one to try pressure. This producing pain, but no good eflfect. he let the aneurism grow as it pleased fo: five years. The operation was now decided on. The tumour ap peared to derive its blood from tv/o arteries ; one, a branch of th< temporal, enlarged and tortuous, which passed into the upper enc of the tumour, while the other, coming from within the orbit, en tered the lower end. These two arteries and the intermediate tu mour beat in concert, and very strongly. Under the apprehension that the disease was merely an enlarget artery, the surgeon first passed a ligature under the arterial brand coming li'om the orbit, and tied it ; but this did not abate the pul sation of the aneurism. He next tied the temporal branch, bu the pulsation remained unaffected. The tumour was then laic open in its whole length. It bled very profusely. A needle, armec with a ligature, was stuck into its centre, where there was one artery larger than the rest ; but from all the surface besides there was one continual gush of blood. The hsemorrhage was repressed and the wound bound up with a compress and bandage. It healec I 131 I slowly, the ligature came away with difficulty, the pulsation began a^ain, and by the time the wound was healed, the tumour was as large as before the operation. For nine months the patient allowed . ' it to go on unmolested, and then consulted Mr. B. It was of a regu- 'lar oval form, and across the middle of it ran the scar of the opera- tion. The spot was not purple on its surface, but was covered by a firm, sound skin. The two arteries were felt pulsating with great force ; and w^hen the patient was heated, stooped, or breathed hard, the pulsations of the tumour became very strong. By this time it was affected also with pain. Mr. B. knew, that if he cut within the active circle of the tumour, he should have innumerable 'blood-vessels to contend with. He therefore resolved to cut out this 'aneurism, not to cut into it. He made an oval incision, which comprehended about a fourth part of the surface of the tumour, I dissected the skin of each side down from it rapidly, went down to the root of the tumour, and turned it out from the bone. It bled furiously during the operation, but the moment it was turned out, Ihe bleeding ceased. The two arteries were tied, the eyebrow was 'brought nicely together, and the incision healed in ten days. The lumour appeared a perfect cellular mass, like a piece of sponge soaked in blood.* ' This, then, is a striking example of the subcutaneous arterial aneimsm by anastomosis, and of the mode of cure by excision. 'The following case, related by Mr. Allan Burns, furnishes an in- istance of the cutaneous and venous variety of this disease. I A middle-aged, stout man, presented a large, livid, compressible jtumour, in the vicinity of the right orbit. The swelling had ex- I'isted from birth, was sometimes more distended than at others, but 'ivas seldom productive of pain, except when injured, on which loccasion it poured out a considerable quantity of fluid blood. It 'never pulsated nor throbbed ; but during exertion, or walking in 'i very hot or very cold day, it became exceedingly tense. Ex- Lernally it covered about one-third of the temporal extremity of the 'upper eyelid, and it occupied the whole extent of the lower one. Ilhe folds of which were separated to such an extent, as to produce kn unseemly, irregular, and pendulous swelling, which hung down bver the cheek. Towards the outer canthus of the eye, the morbid texture was interposed between the conjunctiva and the sclerotica, ito within the eighth of an inch of the cornea. It was chiefly in this direction that the disease was spreading. From the external 'angle of the eye the tumour was prolonged both outwards, and 'downwards. In the first direction it extended to the point of junc- tion of the temporal and malar bones; in the latter, it descended 'nearly half an inch below the line of the parotid duct. Through its whole extent, the tumour was free of pulsation ; no large artery bould be traced into it ; by pressure it was readily emptied of its * Principles of Surgery, Vol. i. p. 461. Edin. 1801. 132 !l contents ; but slowly, on the removal of the pressure, it was again filled. When emptied, by rubbing the collapsed sac between the fingers, a doughy impression was communicated to them. On the surface it was of a dark purple colour, with a tint of blue on those parts covered by the skin, but where invested by the conjunctiva, it had a shade of red. It was cold and flabby, communicating to the fingers the same sensation which is received on grasping the wattles of a turkey cock. As the tumour was increasing, and threatened to extend over the eye, the patient was anxious for its removal. Mr. B. began the operation by detaching the lower eye- lid along its whole extent, he then dissected away that part of the tumour adhering to the sclerotica, and next removed that which adhered to the upper eyelid. This being done, he tied a pretty large artery which passed into the tumour from the outer and lower part of the orbit, by the temporal side of the inferior oblique muscle. The next stage of the operation consisted is dissecting off the tu- mour from the aponeurosis of (he temporal muscle, the zygomatic process, the malar bone, and from over the branches of the portio dura, and the parotid duct. After the great body of the tumour was in this way removed, Mr. B. found that still a part of the spongy morbid mass remained attached to the parts behind the parotid duct and portio dura. He also discovered that some of the tumour dipt beneath the fascia of the temporal muscle, which was reticulated. From these parts there was a general oozing of blood ; and from the divided transverse fascial artery, as well as from the arteries which perforated the malar bone and the masseter muscle, there was a pretty profuse bleeding. The vessels were secured, and then with the forceps and scissors, Mr. B. cleared away the diseased matter from behind the parotid duct and portio dura, both of which were thus detached from all connexion with the neigh- bouring parts. In the same way, he was obliged to cut away a quantity of diseased substance from behind the zygoma. As the morbid parts were here ill defined, and much intermixed with the fibres of the temporal muscle, a considerable part of it required to be taken away, and in doing this, the deep-seated anterior temporal artery was divided. What of the tumour remained on the cheek, adhered so firmly to the zygomatic muscle, and was so closely in- corporated with its substance, that the one could not be separated from the other. The insulated part of the portio dura and the parotid duct were now laid back on the masseter muscle, and the edges of the integuments brought into contact over them, and sup- ported by means of a single suture. Over the malar bone the lips of the wound could not be made to approach, nor did the oozing from the bone cease. A fold of linen and a layer of sponge were therefore laid into this part of the wound, and retained there by a compress and bandage, appHed so tightly, as to restrain the bleeding. The sponge was removed two days afterwards, and an attempt made to bring the lips of the wound nearer to each other. 133 The sore soon began to granulate, and threw out a flabby red fun- gus, the growth of which could not be checked by the application . of sulphate of copper. By bringing the edges of the sore together, i it was at length reduced to the size of a shilling, and was soon j afterwards completely cicatrized. Three years after the operation, i the patient continued free from any return of the disease, and the ■ cicatrice was becoming smaller. The only inconvenience which i he experienced, arose from the motion of the upper eyelid being 1 impaired, by its adhesion to that part of the sclerotica Ifrom which I the tumour had been dissected. From the same cause, the eye ' did not possess the same latitude of motion as formerly. It required ! a considerable effort to turn the pupil toward the nose.* I It will be evident, upon the slightest consideration, how very different in activity, if not in nature, this case of Mr. Burns is from that of Mr. Bell, and how much less the danger attending the extirpation of such a passive or venous aneurism by anasto- } mosis, compared to that which is inseparable from every atterapt to touch with the knife the active, or arterial tumour of the same sort. I The terms active and passive, applied to this disease, cannot, I I think, be objected to ; but probably the terms arterial and venous I may be incorrect. We are, as yet, in ignorance of the real struc- I ture of aneurism by anastomosis, and therefore cannot pretend to i explain its varieties. ; The bold and successful practice of Mr. Travers, who, for an j aneurism by anastomosis, within the orbit, tied the common caro- I tid artery, has been followed by Mr. Wardrop in several cases of this disease, situated externally. In these cases, Mr. W. went upon the probability, that if the current of blood through a neevus were arrested by tying the arterial trunk supplying it, the blood contained in the cells, or what may be considered as the parenchy- ma of the tumour, would be put at rest, and undergo a process of coagulation, similar to the blood in a common aneurismal sac after the artery has been tied ; and likewise, that the coagulated blood would be afterwards absorbed, and that the parenchyma of the tumour would gradually shrink. Mr. Wardrop has pubhshed the particulars of three cases of nsevus of the face, in which he tied the common carotid artery. All the three patients were young children. Two of them died, the circumstances previous to the operation being very unfavourable. The successful case was that of a female child, five months old, who had a large subcutaneous nsevus on the left side of the fac-e, covering one half of the root of the nose, the eyebrow, and the upper eyelid, which could not be sufficiently opened to expose the eyeball, nor could the precise lim- its of the disease be traced in the orbit, within which it seemed to penetrate deeply. The tumour was of a pale blue colour, and there were numerous tortuous veins in the integuments covering , * Observations on the Surgical Anatomy of the Head and Neck, p. 331. Glas- gow, 1834. 134 it. It had no pulsation, felt doughy and inelastic, and when squeezed could be greatly diminished ; on removal of the pressure its original size was rapidly restored. As it would have been ex- tremely dangerous, and probably even impracticable, to have re- moved this tumour with the knife, and as it had been rapidly increasing since a few days after the birth of the child, Mr. W. concluded that the only chance of arresting the progress of the dis- ease, was by tying the trunk of the common carotid artery of that side on which the tumour was situated. The incision of the in- teguments was made about the middle of the neck, along the tracheal edge of the mastoid muscle, and the rest of the dissection was accomplished chiefly with a sharp-pointed double-edged silver knife. The operation was more difficult than might have been expected in a simple dissection amongst healthy parts, from the unceasing crying of the infant, which kept the larnyx and trachea in constant motion upwards and downwards. This not only prevented the pulsation of the carotid from being distinguished, but when the sheath of the vessel was distinctly penetrated by the point of the knife, rendered it difficult to get the point of Bremner's aneurismal needle conducted by the finger fairly within the sheath. When, however, the latter step of the operation was accomphshed, the needle passed around the artery with great facility. Some divided vessels bled a good deal during the operation, so that the wound was kept filled with blood, and the dissection was necessarily con- ducted with the finger as the only guide. The ligature being tied around the artery, the edges of the wound were brought together by a single stitch, and no adhesive plaster nor bandage employed. The infant appeared pale and much exhausted after the operation, and had a teaspoonful of the syrup of white poppies. A remarkable change was immediately observed in the tumour. No sooner had the carotid been tied, than the child was observed to raise the upper eyelid sufficiently to expose the eyeball, which, until that period, had never been in view, on account of the swollen state of the hd. The colour of the tumour also changed, losing its scarlet hue, and appearing of a much darker blue shade, a change, observes Mr. W., which evidently had arisen from the collapse of the arteries, whilst the veins and cells of the tumour remained filled with venous blood. Soon after the operation the child became tranquil, and in a few hours was permitted to suck, care having been taken to keep the mother's mind tranquil, by her absence during the operation, and by concealing from her the extent of the wound. The child passed u very quiet night, the operation seeming to produce very slight excitement in the general system. She continued to suck as if nothing had happened, and the wound inflamed so little as to re- quire no dressing. The ligature came away upon the eleventh day. On the day following the operation, the tumour continued of the same diminished bulk, and of the same dark purple colour, which it had assumed immediately after the artery was tied, and 135 ^ on feeling it, it seemed either as if the blood which it contained had coagulated, or that it was emptied of its blood ; for pressure, instead of emptying its contents, now made no sensible alteration in its size. A gradual, though not always regularly progressive diminution followed ; by degrees, more and more of the eyeball became ex- posed ; and ten months after the operation, nothing of the tumour remained, more than the membranous bag which was originally distended with blood.* SECTION XVI. NEURALGIA, OR TIC DOULOUREUX. The branches of the first and second divisions of the fifth pair of nerves, distributed to the eye, eyeUds, and circum -orbital region, are more frequently the seats of severe pain than any other nerves of the body. We meet, in the first place, with cases, in which these nerves are affected with paroxysms of pain, without any other signs of disease being present. In the second place, these nerves are affected with pain, while, at the same time, the sclerotica and iris are inflamed. In a third set of cases, the teeth are decayed, often the vitreous humour glaucomatous, and vision impaired. In a fourth set, there are attendant on the pain, unequivocal signs of organic disease within the cranium. To the first and fourth of these sets of cases, the names neuralgia and tic douloureux are generally appUed. The second and third sets are accounted rheu- matic. i^ymptoms. In the commencement of neuralgia, the pain occurs only momentarily, and perhaps not oftener than once or twice in twenty-four hours. The upper eyelid, the middle of the eyebrow, and the temple, are its most frequent seats. The side of the nose, the lower lid, and the cheek, are less commonly affected in incipient cases. As the disease proceeds, the pain becomes more violent, but still continues only for an instant. Gradually its attacks are more frequently repeated, last longer, although rarely above half a minute, and attain a degree of most overpowering severity. The pain is almost always referred to one spot ; it appears to be situated in one or other of the large branches of the fifth pair ; if it spreads, it does so in the direction of the ramifications of the nerves. In advanced cases, we observe, that during a paroxysm, the eyebrows are knit, the lids firmly closed, the angle of the mouth drawn towards the ear, the lower jaw fixed, and respiration as much as possible sup- pressed. The muscles in the immediate vicinity of the pain are sometimes affected with a degree of quivering, tremor, or slight convulsion ; but this is not an invariable symptom, and when it does occur, seems to be merely an effect of the violence of the pain. The pain is not equally violent during the whole time of an attack. * Lancet, Vol. xii. p. 267. London, 1827. Mr. Wardrop's unsuccessful cases are contained in the Medico-Chirurgical Transactions, Vol. ix., and in the volume of the Lancet now quoted. 136 In general, it increases by degrees, and is most severe a short time before it ceases, which it commonly does with equal suddeness as it makes its attack. This disease is completely intermittent. Whenever the fit is over, the patient feels peifectly free from un- easiness in the part, which but an instant iDcfore was the seat of excruciating pain. The symptoms occasionally attendant on neuralgia of the fifth pair, and indicative of serious organic changes within the cranium, are amaurosis, palsy of the muscles of the eyeball, and of the leva- tor palpebrae superioris. inflammation of the cornea, ending in ulcer- ation, and deformity of the hones forming the back and roof of the throat. The inflammation and other changes of the eye in such cases resemble very much the effects produced in Majendie's experi- ment of dividing the trunk of the fifth pair. CoyistitufAonal Symptoms. It is only in confirmed cases that any symptoms of this kind are present. When the disease has continued for a length of time without amelioration, and the attacks are very frequent, the patient becomes restless and melanchol3^ in- sensible to the pleasures of society, and incapable of occupation, the appetite for food fails, digestion is impaired, the bowels become bound, the body becomes emaciated, the sexual passion is extin- guished, and the patient is almost totally deprived of sleep. Subjects. No age is exempt from this disease. Men are more frequently affected wnth it than women. It is by no means the nervous or hypochondriac that are most exposed to it. Causes. In many cases, this disease appears to arise from causes similar to those which induce rheumatic opthalmia, and es- pecially continued exposure to draughts of cold air. While causes of this sort give origin to the first attacks, we observe a variety of occasional circumstances which operate in re-inducing the parox- ysms, as the motions of the face in speaking, chewing, or swallow- ing, simple touching of the part, the shocks which the body is apt to undergo in walking or riding, the blov\-ing of the wind over the face, the sudden opening or shutting of a door, and many others. The paroxysms are much more frequent during the day, on ac- count of the presence of many more exciting causes, than during the night. The complaint is much aggravated during the preva- lence of easterlv and north-easterly winds. We are iniable to say any thing certain regarding the proximate cause of simple neuralgia. When there are paralytic symptoms along with neuralgia, it is probable that pressure on the third and fifth pairs exists within the cranium, from thickening of the dura mater, spiculee of bone, or the hke. Treatment. 1. We are highly indebted to Mr. Hutchinson, of Southwell, for the introduction of the precipitated carbonate of iron, as a remedy in neuralgia. I have used it in a variety of cases, both simple and complicated. In the former it has always proved successful. In painful affections of the circum-orbital region, ac- 137 conipanying glaucoma and amaurosis, I have also found it highly serviceable. In cases apparently connected with serious organic changes within the cranium, it has not appeared to be productive of any effect. The dose of the carbonate of iron may be from fifteen grains to a drachm twice or thrice a-day. Mr. H. appears to give a drachm as his usual dose ; but I have found it effectual in much smaller quantities. Should the medicine produce no relief in small doses, it ought to be tried in larger quantity. Mr. H. mentions a case in which half a drachm three times a-day, produced little per- ceptible benefit; he increased the dose to a drachm twice a-day, Avhen, after three days, a very sensible abatement of the number and violence of the paroxysms was observed ; he again increased the dose to four scruples twice a-day, in which the patient persevered regularly for ten weeks, at the expiration of which time, not the slightest vestige of the disease remained. He gives several other cases, in which little or no effect was produced by smaller doses than four scruples twice a-day. Mr. H.'s pamphlet is well worthy of perusal.* 2. Another remedy of great utihty in the treatment of this dis- ease is belladonna, for the suggestion of which we are indebted to Mr. Bailey, of Harwich. It is a medicine of so much activity, that it must be given with a very cautious hand. The form which I have adopted for internal, and sometimes also for external use, is a vinous tincture of the extract, prepared by macerating, for four days, one drachm of the extract in one pint of white wine. Of this, as a dose, I begin with five drops thrice a-day, increasing gradually to 15 drops. Besides soothing, and in many cases, removing entirely the neuralgia, the use of this medicine induces a very peculiar sense of thirst and constriction in the throat ; and in larger doses, brings on cramp of the stomach, dilatation of the pupils, temporary blind- ness, vertigo, and a highly distressing feeling of weakness and sinking. The cases related by Mr. B. are extremely interesting-.f He ventures on 2 or even 3 grains of the extract at once, and ap- pears to have been led to this mode of exhibiting the medicine from the difficulty of getting the patients to continue smaller doses for any length of time, in consequence of its unpleasant effects, while many were completely and permanently relieved by a single large dose. I have found belladonna useful in almost every variety of neuralgia ; but of late I have prescribed it less frequently, in con- sequence of making use of the carbonate of iron. 3. Calomel and opium have been recommended for neuralgia, and occasionally prove useful ; although, in many instances, any degree of affection of the mouth in this complaint, is found to ag- gravate the symptoms. In a case of neuralgia, attended with ul- '^ Cases of Neuralgia Spasmodica, commonly called Tic Douloureux, successfully treated. London, 1822. t Observations relative to the Use of Belladonna in Painful Disorders of the Head and Face. London, 1818. 18 138 cerated cornea, arising without any active inflammation, and ap- parently merely as a consequence of the diseased state of the fifth pair of nerves, I found calomel and opium internally, and the lunar caustic solution externally, successful in procuring the cicatrization of the ulcer. 4. Arsenic has often been tried in this disease, but appears to have little or no effect. 5. The division of the afiected nerve is also laid aside. 6. Plasters worn over the seat of the pain sometimes serve to moderate it. They are made with opium, cicuta, belladonna, and other narcotics. SECTION XVII. TWITCHING OR QUIVERING OF THE EYELIDS. I have often been consulted by patients who complained of a tremulous, quivering, or twitching motion of one or other eyelid, or of both, which they w^ere unable to control or to prevent, and which, from the frequency of its repetition, had become very an- noying, although not attended with any pain. This, I believe, is the complaint called by the French ticnon-douloureux. In many cases of this disease, the quivering of the orbicularis palpebrarum is so shght, as not to produce any visible motion of the affected lid ; but in other cases, the motion is very evident, and is not confined to the lids, but extends to other muscles of the face, and especially to the zygomatici, so that w^hile the hds are affected wath an oscil- latory or wiuking motion, the angle of the mouth is drawni up- w^ards. Agitation of mind generally aggravates this convulsive state of the face, so that in speaking to a stranger, it becomes much increased. The patient is conscious of this, his feehngs are hurt by the knowledge of his being subject to the complaint, and he becomes anxious to undergo any sort of treatment likely to reheve him, not excepting an operation. Although in by far the greater number of cases, no pain attends this disease, it is occasionally ac- companied by pain so severe, as to resemble the tic douloureux. 1 have uniformly found the digestive organs deranged in the subjects of this disease. The physiological discoveries of Mr. Charles Bell regarding the offices of the fifth pair, and portio dura of the seventh pair, lead us to refer the diseased motions of the face, as well as all its healthy motions, both voluntary and involuntary, to the influence of the latter nerve. Treatment. 1. The most essential part of the treatment con- sists in the use of alterative, laxative, and tonic medicines. A blue pill every night, or every second night, and one or two compound rhubarb pills every morning, for a fortnight, will generally be at- tended with much benefit ; after which a course of bitter infiision, cinchona, or carbonate of iron, ought to be prescribed, along with country air and exercise. I- 139 2. Anodyne liniments rubbed in the course of the portio dura tiave been recommended. 3. Pressure, so as to hmit the motion of the parts spasmodically ; affected, has been found advantageous, tending to break the habit, 3n which, in a great measure, the complaint depends, however it may have been originally produced. SECTION XVIII.— -MORBID NICTITATION. Natural nictitation appears to be performed chiefly by the alter- nate relaxation and contraction of the levator palpebrse superioris, and is accomplished so instantaneously and easily as scarcely to at- tract the attention of ourselves or others ; but there is a morbid nictitation, which appears to be more a convulsive action of the or- 'bicularis palpebrarum, too remarkable not to be observed by others, 'and of which, at last, the patient himself becomes conscious. In some cases it seems to affect the upper ; and in other cases, more the lower lid. Sometimes one eye only ; at other times both eyes are affected. Although different from the subject of the last section, the present disease is aggravated by the same causes which aggra- vate the former, especially by agitation of mind, and disordered di- gestion. Sometimes a single eyelash, growing inwards, so as to touch the eyeball, is the cause of morbid nictitation. In other instances, slight ophthalmia produces it. These causes being removed, the com- plaint w^ill cease. In all other cases, a treatment similar to what has been recommended for quivering of the eyelids, must be adopted. SECTION XIX. PHOTOPHOBIA, AND SPASM OF THE EYELIDS. Intolerance of light, and spasmodic contraction of the orbicularis palpebiarum, almost always go together, as effects produced by the same cause, so that we rarely observe any thing like a pure blepha- ro-spasmus. The common causes of photophobia, and spasm of the lids, are, a particle of dust in one or other of the folds of the conjunc- tiva, an inverted eyelash, or strumous conjunctivitis. In the last instance, the spasm is often continued for weeks together, the pa- tient being unable all that time to bear the least accession of light, or to open the eyes in the smallest degree. The inflammation dur- ing all this time may be very inconsiderable, so that on forcing open the lids, scarcel}'" a red vessel is discovered. Such, however, is the sympathy between the conjunctiva, which is the seat of the disease, and the neighbouring parts, that the admitted light seems to the patient to blaze like the rays of the sun reflected from a mirror, the lachrymal gland instantly pours out a tide of burning tears, and the spasm of the orbicularis palpebrarum forces the lids 140 together with new violence. The photophobia, and spasm of the eyelids, depending on the causes aheady mentioned, generally sub- side very soon after the foreign particle is removed, or the ophthal- mia subdued. As for cases of pure blepharo-spasmus, I have seen but very few. In some patients, however, we find morbid nictitation go to such a degree, that the lids cannot be opened for several seconds, during which period, the eyeball is strongly pressed by the contraction of the orbicularis. The venerable Blumenbach is subject to an affec- tion of this sort, so that during conversation, or at lecture, he em- ploys his finger to overcome the closed state of the lids. In other cases, spasm of the orbicularis of one side is brought on in consequence of a blow on the head, or other injury, the effects of which have been communicated to the brain or its membranes. The spasm continues long, for weeks, perhaps, or months, and is apt to be mistaken for palsy of the levator of the upper lid. A rest- less state of the edge of the upper lid, and the difficulty experienced in raising the lid even wdth the finger, will serve to distinguish this state from palsy. The treatment of pure blepharo-spasmus will consist in laxatives, tonics, and antispasmodics, internally, and in counter-irritation ex- ternally. This is to be accomplished by friction with volatile lini- ment, tincture of cantharides, and the like, on the forehead and temple, and behind and before the ear, the apphcation of blisters, and the insertion of issues. Fomentations with poppy, or chamo- mile decoction are useful. Poultices, containing opium, hyoscya- mus, or cicuta, are also recommended to be applied over the eye. In cases where the spasm is traced to injury of the head, blood-let- ting from the arm, leeches to the head, and a course of mercury, will be required. Benedict has treated of the intolerance of light which attends strumous ophthalmia, as a separate disease, under the name of pho- tophobia infantimi scrophulosa. He recommends chiefly small doses of calomel, and the warm bath.* SECTION XX. PALSY OF THE ORBICULARIS PALPEBRARUM. In many cases of partial palsy of the face, there is a degree of lagophthalmos present, or in other words, the eyelids cannot be completely closed, on account of paralysis of the orbicularis palpe- brarum. The patient cannot elevate his eyebrow, nor frown ; he cannot wink hard, nor press the eyelids against the eyeball. The tears run over on the cheek, from want of the action of the lower Md, which hangs depressed and everted ; exposed to dust flying about, the patient is distressed by its getting into his eye ; and thus inflammation and opacity of the cornea may be excited. The • Beitrage ftlr practische Medizin und Ophthalmiatrik. Vol. i. p. 3. Leipzig, 1812. 141 other muscles of the face are at the same time paralyzed. The sensation of touch is perfect, depending on the fifth pair ; but the motion of the lips is lost on the paralyzed side^ the mouth is dragged from the palsied towards the sound side ; and even the nose is twisted. From the exposed state of the eye, the patient has a feehng of cold in it, which he remedies by covering the eye, perhaps, with his hand. Occasionally he complains of pain at the root of the ear, or in the neighbourhood of the stylo-mastoid fora- men, from which the portio dura escapes, to send its branches over the face. Pain is sometimes felt, at the commencement of the disease, radiating along the branches of the nerve. Causes. Exposure to a current of cold air, producing inflamma- tion of the portio dura, and, perhaps, in some cases, inflammatory sweUing and diminution of the caliber of the Fallopian aqueduct, so as to press on the Uunk of the nerve, is the most frequent cause of partial palsy of the face. It has been known to arise from the pressure of a lymphatic gland between the mastoid process and the angle of the jaw^ owing to inflammation of the mouth from the action of mercury. An abscess of the tympanum, affecting the Fallopian aqueduct, may produce it ; or a division of the portio dura in any surgical operation about the angle of the jaw. One or other branch of the nerve may in this way be divided, and con- sequently one or other hd only be palsied. Care must be taken lest the affection be erroneously supposed to arise from disease within the cranium. Treatment. This must be directed neither against the brain nor against the eyelids, but against the portio dura. Antiphlogistic means of cure are to be adopted in the first instance, as leeches behind the ear and near the angle of the jaw, cupping on the back of the neck, and free purging. Calomel and opium, and the use of diaphoretics, may next be had recourse to. A semilunar blister round the ear, and stimulating liniments to the paralyzed parts, will be found of advantage. Should these means not prove effec- tual, a trial may be given to electricity. SECTION XXI. — PTOSIS, OR PALLING DOWN OF THE UPPER EYELID. Inability to raise the uppei- eyelid may either depend on a me- : -chanical cause, or arise from weakness, or be paralytic. 1. Mechanical. After inflammation of the upper eyelid, attended with consider- able (Edematous or sanguineous effusion into its substance, or treated by the long-continued use of cataplasms, we not unfrequently find the integuments so much relaxed, that they form a fold, hanging down over the opening of the lids, while the levator palpebrse 142 superioris is unable, from the weight and bulk of the Ud, to raise it so as to uncover the eye. We perceive distinctly the endeavours of the muscle, as soon as the patient is earnestly desirous of opening his eye, but the eyelid is either raised only to a very inconsiderable degree, or remains completely prolapsed. If we take hold, between the finger and thumb, of the relaxed fold of skin, so as to relieve the levator muscle of the additional weight of this superfluous por- tion of integuments, the patient can, without diflficulty, open his eye ; but as soon as we quit our hold, the eyelid descends gradually to its former position. Sometimes the relaxation does not occupy so much the middle of the eyelid as its temporal portion. It is also occasionally the case, that when the fold of integuments is very considerable, it presses, by its weight, the edge of the lid, along with its cilia, inwards, so as to produce a degree of entropium. For the cure of this variety of ptosis, the common practice is to remove a transverse fold of the integuments of the affected hd. In order to perform this with the necessary exactness, with a broad convex-edged pair of forceps, we take hold of the skin, where it appears most relaxed, and then desire the patient repeatedly to open and shut the e3'^e. If he be able to do this, it is a proof that the forceps include neither too much nor too little of the skin. If he cannot lift the lid, we have taken hold of too little, and must apply the forceps again, so as to include a greater portion of skin. If he can, indeed, lift the lid, but not completely shut it again, we must let go a little of the skin from the grasp of the instrument. It is important also to take care that we do not apply the blade of the forceps too close to the edge of the lid, for if this be done, too little space will be left for the application of stitches. As soon, then, as the forceps are properly applied, we squeeze their blades together with moderate firmness, that the integuments may not escape, and then remove the portion laid hold of, by a single stroke of the scissors. The bleeding is inconsiderable, and ceases in a few minutes by the use of cold water. Never more than two stitches are necessary ; one is frequently suflScient. Union is gen- erally effected without any suppuration, and as soon as the union is complete, the prolapsus is cured. 2. Atonic. In some instances, we meet with a depressed state of the upper eyehd, dependent apparently on mere w^eakness of the levator muscle. In this case, mechanical support, by means of a strip of adhe- sive plaster, assists in restoring to the muscle its wonted power- Applications of a strengthening kind are to be made to the lids, as bathing with rose-water, friction with tinctura saponis, and the like. Electricity may also be tried, and general tonics. 143 3. Paralytic. Palsy of the levator palpebrse supeiioris is exceedingly unlikely to arise from a division of the branch of the motor oculi, which supplies that muscle with nervous energy ; for that branch lies deep in the orbit, enters the muscle by its inferior side, and is therefore not likely to be touched, except in a wound penetrating so much into the orbit, as to implicate other parts.* Palsy of the levator of the upper lid is, however, an affection by no means uncommon. In one set of cases, it bears an analogy in point of cause to the partial palsy of the face already spoken of, or, in other words, it arises from cold, and is part of a rheumatic palsy of the eye. In another set of cases, the cause is cerebral ; it is serous effusion, or some tumour, formed within the cranium, and pressing on the third pair of nerves. It is often difficult, es- pecially in the incipient stage, to distinguish these two sets of cases. In both, we generally find either all the muscles of the eyeball also paralyzed, so that the eye stands stock-still in the orbit, or the abductor retains its power, so that the eye is turned towards the temple, while the other recti being paralyzed, the patient is unable to move his e3'e upwards, downwards, or inwards. In rheumatic cases, one side only is generally affected, and the abductor retains its power. In cerebral cases, both eyes are more apt to be affected from the beginning, although sometimes one side is first paralyzed and then the other. The effect of palsy of the levator palpebrse superioris, is, of course, to deprive the patient of sight. He sees none, unless he raises the lid with his finger. When he does so, he generally sees double, and if he tries to walk across the room, he is affected with a great degree of vertigo. The double-vision, and the vertigo, cease as soon as the lid is allowed to drop, and are to be attributed to the misplaced state of the eyeball, which generally attends this paralysis of the upper lid. The rheumatic variety of this palsy is brought on by exposure to currents of cold air. The cerebral is either sudden, or slow ; the sudden arising after fatiguing exertion, exposure to the direct rays of the sun, intoxication, blows on the head, and the like ; the slow keeping pace with the growth of scrofulous tumours, fungous growths from the dura mater, and other organic changes at the basis of the skull. Treatment. Both in the rheumatic and in the sudden cerebral palsy of the upper lid, we employ blood-letting, general and local, rest, the antiphlogistic regimen, and blistering of the head. After the use of these means, we generally find the vertigo to be re- moved, and gradually the other symptoms begin to yield. In both cases, we employ mercury till the mouth is affected, combining it * Seepage 101. 144 in rheumatic cases with opium, as a sudorific, and in cerebral eases expecting it to prove useful as a sorbefacient. Sudorifics, as gnaiac, and stimulants, as camphor, have been highly recommended in the rheumatic cases. Issues in the neck, and behind the angle of the jaw, and the use of electricity, have been attended with advan- tage. In slow cerebral cases, I have seen almost every sort of practice tried without effect. Some cases of ptosis are congenital. I am unable to say whether they are paralytic, or arise from some defect in the struc- ture of the levator muscle. They sometimes appear, for a time, to be bettered by the operation already described, for ptosis arising from mechanical causes ; but the relief is only temporar)^, for the lid soon returns to its former depressed and motionless state. SECTION XXII. LAGOPHTHALMOS, AND RETRACTION OP THE EYELIDS. The term lagophthalmos is employed to denote that state, in which the eyelids cannot l^e completely closed, so that even during sleep, a part of the surface of the eyetell remains exposed to the action of the air, and the irritation, of foreign particles. This state is generally the result of shortening of the upper eyelid, from the contraction attending the cicatrization of a burn or other injury, or of the retraction of that lid arising from caries of the roof of the or- bit ; and in either case, lagophthalmos may or may not be attended with eversion of the affected lid. I have been consulted on account of a great degree of retraction or depression of the lower lid, consequent neither to destruction of its integuments, nor disease of the bone. I was led to suspect that suppuration between the eyeball and the floor of the orbit, had been the cause of this diseased position of the lid, but nothing of this kind appeared from the history of the case to have happened. Another variety of lagophthalmos is the result of palsy of the orbicularis palpebrarum, which allows the lower eyelid to drop, and prevents it even during the strongest act bi volition from meeting" exactly with the upper. A slight degree of lagophthalmos may not be attended b}" almost any bad consequences. When more considerable, inflammation of the conjunctiva and cornea, opacity of the cornea, and even staphy- loma, may be the results. The exposed eye is incapable of the usual exertion, and is affected with epiphora and intolerance of hght. Of the lagophthalmos from palsy, nothing farther reqtdres to be said. The ancients attempted to reUeve this state of the eyehds^ w^hen it arose from a cicatrice, by a transverse incision through the contracted integuments, separating the edges of the incision as much as possible, and endeavouring to keep them separate by the inter- 145 position of dressings, till the cure was complete. This plan was found to be ineffectual ; as the cicatrice, arising from the operation itself, necessarily gave rise to a new degree of contraction. The lagophthalmos arising from caries of the roof of the orbit, is occa- sionally attended by a considerable transverse elongation of the eye- lid, at the same time that it is drawn up into an angle, and im- movably fixed in the elevated position. Under these circumstances, it has occurred to me that an operation similar to that which is practised for the worst degree of eversion, might be performed with advantage ; namely, cutting out a triangular portion of the whole thickness of the eyelid, detaching the lid as completely as possible from the roof of the orbit, and then bringing the edges of the wound together by stitches, so as to make the lid sit close on the eyeball, and thus, by the transverse shortening produced by the operation, counteracting any tendency which the lid might have again to be- come perpendicularly shortened. Of course, nothing of this sort should be attempted till the bone is perfectly sound. As palliative means, in all cases of lagophthalmos, may be men- tioned, the lunar caustic solution, which, applied once a-day to the conjunctiva, lessens the tendency to inflammation, caused by the exposed state of the eye ; and the use of such mechanical means as may moderate the access of hght and air. 'SECTION XXIII. ECTROPIUM, OR EVERSION OF THE EYELIDS. 1. Eversion of either lid, from inftammation and strangulation. This first variety of eversion takes place only when the con- junctiva is in a state of acute inflammation. When it affects the upper lid, it is in some measure accidental. A child, for example, is labouring under acute puro-mucous ophthalmia ; the attendant, upon attempting to look at the eye, or to remove the copious puru- lent discharge, unfortunately turns the upper eyelid inside out : the child begins to cry violently, this increases the eversion, and all attempts to reduce the lid to its natural position are found to be in- effectual. It is allowed to remain everted for some hours, or, as I have repeatedly seen it happen, for several days, and then the child is brought for advice. The everted lid is by this time greatly in- jected with blood ; sometimes to such a degree, that all attempts by pressure fail to overcome the eversion ; or if we succeed in restoring the lid to its natural position, it very probably returns to the state of eversion, the moment that the child begins to cry. When this variety of eversion affects the lower lid, there is noth- ing accidental in its production ; it is entirely the result of the swelling and protrusion of the inflamed conjunctiva. The contagious or Egyptian ophthalmia, and the ophthalmia neonatorum, are the most frequent sources of this variety of ever- sion. 19 146 Treatment. We have recourse, in the first instance, to scarifi- cation of the everted conjunctiva. After the tumefaction of the eyehd is somewhat reduced by the discharge of blood, we are in general able to return it to its natural position, laying hold of it in such a manner as to press out from it as much as possible of the thin i fluid effused into its substance, and suddenly bending its edge, if it be the upper lid, downwards and backwards. If the state of inflam- mation is not very acute, we ought to maintain the lid in its natu- ral position by means of a compress and roller. If the ophthal- mia be still severe, we must content ourselves with recommending great care in the attendants to avoid whatever might cause the child to cry, and instruct them in the manner of reducing the eversion, should it happen to return. From day to day, or more frequently than once a day, if this is thought necessary, the e3'^e is to be examined, and the proper means applied to the conjunctiva for removing the ophthalmia, as lunar caustic solution, sulphas cu- pri, and the like. I have seen repeated instances in which scarification failed, or if we succeeded by its means in lessening the degree of eversion, it speedily returned. In such cases, we must have recourse to the removal of a portion of the diseased conjunctiva. With a hook, or a pair of hooked forceps, we lay hold of the middle of the exposed and thickened portion of that membrane, and remove, with the scissors, a fold of it of the shape of a myrtle leaf. The wound bleeds profusely, and this assists in reducing the lid to a state fa- vourable for replacement. Sti'ips of plaster, passing from the up- per to the lower lid, and a compress and bandage, are then ap- plied, and are to be removed from time to time, till the cure is complete. Prognosis. It is important to observe, that although in every case of this variety of Reversion, our prognosis may be favourable regarding the mere eversion, we must pronounce nothing regard- ing the vision of the patient, unless we are able distinctly to bring the cornea into view. In neglected cases, the sw^elling of the everted conjunctiva may be such, that we shall find it impossible to do this, on our first examination of the eye ; and under such cir- cumstances w^e ought to forewarn the friends of the patient that we can promise nothing regarding the sight. After the use of scarification and other means, we bring the cornea into view, but not unfrequently we find the eye staphylomatous, and of course vision lost. 2. Eiiersion of the loiver lid from relaxation. There occurs not unfrequently, especially in old persons, an eversion of the lower hd, as a consequence of chronic inflammation of the conjunctiva and Meibomian follicles. The orbicularis pal- pebrarum appears to have lost its power of supporting the lid, and the tensor tarsi, being also weakened, allows the punctum lachry- 147 male to fall forwards. The exposed conjunctiva is swollen, of a pale red colour, and sensible to the touch. Gradually, from the constant influence of the air upon a part not intended to be exposed to this excitement, and the occasional contact of external bodies, the inside of the everted lid becomes redder, firmer, and almost in- sensible to the contact of those substances which formerly excited pain or brought on bleeding from its surface. The consequences of this disease are stillicidium lachrymarum, and occasional attacks of inflammation of the eyeball. Both these are the unavoidable eflfects of the interruption of the natural functions of the lower eye- lid. In the state of eversion, it no longer covers completely and accurately the inferior part of the eyeball, which consequently re- mains exposed to innumerable causes of irritation, from which it ought to be guarded. In this state also, the tears are no longer guided onwards to the punctum lachrymale by the edge of the eye- lid, nor is the punctum kept in contact with the eyeball as it is in health, so that the tears are allowed to drop over on the cheek. Treatment. Besides removing the inflamed state of the lids and conjunctiva, which gives rise to this variety of eversion, we find that the application of escharotics to the exposed conjunctiva is the most effectual means of counteracting the tendency to mis- placement. The sulphas cupri, and the nitras argenti, solid or in solution, are to be preferred. Scarification of the inflamed con- junctiva is also useful, as well as keeping the lid raised into its nat- ural position, by means of a compress and roller, very carefully applied. Inveterate cases require for their cure that a considerable portion of the relaxed and thickened conjunctiva should be removed. In order to execute this operation with exactness, it is necessary to cal- culate beforehand what amount of contraction of the conjunctiva would be sufficient to reinstate the eyelid in its natural position. If we remove too little, a degree of eversion will remain. If we remove too much, we produce a new disease, namely, inversion, which is at least as bad as that which we had been endeavouring to relieve. The operation and after-treatment are the same as have already been mentioned under the first variety of eversion. If our calculation in the quantity of conjunctiva to be removed has been correct, we find the ectropium cured as soon as the cicatrice is completed. 3. Eversion of the lower lid, from excoriation. The most common cause of eversion is excoriation of the lower lid and cheek, in consequence of long-continued ophthalmia tarsi. We find the edges of the everted lid rounded off, the Meibomian apertures partially or totally obliterated, the cilia destroyed, and a considerable portion of inflamed conjunctiva permanently exposed to view. Treatment. We endeavour to remove the remaining symptoms of the ophthalmia tarsi, by the means of cure already recommended. 148 The skin of the everted lid is to be softened, and protected from farther irritation, by the frequent application of simple cerate, or ox- ide of zinc ointment. Scarification of the exposed conjunctiva, and the application of fluid and solid escharotics. especially the sulphas cupri and nitras argenti, will do much both to remove the inflam- mation and restore the natural position of the lid. Should these means not prove completely effectual, a portion of the conjunctiva must be extirpated, as has been already recommended for the first and second varieties of eversion : or destroyed by a very cautious application of sulphuric acid. In very bad cases of this sort we may, with advantage, have recourse to the removal of a portion of the whole thickness of the lid, of the shape of the letter V, an ope- ration recommended by Sir William Adams,* and which we are frequently obliged to practise in eversion arising from a cicatrice. 4. Eversion of the lower lid from disunion at the temporal angle of the lids. This variety of eversion seldom occurs except in those pretty far advanced in life, and who, for a long time, have been aflfected with inflammation of the edges of the lids. A succession of ulcers at their outer angle at length efiects their disunion, and allows the low- er lid to become everted. Treatment. In this variety of eversion, an operation similar in principle to that for harelip, has been recommended, namely, the removal of the edges of the ulcerated and disunited commissure of the lids, which are then to be brought into contact, and healed by the first intention. Such an operation appears to be the only means of cure for this variety of eversion ; but of course v^e need not think of performing it till all appearances of ulceration and inflammation of the lids have completely subsided. These being the original causes of the disease would completely thwart our attempts for its cure. 5. Eversion of either lid., from, a cicatrice. The cicatrice which operates in the production of this variety of eversion, may be the consequence of a w'ound, an abscess, an ulcer, or a burn. Not even the simplest incision can be healed without some de- gree of induration and contraction in the parts immediately sur- rounding the cicatrice. In cases of abscess opening externally, we observe that the whole circumference of the abscess contracts, till lit- tle or no cavity is left, and that when the cure is completed, instead of the elevation which existed when the abscess was filled with pus, the surface presents an evident depression. In the middle of this depression is the cicatrised wound by which the abscess was laid open, and we find the skin drawn towards the cicatrice and render- ed unnaturally tense by this contraction. In cases of ulcers and ♦ Practical ObserTations on Ectropium, &c. London, 1814. 149 burns, in which a considerable portion of skin has been destroyed, these phenomena are still more striking. Though nature contrives to cover up an ulcer by a process of cicatrization, and to produce, in place of the portion of skin which had been destroyed, a supplemen- tary substance, yet matters are not restored exactly to their former state. The ulcer is covered, partly at the expense of the surround- ing sound skin which is drawn together and contracted over the sore, and partly by the formation of a new membrane, which, though we give it the name of skin, possesses but few of the properties of the old integuments. It is neither so large as the piece of skin which has been lost, nor is it so yielding, nor so elastic, nor so moveable upon the part which it covers. It is smooth and shining, and scarcely capable of distention, but above all, so far as the pre- sent subject is concerned, the surrounding original cutis is drawn towards this supplementary production, is puckered and thrown into folds, and, to use the homely comparison of Mr. Hunter, the whole appears as if a piece of skin had been sewed into a hole by much too large for it, and therefore it had been necessary to throw^ the surrounding old skin into folds, or gather the surrounding skin, in order to bring it into contract with the new. To apply these facts to the subject before us, if merely an incis- I ion, for instance, be made below the edge of the under eyelid, a degree of induration and contraction will infaUibly result, and the edge of the lid will be, though perhaps in a very small degree, permanently drawn downwards. If an abscess take place in the same situation, a considerable depression will be left after it is evac- uated and cured, the integuments will be contracted towards the cicatrice which closes the opening of the abscess, and a still greater degree of displacement than in the case of simple \vound, with some degree of eversion, will be produced. In the case of an ulcer or a burn, the degree of eversion is in exact proportion to the situ- ation of the cicatrice and the loss of substance which had been produced. Nay, there is a greater degree of contraction when these accidents take place in the eyelids than if they had happened in sev- eral other parts of the body, where the integuments are more on the stretch. The eyelids are so loose, that very httle new skin is formed, the cicatrice is proportionally smaller, the contraction greater, and the eversion more considerable. Treatment. Such being the origin of this variety of eversion, it comes to be a question, how far it is curable, or in other words, whether there be any method of removing or diminishing the con- traction attendant on cicatrization. This contraction, so far from diminishing, increases gradually for some time after the process of cicatrization has been completed, the granulations becoming absorbed, by which the closure of the wound was in some measure effected, and on which the new skin was formed. Matters then appear for a while to remain stationary, 1 but in the course of the ensuing years, and in consequence of the 150 mechanical motion to which the parts are subject, a slight increase takes place in the flexibility of the cicatrized surface, and it becomes somewhat less firmly attached to the parts which it covers. The parts, which were at first matted immoveably together, yield a little to the motions impressed on them by external causes, and the absorbents appear to contribute to this slight relaxation, by re- moving some of the adventitious substance which bound the in- tegumems to the parts beneath. This is all the return which is ever made to the natural state by the action of the part themselves. The everted eyelid, after some years, will have loosened itself a fc very little from its unnatural situation, and not quite so nmch o] the eyeball will now be exposed as was the case immediately after the completion of the process of cicatrization. The hand of art, however, has sought to relieve not only the present variety of eversion, but similar consequences of cicatrization in various parts of the body, by a more speedy and effectual method. Celsus gives us a very distinct account of the operation, practised in his time, for the cure of this kind of eversion.* When the dis- ease was situated in the upper eyelid, an incision, down to the cartilage, was made, in the form of a crescent, the extremities of which were turned downwards. When the disease affected the lower lid, an incision of the same form w^as made there, the extrem- ities still pointing downwards. The edges of these incisions were kept open as much as possible, by means of Unt put into the wound, so that they healed up by a slow process of granulation and cica- trization- It was expected that the space between the edges of the incision would be filled up by new substance, that the eyelid would consequently be considerably elongated, that the edge would return to its natural position, or in other words, that the eversion would be cured. This operation was frequently tried in later times, but so far from permanently curing eversion, it was found in the end to in- crease the very disease it was performed to relieve. Immediately after the incision, indeed, the eyelid can be brought nearly, if not altogether, into its natural situation ; so long as the processes of gran- ulation and cicatrization are going on, the case continues at least much better than it had been before; but as soon as the cure is pronounced complete, it is found that the eversion begins to return, and that at the end of perhaps a year, matters are rather worse than they were before the operation. The following case, by Bordenave, sufficiently illustrates both the failure of this operation, and the good effects of extirpating a portion of the conjunctiva, in this variety of eversion. A young man, aged 21 years, had eversion of the right lower eyelid, from a cicatrice, the consequence of a burn of the face, which had happened during infancy. The eversion was consid- erable, the internal part of the eyehd protruding presented a red- * De Re Medica, Lib. VII. Cap. i. Sect. 2. 151 ness which was disagreeable to look at, and the eye could not be covered by bringing the lids together. Bordenave examined the state of parts, and found the cicatrice considerably flexible. He be- lieved himself justified in hoping to cure it by the ordinary opera- tion, which he performed some days afterwards, according to the prescribed rules. Having made a semilunar incision of moderate depth, below the tarsus, he separated the lips of the wound with charpie, and kept them in this state by adhesive plasters, com- presses, and a suitable bandage. Some days afterwards, suppura- tion established itself. The eyelid appeared extremely relaxed, it covered almost entirely the eye, and the cure seemed certain. But these appearances of success were not of long duration ; the cica- trice being completed, and the eyelid no longer restrained, things returned to their former state. Not convinced, however, of the faultiness of the operation, Bordenave believed that he had not performed it with sufficient exactness ; and therefore he repeated it, but with no better success. He says, that he should have despaired of curing the case, had not the patient's eagerness to be relieved, forced him in some manner to try a different treatment. Seeing that he was unable to elongate the eyelid, in order to conceal the everted conjunctiva, he resolved to remove a portion of this mem- brane in almost all its length. This he did with a straight bis- toury, and found it exceedingly useful. Some time after, the conjunctiva still protruding a little, he practised a second section, which had all the success desired. In proportion as the conjuncti- va cicatrized, the eyelid returned to its proper direction, it applied itself more immediately upon the eye, at last the eye closed itself much better, and the deformity became scarcely visible.* In slight cases, then, of eversion, arising from a cicatrice, this simple operation of removing a fold of the conjunctiva may be sufficient. In worse cases, it may be proper to combine the old operation, of dividing the cicatrice, with this method of counteract- ing the eversion, by anew cicatrice on the inside of the lid. There are cases, however, of this variety of eversion, which neither of these plans is sufficient to remedy. We meet with cases, in which the degree of eversion is very great, the eyelid dragged much from its natural position, its length in the transverse direc- tion much increased, and its outer surface bound down unnatu- rally by adhesions. The division of the cicatrice, so as to loosen the lid from its unnatural situation, is the first step to be taken for the relief of such a case ; next, a portion of the conjunctiva may be removed ; but in order to counteract the morbid elongation of the lid from the one canthus to the other, it is necessary to remove a portion of its whole thickness, of the shape of the letter V, and then bring the edges of the wound together by a stitch or two. This makes the lid again sit close upon the eyeball, as in health, and completely cures the eversion. * Memoiresde I'Acadeniie de Chirurgie. Tome xiii. p. 170. 13mo. Paris, 1774, 152 It occasionally happens from an extensive burn, that both eyelids are everted, and dragged towards the temple. In such cases, besides dividing the cicatrice, removing part of the exposed conjunctiva, and perhaps cutting out a portion of the whole thick- ness of one or of both lids, it has been found useful to pare away a small portion of the edge of each hd at their outer angle, and then to bring the two together by a stitch. This tends to reduce the opening between the lids to its natural length, and removes much of the deformity. 5. Eversion from caries of the orbit. I have already had occasion to refer to this variety of eversion, and to the great degree of shortening of the lid with which it is in general attended.* There is one circumstance upon which I have perhaps not sufficiently insisted, which we may remark more or less in every variety of eversion, but which is often very strik- ingly displayed in those cases where the upper lid is dragged up under the edge of the orbit from an affection of the bone, namely, the degree of accommodation of the lower hd to the deficient state of the upper. In the act of winking, the lower lid is thrust up by the contraction of the orbicularis palpebrarum, so as to meet the upper, and almost to cover the eye. As to the treatment, I have nothing to add to what I have said under the head of lagophthalmos. SECTION XXIV. TRICHIASIS AND DISTICHIASIS. Trichiasis is an inversion of the eyelashes ; distichiasis, a double row of eyelashes. Syinptoms. We very seldom find all the eyelashes turned towards the eyeball, except when the trichiasis is merely a symp- ton of inversion of the edge of the eyelid, a disease which we leave out of view for the present, and even when it is a symptom of in- version of the edge of the eyelid, the trichiasis sometimes remains partial. In the same manner, the pseudo-cilia which are produced in distichiasis, seldom occupy the whole length of the eyehd, but in most cases are strewed here and there in parcels, between the natural place of the cilia and the Meibomian apertures. Both these diseases, especially when only one or two small colourless e5^elashes are inverted, are apt to escape being noticed, and those diseased appearances of the eyeball which are owing to their irritation, are supposed to be occasioned b}^ some disorder of the eyeball itself. Means are directed against the effects while the cause is overlooked, and the eye may be seriously injured, and even vision lost, from a derangement which on a superficial view appears trivial. In every case in which the patient, after an attack of ophthalmia, recovers ■ * See pages 34 and 144. 153 with extreme slowness, the surface of the cornea continuing dim and strewed with blood-vessels, and the eye discharging tears upon the smallest increase of light, we ought carefully to examine the edges of the eyelids, and discover whether any of the eyelashes be inverted, or any false eyelashes be present. The false eyelashes are in general so soft, short, and light-coloured, that they can be seen only when the eyelids are opened wide, but at the same time allowed to remain in contact with the eyeball. The moment that the edge of the lid is drawn forwards from touching the eyeball, the false cilia are scarcely or not at all visible. On again applying the edge of the lid to the eyeball, they return into view. Causes. Trichiasis and distichiasis are in an especial manner the consequences of neglected opthalmia tarsi, and strumous op- thalmia. Small-pox was formerly a very abundant source of these derangements of the cilia. In fact, every affection of the lids at- tended wdth abscesses and ulcers at the roots of the eyelashes, is apt to give rise to trichiasis and distichiasis, especially if the patient is allowed to lie much on the face, so that the cilia, loaded with mucus, or matted together by the diseased secretion of the Meibom- ian follicles, are forced into a constant direction towards the eyeball. Prognosis. If there be no degeneration of the edges of the eye- lids present, the prognosis in trichiasis may be favourable. Disti- chiasis, on the other hand, can very seldom be radically cured ; and even as seldom can trichiasis, when connected with evident altera- tions in the edges of the lids. Treatment. All the proposals which have been made for re- storing the cilia in trichiasis to their proper direction, as, constantly turning them outwards, keeping the lids everted by adhesive plas- ters, &c. are of as little value as those for hindering the growth of pseudo-cilia, namely, the appUcation of escharotics to the edge of the lids, the burning of the foramina whence the eyelashes issue with a red-hot needle, and the like. From whatever causes trichi- asis or distichiasis has originated, we must carefully remove, one after the other, all the inverted and misplaced cilia, by means of a proper pair of forceps. Each eyelash is to be laid hold of as close as possible to the skin, and pulled out quickly in a straight direc- tion, in order that it may not break. Except when the edge of the lid is perfect, and the trichiasis entirely the result of the cilia having been matted together by mucus, this operation must be regarded as merely palliative. Carefully and frequently repeated, it occasion- ally proves, even in cases of distichiasis, especially in young sub- jects, a radical means of cure ; but on this we cannot depend, and, therefore, as soon as the inverted cilia or pseudo-ciha make their appearance, they must be extracted. We meet with patients who :for many years have been obliged, every two or three weeks, to have this repeated. The constant repetition even of this trifling operation being found by many extremely annoying, we are often asked whether there is 20 154 no means by which trichiasis or distichiasis could be permanently removed ; and with this view, the operations for inversion of the hds have sometimes been had recourse to. False eyelashes are sometimes met with growing from different parts of the conjunctiva, even from the conjunctiva cornese. Dr. Monteath mentions a case, in which one exceedingly strong hair grew from the inner surface of the lower lid. It was directed per- pendicularly towards the eyeball, and irritated it. The natural cilia were of a light colour, the pseudo-cilium jet black, and double the strength of the common cilia. I once met with an eyelash fully an inch long, soft, and woolly, in a patient who had long suffered from ophthalmia. SECTIOX XXV. ENTROPIUM, OR INVERSION OF THE EYELIDS. There are two varieties or degrees of inversion, which differ ma- terially in their causes, symptoms, and modes of cure. The one is acute, the other chronic. 1. The acute variety generally takes its origin in an attack of ophthalmia, during which the patient had kept the eyehds long shut, or perhaps covered with a poultice. I have seen it take place during the inflammation following extraction of the cataract. The lower lid is the more frequent seat of this variety of inversion. The skin of the inverted lid is generally swollen and puffy. Its edge is perfectly regular in fornj, not thickened nor indurated, but entirely rolled back towards the eyeball, and the eyelashes fairly out of view. On applying the finger to the outer surface of the lid, and drawing it a little, the eyelashes start into view, chnging to the surface of the eyeball ; a little more traction rolls the edge of the lid completely into its natural place, and if we now give over dragging at the lid, it will remain so for perhaps a minute or two, and then with a sudden jerk, become inverted as before. This kind of inversion appears to be in part owing to an irreg- ular action of the orbicularis palpebrarum. The principal part of the muscle seems to have lost its wonted power of supporting the body of the lid, while its ciliary edge continuing to act rolls the lid into the inverted position. The conjunctiva of the eyeball is much irritated by the eyelashes rubbing against it in the act of winking, and hence the patient keeps the eye shut, and as much as possible at rest. The corneal conjunctiva becomes inflamed ; and the consequence of neglecting the inversion, may be total opacity of the cornea. 2. The other variety of inversion is the result of long-continued ophthalmia tarsi, or chronic catarrhal inflammation of the conjunc- tiva. The upper lid is equally liable to be affected with the lower, and often both are inverted at the same time. The edge of the affected lid is thickened, irregukir and notched, and shortened from ' 155 canthus to canthus. No degree of traction which we employ is sufficient to roll the inverted lid into its natural situation ; we may drag it from the eyeball, and bring the cilia into view, but still the edge of the lid continues inverted. The cilia are generally few in number, and dwarfish from disease. Still, they are sufficient to keep up constant uneasiness, and by the irritation which they oc- casion, to render the cornea vascular and nebulous. At length, the cornea becomes quite opaque, and its conjunctival layer acquires a degree of morbid thickness and insensibihty, which renders the disease less insupportable in point of pain. Irregular action of the orbicularis palpebrarum may also have to do Avith the production of this kind of inversion, but it is evident that the structure of the hd is here much more impaired. Inflam- mation has altered the parts surrounding the tarsus, and even the cartilage itself Repeated ulcerations hare destroyed the form of the edge of the hd, notched it with cicatrices, and permanently fixed it in the state of contraction and inversion. Treatment. As the one of these two kinds or degrees of inver- sion is much less complicated in its symptoms than the other, so is the method of cure for the one simple, for the other complex. We find, in the first kind, that when we take hold of a transverse fold of the skin of the inverted lid, the displacement is for the time removed, and the patient can open and shut the eye without dif- ficulty, and without any return of the inversion. Remove, then, this fold of skin, having laid hold of it with a pair of broad con- vex-edged forceps, bring the edges of the wound together by two stitches, and as soon as union is completed, the inversion will be found to be cured. The portion of skin removed in this way might be destroyed by escharotics. A piece of wood dipped in sulphuric acid is some- times used for this purpose, being rubbed along, about the distance of a line's breadth from the edge of the inverted lid, till the skin begins to grow dark. The eschar which follows necessarily con- tracts the skin, and tends to re-adjust the position of the inverted lid. If this is not effected by the first apphcation, a second or a third may be made, till the inversion is completely removed. At each application of the sulphuric acid, care must be taken, by dry- ing the portion of skin which has been touched, that none of the caustic flows in on the eye. In the second kind of inversion, neither the operation just de- scribed, nor the application of escharotics, is of any use. Portion after portion of the skin may thus be removed, but the inversion continues as before. The altered condition of the tarsus prevents the lid from resuming its natural position. The tarsus, then, must be attacked. Some have cut it out altogether ; others have pared away its edge, removing in this way that part of the lid whence the cilia grow, as well as the Meibomian apertures. I remember having seen a Jew girl in Vienna, who had been operated on in I this manner, by Dr. C. Jaeger. The pain and inflammation of 156 the eye, and the opacity of the cornea, caused by the inversion, were of course removed, and the deformity produced by this cur- taihiient of the hds was very trifling. A perpetual Hppitudo, how- ever, must follow the obliteration of the Meibomian apertures. The operation proposed by Dr. F. Jaeger is quite different both from Mr. Saunders' extirpation of the cartilage, and from the paring of the edge of the lid performed by Dr. C. Jaeger. It consists in removing that portion of the integuments in which the cilia are inserted, leaving the cartilage, and as far as possible, the Meibomian apertures, entire. I consider this operation unnecessary for the cure of the first degree of inversion, and inapplicable to the second. As an evident shortening of the lid in the transverse direction attends this kind of inversion, and produces a degree of constriction of the eyeball, the idea suggested itself to Mr. Ware, of relieving the affected lid, by a perpendicular incision through its whole thickness, either at its temporal extremity, or in its middle. Such an incision would at least release the eyeball from the state of pressure caused by the contracted lid. It was probably from this hint by Mr. Ware, that Mr. Crampton was led to devise the operation which is now generally adopted in cases of the second degree of inversion. Supposing it to be the upper lid which is effected, with a narrow, slightly curved, and sharp-pointed bistoury, pushed through the inverted lid from with- in outwards, it is to be divided perpendicularly, for the length of about three lines, close to its temporal extremity. A similar incision is then to be made at the nasal extremity of the affected lid, taking care to avoid the lachrymal canal.* These incisions being made, the eyelid immediately feels unconfined, it can be raised from the eyeball, and the patient is already freed from a great part of his uneasiness. Were we now to leave the lid to itself, it would speedily resume its former place, the incisions by which we had liberated it would unite by the first intention, and no permanent relief would be effected. To prevent immediate union, Mr. C. employed an instrument similar to Pellier's speculum, by which he kept the eyelid constantly suspended, and permitted only a slow union by granulation. Instead of the speculum. I have always recommended that a fold of the skin of the affected lid should be removed, exactly as in the operation for the first kind of inversion. The edges of the wound made by the removal of this fold are then to be brought together by two or three stitches. The perpendicu- lar incisions slowly fill up by granulation ; the slower the better ; the union, when at length completed, does not comprehend the orbicularis palpebrarum ; the divided fibres of the muscle shrink, hke the divided ends of every other muscle ; the diseased cartilage * Mr. Crampton cut through the lachrymal canal ; but ever since I began to give lectures on the Eye, in 1818, 1 have directed this to be avoided. I have always dis- countenanced also the transverse incision of the conjunctiva, recommended by Mr. C, and particularly insisted on the propriety of following up the first steps of Mr. C.'s operation, by the extirpation of a transverse fold of the integuments. 157 loses also much of its induration and irregularity, and thus the lid, when re-united, is found improved in structure, and almost natural in position. I have already mentioned, that in trichiasis and distichiasis, we sometimes have recourse to the operations practised for the cure of inversion. A fold of skin is cut away, a portion is destroyed by sulphuric acid, or even Mr. Crampton's method is adopted. Tri- chiasis and distichiasis are often partial, and when this is ike case, the corresponding portion of skin only is removed, or the portion of the edge of the lid which bears the misplaced eyelashes only is insulated by two perpendicular incisions, bent outwards by the ex- tirpation of a portion of the skin, and permitted to re-adhere only by a slow process of granulation. SECTION XXVI. PHTHEIRIASIS. Pediculi sometimes lodge among the cilia and eyebrow^s, and cause intolerable itching. "A child came to the Infirmary,"' says Mr. Lawrence, "complaining of the eyes being sore, and said they itched very much. I looked at the eye, and could not see much the matter, but I thought that the ciUa had rather a thick appearance, and on a more accurate examination, I found that this was caused by an infinite number of pediculi sticking over the hairs. I ordered the free apj)lication of the citrine oint- ment, and wished to see its effect ; but the mother, who came with the child, was so much ofiTended at being told the cause of the complaint, that she did not bring the child back again." * In such cases, some mercurial salve, as that recommended by Mr. L., and attention to cleanliness, will be effectual. SECTION XXVII. MADAROSIS. Neglected ophthalmia tarsi is apt to end in the destruction of the ' bulbs of the cilia, which of course cannot afterwards be reproduced. Both the ciha and the hairs of the eyebrow are also liable to fall out, from different constitutional diseases ; but in this case they generally grow again. The want of the eyelashes and hairs of the eyebrow is productive of frequent nictitation, in order to mode- rate the glare of day, and prevent the entrance of foreign particles into the eye. I I was consulted, some time ago, by a man who had lost every ' hair of his body. His head was perfectly bald, he had no eye- brows nor eyelashes, his beard was gone, no hair in the arm-pits, on the pubes, nor on the hmbs. He was anxious to regain chiefly ! the eyebrows and eyelashes, as he found his eyes much weakened j by the want of them. He w^as inclined to attribute his disease I : * Lectures ia the Lancet, Vol. x. p. 323. London, 1826. 158 to some slight venereal complaint, \vhich he had had. and which' had been cured by mercury. The treatment, both local, and general already recommended for ophthalmia tarsi, must be carefully adopted in cases of threat- ened madarosis. In constitutional cases, also, tonics are to be em- ployed both internally and externally, as it is evident that weak- ness has much to do in the production of this disease. Cinchona is particularly recommended internally, and an infusion of the petals of the rosa centifolia in wine as a collyrium. When there is a suspicion of syphilis being the cause, mercury and sarsaparilla should be tried. Auchylo-blepharon. although strictly a disease of the eyelids, I shall take up along with sym-blepharon. in a following chapter. CHAPTER lY. DISEASES OF THE TUXICA CONJUNCTIVA. The principal morbid affections of the conjunctiva fall under the heads of ophthalmia, and consequences of ophthalmia. There are, however, a few diseases of this portion of the tutamina ocuh, which, I conceive, it will be convenient to introduce here. The tears flow over the conjunctiva ; we have considered the diseases of the secret- ing lachrymal organs ; this conducting organ of the tears seems na- turally to claim our attention, before proceeding to the excreting lachrymal apparatus. The conjunctiva is a muco-cutaneous membrane, connected to the neighbouring parts by cellular substance. This cellular sub- stance is liable to phlegmonous intiammation, inflamniatory cedema or chemosis. and to ecchyrnosis, and emphysema : while the con- junctiva itself is subject chiefly to blenorrhoea on the one hand, and on the other to eruptive inflammations. We meet with fungus, warts, and tumours of the conjunctiva. In some cases, it seems to lose its faculty of secreting mucus, and becomes dry and shrivelled ; while, in other cases, its glandular structure is affected with a mor- bid degree of development. The compound nature of the mem- brane, expressed by the term juuco-cutaneous, serves as a key to its pathology. SECTION I. INJURIES OF THE COXJUXCTIVA, AND FOREIGN SrSSTAXCES IN ITS FOLDS. Fine dust, blown into the eye, may often be removed, by pre-' ventinof the tears from beinsr carried into the lachrvmal sac. For 159 this purpose, pressure is to be continued for some time, immediately under the tendon of the orbicularis palpebrarum. In this way, the dust is washed by the tears into the neighbourhood of the caruncula lachrymalis, whence they can without difficulty be withdrawn with the finger, or with a pair of small forceps. When larger paiticles of dust have lighted upon the eye, they may often be seen lying on its surface, and are to be removed with the forceps. If they are not visible on the eyeball, the lower lid is first to be drawn downwards, when sometimes the foreign body will come into view. If nothing is discovered in the lower fold of the conjunctiva, then the upper lid is to be everted. This is done by laying hold of the eyelashes with the finger and thumb, and whilst by this means the edge of the lid is drawn outwards and upwards, a slight counterpoise is to be made with a probe, on the outer sur- face of the lid, opposite to the upper edge of its cartilage. Between these two forces, the lid is readily everted, so that its internal surface is exposed ; and in many cases, indeed in most cases in which a particle of dust lodges in the eye, a single black point will be ob- served adhering to the inside of the lid, and can readily be removed. The foreign particle, however, may be a minute fragrant of some transparent substance, adhering to the inside of the upper hd, and may not be detected, unless with the probe we go over the surface of the conjunctiva. The pain, and spasm of the orbicularis palpe- brarum, which are generally acute, subside almost immediately on the foreign body being removed. Should it be necessary to search for particles which cannot be seen, a hair-pencil dipped in some adhesive fluid, as honey, may assist US in entangling them ; or the upper fold may be washed out by means of a syringe^and tepid water. It is remarkable, that while the smallest particle of dust, fixed on the inside of the upper eyelid, generally gives rise to intolerable un- easiness, till it be removed, foreign bodies of considerable size may lodge in the looser part of the folds of the conjunctiva for many- weeks, without inducing any violent symptoms. The conjunctiva, in such cases, is apt to become fungous, so as even to cover com- pletely the foreign substance, and hide it from view. Dr. Monteath, in his Notes to Weller's Manual, relates the case of a young girl, who had a soft red fungus growing out of the eye, as large as a filbert. It was of some weeks' standing, and was at- tributed to a hurt inflicted by a straw striking the eye. This fun- gus originated in the conjunctiva, where it is reflected from the low- er eyelid to the eyeball. It was cut away ; but in three weeks was as large as ever. It was again removed, and at the angle of reflex- ion of the conjunctiva, a bit of straw, hall an inch in length, was observed and extracted. The cure was complete in a few days. The same author relates the case of a man, who consulted him on account of an inflamed state of his eye, induced by a fall, five months before, among some bushes, in descending a steep moun- 160 tain. He felt some part of his eye wounded at the moment, and had never enjoyed freedom from a tender state of it, from that period, though he had apphed a great variety of medicines. On everting the upper eyehd, a fungous state of ihe conjunctiva was discovered very high up in the angle of reflection of that membrane, and on examination with the probe, it was evident that a foreign body lodged there. It was laid hold of and extracted with the forceps, and proved to be a portion of a twig of a bush, f ths of an inch in length, and nearly as thick as a crow-quill. This substance had remained in the upper fold of the conjunctiva for five months, and had got into that situation without wounding the eye. The foreign bod}'^, being hard and angular, may penetrate into the conjunctiva, it may gradually insinuate itself under that membrane, or it may have been driven under it, at once, by the projectile force with which it had been sent against the eye. In such cases, it is sometimes necessary to raise a portion of the conjunctiva with the for- ceps, and snip it off along with the foreign substance. If this is not done, the conjunctiva heals over the foreign body, and the irritation ceases. Mr. Wardrop tells us, that in one case he found a piece of whinstone, inclosed in a sac of cellular membrane, lying close to the sclerotic coat, where it had remained for ten years prior to the person's death, without his experiencing the least uneasiness, or even suspecting its presence. If, after the foreign substance has been removed, the spasms of the orbicularis palpebrarum should still continue, which is par- ticularly apt to be the case when the conjunctiva has been both me- chanically and chemically injured, the patient ought to be removed to a dark room, kept quiet, and a soft warm poultice, containing a quantity of aqueous solution of opium, applied over the eye, in a thin hnen bag. Particles of quick lime, potash, and other caustic substances, must immediately be extracted from the eye, with the forceps, or any other instrument which is at hand. When they are in the state of powder, we are warned that it is dangerous to remove them by means of water, because the lime thereby slaking, and the caustic dissolving, are apt to spread farther, and of course to produce more extensive injury. It is therefore recommended to remove such substances by means of a hair-pencil, dipped in oil or smeared with fresh butter. Mr. Guthrie, however, judiciously observes that, were oil not at hand, he should not hesitate to force open the lids, and cause a strong stream of water to pass between them, so as to carry away the lime without giving it time to do mischief, then to evert the lids, and continue the same ope- ration until every particle of the lime was removed. Gunpowder exploded into the eye fixes in the conjunctiva, and must be carefully picked out with the point of a needle, else the membrane will close over the grains, so that they will remain indelible. 161 Hot and caustic fluids blister the conjunctiva, and bring on in- flammation of a highly dangerous character. A stream of cold or slightly tepid water, injected over the whole surface of the con- junctiva, is the remedy to be had recourse to in the first in- stance. The stings of insects sometimes fix in the conjunctiva, and are to be carefully removed, either by a pair of forceps or the point of a cataract needle. The inflammation of the conjunctiva which follows the various injuries above enumerated, is by no means of uniform character. Of course, rest, and the antiphlogistic regimen are necessary in every case of injury of the eye. But, as I shall explain more fully, under the head of Traumatic Ophthalmia, the local applications must be regulated by the peculiar symptoms excited, and even the internal remedies to be employed are not of that uniform sort with which inflammation, in less complicated parts of the body, is usually treated. SECTION II. SUBCONJUNCTIVAL ECCHYMOSIS. Extravasation of blood into the subconjunctival cellular mem- brane occurs from various causes, as blows on the eye, blows on the eyebrow, fits of coughing, &c. I have seen a slight blow on the forehead produce ecchymosis beneath the conjunctiva of both eyes. In some cases, no evident cause appears why the vessels should have opened, for the patient on awaking in the morning finds the conjunctiva of a deep red colour, without any pain being present, or any thing having happened likely to produce such an effect. The extravasated blood is gradually absorbed, the con- junctiva becoming first yellow, and then resuming its natural ap- pearance. A shghtly astringent collyriurn generally forms the whole treatment. SECTION III. SUBCONJUNCTIVAL EMPHYSEMA. We have already explained how the eyelids are subject to em- physema, in cases of fracture of the frontal sinus, the air passing from the nostril through the fractured os frontis into their cellular membrane. From similar injuries, extending between the nostril and the orbit, the cellular membrane which connects the conjunc- tiva to the neighbouring parts, is sometimes filled with air. Should the swelling, arising from the effused air, prove so great as to give rise to pain, or impede the motion of the eyeball or eye- lids, the conjunctiva may be punctured, so as to let it escape, till the fracture is supposed to be consolidated. The patient ought to avoid forcible blowing of the nose, by which this emphysema, as well as that of the eyehds, is apt to be induced. 21 162 SECTION IV. SUBCONJUNCTIVAL PHLEGMON. The subconjunctival cellular membrane is occasionally the seat of phlegmonous inflammation. The conjunctiva in this case is in- jected with red vessels, generally on the temporal side of the eye. the part affected is much thickened, and after some days presents c prominence about the size of a split pea, which rarely goes the length of suppuration. This disease will easily be distinguished from any of the opthalmiee. We might suppose slight injuries to be the most probable causes of this complaint ; but, in general, Uke phlegmonous inflammation, in many other instances, it is produced without any evident cause In one case, I observed subconjunctival phlegmon precede an attack of syphilitic iritis ; but this must be extremely rare. Bloodletting of any kind is scarcely ever necessary in this com- plaint. The patient should be purged. Warm fomentations tc the eye are to be used. If the phlegmon goes on to suppuration, il is to be opened with the lancet. SECTION V. PTERYGIUM. This term is applied to a disease w^iich consists of a thickened and elevated portion of the conjunctiva of the eyeball, of a triangu- lar form, its base generally turned to the caruncula lachrymal!- while its apex advances towards the edge, or stretches even as fai as the middle of the cornea. In some cases the base of the ptery gium is towards the temporal angle of the eye, and occasionally both sides of the eye are affected with this disease. ^ymjitoms. One variety of pterygium is semi-transparent, and thinly strewed with blood-vessels. This is the iJterygium tenue. Another variety presents, from the size and course of its blood-ves- sels, almost the appearance of a thin dissected muscle. This is the literygium crassum. We can lay hold of both these varieties with a pair of forceps without much difl&culty, and without giving the patieiat any pain, and raise them, not merely from the scleroti- ca, but even from the cornea. We can do this with greater ease, when the patient turns his eye towards the side whence the ptery- gium originates. These diseases proceed even to their complete development without giving any pain, and even almost without an}^ disagreeable feeling in the eye. Frequently the patient re- ceives the first intimation of his disease from some other person, or from examining his eyes in a glass, or from the disease gaining that part of the cornea which is opposite to the pupil, and thereby obscuring vision. The great number of pterygia which have their basis turned towards the nasal angle of the eye, in comparison of the few which arise from any other part of the circumference of the eyeball, might I 163 1 lead us perhaps to suppose that this disease consisted in an elonga- I ,ion of the semihmar fold of the conjunctiva, or that it took its mghi from the caruticula lachiymahs ; but on carefully examining .1 pterygium, it will appear evident, that neither the membrana semilunaris, nor the caruncula lachrymalis, takes any share in the I jisease. Besides, we have the occasional occurrence of pterygium on the temporal, and even on the superior and inferior sides of the 3ye. Pterygium on both sides of the same eye had occurred only twice to Beer. In these cases they met in the centre of the cornea, and almost entirely deprived the patients of sight. In one case Beer found three pterygia on the same eye. Mr. Wardrop men- tions having seen two pterygia on each eye of the same individual. Schmidt gives an account and figure of an extraordinary pterygi- um, which so strongly resembled a muscle in its structure, that one might have almost believed that the rectus superior oculi had been misplaced. It took its origin from behind the upper eyelid, over the eyeball to the upper edge of the cornea, exactly in the form of a layer of muscular fibres. At the edge of the cornea, this pterygium became thicker and almost tendinous, and opposite to the pupil it interwove itself with the cornea in the same manner as the straight muscles do with the sclerotica. This pterygium was successfully removed by operation.* Causes. Many writers have considered pterygium as a conse- quence of ophthalmia ; but this opinion appears to be incorrect. It is true, indeed, that tedious or neglected ophthalmia, or ophthal- mia treated with many relaxing external applications, is apt to leave the conjunctiva of the eyeball so loose, that on every motion of the eye, it falls into a number of folds. Such cases, however, never appear to terminate in pterygium. Beer was led to believe, from a careful examination of the evi- dent or supposed causes of the numerous cases which had come under his observation, that pterygium most frequently owed its origin to the influence of lime or fine stone-dust upon the conjunc- tiva, by far the greater number of patients who had come under his care with this complaint, being day-labourers, who are ex- tremely exposed to this cause. Prognosis. Even Avhen a pterygium has reached its complete development, the prognosis is always favourable, as the disease appears to be entirely of a local nature. The duration of the cure, indeed, is exceedingly various. Much depends on whether the operation, which is the quickest and most certain means of cure, be immediately determined on by the patient, and be performed without leaving behind any part of the pterygium, or whether we content ourselves wiih alternate scarifications and stimulating ap- * Ophttialmologisclie Bibliothek von Himly unci Schmidt. Vol. ii. p. 57. Jena, 1803. Mr. Travers has represented two pter3rgia occupying the upper part of the eye. One of these extended to the lower margin of the corneaj and was of sarcoma- tous density. Synopsis of the Diseases of the Eye, p. 424. London, 1820. 164 plications, till the pterygium disappear by a tedious process of organic change of substance. When properly treated, no trace of the disease remains ; neither over the sclerotica nor on the cornea. Treatment. In cases of pterygium tenue, not yet reaching to the cornea; it will in general be sufficient to lay hold of the ptery- gium with a small pair of hooked forceps, and then divide it by two or three vertical scarifications. After this it shrinks and dis- appears. These scarifications may perhaps require to be repeated. In the meantime, the part may be touched daily with the vinous tincture of opium, or the red precipitate salve. With regard to pterygium crassum, the best plan is immediately to remove it by operation. If the patient refuses to submit to this, we have no other resource than the employment of scarifications, as in the former case. The probability, however, is, that the pa- tient will tire of a mode of cure so tedious ; and there is also a danger, that the pterygium, instead of disappearing, shall become only more luxuriant and extensive. If the patient submits to the operation, it is to be performed in the following manner. The patier^t being laid on his back on a table, the assistant takes charge of both eyelids, separating them so as fully to expose the eyeball. The operator lays hold of the pterygium with a pair of hooked forceps, near its base, and with a small scalpel divides it by a ver- tical incision. If the pterygium is on the nasal side of the eye, the breadth of at least a line is to be left between the incision and the semilunar fold of the conjunctiva. The forceps are now to be shifted to its apex, and the pterygium cautiously dissected back from the cornea and sclerotica, till it be completely removed. If any remains of it appear still to be left, they must be laid hold of with the forceps, and snipped off with the scissors. On the follow- ing day, the whole surface of the wound is found in a state of su- perficial inflammation and suppuration. To this there quickly follows the reproduction of a new portion of conjunctiva, and the cure is generally completed in twelve or fourteen days. There is enumerated a third variety of pterygium, under the name of 'pterygium ping-ue, or pinguecula. This appears to have its seat partly in the conjunctiva of the eyeball, party in the cellular membrane connecting the conjunctiva to the sclerotica. It presents, in the greater number of cases, a small, yellowish, well-defined elevation, situated close to the edge of the cornea, over which it very rarely advances, and never to such a degree as to interfere with vision. Almost constantly it is situated on the tem- poral side of the eye. Weller assures us, that this little tubercle contains no fat. It seldom gives rise to any inconvenience. If it does, it is to be laid hold of with the hooked forceps, and removed with the scissors. There is a fourth variety of pterygium described by Mr. Ward- rop, under the name of fleshy pterygium. This appears by his account, to originate in common triangular pterygium improperly 165 treated by repeated scarifications, which, instead of causing its dim- inution, make it grow more rapidly, till at last it projects from between the eyelids, and involves the semilunar membrane and ca- runcula lachrymalis. It is to be removed with the knife. I SECTION VI.— CONJUNCTIVA ARIDA. ! In this rare disease, the conjunctiva, both where it covers the I sclerotica, and on the surface of the cornea, loses its natural slipperi- ness and moisture, and becomes dry and shrivelled hke a bit of cu- ticle which has been detached after the application of a bUster. In ; one case which fell under my observation, and which did not ap- pear to be the result of inflammation, the conjunctiva corneee only was affected, and ,pr-esented an appearance as if it had been a piece iof silk paper laid upon the surface of the cornea. It is to this dis- [ease in a more advanced stage, that Mr. Travels refers, when he isays, "I have seen several cases of the conversion of the conjunc- ■ tiva into a skin, rugous and opaque, knitting the hds close to the globe, so as to obliterate the sinus palpebrales."* He calls it cuti- i cular conjunctiva. He regards it as one of the sequelae of chronic [inflammation of the conjunctiva, and as immediately depending on [an obliteration of the lachrymal ducts. He says, that in such cases there is no secretion of tears. ,; SECTION VII. — FUNGUS OF THE CONJUNCTIVA. The conjunctiva is subject to two different fungous diseases, both }• of them attended with inflammation, but neither of them sequelae 1 of the specific diseases to which we appropriate the name of ophthal- \ miae. The one has been described by Beer, under the name of exophthaltmia fungosa.t Mr. Allan, in the third volume of his Surgery., has also described and figured this disease. The other fungous state of the conjunctiva I have not found described by any author. Symptoms. The first variety of fungus of the conjunctiva is of a deep red colour, inchning to livid ; it affects chiefly the conjunc- tiva covering the sclerotica, over which it is elevated in irregulai* soft smooth masses ; it sometimes rises from the inside of the lids, but never from the surface of the cornea. The fungus is pressed, however, by the ejj^elids, over the edge of the cornea, and sometimes to such a degree, as to hide it completely. Unattended by pain, this disease goes on increasing, till it projects from between the lids, and prevents them from closing. If neglected, it may reach to a great size, and is liable to be confounded with the last stage of spon- goid tumour of the eyeball. Exposed to the influence of the air, * Synopsis of the Diseases of the Eye, p. 120. London, 1820. t Schwammichte Exophtalmie ; Sarcosis bulbi. 166 the secretion from the surface of the fungus becomes encrusted, while the irritation of the foreign substances which come into con- tact with it, renders it tender and apt to bleed. For a time the firmness of the cornea and sclerotica is suflficient to resist the effects of the pressure of the fungous mass by which they are surrounded, and which makes way for itself chiefly by projecting and dilating the eyelids ; but at length the eyeball begins to suffer from the pressure, inflames, bursts, and is destroyed. The second variety of fungus of the conjunctiva, almost of gela- tinous consistence, and of a light yellow or brownish colour, is met with chiefly on the inside of the lids, especially of the upper, and in the superior fold of the conjunctiva. It sometimes attains a very considerable size, and although soft, and destitute of red vessels, is apt to prove destructive, by the pressure which it exercises on the eyeball. Although neither of these fungous affections of the con- junctiva appears to be strictly malignant, it is evident, that by their mere mechanical effects, they may prove destructive both of vision and of life. Even after the eyeball has been destroyed by their pressure, they may go on to increase, affect the bones of the orbit, and wear out the patient by fever. Treatment. In the early stage of these diseases, leeches to the conjunctiva would probabh" be useful ; and benefit might perhaps, be derived from the application of the vinous tincture of opium, or of gentle astringents in solution. At a later period, escharotics are naturally thought of, especially the solid nitras argenti. Should the disease still advance, extirpation of the fungus ought not to be delayed ; and in both varieties, but especially in the second, it will be found of much advantage to commence the operation by sepa- rating the eyelids at their temporal angle, by an incision carried to- wards the temple, so as to allow the whole of the diseased conjunc- tiva to be exposed to view. The extirpation will now be accom- phshed with comparative ease, by means of the hooked forceps and a small scalpel, with the occasional aid of the scissors. The first variety of fungus, when we attempt to dissect it from the sclerotica, bleeds profusely, so that the assistant must be prepared to clear away the blood as the operator proceeds, by injecting cold water over the eye. After the whole of the fungus is removed, the eye- lids, where they have been disunited, are to be brought together with a stitch. The surface exposed by the removal of the disease, will in a day or two be covered with purulent matter, and slowly become invested by a pseudo-conjunctiva. Any tendency to repj-o- duction m.ust be prevented by the use of the nitras argenti. and sym-blepharon guarded against by frequent motion of the eye, and the introduction of a little mild salve into the folds of the conjunc- tiva. When fungus of the conjunctiva has been allowed to proceed in its course till the eyeball, by its pressure, is destroyed, it would be difficult to remove the fungus growth by itself, and it is quite un- > 167 necessary to attempt to do so. In such cases, we must have re- course to extirpation of the eyeball, taking care also to remove any part of the fungus arising from the inside of the eyeUds. SECTION VIII. WARTS OF THE CONJUNCTIVA. Warts, red, fleshy, and somewhat granulated, single, or in clus- ters, are met with, growing from every part of the conjunctiva, not excepting the surface of the cornea. Mr. Travers compares them to the warts which arise from the inside of the prepuce, and attri- butes their origin to a similar cause, namely, irritation from a dis- eased secretion. I have already had occasion to refer to a case, in which the removal of a small wart from the external surface of the lower eyelid, was followed by a crop of warts on the conjunctiva of the eyeball. Mr. Wardrop has described and figured a congenital warty excrescence of the corneal conjunctiva. He mentions that it was firm and immoveable, with a rough granulated appearance externally, and from its brownish colour, did not appear very vas- cular. It was small when first observed, and increased in size in proportion with the other parts of the body.* Although the pro- gress of these excrescences is slow, they cause considerable irrita- tion and inflammation sometimes extending to the cornea, and ought therefore to be immediately removed with the scissors. Es- charotics appear to have scarcely any power in diminishing their bulk, although they may perhaps delay their progress. SECTION IX. TUMOURS OF THE CONJUNCTIVA. A variety of tumours take their origin in the conjunctiva, or in I the cellular membrane which connects it to the neighbouring parts. Some of them are congenital, others arise in after-life. Mr. Wardrop has described and figured a tumour, about the bulk of a horse-bean, of which a small part seemed to grow from the. cornea, while the rest was situated on the sclerotica, next the tem- poral angle of the eye. Its surface was smooth, and covered by the conjunctiva. Upwards of twelve very long and strong hairs grew from its middle, passed through between the eyehds, and hung over the cheek. The patient, at this time upwards of 50 years old, remarked that these hairs did not appear until he had advanced to his sixteenth year, at which time also his beard grew.t Some conjunctival tumours contain a watery fluid, and disappear on being punctured. Others are adipose, steatoraatous, or even cartilaginous, and require to be extirpated. This, in most cases, is easily effected, for, in general, they are but loosely attached to I the sclerotica. I * Morbid Anatomy of the Human Eye. Vol. i. p. 32. London, 1819. t Ibid. 168 Mr. Travers has given an account of the case of a lady, in whom the cornea was concealed by a tumour, of a dark purple colour, protruding to such an extent between the ej^elids, as to oc- casion great inconvenience and deformity. It had the appearance of being disposed in lobes, somewhat resembling a bunch of cur- rants of unequal size. Mr. Travers extirpated, in this case, the anterior hemisphere of the eyeball. On examination of the tu- mour, the cornea and sclerotica proved to be entire, and the mor- bid growth, lying upon and adhering to the cornea and a small portion of the sclerotica, had acquired the lobulated appearance, as if by degeneration of the covering conjunctiva, for delicate white bands, the only vestiges of this membrane, were seen intersecting the lobules at irregular distances, in the form of septa. The sub- stance, on dissection, was found to be partly firm, partly pulpy, of a dark colour, here and there mottled with white, and measured a quarter of an inch in thickness from the external surface of the cornea.* Had Mr. T. been aware of the external seat of this tu- mour, perhaps he might have endeavoured to extirpate it, without sacrificing any part of the eyeball. In the explanation of the two figures which he has given of the tumour, he tells us that when he first saw the case, he formed the idea that it was a fungus originating from the iris or choroid, consequent to a slough of the cornea. The patient recovered quickly from the operation, and the remaining part of the eyeball collapsed. From the dark col- our, and partly pulpy consistence of the morbid growth, may we not suspect it to have been of the nature of melanosis ? Mr. T. mentions that the surface of the cornea was rough, and had a brownish tint, as if beginning to degenerate into the morbid mass which lay above it. The figure which Mr. T. has given of the external appearance of the tumour is very simiiiar to the eye of a gentleman, by whom I was consulted about two years ago, and who submitted by my advice to have the anterior half of the eye- ball extirpated, as in Mr. T.'s case. Dr. Monteath being consulted, approved of and performed the proposed operation : but on exam- ining the portion of ihe eye which was removed, we found the melanotic degeneration to occup)^ the whole place of the vitreous humour, so that the rest of the eye was immediately extirpated. The case did well, and I have heard of no return of the disease. * Synopsis of the Diseases of the EyCj p. 102 and 394. London, 1820. 169 CHAPTER V. DISEASES OF THE SEMILUNAR MEMBRANE, AND CARUN- CULA LACHRYMALIS. SECTION I. INFLAMMATION OF THE SEMILUNAR MEMBRANE AND CARUNCULA LACHRYMALIS. ' Symptoms. The semilunar membrane and caruncula lachryma- \ lis, when inflamed, become much enlarged, of a bright red colour, \ and affected with considerable pain, especially when the lids are ' moved. The inflammation extends in some degree to the con- , junctiva, of which, indeed, the semilunar membrane is a portion, and by which the caruncula is invested. The sensation as if some foreign body was lodged in the inner angle of the eye at- tends this disease, the absorption of the tears is obstructed, and an increased secretion of mucus, sometimes puriform, flows from the ' Meibomian follicles, conjunctiva, and caruncula. In some cases, suppuration takes place in the substance of the caruncula, the red- , ness and swelling increasing for a time, till matter forms, when the '. swelling points, breaks, and discharges itself. Fungous excres- I cences are apt to follow, and sometimes a permanent distortion of ' the caruncula ; while in other instances, it is entirely destroyed by the suppuration. Causes. The influence of cold is the most frequent cause of this inflammation. I had a very distinct instance of this, in a . patient who caught cold while i-ecovering from dysentery. Slight ; injuries may also induce this disease. Foreign bodies lodging be- , hind the semilunar membrane, or so fixed as to irritate the car- I uncula, may also be the cause. Dr. Monteath mentions his having seen tViis disease in two instances, produced by a loose eyelash, the root or thick end of v/hich had fairly entered the upper punctura \ and lachrymal canal. Its other extremity consequently pointed ^ downwards to the caruncula, which it constantly irritated. The ■ troublesome irritation which had been excited in both instances, immediately subsided on removing the eyelash from the lachrymal canal. Treatment. The removal of the cause, when that is known and removeable, as in the instance just quoted ; bathing the parts frequently with tepid w^ater ; touching them once a-day with the lunar caustic solution ; and the use of laxatives, make up the gen- eral treatment. Should the swelling go on increasing, a leech : may with propriety be applied to the inflamed caruncula ; and if suppuration threatens, a bread and water poultice, in a thin linen bag, is to be laid over the inner angle of the eye. The suppurated caruncula is to be opened with the lancet. Should it threaten- to throw out fungous granulations, we must endeavor to repress them 22 170 by the vinous tincture of opium, or the appHcation of sulphas cupri^ or nitras argenti. If these means are insufficient, the fungus must be removed with the scissors. SECTION II. ENCANTHIS. This term is applied to a chronic enlargement of the caruncula lachrymalis and semilunar membrane, but especially of the former. Encanthis benigna has been distinguished from encanthis mahgna ; the former a mere fungus state of the parts, the effect of simple mflammation, and disappearing under the use of the remedies already enumerated ; the latter a scirrhous affection of the glan- dular substance of the caruncula, degenerating, if neglected, into cancerous ulceration. SymiHonis. In scirrhous encanthis, the caruncula presents the appearance of a very hard, irregular swelling. It involves the semilunar fold, and extends to the conjunctiva lining the lids. It is at first of a uniform red colour, but after it has attained a con- siderable bulk beyond the natural size of the caruncula, it becomes here and there of a whitish colour, with varicose vessels ramifying over its surface. It is the seat of lancinating pain. It impedes, by its size, the functions of the eyelids and excreting lachrymal passages. The hairs growing from it become much stronger than natural. Its surface is easily excited to bleed. At last it ulcerates, the edges of the sore become everted, and the discharge is thin and acrid, irritating and excoriating the neighboring parts. If allowed stUl to proceed in its course, the cancerous ulceration spreads to the Uds, lays open the lachrymal passages, attacks even the eyeball, and in fact runs a course similar to that of cancer of the lids, as ah-eady described. Treatment. The scirrhous encanthis requires to be extirpated. For this purpose a curved needle, armed with a linen thread, is to be passed through the tumour, by means of which it may be drawn out from the neighbouring parts, while, with a small scalpel or the scissorS; it is completely separated from its connexions. It is proba- ble, that the removal of the caruncula and semilunar fold, will be followed by incurable stillicidium lachrymarum, but of course this is not to be compared with the dangers attending a scirrhous^ or cancerous affection of these parts, if left to itself. 171 CHAPTER VI. DISEASES OF THE EXCRETING LACHRYMAL ORGANS. SECTION I.^INJURIES OF THE EXCRETING LA.CHRYMAL ORGANS. 1. Injuries of the Lachrymal Canals. If the canals which lead from the puncta lachrymalia to the lach- rymal sac are wounded, the important question is, how far the eyelids are likely to be distorted, and the integrity of either of the canals destroyed, by the cicatrice which must follow, or by the sup- purative inflammation which in every case is to be dreaded. When the wound has been occasioned by a clean cutting instrument, we may hope for a cure, without either distortion of the eyehds or permanent interruption of the function of the canals. When the part is torn or bruised, it will probably be completely destroyed by the consequent suppuration ; and if both canals are included in the injury, an irremediable stillicidium, or discharge of tears and mucus from the nasal angle of the eye, is the unavoidable con- sequence. In lacerated wounds, then, our prognosis must be doubtful. Yet even such wounds are sometimes happily cured. Schmidt relates the case of a person who in a game at blindman's buff, was laid hold of by the finger of one of the party, exactly in the nasal angle of the eye, and had the under eyelid torn away to the length of half an inch from the upper. Mohrenheim, who happened to be in the company, pronounced an unfavourable prognosis ; but by Schmidt's care the case was cured in eight days, without the ■slightest stillicidium or ectropium. The indications in cases of wounds of the canals, are, to bring the separated parts into apposition, and then to keep them so. This can scarcely be effected without the introduction of a stitch. Slips of plaster are then to be applied by one end to the cheek or to the temple, thence to pass over the wound, and be fixed by the other end to the forehead or to the nose : for if they be short, and applied merely over the wound, they will soon be moistened and displaced by the tears. A compress and bandage are necessary ; and the patient must be careful to keep the eyes at rest till the wound is perfectly united. If the wounded canal does not unite, but each end of the division cicatrizes separately, little is to be hoped from making raw the edges of the wound, and again trying to unite them with greater ■accuracy. 2. Injuries of the Lachrymal Sac. The lachrymal sac is pretty well protected from injury. It is 172 occasionally, however, laid open both in incised and lacerated ■u-ounds. These must be treated with care, lest they degenerate into fistulee. Schmidt mentions a case in which a penetrating wound of the sac ended in this way. Should the opening into the sac, having contracted to a small size, threaten to cicatrize over its edges, they must be touched with the nitras argenti, and brought to heal slowly by gi-anulation. 3, Injuries of the Nasal Duct. The duct itself is completely secured from all immediate injury ; but the osseous canal, through which it passes, is sometimes frac- tured, and its sides pressed together, by severe blows on the face. I have seen this follow a kick from a horse, received on the side of the nose. The consequence was complete obliteration of the passage for the tears. SECTION II. ACUTE INFLAMMATION OF THE EXCRETING LACHRYMAL ORGANS. Symptoms. With a feeling of obtuse, deep-seated pain, extend- ing to the nose and to the eye, a circumscribed swelling appears in the situation of the lachrymal sac, hard, very sensible to the touch, and affected with stinging pain whenever it is pressed. This swelling becomes gradually red, at last extremely red, and | then the least touch is insupportable. The papillee are shrunk, i the puncta scarcely visible, the absorption and conveyance of the | tears into the lachrymal sac, and through the nasal duct into the I nose, completely stopped, and a stilhcidium lachrymarum is present. | The nostril on the affected side is at first uncommonly moist ; but | it soon becomes dry, the inflammation extending to the mucous I membrane of the nostril. The inflammation affects the caruncula ' lachrymalis, and the conjunctiva, spreading also to the orbicularis i palpebrarum, and to the integuments of the lower eyelid. The redness about the nasal angle of the eye, extending with some degree of sweUing even to the cheek, gives to the parts when viewed at a distance an appearance as if the integuments were attacked b)^ erysipelas ; but on a nearer examination, the pecuUar redness, and all the other characteristics of phlegmonous inflam- mation, are recognised ; and in the midst of the diffused discolora- tion and tumefaction, the circumscribed swelling of the lachrymal sac is evident not merely to the touch, but even to view. The primary and chief seat of this disease is the mucous mem- brane of the whole of the excreting parts of the lachrymal organs. When the pure inflammation has reached its highest degree, and is about to pass into the suppurative stage, this mucous membrane begins to be exceedingly tumefied. The tumefaction of the parietes of the lachrymal canals and of the nasal duct is very soon so great, 173 tliat these tubes cease to be pervious. The same tumefaction ex- tends also to the parietes of the sac. The nasal duct being inclosed in an osseous canal cannot become tumefied by inflammation, and at the same time leave a free passage to the tears. The anteriot side of the sac, on the other hand, being covered only by soft parts, is gradually distended, so as to form the tumour already mentioned, and which l^ecomes much more considerable when the disease is so far advanced that the mucus secreted is of an inordinate quantity and puriform. The pressure from within the sac produces pro- gressive absorption, so that the matter comes gradually towards the surface, while the thickening of the mucous membrane behind serves to secure the deeper-seated parts. Mr. Hunter has repeated- ly referred to the matter within the sac not following the shortest way, which would be directly into the nose, but coming to the ex- ternal surface, as an illustration of the instinctive provision which exists in the body for bringing extraneous and morbid substances to the skin for their exit.* Occasionally, hovi^ever, the means of protection becomes a cause of future evil, for there sometimes takes place such a change in the texture of the parietes of the canals, sac, and duct, that they can scarcely ever return to their natural state. The thickening of their mucous and fibrous coats continues in this case after the inflammatory disease has run its course; and when the inflammation is violent, this thickening is sometimes so great as to produce the complete and incurable obliteration of the excre- tory lachrymal apparatus. This permanent obliteration appears to depend upon an effusion of coagulable lymph into the substance of the mucous and fibrous coats, and into the cellular substance by which these are connected and surrounded. Stricture of a portion of one or both of the canals, or of the duct, is produced in the same manner. Weakly patients, towards the end of the inflammatory stage, •complain of headach, and present the other symptoms of febrile disturbance of the constitution. The pain of the parts primarily affected is often very severe, in consequence, no doubt, of the un- yielding nature of the surrounding structures. The "whole head suffers, and the fever is occasionally attended with delirium. As happens with all mucous membranes in a state of inflamma- tion, a very abundant morbid secretion of mucus takes place at the transition of the first into the second stage. This fluid collects in such a quantity within the lachrymal sac, that the tumour is strikingly increased in size, and is felt distinctly to fluctuate. The accumulated mucus cannot escape in any considerable quantity from the sac into the nose, on account of the swollen state of the hning membrane of the nasal duct, or it may be on account of its actual obhteration, or at least stricture. From the same causes the accumulated mucus cannot be regurgitated by the lachrymal * Hunter on the Blood, Inflammation, and Gun-shot Wounds, Vol. ii. pp. 298, ;: 331, 8vo. London, 1802. 174 canals. Besides, though the tears are more plentifully secreted during this disease than during health, they are not absorbed and conveyed into the sac, where they might have the effect of diluting this morbid mucous secretion. With the commencement of the suppurative stage, there is also a morbid secretion from the carun- cula lachrymalis and the mucous membrane of the nostril. The tumour of the lachrymal sac increases more and more, the redness becomes darker, the skin over the tumour more and more shining, the fluctuation more distinct, and the morbid secretion is now completely puriform. The sac and the parts by which it is covered, altered by inflammation, are incapable of any further dis- tention. The skin covering the sac sometimes mortifies and sloughs ; but more commonly in the middle of the swelling, a yel- lowish, soft point is observed, which soon gives way. The collec- tion of puriform mucus, left to itself, works a passage through the orbicularis palpebrarum, and through the integuments ; but by this opening, the thinner parts merely of the puriform secretion will be discliarged, and the tumour will, at least for a considerable time, be but inconsiderably diminished. By and by w^e observe, when we press upon the superior part of the sac, that not merely puriform mucus is discharged by the opening, but occasionally also a quantity of pure tears, a proof that the conveyance of the tears into the sac is re-estabhshed. For some time after the process of suppuration has ended, there continues from the mucous membrane of the €ac a morbid secre- tion, opaque and still somewhat like pus. It occasionally accumu- lates so as to push out the little plug of lint, which may have been placed in the opening of the sac. At length this morbid secretion also ceases in its turn, and the proper mucus comes to be secreted in natural quantity. It is in general transparent, although for a while it presents occasional streaks of a white colour. These at last entirely disappear, and the mucus becomes thinner in consequence of a due intermixture of tears. The opening of the sac now heals either spontaneously or by the assistance of art. Most frequently it begins with con- tracting to an almost capillar}^ aperture, by which, if the nasal duct has not returned to its natural dilatation, tears and mucus are discharged. Should this capillary opening close, and the duct still continue impervious, the patient is obliged several times in the day to press upon the sac, that the mucus and tears which it con- tains may be discharged through the lachrymal canals. Causes. Among the causes of this disease, exposure to cold, and contusions on the side of the nose, are those most frequently noticed by patients. Beer mentions the case of a child of four years old, in w4iom it arose from the irritation of a large pea which had been thrust so deep into one of the nostrils that it was with difl&culty extracted.* In every instance, this is a sudden and rapid * Praktische Beobachtungen Uber Augenkrankheiten, p. 32. Wien, 1791. 175 ' disease, unpreceded by any signs of obstruction of the lachrymal passages, and occurring, in general, in healthy individuals. Prognosis. The prognosis in acute inflammation of the lach- rymal sac is, in every period of its course, more favourable than in the chronic disease, which has probably been long preceded by imperfect transmission of the tears into the nose, and occurs in persons vi^hose constitution is in a state of weakness and derange- ment. When this disease arises from no considerable injury of the sac, but from some slight, perhaps unknown cause, the prognosis is jVery favourable during the first stage ; that is, before the secretion of puriform mucus has commenced. If the disease has reached the suppurative stage, we have to contend indeed with a blenor- rhoea, or morbid secretion and accumulation of mucus; but under proper treatment these symptoms will readily disappear. When the inflammation is from the beginning severe, or the case has been neglected or mistreated, the nasal duct and lachrymal canals run the risk of obliteration ; and it is to be accounted fortunate if the duct is obliterated at its lower extremity only, or the canals merely at their termination in the sac. Not unfrequently the whole length of the duct is converted into a ligamentous, almost cartilaginous substance, which baifles every attempt to restore its natural caliber ; and in this case, both the lachrymal canals and the sac itself usually become impervious. The possibility of such events must be borne in mind, when we are called in even during the first stage. The prognosis during the second or suppurative stage is extreme- ly dubious. No surgeon, however great his experience, can know how far during the first stage, the permeability of the canals has been affected ; nor can heat this period attempt to ascertain by probes the state of the parts, without exposing them to essential injury. If we are called in just as the suppuration has fairly commenced, our treatment may perhaps moderate that process ; and, at least, we have it in our power to open the sac at the proper time and in the proper place. If we are later, we probably have a fistula to contend with. Treatment. It is by combating the inflammation that we are to cure this disease, and not by attacking merely one or even seve- ral of the symptoms. Dilatation, for instance, by the introduction of probes through the canals, into the sac, and even into the nose, would only be subjecting the inflamed parts to a new cause of irri- tation, and might thus produce effects which would render a com- plete cure difficult if not impossible. The method of treatment before the process of suppuration has commenced, is sufficiently simple. In mild cases, it consists in ob- serving the antiphlogistic regimen, and in carefully applying to the inflamed parts a piece of folded linen, moistened with cold or tepid water, or with a diluted solution of acetate of lead. In severe cases, 176 bleeding at the arm, immediately followed by the application ol leeches in the neighbourhood of the inflamed parts, ought to be em- ployed. Leeches over the swelling will be found particularly use- ful. Should any constitutional symptoms supervene towards the termination of this stage, the bowels are to be freely opened, and a gentle degree of perspiration maintained by the use of some o] the common diaphoretics. Our object here is to arrest the process of inflammation, and to prevent it from passing into suppuration, i Where this is impossible, and the symptoms declare that the pro- cess of suppuration is commencing, our debilitating plan of treat- ment should immediately cease. If it be continued, the mucous membrane, which is the seat of the inflammation, swells much mon than it would have otherwise done, and the consequent blenorrhoef continues so stubbornly that it threatens sometimes to be inveterate and incurable. The cold lotion should now give way to a warn emollient poultice. Should our hopes of checking the disease be still disappointed and the secretion of puriform mucus go on augmenting, the sa< must be opened with the knife, as soon as it is so overfilled and th(, parts which cover it so far disorganized that the middle of the tu mour becomes soft and yellowish, pointing like an abscess. Wt make our incision in the direction of the longer diam.eter of the tu mour, and as we withdraw the lancet, enlarge the opening down wards through the integuments, that the matter may have a fre< exit. We may now introduce a common silver probe into the sac and direct it downwards into the nasal duct. We shall almost al ways find that it descends freely into the nostril. With tepid wa ter and the lachrymal syringe, we next wash out the parts, and thi is to be repeated daily. A common poultice is now to be applied inclosed in a thin linen bag, and after the opening has continued fo several days, and the matter has been freely evacuated, if the sa^ should continue hard, a warm poultice of cicuta leaves with cam phor is recommended for discussing the induration. A bit of leatb er spread with mei'curial plaster is also found useful for this jjurpose As soon as the object of this application is gained, the wound i to be filled with a small quantity of soft lint, dipped in the vinou tincture of opium, and the whole covered with a piece of adhesiv plaster. Under this treatment the process of suppuration dimin ishes, and the matter discharged begins to lose more and more th character of pus, and to approach to that of mucus. Should this unnatural secretion threaten to become habitual, th small quantity of lint introduced into the wound is to be covere with red j)recipitate ointment. With this the wound is to be dresse daily ; but after removing the old dressing and the mucus whicl may have accumulated, a little of a weak solution of the sulphat of zinc (gr. ii. § i.) made lukewarm, is to be dropped into the na sal angle of the eye, and some of the same solution is to be inject ed through the wound into the sac. 177 At this period, if the treatment has been properly conducted, we most frequently find that the lachrymal canals and the nasal duct have of themselves become permeable, the secretion of mucus na- tural in quantity and quality, and mixed duly with the fluids ab- sorbed from the lacus lachrymarum. We therefore proceed to ap- ply such dressings to the opening of the sac as may induce it to close. If we have any doubt of the complete permeabihty of the lachrymal canals and nasal duct, we have recourse to that exami- nation of the parts which I shall describe in the ninth and tenth sections of this chapter. SECTION III. CHRONIC BLEN6RRHCEA OF THE EXCRETING LACHRYMAL ORGANS. This is by far the most common disease to which the excreting lachrymal organs are subject. SyTnptoms. The inflammation with which this disease com- mences, is very seldom considerable. In scrofulous patients espe- cially, the purely inflammatory stage is not unfrequently completely^ overlooked, and no advice is asked or treatment thought of, till mucus has accumulated to such a degree as considerably to distend the lachrymal sac. The first thing which, in general, attracts the patient's attention, is weakness of the eye, from the tears gathering at the internal canthus. When he begins to read, or look earnestly at any minute object, he finds a tear ready to drop over on the cheek ; and to relieve himself of this inconvenience, he puts up his finger upon the sac, and forces its contents down into the nose. He goes on in this way perhaps for months or years. But after a time, he finds that the tears no longer go down into the nose, when he presses at the inner corner of the eye, as they did before ; but regurgitate by the puncta lachrymalia. This, however, still affords rehef, and the patient may persist in the practice for a great length of time. If he gets alarmed about the complaint, and applies at this stage of it for advice, we find that when we press upon the tu- mour formed by the distended sac, a quantity of puriform mucus wells out through the puncta and overflows the eye ; for so far are the canals from being obstructed, that except when there is a smart renewal of inflammation, they even absorb and convey the tears into the sac. Rarely, however, at this stage of the complaint, can our pressure empty the contents of the sac through the nasal duct, as its permeability is for the most part suspended by general tume- faction of its mucous membrane, or by stricture at some particular points ; and hence also the patient almost constantly complains of dryness in the nostril. The evacuation of the contents of the sac, whether by the duct or by the canals, produces but an inconsidera- ble diminution in the tumour. The degree of inflammation which exists in different cases of 23 178 chronic blenoiThcea, and even in the same case at different times, is very various. Sometimes we find the integuments perfectly free from discoloration, and meiely elevated by the distended sac. At other times, they are severely inflamed, exquisitely tender to the touch, thinned by the pressure of the puriform mucus, and ready to give way. The extent, too, of the inflammation is various. The lining membrane of the sac is its chief seat. In many cases, we have reason to suspect that the whole excretory passages are affected ; while in others it is evident that one or other of the lachrymal canals only is the source of the blenorrhoeal discharge. I had under my care a lady in whom the upper lachrymal canal only seemed to be affected. The surgeon in the country, under whose care she had been, had treated the case as one of inflammation of the conjunc- tiva : there was no lachrymal tumour : the matter, oozing from the upper punctum, inflamed the conjunctiva : and it was not tilJ after several days, that I detected, on making pressure along the course of the upper canal, that this was the seat of the disease. In the course of this tedious disease, the accumulated mucus, also, varies much both in quantity and in quality. For instance, the mucus accumulates more rapidly and is much thicker aftei taking food than at other times. The secretion of it is very plenti- ful, but thinner than usual, when the patient continues long in a moist and cold atmosphere. In this case, the over-filling of the sac sometimes takes place so rapidly, that the compression of the orbi- cularis palpebrarum in the action of winking is sufficient to evacu- ate the sac through the canals to such a degree that the whole surface of the eyeball is suddenly overflowed, and the puriform fluic runs down upon the cheek. After the patient remains for a short time in a warm and dry atmosphere, the morbid secretion becomes sparing and ropy. We find that this chronic blenorrhoea almost completely disappears in many individuals during warm weather, upon which the yet unexperienced patient and the unexperienced surgeon are apt to express a great but a premature joy, for on the very first change to cold and wet weather, the disease most fre- quently returns as before. During chronic blenorrhoea, the lachrymal sac is extremel}' liable to repeated attacks of inflammation ; in which the sac becomes distended, the integuments over it inflamed, swollen, and aflected wuth pain, and the nasal duct and lachrymal canals completely obstructed. Unless the inflammation is resolved,, the swelling points like an abscess, bursts, and discharges slowly the puriform mucus contained in the sac. If still neglected, the opening is very apt to degenerate into a fistula, and sometimes several fistulous openings form. This disease may be regarded as the same with that which we have considered in the last section, only modified by some constitu- tional disorder, in most cases, by scrofula. There are other peortions I 179 , , of the mucous system, the inflammation of which is strikingly modi- fied by this latter cause. Mr. Hunter " suspected that there was something scrofulous in some gleets ; " * and with a gleet, or chronic, periodic, puro-mucous inflammation of the urethra, this disease of the lachrymal passages presents a very striking analogy. Indeed it may be asserted in general, that the effect of scrofula ,upon any inflammatory disease is to prolong its second stage, and to render it chronic. In other cases, this chronic blenorrhoea of the excreting parts of the lachrymal organs appears to depend upon the weakly constitution of the patient, although he be free from scrofula ; and in others, it is evidently kept up, and in some it appears to be produced, by the disordered state of the digestive I organs. Even regarded locally, the present disease is seldom a primary I affection, but is frequently excited by catarrhal inflammation of the Schneiderian membrane, or of the conjunctiva, long continued dis- order of the Meibomian glans, or a stricture of the nasal duct. In some cases, a collection of puro-mucous fluid within the lachrymal sac appears to arise entirely from the absorption of such fluid from the eyelids, where it is secreted in consequence of blenorrhosal inflammation of the conjunctiva, or of inflammation of the Meibo- mian foUicles ; and this absorbed fluid, exciting inflammation of the I lining membrane of the excreting lachrymal passages, speedily I becomes the source of additional purifoim mucus. Inflammation ^ of the Schneiderian membrane acts by the sympathy of continuity in bringing on this disease. As for stricture of the nasal duct, it operates both as cause and effect; an effect, in the first instance, and then a powerful cause of the continuance of the disease. Very I often this disease is complicated, at least so far as its origin is con- .cerned, with other constitutional diseases besides those already I mentioned. Small-pox, measles, and scarlet fever, frequently call into action an occult scrofulous disposition, and at the same time give rise to the particular local disease which forms the subject of .this section. Prognosis. As for the prognosis, it must of course vary ac- cording to the constitutional cause to which the prolongation of this local affection is to be attributed. For instance, when scrofula is present, much depends upon whether the scrofulous diathesis be completely developed in the patient, merely commencing to declare itself, or, as happens at certain periods of life, already beginning to retreat. Very frequently, we shall find it impossible to effect a cure, while the scrofula continues in activity ; and a similar obser- vation may be made in regard to those cases, in which the disease is kept up by the weakly constitution of the patient, or by the dis- ordered state of his digestive organs. Even when we succeed in removing the blenorrhoea, we cannot pronounce the disease to be radically cured, nor ought the patient to deviate from such a gene- * Treatise on the Venereal Disease, p. 159. London, 1810. 180 ral plan of treatment as the bad state of his constitution may de- mand. The oftener a blenorrhoea, ah'eady become in some measure ha- bitual, has been attended with new attacks of inflammation, the less is our hope of ever completely curing it. If, in consequence of these renewals of inflammation, a fistula of the sac should form, there sometimes follows a complete closure of the nasal duct, while the mucous membrane of the sac itself becomes so thickened and fungous on its internal surface, that the parietes approach each other more and more nearly, till, at last, the attacks continuing to be repeated, the cavity appears to be obliterated. Should the tumefaction and induration of the mucous membrane and of the surrounding parts become so great, that after complete evacuation of the sac, the sweUing is but little diminished and scarcely yields to the pressure of the finger, the cure is extremely tedious and rarely comes to be complete. Both the nasal duct and the sac most frequently remain in this case impermeable, and even though the blenorrhcea ceases, a stillicidium lachrymarum con- tinues. If the evacuation of the sac during this disease be left entirely to the action of the orbicularis palpebrarum, instead of being carefully and frequently effected by pressure, this spontaneous evacuation will take place more and more seldom, the sac wiU become more and more over distended, the swelling even after the most complete evacuation will merely subside and not disappear, and a manifest laxity will become obvious in the anterior part of the sac and in the parts by which it is covered. This is a particular state, of v'hich I shall treat in a subsequent section, under the name of relaxation of the sac. In a case of long continued blenorrhcEa with stillicidium, 1 ob- served the pupil of the eye of the affected side become expanded and fixed, and vision dim, while on the other side no amaurotic tendency was manifest. By adopting proper measures for the re- lief of the blenorrhoea, the amaurosis was removed. Local Treat7nent. The local treatment of chronic blenorrhcea of the excreting lachrymal organs, necessarily varies according to the particular symptoms which are present, their severity, and their duration. The objects of the treatment are to remove the inflam- mation and puriform discharge, to reMeve the swollen state of the lining membrane of the passages, and to restore the tears to their natural course. 1. Injections. I have occasionally succeeded in completely curing slight incipient cases by injections with Anel's syringe, but much more frequently I have failed. The sac is first to be emptied, and if possible, emptied into the nostril. The lachrymal canals are then to be injected with tepid water. In syiinging the upper, the point of the syringe is first of all entered from below upwards, till it reach the angle of the canal ; the instrument is then to be 181 'turned in a circle till its point comes to be directed downwards and inwards, while at the same time we draw the eyelid somewhat up- wards and outwards. In syringing the inferior canal, we introduce the point from above downwards, and then lower the instrument jto the horizontal position. Continuing to carry the point onwards ; in the directions described, it enters the sac, the piston is now press- ed down, the sac is filled with the fluid, and, if the passage is free, jit flows from the nostril, or into the back of the throat. If the pas- I sage is not free, the sac is left distended. With the finger we en- ideavour to press the fluid with which it is filled down into the nostril, placing the finger for this purpose between the puncta and ; the sac, and pressing from the puncta towards the nose, not from ; the nose towards the puncta. We then take up with the syringe jthe medicated injection, and use it in the same manner. One or ; two grains of nitras argenti, or from two to four grains of sulphas jzinci to the ounce of distilled water will be sufficiently strong. i These injections are to be repeated once every day, or every second I day, according to the effects which they produce. If they irritate jmuch, the tepid water injections only are to be used ; and if after a I fortnight or three weeks, no improvement has taken place, neither ' in the discharge nor in the freedom of the passage into the nostril, i they may be laid aside. The probability is, that in such a case, i there is a stricture of the nasal duct. i Sir William Blizard proposed to treat cases of this sort by filling the lachrymal sac with quicksilver ; but I do not see that this could be of any service, neither in chronic blenorrhoea nor in obstructed ; nasal duct, unless in a very early stage of these diseases. The , method was as follows. After emptying the sac, as has been al- ready directed, a tube, such as was formerly used for injecting the lymphatics, fitted with a fine steel tubule and stop-cock, was taken, and the point of the tubule introduced into the lower punctum, mercury poured into the tube, and the cock opened. The mercury ran through the tubule into the sac, fiUing it, descending into the nasal duct, and if the duct was patent, ran into the nostril ; but if the duct was obstructed, the mercury regurgitated by the upper punctum. The instrument was withdrawn, and the patient di- rected to take care not to touch the eye, but to allow the mercury to descend at its leisure into the nose, which, from its gravity and subtility, it scarcely ever fails to do in a short time, unless the duct be completely obliterated. Next day, or two days after, the same process is to be repeated, and in some incipient cases, it has been found of use, so that after repeating the injection half a dozen, or a dozen times, the mercur}'^ is seen running from the nose in a stream, giving evidence at least of there being no considerable obstruction of the nasal duct. 2. Lotions. These are of two sorts, refrigerant and astringent ; the one to be applied only externally, as the solution of acetas plumbi : the other intended to be taken up by the puncta lachry- 182 malia, and conveyed into contact with the lining membrane of the sac and duct, as the solution of nitras argenti or sulphas zinci. The former set of lotions are employed by means of a fold of linen, laid over the inflamed integuments ; the latter, when the sac has been emptied, are poured into the nasal angle of the eye, the patient lying on his back, and are allowed slowly to reach their destina- tion. 3. iSalves. These are employed chiefly when the conjunctiva and Meibomian follicles are affected. The red precipitate and white precipitate of mercury salves are generally preferred. Melted on the end of the finger, about the bulk of a hemp seed of either is introduced on the inside of the lower lid, rubbed along the edges of the lids, and into the neighbourhood of the puncta lachry malia. They correct the unhealthy state of the parts to which they are applied ; and may perhaps be absorbed by the puncta. 3. Leeches. The pain, redness, and swelling of the integu- ments during a renewal of the inflammation, will evidently de- mand the employment of this remedy ; but even when the ex- ternal signs of inflammation are not such as to attract much at- tention, when the sac is but little distended, and the integuments scarcely affected, much advantage will be derived from the repeat- ed application of leeches over the seat of the lachrymal sac. 4. Poultices. Should we fail in reducing the inflammation by the means already enumerated, we must proceed as in a case of acute inflammation, apply an emollient poultice, and wait till the suppurating sac advances. 5. Incision of the sac. As soon as the fluctuation of the ab- scess is distinct, w^e lay the sac open as has been directed in the last section. On examining the nasal duct, we almost uniformly find it contracted at one or several points of its extent, and to rem- edy this, we generally introduce the headed piece of silver wire, called a style. 6. Style. The introduction of a style is a very common, and a very useful method of treating chronic blenorrhoea, not merely after a renewal of inflammation, terminating in abscess of the sac, but at every stage of the complaint, except the mere incipient one. It is an instrument which may be worn for an unlimited time, not only without annoyance to the patient, but with a great degree of comfort. The eyelids being drawn outwards, so as to put the ten- don of the orbicularis palpebrarum on the stretch, an incision is made with the lancet into the sac. Even in cases w^here the sweUing is small, and scarcely any external inflammation present, we shall be surprised at the large quantity of matter which is im- mediately discharged on opening the sac. The common silver probe is now introduced, and made to descend through the nasal duct till it strike the floor of the nostril ; the probe is withdrawn, and a little tepid water is injected, and then the style is introduced, but not pushed down so completely that its head comes into con- 183 tact with the integuments, till a bit of court plaster is applied, so as to bring the edges of the incision as much together as the presence of the style will permit. The wound closes gradually round the style, which is not to be taken entirely out for the first four or five days, but merely raised a little daily, so as to allow the wound to be cleaned, and a new piece of court plaster inserted below the edge of the head of the style. After the wound has healed so much that the opening closely embraces the style, this is to be taken out every morning, the nasal duct injected with tepid water, or with some mild astringent solution, and .then the style replaced. The aperture through the integuments into the sac soon becomes per- fectly fistulous, having no disposition to close. During the time that the style is worn, the blenorrhcea disap- pears almost completely. The tears and mucus, absorbed by the lachrymal canals, would appear to be attracted along its surface through the nasal duct, and thus the function of the parts being restored, the inflammation and blenorrhceal discharge quickly subside. It frequently happens that a patient, after wearing a style for three or four months, has it removed, thinking the disease perfectly cured. After a time, however, the blenorrhcea returns, the style is reintroduced, and the symptoms subside. After three or four months it again becomes a question, whether the style should be removed. The patient often objects to this being done. He knows the inconvenience of the disease, and the little trouble of the remedy, and prefers continuing to wear the style, to running the risk of the blenorrhcea returning. I have known even ladies object to giving up the style, having once experienced a relapse from the removal of it. The head of the style may be covered with black sealing wax, and then it looks like a little patch. It must on no account be left without regular removal and replacement. A patient in the lower ranks of life called upon me some time ago, with a style, which had been introduced by Dr. Monteath, and which had not been taken out for more than six months. It was corroded almost through, about a quarter of an inch below ihe head. It is important to remark, that the style itself is occasionally a cause of irritation. It often is so, for some days after it is first in- troduced. We are obliged to apply an emollient poultice over the sac, or even to withdraw the style. Months after it has been in- troduced, and proved highly serviceable, we find that the patient complains of matter being still discharged by the side of the style. In such cases, we should consider how far the style itself is a cause of this discharge ; and if the Meibomian follicles, the conjunctiva, and the lachrymal passages, appear in every other respect to be sound, except only in the puro-mucous discharge by the side of the style, let it be removed, and a trial made whether every thing ' will not, now that the passage is patent, go on as it ought to do. 184 When we remove a style with the intention of no longer re- placing it, we must make raw the edge of the opening through the integuments, which it leaves behind ; for if this is not done, it is apt to contract to an almost capillary fistula, very difficult to close. 7. Counter-irritation. As a remedy of considerable use in chronic blenorrhoea, I may mention blisters and issues behind the ears and on the nape of the neck. The employment of sternuta- tories may also be arranged under this head. By the discharge which they cause from the nostril, they sometimes prove serviceable. 8. Electricity has frequently been serviceable in chronic blen- orrhoea. The method which has been found successful is that of drawing theelectric fluid with a wooden point, or taking very small sparks from the part. This is to be continued for three or four minutes every day. When an obstruction of the nasal duct is sus- pected, electric shocks may be passed down the duct, by placing one director upon the lachrymal sac, and another up the nostril.* Other local remedies for chronic blenorrhoea have been proposed, but do not appear to deserve notice. General treatment. However well chosen, and carefully con- ducted our local treatment of this tedious and troublesome disease, we shall probably find it to have comparatively little effect, unless we at the same time employ every means we possess of improving the patient's general health. In scrofulous cases, the constitutional treatment consists, in a great measure, in regulating the patient's diet and manner of life. In weakly persons, whether scrofulous or not, the employment of the preparations of iron and cinchona will be found highly bene- ficial. When the prolongation of the disease depends on derange- ment of the digestive organs, it will be necessary to begin by re- storing these to a healthy state. This will be best eflfected by small doses of blue pill at bedtime, followed by a laxative in the morning, as has been recommended by Mr. Abernethy, in his Surgical Ob- servations on the Constitutional Origin and Treatment of Local Diseases. In almost every case, advantage will be reaped from country air and exercise. SECTION IV. STILLICIDIUM LACHRYMARUM. It is necessary to distinguish this disease from epiphora. The cause of stiUicidium lies in some obstacle to the absorption and conveyance of the tears into the nostril. Epiphora, on the other hand, consists in a superabundant quantity of tears, and is a dis- ease, therefore, of the secreting, not of the excreting parts of the lachrymal organs. T have nothing farther to add to what has been said in the pre- • Cavallo on Electricity, Vol. ii. pp. 149, 167, 186. London, 1795. 185 ceding sections, regarding stillicidium as a symptom merely of in- flammation of the sac and neighbouring parts. As the inflamma- tion subsides, this symptom disappears. Neither do I mean to treat of incurable stillicidium, arising from obliteration of any of the excreting parts of the lachrymal organs. The stillicidium now to be considered, is the result of relaxation of the puncta and ca- nals, attended, it is probable, with atony of the tensor tarsi. It is most frequently a sequela of inflammation, continuing after all the other symptoms have disappeared ; and is to be regarded as, in general, a curable disease. iS'i/?nptonis. The puncta stand widely open, and are turned forwards from the conjunctiva of the eyeball, with which they nat- urally are in contact. They appear to have lost their contractile and absorbing power. The quantity of tears, which from time to time roll over the cheek, is not considerable ; they fall in single drops, at intervals, and only from the nasal angle of the eye. The nostril belonging to the atfected side is dry, as little or none of the fluids collected in the lacus lachrymarum is conveyed into the sac, there to mix with the mucus secreted by its lining membrane, and thence to be discharged into the nose. * Erysipelatous inflammation of the eyelids, or of the integuments covering the lachrymal sac, and puro-mucous ophthalmia, are apt to give rise to the present kind of stillicidium, and to the patulous state of the puncta, upon which it depends ; but perhaps the most common cause is an injudicious and too frequent use of Anel's probes and syringe in the treatment of chronic blenorrhoea. Schmidt mentions two cases which fell under his observation, in which the papillae lachrymales were absolutely split, in consequence of the repeated introduction of these instruments, so that the pa- tients were left with incurable stillicidium. Prognosis. This, in ordinary cases, is favourable ; for the dis- ease will either disappear under the influence of warm and dry weather, or may be removed by the careful employment of astrin- gents. Treatment. A solution of borax in peppermint water, with a small quantity of camphorated spirits, or of tincture of opium ; a solution of the sulphate of iron ; or a pretty strong solution of the lapis divinus, with the same addition of spirit or of tincture, may be used. These, with a hair pencil, are to be applied to the relaxed puncta, and afterwards dropped into the nasal angle of the eye, sev- eral times a day, the patient lying on his back for some minutes after the application. SECTION V. FISTULA OF THE LACHRYMAL SAC. It must be apparent from what has been said in the foregoing sections, that this disease is usually the consequence of mistreat- 24 186 . ment or neglect of the acute inflammation of the excreting lachry- mal organs, or of reiterated attacks of inflammation in the same parts during the course of chronic blenorrhoea. If the inflamed sac be not opened at the proper time^ but the collection of puri- form mucus be left to itself, it will form a passage through the fibrous layer by which the sac is covered, the orbicularis palpebra- rum, and the integuments. The opening thus formed may close soon after, and every thing go on well. But in many cases, the opening- merely contracts, manifests no disposition to heal, and degenerates into a fistula of the sac. Symptoms. While employing this term fistula, let us not for- get any part of its import. It implies a narrow canal, with a small opening, the circumference of which is hard and callous. Through such an opening into the lachrymal sac. then, a great portion of the mucus and tears taken up by the puncta are discharged, very little, or none, going down through the nasal duct. It rarely hap- pens that the opening through the anterior part of the sac is directly opposite to that which has been wrought through the fibrous layer of the lower eyelid, the orbicularis palpebrarum, and the integu- ments. It even someti?iies happens, that though there be but one opening into the sac. the matter has formed beneath the skin seve- ral sinuses, which open by small orifices at different places, more or less remote from one another. This complicated kind of fistula occurs inost frequentl\^ in patients of bad constitution, and is the re- sult of often renewed attacks of inflammation, during the course of chronic blenorrhcEa. In such palients, it occasionally happens that the matter penetrates not merely through the anterior part of the sac, but through its posterior part also, and through the os unguis into the nose, thus causing what may be distinguished by the name of carious fistula. This particular variety seldom if ever occurs un- less the individual is affected with scrofula, syphilis, or some other constitutional disease. Even when inflammation of the excreting parts of the lachrymal organs is in the greatest degree neglected^ caries of the os unguis is extremel)" rare, if the patient's constitu- tion be perfectl}^ healthy. Lachrymal fistula is occasionally com- plicated with a fungous state of the sac, and generally with stric- ture of the nasal duct. Prognosis. The least disagi'eeable circumstance which takes place when inflammation of the sac has ended in fistula, is an ex- ternal cicatrice more or less visible. In general, the cicatrice is pretty deep, and accordmg to its depth and extent it invariably pro- duces a degree of ectropium. In every case of fistula, there is a danger of long-continued atony of the puticta and canals, with con- sequent stillicidium, of disorganization of the canals from tedious suppuration or from supervening ulceration, of destruction of the sac and nasal duct from the same causes, and, in certain states of the constitution, of caries of the os unguis. If the fistula be allowed to continue for a great length of time, contraction or even obliteration 187 of the nasal duct, from disuse, is an unavoidable consequence. The prognosis is favourable, when on pressing the sac a quantity of tears issues along with the morbid mucous secretion, although not mix- led with it ; for this proves that the absorption of the tears by the puncta, and their conveyance into the sac, by the canals, are re- stored. The restoration of the nasal duct only now remains doubtful. Treatment. When a case of fistula of the sac presents itself, we have first of all to examine the fistulous opening with the probe, and to ascertain whether the fistulous opening of the integuments corresponds or not with that of the sac. If they correspond, the point of a lancet is to be introduced into the fistula, and the open- ing both of the integuments and of the sac enlarged upwards and downwards. By the considerable opening thus made, a quantity of soft lint, moistened with the vinous tincture of opium, is to be passed into the sac, but not to such a depth as to fill or stop it up. Over the lint is appKed a piece of adhesive plaster, and over the plaster an emollient poultice or a warm cicuta poultice with camphor. This treatment is to be continued till no trace of the fistulous hard- ness remains. During this treatment the absorption and convey- ance of the tears into the sac are frequently re-established, and a similar restoration occasionally extends to their conveyance into the nostril. To ensure, however, an immediate transmission of the tears, we not unfrequently introduce a style into the nasal duct, as soon as we have laid open the fistula. When the fistula is complicated, we carefully examine with the probe the fistulous opening or openings, and ascertain the direction of the sinus or sinuses. If the sinuses are superficial, which may sometimes be judged to be the case from the discoloured streaks which are seen extendiiig from their external orifices towards the sac, they are to be laid open with a small bistoury, quite up to the sac. The opening into the sac is then to be enlarged upwards and downwards, as in the former case. The same treatment also as in simple fistula is to be followed. i , Should one of the sinuses be so deeply seated, that in order to lay it open it would be necessary to divide a considerable quantity of muscular substance, vessels, and nerves, we content ourselves with enlarging the fistulous opening ; after which we pass a common silver probe along the sinus to its commencement in the sac, and then divide the integuments immediately over the end of the probe, so as to form a counter-opening to the sinus. Through the sinus, diluted vinous tincture of opium is daily to be injected, the poultice applied as before to promote the removal of the hardness which pre- vails throughout the sinus, and this being gained, the cure is to be completed by compression. So long, however, as any hardness remains, compression is of no use ; even if the opening heal up, the sinus continues, and the opening after a while returns. As for the I'isac, it is to be treated as in the former case. 188 It occasionally happens that one of the sinuses is so deeply situa- ted, that a portion of the superior maxillary bone over which it runs is laid bare or becomes carious. When this is the case, the fistulous opening is surrounded by fungous granulations, an ichorous matter is discharged, the integuments around are of a deep red colour, and the denuded or carious bone is felt with the probe. A solution of nitras argenti is to be injected into the sinus, and the lint with which the parts are dressed is to be moistened with tincture of myrrh. Such is the treatment of the different varieties of fistula of the lachrymal sac, with the exception of that variety in which the os unguis is carious, a subject which I shall consider separately. I have only farther to remark under the present head, that no fistula is to be allowed to close, till the surgeon shall have made a careful examination of the state of the lachrymal canals and of the nasal duct, and satisfied himself of the permeability and eflfectiveness of these parts. SECTION VI. CARIES OF THE OS UNGUIS. This disease is much less frequent than it was once supposed. " For my own part," says Mr. Sharp, " since I have doubted its frequency, it has not been my fortune to meet with a single instance of it." * Janin observes, " It is so rare to find this bone carious, that, without external causes, I doubt if it can become so. Among the gi'eat number of diseases of the lachrymal sac which I have treated, I have found only a single case of caries, and this was occasioned by a gunshot wound." t M. Demours puts the following questions concerning the diseases of the os unguis. " Is the bone denuded once in a hundred times ? In those cases in which it is denuded, is it carious once in twenty times ? " J It cannot be doubted that carious fistula occasionally arises in the manner described in the last section. Neither is there any doubt that the os unguis sometimes becomes affected with inflammation from scrofula, and oftener from syphilis, and that the inflammation in these cases may terminate in caries. The idea of the frequency of caries of this bone, which, notwithstanding the testimony of Sharp and Janin, has continued to prevail, appears to be founded chiefly upon the mismanaging treatment of surgeons themselves, and above all is to be attributed to their rude examination of the parts with probes and other instruments. A patient presents him- self with fistula of the lachrymal sac ; the idea of caries starts up in the surgeon's mind, and he forthwith takes a probe in order to examine whether there is caries or not ; he penetrates the posterior part of the lachrymal sac, touches the bone with the point of the * Treatise of the Operations of Surgery, p. 178. London, 1758. t Memoires sur I'CEil, p. 119. Lyon, 1772. J Traite des Maladies des Yeux, Tome i. p. 159. Paris, 1818. 189 mstrument, which he moves about to this side and to that, in order to make himself sure of what he is seeking for; and at last distinctly feehng the bone, which he has denuded, he pronounces the os unguis to be carious, Syni'pto'ms. In cases of caries of the os unguis from scrofula or syphilis, the swelling is more deeply seated, and the symptoms of disease in the excretory apparatus of the tears are more slowly de- veloped than in primary affections of these parts. For some time after the obscure tumefaction has continued, with very considerable pain, in the neighbourhood of the os unguis, the excreting lachrymal organs continue to execute their functions ; whereas the tears are no longer absorbed nor conveyed into the nostril, when the mucous membrane is the part first affected. At length, the lachrymal sac and nasal duct becoming inflam-ed, the symptoms bear a nearer resemblance to those described in the preceding sections. The posterior part of the sac becomes ulcerated, and unless some suc- cessful plan of treatment be adopted agaimst the constitutional dis- ease, the caries of the bones and the ulceration of the soft parts continue, the integuments give way and discharge a foetid ichor, , and the lachrymal organs may be entirely destroyed. j '^ General treatment: In such cases, if the local affection depends" ; upon syphilis, the proper remedies against that disease are to be exhibited. A tonic plan of treatment must be followed if the caries appears to be of scrofulous origin. A course of Plummer's pill will generally be found advantageous. No operation practised upon the diseased bone can be of any use, neither while the scrofulous or syphilitic action is going on, nor afterwards. On the contrary, such operation would in all likelihood exasperate the disease, and render that certain, which, even in the least unfavourable case of this kind and under the best directed treatment, is scarcely avoid- able, namely, the obliteration of the lachrymal sac. Local treatment. The introduction of a style, and the cautious injection of a solution of nitras argenti, make up the local treat- ment. The former serves to attract the tears along their natural course, while the latter corrects the blenorrhoeal discharge, represses the tendency to fungus, and improves the condition of the bone. ,j SECTION VII. RELAXATION OF THE LA-CHRYMAL SAC. tSympioms. This disease presents a tumour of the shape and size of a horse-bean ; the integuments covering jt are scarcely or not at all discoloured, it is not painful, and it yields extremely easily to the pressure of the finger. These symptoms are suflficiently characteristic to distinguish relaxation from mucocele. Upon pressure, the contents of the sac in the state of relaxation i are discharged either by the canals and puncta, or by the nasal duct, according to the direction in which the pressure is applied. 190 The fluid is usually transparent, or presents merely a streak of whitish matter ; but occasionally, from the presence of blenorrhoea, it is entirely yellowish and opaque. Upon evacuation of the sac, the tumour is indeed for an instant almost completely removed, but its integuments remain folded and wrinkled, and it very soon becomes filled, again. If the fluid does not consist of mucus duly mixed with tears, but presents whitish streaks, or if it consists en- tirely of a catarrhal matter, we feel a little elasticity in the sac after the evacuation, and there remains some degree of swelling. These appearances are to be attributed to the tumefaction of the lining membrane of the sac, and are totally wanting in the more common cases of relaxation. The sac in this disease has lost its natural contractility of textute, Even that part of the orbicularis palpebrarum which covers the sac, and to which the duty of emptying it belongs when it becomes filled with fluid, having suffered from long-continued extension, is incapable of contracting with a suflflcient degree of force, and is in fact exactly in the state of the muscles of the abdomen after the removal of the water of an ascites. The patient is consequently obliged to do with his finger, what ought to be done spontaneously by the parts themselves. He is obliged to evacuate the sac by pressure frequently in the course of the day, and it is fortunate if he begins and continues the practice of evacuating it by the natural route through the nasal duct, and not through the lachrymal canals. The cause of relaxation is the constant over-distension of the sac by puriform mucus, during previous inflammation, and especially during neglected chronic blenorrhoea. Sometimes, as has been already stated, the blenorrhcea still continues, or has recurred. Most frequently the blenorrhoea has disappeared, and left relaxation behind it, along with an excessive secretion of healthy mucus. In this case we are called upon to limit this secretion, and to restore their natural cohesion and elasticity to the anterior side of the sac, the orbicularis palpebrarum, and the integuments, in order that the orbicularis palpebrarum may be able to recommence this im- portant part of its function, the evacuation of the contents of the sac through the nasal duct. Prognosis. The prognosis in this disease is always favourable. The distension and extenuation of the anterior side of the sac, and of the muscle and integuments by which it is covered, are never to such a degree that we should despair, b}' patient and proper treatment; of restoring their natural and elastic force. We ought indeed to forewarn the patient that the cure wfll be tedious, and require much attention upon his part. Treatment. This consists in the use of two distinct means, each of which, as may be seen by the testiraou}^ of Pellier and others, is, when used alone, apt to fail.* * Pott, Observations on the Fistula Lachrymalis. Works, Vol, i. p. 252. Lon- don, 1808. PeUier de Cluensy, Cours d'Operations sur la Chirurgie des Yeux. Tome ii. p. 207. Paris, 1790. 191 The first is the compression of the sac ; and here let it be ob- served, that the present is the only case in which compression of the sac is useful. In any other disease of that part, this practice would produce the most destructive effects. The compression must be carefully applied, constantly continued, and gradually in- creased. Machines have been invented for this purpose, but they never fulfil with precision all these conditions. We cannot by such an instrument as Sharp's or Petit's compressorium, the first invention of which we owe to Hieronymus Fabricius, keep up a regular and an increasing pressure ; the compressing surface upon the least occasion, especially during the night, is disarranged; and the patient is hindered from pursuing his business by the presence of such an apparatus. Graduated compresses, then, are to be pre- ferred ; over these a firm leather pad of a proper form is to be placed ; and the whole is to be supported by a narrow roller passing round the head. In this manner the pressure takes place exactly upon the part which ought to be acted upon ; it can be daily in creased ; the pad cannot, even when the patient is very restless, be shoved aside ; nor need such an apparatus prevent him from following his ordinary employment, even out of doors. The second part of the treatment consists in the application of some astringent fluid, both to the external surface of the tumour, and to the internal surface of the relaxed sac. A great variety of astringents might be mentioned as proper for this purpose ; such as the sulphate of iron or of copper in solution, an infusion of oak bark, &c. The graduated compresses are to be moistened twice or thrice daily with the astringent fluid which shall have been selected. A small quantity also of the same, or of some similar fluid, is to be dropped into the lacus lachrymarum, and left to be absorbed by the puncta. SECTION VIII. MUCOCELE OF THE LACHRYMAL SAC. Symptoms. This disease presents in its commencement the oblong shape of the sac, the tumour which it forms slowly increases, and I have seen it reach the size even of a pigeon's egg^ without bursting. The integuments covering the tumour, are commonly of a livid or purple colour, and this colour with the growth of the disease becomes darker. A mucocele is so hard that it scarcely yields at all to the pressure of the finger. No degree of pressure is capable of evacuating, either through the puncta or into the nostril, the mucus which in this disease is pent up within the lachrymal sac. During the early period of its growth, the tumour is com- pletely devoid of pain. It is not until the over-filling of the sac has reached its highest possible degree, and the mucocele threatens to burst, that the patient complains of a painful feeling of tension, or rather of a continual sensation of pressure in the nose, in the region 192 of the eyebrow, and ia the eyeball. If we touch the tumour in- considerately, this feeling becomes more perceptible. The patierit at this period can no more than half open his eyelids on account of the size of the tumour. Tn examining a mucocele of the lachrymal sac, we distinguish only a very indistinct, and in many cases, not the least, fluctuation. This depends upon the consistence of the contained mucus, and the presence of indistinct fluctuation, or its total absence merits our attention when we come to open the mucocele, as the operation is modified accordingly. The contained mucus may be in some measure hquid, or it may have acquired a gluey consistence. In the former case, the colour of the integuments is purplish, an in- distinct fluctuation is felt, the tumour is still a little elastic, and does not exceed the size of a horse-bean ; the mucocele is not yet in- veterate ; it probably has continued not above a few weeks. In the latter case, the colour of the integuments is blue like that of a varicose vein, the mucocele feels like a pebble, and presents not the slightest degree of fluctuation ; the tumour is already so large as to rise over the caruncula lachrymalis ]. the disease is of at least seve-| ral months' continuance. i The colour of the integuments in mucocele has led some authors to describe this disease under the name of varix of the lachrymal sac ; while the hardness and size of the tumour, added to its colour, have sometimes led to the extirpation of the lachrymal sac affected with mucocele, under the idea that it was a cancerous tumour. Causes. Mucocele is the consequence of an obstructed state of i the lachrymal canals and nasal duct. The natural secretion of mucus from the internal surface of the sac goes on, but as it can neither be diluted by the tears, discharged into the nose, nor com- pletely re-absorbed by the membrane which secretes it. it accumu- lates, and forms the tumour in question. Mucocele very rarely occurs after the inflammation of the excre- ting lachrymal organs has been so violent as to cause the absolute obliteration of the nasal duct. When the inflammation is so vio- lent as to efiect this, it almost constantly produces at the same time an obliteration of the sac. The sides of this cavity come together, and the texture of its parietes is so altered by the inflammation, that the sac is incapable of returning to its natural caliber. Neither mucocele nor relaxation can ever afterwards take place, and the case is incurable. It is upon obstruction then, and not obliteration I of the nasal duct, that the origin of mucocele usually depends, and j this obstruction is accompanied by a similar affection of the lachry- i mal canals. Yet cases of mucocele do occasionally occur, in which I both the lachrymal canals and the nasal duct are absolutely obhte- rated. Prognosis. When a patient presents himself with a mucocele of the lachrymal sac, the question is not whether we can remov^ the tumour merely. We know that we can always lay open the sac, clear out its contents, and thus remove the mere mucocele. i 193 The important question is, whether the absorption and conveyance of the tears into the sac, and their evacuation into the nose, can be restored ; but to enable us to answer this question, it is necessary to open the sac, and to clear out the accumulated mucus. When the mucocele has not been the immediate consequence of a violent inflammation, we have reason indeed to hope for a favourable is- sue, even before the sac is laid open, and the real state of the ca- nals and duct ascertained. . Treatment. The opening of the sac is to be performed with a lancet fixed in a handle. The instrument is to be introduced into the most prominent part, and pushed on till its point has reached the centre of the tumour. The wound is then to be enlarged up- wards and downwards in the direction of the length of the sac, both that its contents may be easily evacuated, and that we may be able to go on without difficulty in the remaining stages of the treatment. In performing this operation, as well as in enlarging a fistula of the lachrymal sac, it is better to avoid if possible dividing the tendon of the orbicularis palpebrarum. Yet the inconvenience arising from cutting that tendon across is much less than might have been supposed ; for after the wound has healed, the eyelids retain their natural position, and the muscle performs its functions as before. This is to be attributed partly to the ligamentous layer which lies beneath the muscle and supports the eyelids, and partly, as Mr. Sharp has remarked, to the firm cicatrice which is left when the cure is completed.* If the mucus be liquid, a little of it issues as soon as the incision has been completed. The remainder is to be cleared out, by means of a small syringe introduced by the wound, and through which a quantity of water is to be repeatedly injected. If the mucus has entirely lost its fluidity, so as to resemble glue in colour and consistence, it is to be extracted by the repeated introduction of a small pair of forceps. After the mucocele has by this means been pretty well emptied, a probe is to be introduced, and moved about so as to dislodge any of the inspissated mucus that may remain. The sac is then to be completely washed out by injecting tepid water. A small quantity of soft lint is now to be placed within the lips of the wound, and covered with a piece of court-plaster. Next day, the lachrymal canals and nasal duct are to be examined, and the causes upon which the mucocele had depended being ascertained, the proper treatment is to be commenced. SECTION IX. — OBSTRUCTION OF THE PUNCTA LACHRYMALIA AND LACHRYMAL CANALS. The puncta lachrymaha are sometimes congenitally wanting. This may or may not be attended by defect of the lachrymal '* Treatise of the Operations of Surgery, p. 181. London, 1758. 25 194 canals. If no vestige of the puncta can be discovered, the case is hopeless. In another set of cases, the puncta are contracted, but are stil patent, and may easily be opened with the point of a middle-sizec pin. after which Anel's probe will pass without difficulty. The lachrymal canals are sometimes stopped up by calcareous depositions from the tears. "In mOiC than one instance," ?^ys Mr. Travers, '• I have turned out a considerable quantity of calca- reous matter wedged in these ducts, like the calculi of the salivary ducts."* The most frequent cause of obstruction of the canals is tumefac- tion of their lining- membrane, continuing after all the other symp- toms aitendant on acute or chronic inflammation of the secreting lachrymal organs have disappeared. If an artificial opening has been made into the sac during in- flammation, or if a fistula of the sac has formed, neither the artifi- cial opening nor the fistula is to be healed up, till the state of the lachrymal canals has been ascertained. The state of the canals is also to be ascertained on the day following the opening of a muco- cele. In all these cases, the examination of the canals is to be per- formed in the same manner. In this examination it is our object to ascertain, not merely whe- ther the lachrymal canals be obstructed, but also the cause of their obstruction. This may depend upon the presence of inspissatedj mucus, tumefaction of their lining membrane, stricture, or absolut obliteration in a part or throughout the whole of their extent. For the examination of the canals, we make use of Anel's probe^ w^hich is to be held like a writing pen, in the right hand if we are to operate on the left side, and vice versa. The little finger, ap plied to the cheek, is to serve as a support. By means of the fingers of the hand which does not hold the probe, the eyehd is to be drawn somewhat towards the temple, so as to be put on the stretch ; and the edge of the eyelid to be brought a little forward, so as to bring the punctum into view. If we are examining the superior canal, we first of all introduce the point of the probe into the punctum from below upwards till it reach the- angle of the canal. We now turn the instrument in a circle till its point comes to be directed ob- hquely downwards and inwards, while at the same time w^e draw the eyelid somewhat upwards as well as outwards. If we are ex- amining the inferior canal we introduce the point of the probe intc the punctum from above downwards, and then lower the handle of the instrument to a horizontal direction. If upon continuing to press the probe onwards in the directions described, it enters the sac, so that we come to touch the nasal side of that cavity with the point of the instrument, we are assured that there is no obliteration of the canals. If an obhteration exists, a state of the canals which we may partly suspect beforehand from the contracted appearance • Synopsis of the Diseases of the Eye, p. 238. London, 1820. 195 )f the papillae and puncta, we find an inconquerable obstacle to the oassage of the probe, and ascertain at once the extent and situation of the obUteration. When the presence of mucus is the sole cause of the obstruction, fhe conveyance of the tears through the canals is immediately re- stored by carrying the probe onwards into the sac. When there is lumefaction of the mucous membrane, the conveyance of the tears s not restored by merely sounding the canals, for as soon as the probe is withdrawn, the contraction of their caliber returns. Such ,umefaction, indeed, depends in every case upon inflammation, and consequently will subside only as this disappears. In any doubtful case, we can easily convince ourselves of the real '?tate of the canals after sounding them, by dropping a small quanti- ,y of an aqueous solution of saffron, or any other mild highly- joloured solution, into the lacus lachrymarum while the patient hes m his back. If the canals execute their office, the fluid will dis- appear from the lacus lachrymarum without faUing down upon the :heek, and will show itself distinctly by its colour at the opening of he sac. When one or both of the canals are contracted or obliterated iirough a small part of their extent, for instance for the length of i line, we ought to force the probe, but not violently, through the ^stricture or obUteration into the sac. The edges of the eyeUds ought to be kept moist for some days after with a thin and mild ')intment, and the probe passed daily along the canal into the sac. When the canals are completely obliterated, I know no means of preventing an incurable stillicidium. It is easy to describe methods ■)f making new puncta and canals, but it is another matter to get iiese new puncta and canals to absorb and convey the tears. In ^;uch a case some have recommended to lay the sac completely open, 'ipply lunar caustic to its lining membrane so as to excite a degree of inflammation, and then by moderate compression, endeavour to ;l;ecure the obliteration of its cavity, or to dress it for sometime with strong red precipitate ointment, and gradually to allow it to contract. 'These means are recommended for the purpose of preventing a fmucocele of the sac. ' SECTION X. -OBSTRUCTION OP THE NASAL DUCT. The examination of the nasal duct, equally with that of the I achrymal canals, is to be instituted before healing up any artificial opening or fistula of the sac ; it is also to be instituted on the day ifter a mucocele has been laid open. I The best instrument for examining the nasal duct is a common jsilver probe. This is to be introduced horizontally till it touches .he nasal side of the sac, it should then be raised into a vertical po- sition, and its point diiected downwards and a little backwards. jiTurning the probe upon its axis, we pass it from the sac into tlie 196 duct : and as we continue to press it gently downward:, the instru- ment, if the duct is perviouS; enters into the nose. If its point meets \\ith some obstruction; we must not immediately conclude that there is an obliteration of the duct. We must press down the probe a httle more strongly, yet without violence : turning it round between the fingers, and giving it different directions. By these means the obstacle may frequently be overcomej and the probe will suddenly descend. If the obstacle remains as before, and is extremely firm, still this is not sufficient ground for us to conclude that there is a real oblit- eration : because there are many other causes, particularly diseased states of the mucous membrane, from which the dilficulty we en- counter may proceed. That membrane may be tumefied, its mu- cous cryptae enlarged and indurated, and thereby the caliber of the duct nrore or less diminished, yet these obstacles may be capable of pelding. so that by considerable pressure we may succeed in pass- ing the probe into the nose. In other cases, the tumefaction and induration of the mucous membrane may }ield so Uttle, as to ren- der it impossible to reach the nose with a probe of the ordina ^ size, so that it requires great patience to pass a small silver pro;.: through the duct. If we cannot reach the nose with the small probe, if its point hii constantly against the same unyielding obstacle, if we are able ic press it down with veiy considerable force without the patient com- plaining of any painful feeling, there is great cause to suspect an absolute obliteration of the duct. The probe being carried down tc the obstacle, we lean our hand over the brow of the patient, and holding the instrument firmly between the thumb and index-finger increase the pressure till it has sunk to the farther depth of half a line or a line. We suddenly relax the pressure. If the probe risee from the obstacle as from an elastic cartilage, the patient during the whole of this experiment feehng no pain, we may safely con- clude that the duct is obliterated. From the depth to which the probe can be passed, we ascertain the distance of the obliteratior from the termination of the duct. Though the nasal duct is only seven-twelfths of an inch ir length, there are three points in its course at which stricture is par- ticularh' apt to occur. One of these is exactly where the sac end; and the duct begins. The caliber of the duct is there narrowed bj a circular fold, the thickening of which frequently causes the ob- struction. Janin details the appearances upon dissection of a stric ture in this situation, and describes the mucous membrane of th' duct as presenting a plaited appearance like the sleeve of a shirt a^ the wrist.* A second fold of tlie same kind occurs in the middlf of the duct, in many subjects, though not in all : "^ and hence th^ * Memoires sur r rF.il p. 115. Lvon, 1T7'2. t Soemmerriag, Abbildungen des Menschlichen Auges, p. 32. Frankfurt an Main, 1501. 197 part becomes, from a similar cause, the frequent seat of stricture, ' The third, and perhaps the most usual situation of stricture, is at the termination of the duct in the nostril. If we succeed, though it may not be without great difficulty and 1 after many trials repeated during several days, in bringing a probe ■ into the nose, which we can easily recognise by the hitting of the I end of the instrument against the floor of the nostril, as M^ell as from the feehng of the patient, we remain convinced that it is yet possi- ble to restore the whole excretory apparatus of the tears to the ex- ercise of its function. In order to treat of the restoration of the nasal duct with precision, f I shall consider three different cases. The first is when we have already passed a probe through the duct. The second is when we I do not at first succeed in passing a probe, but in which it is yet possible to pass it. The third case is when it is impossible to pass any probe through the natural caliber of the duct. First Case. If we have succeeded with the silver probe, we ought immediately to introduce a nail-headed silver style of the same size, and about an inch and a quarter long, into the duct. We now proceed progressively to restore the duct to its natural cal- iber. This may loe done by a series of silver styles gradually in- creasing in thickness, or by a similar series of gum-elastic bougies. Beer employed for this purpose the common catguts of the viohn. He began with the catgut E. Having softened its point between I the teeth, made seven or eight inches of it perfectly straight, and ) dipped it in a httle oil, he introduced it first horizontally and then t vertically into the sac, and hence into the duct. He pushed it ■ down slowly, till five or six inches of it had descended, in order that its inferior extremity might be drawn forth from the nostril without difficulty, a part of the operation which was left to the pa- tient. The superior part of the catgut was coiled up, inclosed in a piece of linen, and fastened under the hair of the forehead. Into \ the opening of the sac a little lint was laid, and over that a piece of ' court-plaster was apphed. The patient was directed to try, after two or three hours, to bring ' the inferior end of the catgut out of the nose, by shutting his mouth i and the opposite nostril, and driving the air through the nostril into I which the catgut had descended. When he felt it advance, with i the blunt end of a knitting needle, he drew it out of the nostril, ! turned up its extremity to the side of the nose, and fixed it th^re t by a slip of court-plaster. ' On the following day the lint was removed from the opening of the sac, and a quantity of one of the collyria which shall be after- 1 wards enumerated, was injected by the side of the catgut. This ■ injection was intended as well to wash away any mucus accumu- lated in the sac, as to act upon the mucous membrane. The superior end of the catgut was now loosened from the forehead, a sufficient fresh portion undone from the coil, and being besmeared 198 with one of the substances which I shall mention, drawn into the duct by the patient taking hold of the extremity which hung from the nose. The portion of catgut which had been used during the preceding day was now cut otf, and the new end turned up to the side of the nose, and there fastened as before. The same injection was now repeated, the lint and plaster appUed to the opening of the sac, and the coil of catgut bound up. In this manner Beer proceeded day after day till the catgut E was completely used. When it came to an end, the patient pulled it out of the nose. Before proceeding to pass a new catgut, the point of the syringe was introduced through the sac into the duct, and a quantity of tepid water, coloured with vinous tincture of opium, injected, care being taken to observe whether any part of the fluid was discharged by the nostril. The catgut A was now passed as E had formerly been, and its use was continued exactly in the same manner. When it was finished, the injection of a coloured fluid was repeated, in order to ascertain what progress had been made in restoring the natural diameter of the duct. The catgut D followed. After its use, the injection was almost constantly found no longer to drop merely, as it formerly had done, but to flow freely from the nostril. Were this not the case after the employment of one D, this catgut was repeated till the injection was discharged from the nose in a full stream. Then, and not till then, the treatment was brought to a close. If the mucous membrane of the duct, when the use of the catguts ' was commenced, was merel}" somewhat tumefied, and opposed no great obstacle to the probe, the portion of catgut daily introduced was moistened with the vinous tincture of opium, and a quantity of the solutio lapidis divini * made lukewarm, was injected by the sac. The lint too, with which the wound of the sac was dressed, was dipped in the vinous tincture of opium. If the tumefaction of the mucous membrane was firm, so that the silver probe could not be brought into the nose without much opposition, the catgut was besmeared with citrine ointment, at first very much diluted, but gradually increased in strength. The same ointment was apphed to the wound. For an injection in the same case, a solution of corrosive sublimate was employed, together with some vinous tincture of opium. If the cryptee of the mucous mem- brane were indurated and enlarged, so ihatthe probe was felt pass- ing successively over a number of little knots, a weak ointment of red precipitate was employed for besme;iring the catgut, and the patient was directed daily, before the catgut was drawn, to rub in a * R; jEruginis, Nitri puri, Aluminis, utriusque pulverisati § iii. Liquefjantin } vase vitreo in bain eo arenas. Liquefactis adde Camphorae tritte 5 is*'- Misce. Massa !1 refrigerata servetur sub nomine Lapidis Divini. J{; Lapidis Divini, gr. x — xx. Aqua It distillatce, § ss. Solve, et cola. Colato adde Vidi Upii. 5i — 5ii- Aqus Rosarum, § iv. Misce. 199 small quantity of camphorated mercurial ointment around the opening of the sac. Similar applications may be used, if we prefer gum-elastic bougies, or silver styles, for restoring the nasal duct to its natural caliber. Whichever of these instruments we select, its employment must be continued for several months, and the wished-for restoration effected extremely gradually, knov/ing that if we remove the stricture or obstruction suddenly, it will almost to a certainty return. When we consider ourselves w^arranted to discontinue the dilating instrument which we have employed, we place the patient on his back, and repeat the experiment of dropping a deeply-coloured fluid into the lacus lachrymarum ; for the little valvular fold which in many subjects covers the opening of the lachrymal canals into the sac," is apt to become closed from the long-continued pressure of a foreign substance. Should the valve be shut, it must be forced open by the Anelian probe passed through the canals. The wound of the sac is now to be dressed once a day with plain Unt. The coloured fluid is to be daily injected. If for four- teen days successively it flows in a full stream from the nose, we proceed to close the wound. We make its edges somewhat raw with the lancet, and then bring them together with adhesive plaster. Second Case. As soon as we find that the silver probe slicks fast in the duct, we leave it there till the next day, fastening it to the forehead by a proper bandage, closing the opening of the sac with a little lint, and applying over the hnt a piece of court-plaster. For a week, we ought not to despair of overcoming the obstruction, not by main force, but by gentle and daily repeated endeavours to ^et the probe a little and a little farther through the duct, turning :he instrument on its axis at every trial, and varying the direction Df the pressure. If we succeed in this manner, we continue the .reatment as has been explained under the first case. If we fail, this second case must be treated as the third. Third Case. Two causes may conspire to the obliteration of any mucous canal. The one is when the substance of the tube becomes violently inflamed, and consequently extremely swoln : the other when the matter of secretion or of excretion, which in the natural state of things is constantly or frequently moving through the lanal, ceases any longer to pass. When, for instance, a portion af the substance of the urethra is inflamed, its caliber becomes much contracted in consequence of the tumefection of the parietes dF the canal, and this contraction frequently remains permanent onder the name of stricture, after the inflammation has subsided. SThere are two causes why the contraction is not so great in this ;5ase as to close the urethra completely, namely, the considerable j size of the canal, and the frequent and forcible passage of the urine. [Let a small canal, such as the nasal duct, be inflamed to the same [' * RosenmUUer, Partium Externarum Oculi Humani Descriptio. § 125. Lipsiae, 11810. if if > 200 degree, and let no secreted fluid be pushed violently through it, let even the secretion, which in health slowly drops along its in- ternal surface cease, and then it is httle to be wondered at, if it come at last to be completely closed. x\s soon as a mucous canal ceases to be employed in the discharge of its functions, it begins to contract. If a man have a false passage from the urethra, through which the mine is entirely discharged, three inches behind the glans penis, the three inches anterior to the false passage being no longer in use, gradually contract, so that any appearance of a canal is distinguished with difficulty. The apphcation of this to the nasal duct is obvious. I do not mean to assert, that the obliteration of the nasal duct, is, in every case, the consequence either of tumefaction of its parie- tes, or of contraction from disuse. When the mucous membrane of this canal becomes ulcerated or excoriated, as I have no doubt it occasionally does in the course of inflammation, an effusion of coagulable lymph, and a consequent adhesion between the sides of the duct, may give rise to the very worst variety of obhteration. If in our examination of the nasa.! duct we have discovered that part of its extent is obliterated, recourse is to be had to perforation by means of a small triangular or trocar-shaped probe. If the ex- tent of the obliteration be inconsiderable, and placed consequently near the opening of the duct into the nose, this perforation may be performed with confident hope of success. A few drops of blood flow from the nose as soon as the perforation is completed. The probe is immediately to be withdrawn, and a small silver style introduced. This remains for a day or two, and then the very gradual dilatation of the duct, which has already been described, is to be commenced. If a considerable portion of the duct, or even its whole extent, be obliterated, the same operation ought to be performed. This is done with at least equal hopes of success as if we perforated the os unguis. It is true, that nature, constantly tending to destroy every thing contrary to the organic system which she has adopted, would probably close the new passage, after our dilating instruments were laid aside. This is the only case, then, in which the introduction of a metallic tube into the duct, to be left for life, is at all defensible. A gold or silver tube, not more than an inch in length, and pre- senting an elevated ring surrounding the middle of its external surface, may be pushed down into the dilated passage which we have formed. The surrounding substance will probably contract upon this tube, and render it less liable to be displaced, than a similar instrument passed into the natural caliber of the duct. The tube employed ought to be slightly curved inwards and backwards, so as to correspond to the form of the parts into which it is to be introduced. The pewter tubes sold in the shops are toe straight and thick. On trying one of them on the dried craniun] of an adult subject, I find that it cannot be pushed down even mh 1 201 the osseous canal through which the nasal duct passes, without fracturing the os unguis. When a tube is passed into the lachrymal passage, a practice which no one who considers with attention Mr. Ware's candid ac- count of it,* will ever adopt, except in the case of obliterated nasal duct, it may be questioned, whether the tears actually flow through the metallic canal, or descend merely on the outside of the tube, as they do along the surface of a style, and whether a style worn for life would not answer the purpose just as well as, or better than, a tube. It has often occurred to me, that in cases of strictured or obliterated nasal duct, recourse might be had with advantage to the use of a small bougie, armed in the common way with lunar caustic. This might be applied from time to time, exactly as we employ the same means in stricture of the urethra, introducing the bougie from the lachrymal sac down into contact with the strictured or oblitera- ted part of the duct, keeping it there for the space of two or three minutes, and after withdrawing it, injecting the duct with tepid water. Both in Germany and in France, a similar plan has been employed with success.! There are two causes of obstructed nasal duct which I must notice before leaving this subject. The one is lachrymal calculus in the duct. Dr. Krimer relates the case of a woman, aged 32, who for nine months had been affected with disease of the excreting lachrymal organs. The sac was swelled, hard, and upon the most prominent part of the tumour, which was red and painful, there was a small ulcer which penetrated into the sac, and discharged pus, mixed with tears, especially on pressure. The nasal duct appeared entirely obliterated, for the finest sound could not be introduced a line within it. When Dr. K., in order to re-establish the duct, endeavoured to introduce a pointed probe, he withdrew on its extremity a strong concretion of the size of a small pea, the removal of which left the canal entirely free, and the fistula was promptly cured. The calculus was ash-gray, covered with thick mucus, polished, of a calcareous appearance, and insolu- ble in water, alcohol, and weak vinegar. Dr. K. thinks that it was formed in the lachrymal sac, by inspissated mucus.i The other cause of obstructed nasal duct is of a more formidable nature, namely, exostosis of the osseous passage through which the duct descends. " I have often found," says Mr. Travers, "the canal completely obliterated by ossific inflammation at its upper orifice in skulls." § I have met with one case of this kind on * See Ware's Observations on the Treatment of the Fistula Lachrymalis, p. 79. London, 1818. t See a paper by Dr. Harveng, of Manheim, in the Archives Gcnerales de Med- ecine, Tome xviii. p. 48. Paris, 1828. t Dr. Krimer's case was originally published in Grafe and Walther's Journal. I have quoted it from the American Journal of the Medical Sciences, vol. iii. p. 216. Philadelphia, 1828. § Synopsis of the Diseases of the Eye, p. 243. London, 1820. 26 202 dissection, and what is worthy of remark, the individual, as fai as I could learn, had not been much, if at all, troubled with stilli- cidium lachrymarum. If no passage is obtained for the tears and mucus from the sb into the nostril, the patient will be exposed to perpetual attacks inflammation in the sac, which will give rise to much distres and to the formation of fistulse. In such a case, I have seen at tempts made to obliterate the sac, by laying it completely opei and dressing it with escharotics. It is much more difiicult to ob-' literate the sac in this case, than in that which I have described at page 195. Indeed, the obhteration will not be obtained, unless we manage permanently to close the apertures of the lachrymal canals into the sac. If these remain patent, they will gradually re-dilate the sac. I have already had occasion to refer to a case ic w^hich the osseous tube for conveying the nasal duct was obliter- : ated, in consequence of a kick from a horse, which had shatterec and bent in the upper maxillary bone. As it was found impossible in this case to effect any new passage for the tears, not ever through the os vmguis, attempts w^ere made, by caustics of various kinds, and even by the actual cautery, to obhterate the sac and lachrymal canals, but without success. CHAPTER VII. DISEASES OP THE MUSCLES OF THE EYEBALL. SECTION I. INJURIES OF THE MUSCLES OF THE EYEBALL^j Injuries of the muscles of the eyeball are extremely rare. Th^ obliqui are more exposed than the recti. The looseness of the or- bital cellular membrane serves to save, in many cases of penetrating wound, both the eyeball and its muscles. The recti are farther protected by their position behind the eyeball, while the branches of the third pair, by which they are supplied with nervous energy, enter their substance on their central surface, so as to be placed as much out of the way of injury as possible. Still it must occasion- ally happen, (in such wounds, for example, as have been described in the first section of the first chapter,) that the muscles shall sus- tain more or less extensive injury ; and the consequence will be a certain degree of impediment in the motions of the eyeball. The swelling and inflammation which ensue, almost immediate- ly, on penetrating wounds of the orbit, added to the depth of the injured parts, will in general render it impossible to determine the amount, or perhaps even the reality, of injury done in such cases to the muscles. Nor is this of much consequence in a practical point 203 of view; rest, soothing applications, and antiphlogistic means, making up the treatment in all such cases. SECTION II. PALSY OF THE MUSCLES OF THE EYEBALL. I have already had occasion to refer to the frequency of paralytic affections of the muscles supplied by the third nerve or motor oculi.* Palsy of the rectus superior, inferior, and internus, accompanied by la similar affection of the levator palpebree superioris, v^hile the rec- tus externus retains its power, and turns the eyeball permanently i uowards the temple, is a state of these muscles which I have often had an opportunity of observing. If with the finger we lift the I upper eyehd in such a case, and tell the patient to look to the ground, we see that he attempts to do so, but is utterly unable to liccomplish his intention. If we tell him to look upwards or in- ivards, he fails in both ; and even when he endeavours to look straight forwards, the eye is scarcely, if at all, moved from its po- Uition.t In some rare cases it happens, that after this paralytic J state of the muscles supplied by the third pair has continued for ' jome time, the abductor becomes also palsied, so that the eye is no longer turned towards the temple, but looks directly forwards, and ;an be moved by any voluntary effort of the patient neither up- ;vards, downwards, inwards, nor outwards. We may conclude, in mch circumstances, that the disease which originally caused pres- ! sure on the third pair only^ has extended so as to effect the sixth laair also, While the motions produced by the recti are thus partially or to- ;ally impeded, the involuntary movement upwards of the eyeball, ivhich takes place when we wink, or close the eyes in sleep, and vhich is attributed to the action of the obliqui, is in some cases re- gained, while in other causes this motion also is lost. ■ We generally find, in cases of palsy of the muscles of the eye- ijall, that the fifth nerve and the portio dura continue to exercise ..heir functions. The retina also retains its sentient power, at least n a very considerable degree. It not unfrequently happens, how- ; iver, that the pupil is fixed and vision somewhat indistinct. ! Headach, vertigo, and double-visioOj generally attend attacks of oalsy of the muscles of the eyeball. The stomach and bowels are lilso often deranged. Causes. As I have already hinted, there are two varieties of this palsy, the one rheumatic, and the other cerebral. The former irises from exposure to cold, while the cerebral is owing either to 5udden effusion, or slow disorganization within the cranium. Treahnent. I have nothing to add to what has been said under ji^hia head at page 143. The same morbific causes being in opera- [tipn must be combated by the same remedies. In rheumatic, and ' • See page 143. t Luscitas, 204 sudden cerebral cases, we are often successful by merns of deple- tion, counter-irritation, sorbefaction, &c. while in the lIow cerebral cases, we are too often but mere spectators of the loss of one func- tion after another, till death closes the scene. SECTION III. DOUBLE VISION FROM WANT OF CORRESPOND- li ENCE IN THE ACTION OF THE MUSCLES OF THE EYEBALL. In strabismus, there is a want of correspondence in the actions of the muscles of the eyeball, and at the commencement of the complaint, there is double vision ; but it would appear, that double vision occasionally occurs with so very slight a degree of distortion of the eyes, as scarcely to be observable. The double vision to which I refer, takes its origin, at least in some cases, from over- exertion of the eyes, and is an affection of the muscles of the eye- ball. It is of importance to be aware of the existence of cases ol this kind, lest we should confound them with those in which double vision is owing to an affection of the brain, or of the optic nerve. Sir Everard Home, who first pointed out the practical importance of this distinction, has related two cases as illustrative of the symp- toms and treatment of the subject of this section. The cases are interesting in several respects, although it must be confessed that there is no very conclusive evidence to prove that the symptoms were dependent merely on an affection of the muscles of the eye- ball, and not on the state of the brain. The first case which led him to pay attention to the subject, was that of a lieutenant-colonel of engineers, who was in perfect health, shooting moor-game upon his own estate in Scotland. He was very much surprised towards the evening of a fatiguing day's sport, to find all at once that every thing appeared double ; his gun, his horse, and the road, were all double. This appearance distressed him exceedingly, and he became alarmed lest he should not find his way home ; in this, however, he succeeded, by giving the reins to his horse. After a night's rest the double vision was very much gone off; and in two or three days he went again to the moors, when his complaint returned in a more violent degree. He went to Edinburgh for the benefit of medical advice. The disease was referred to the eye itself, and treated accordingly ; the head was shaved, blistered, and bled with leeches. He was put under a course of mercury, and kept upon a very spare diet. This plan was found to aggravate the symptoms ; he therefore, after giving il a sufiicient trial, returned home in despair, and shut himself up in his own house. He gradually left off all medicine, and Hved as usual. His sight was during the whole time perfectly clear, and at the same time near objects appeared single ; at three yards they became double, and by increasing the distance, they separated farther from each other. When he looked at an object, it was perceived by a I 205 by-stander, that the two eyes were not equally directed to it. The complaint was most violent in the morning, and became better after dinner, when he had drank a few glasses of wine. It con- tinued for nearly a twelvemonth, and gradually went off. Sometime after the recovery of this gentleman, a house painter, who had worked a good deal in white lead, was admitted a patient into St. George's Hospital, on account of a fever, attended with violent headach. Upon recovering from the fever, he was very much distressed at seeing every thing double ; and as the fever was entirely gone, he was put under Sir Everard's care for this affection of his eyes. Upon inquiring into his complaints. Sir E. found them to correspond exactly with those of the former case, and therefore treated them as arising entirely from an affection of the muscles. He bound up one eye, and left the other open. The patient now saw objects single and very distinctly, but looking at them gave him pain in the eye, and brought on headach. This led Sir E. to be- lieve he had erroneously tied up the sound eye ; the bandage was therefore removed to the other, and that which had been bound up was left open. He now saw objects without pain or the smallest uneasiness. He was thus kept with one eye confined for a week, after which the bandage was laid aside ; the disease proved to be entirely gone, nor did it return in the smallest degree while he remained in the hospital. Rest alone had been sufficient to allow the muscles to recover their strength, and thus to produce a cure. Sir Everard concludes by observing, that when muscles are strained or over-fatigued, to put them in an easy state, and confine them from motion, is the first object of attention, and that this prac- tice is no less applicable to the muscles of the eye, than to those of other parts.* SECTION IV. STRABISMUS. Symptoms. In this disease, although the patient means to look at the same object with both eyes, one of them, moving involun- tarily, and independently of the motions of the sound eye, turns away from its natural directions. If the sound eye is now closed, the other generally returns to the proper position, and so long as it is used alone, can be carried by the will of the patient in any di- rection he pleases. The instant, however, that the sound eye is again opened, the one affected with strabismus revolves inwards or outwards, and there it remains, not harmonizing in the movements of its fellow, or if it does move along with the sound eye, yet never so as to permit the two axes to 15e pointed at the same object. Hence the patient sees double, especially in the commencement of this disease ; but after it has continued for a length of time, the double vision wears off * Philosophical Transactions for 1797, Part I. p. 7. 206 The eye is much more frequently distorted inwards than out- wards in this disease. The former case is termed strabismus con- vergens, and the latter divergens. In some individuals, we find the eyes to squint alternately, or even both together. The vision of an eye that squints is almost always imperfect ; and, of course, those who squint with both eyes, see indistinctly and confusedly. Those who squint inwards with both are gen- erally very short-sighted. Causes. Strabismus is connected with many remote causes, each of which may be regarded as giving rise to a different variety of the disease. 1. Strabismus appears to take its origin, in many cases, from improper education of the eyes in young children. In all new- born children, there is a great mobility and restlessness of the eyes, an uncertainty with which they fix their eyes on objects, and not unfrequently a degree even of strabismus. Their eyes must be educated to regular and harmonious movement, by exposing them equally to the light, and presenting to their view objects likely to fix their attention, neither too near nor at too great a distance, and - much less in any unnatural direction. Any of these errors appears capable of inducing strabismus. For example, this disease is oc- casionally to be attributed to the bad custom which nurses some- times have of laying a child in such a position in its cradle, that it sees the light, or any other remarkable object, with one eye only. or of holding the child's toy too near its eyes, and of amusing it j by suddenly presenting some favourite object close to its face. | Strabismus divergens is attributed to the improper practice of ac- i customing a child to look at the same time at two objects of which it is fond, but which are distant from one another. The child lying in its cradle, for example, with the window on one side and the nurse on the other, instead of alternately directing its eyes to these two objects, may get into the habit of distorting one of the ■ eyes in order to see both of them at once. * 2. Children occasionally become squinters from a fashion of looking at the point of their nose, or if there be any wart or spot t upon it, by attempting frequently to inspect this deformity. They \ thus distort the eyes, and fall into the habit of doing so uncon- sciously. 3. Imitation has been accused as a cause of squinting. 4. Darwin was of opinion, that the most general cause of squint- ing in children was the custom of covering a weak eye, which had become diseased by any accidental cause, before the habit of ob- serving objects with both eyes was perfectly estabUshed. 5. Strabismus is sometimes attributed to spasm of one of the recti, and this spasm is in its turn supposed to arise from a variety of causes, as terror from a puncture of the eye, &c. I was con- sulted by the friends of a little boy, who became affected wdth strabismus immediately after squirting the oily juice of a piece of orange skin into his eye, which produced a great degree of pain. 207 6. A speck on the cornea is a frequent cause of squinting. By turning" the eye out of the natural axis of vision, the patient is able to see better past the speck. He is very apt so to turn the eye with the speck, if it happens to be the better eye of the two. In this way strabismus is not an unfrequent consequence of strumous ophthahnia. 7. The most frequent cause of strabismus appears to be imper- fect vision from short-sightedness, or from congenital defect of the retina. The distorted eye, in almost every case, is very consid- erably inferior in its power of sensation to the other. I use the words very considerably^ because we meet with many individuals who have the eyes slightly unequal, who do not squint, and with others who have laboured from birth under complete, or almost complete amaurosis of one eye, and yet are quite free from stra- bismus. Buffon considered the inequality which produced stra- bismus as averaging 3-8ths. The impression, then, on the one eye, being considerably weaker, than that on the other, is very liable to be neglected altogether, and that eye, instead of being fixed on the objects before it, is left to wander from the true axis of vision. There seems even to be an instinctive attempt, in some cases, still farther to distort the weak eye, and to turn it so far in- ward, and under the upper lid, that no impression can be received upon it, but that the sound eye only shall become the instrument of sensation. 8. Strabismus is induced by various diseases of the brain, as apoplexy, epilepsy, hydrocephalus, cerebral irritation from worms, or from teething, &c. Amaurosis, affecting both eyes, is generally attended by a shght degree of strabismus. 9. Whatever be the remote cause of strabismus, we cannot doubt that its proximate cause must in some way or other affect the mus- cles of the eyeball. One or more of these muscles must be in a 3tate rendering them incapable of their natural exercise. The muscular substance may be in a state of atony, or the nervous ener- gy which ought to animate them, may be imperfectly supplied. In by far the greater number of cases of strabismus, the eye rolls in- voluntarily inwards, which may lead us to conclude, that the ab- ductor is in a state of unfitness for its office. It is not absolutely paralyzed, for on closing the sound eye, it evidently exerts its proper function, but from some cause to us unknown, as soon as the sound eye is again opened, the muscular force of the abductor is no longer able to support the eye in its natural direction, so that the distortion immediately returns. Treatment. 1. Our first object in the treatment of strabismus, must be to discover the cause. When this is accomplished, the plan of cure will be obvious ; or, perhaps, we shall find reason to consider the defect as irremediable. i 2. As strabismus often arises in children from abdominal irrita- jytion, we ought first to try the effect of an active purge or two ; and 208 then follow this up by mild aperients, and a carefully regulated diet. Squinting children are generally weakly, and often strumous, so that a course of tonic medicine will probably be useful. 3. Strabismus is frequently observed in children to be connected with a careless employment of the eyes, which is instantly corrected by exciting their attention. In other cases, the squint is never ob- served except when the child is in bad temper. 4, When only one eye squints, and when the defect in the sight of that eye is not very great, much may be done, by strengthening its muscles, to cure the strabismus. The strengthening of the mus- cles is effected chiefly by tying up the sound eye, and thus obhging the patient to exercise only the eye v^^hich squints. Whenever the sound eye is bUnd-folded, the weak eye recovers its natural position in the orbit, and its natural motions. The patient finds that the sight gradually improves by use ; and we observe that though the strabismns does return, on again exposing the sound eye, yet it is not to the same extent, and day after day becomes less, if the plan of cure is continued. The patient need not keep the sound eye covered during the whole day. At first, this may be done for half an hour or an hour at a time, and then for longer periods. During the blindfolding of the sound eye, the -weak one is to be exercised both on distant and on near objects, but especially on the former. If the patient be a child, he must be encouraged to exercise the weak eye in playing at ball or shuttlecock, viewing extensive prospects in the countr}', reading books printed in a large type, looking at prints, &c. Many authorities might be produced in favour of the efiicaciousness of this mode of cure. Beer tells us, that by binding up the sound eye every day even for a couple of hours only, he had, in most cases, been successful.* It is worthy of remark, however, that this plan of curing strabismus is often attended by a diminished power both of motion and of vision in the sound eye ; and that it has some- times happened, that the squinting eye being cured by perseverance in this method, the sound eye has then become distorted. If both eyes squint from the first, they must be bUudfolded alternately, each for several days at a time. Another method of exercising the weak e)'e is that recommended by Dr. Jurin, in his Essay on Distinct and Indistinct Vision. Hav- ing placed the patient before us, we bid him close the undistorted eye, and look at us with the other. When we find the axis of this eye fixed directly upon us, we bid him endeavour to keep it in that situation, and open his other eye. Immediately, the distorted eye turns away from us towards his nose, and the axis of the other is pointed at us. But with patience and repeated trials, he will, by degrees, be able to keep the distorted eye fixed upon us, at least for some little time after the other is opened. When we have brought * Pflege gesunder und geschwachter Augen. p. 41. Frankfurt, 1803. 209 him to continue the axes, of both eyes fixed upon us, as we stand directly before him, it will be time to change his position, and to set him first a little to one side of us and then to the other, and so to practise the same thing. When, in all these situations, he can perfectly and readily turn the axes of both eyes towards us, the cure is effected. An adult may practise all this in a mirror, without any director, though not so easily as with one. 5. As there is an inequality in the sensations of the sound and of the weak eye, it has been suggested that we should endeavour to render them more on a par, and that this of itself would tend to correct the distortion. Buffon recommended, therefore, that the patient should wear a pair of spectacles with a plane glass op- posite to the bad eye, and a convex glass opposite to the good eye. In this way, the vision of the good eye would be rendered less distinct, and consequently it would be less in a state to act inde- pendently of the other.* As the weak eye is often short-sighted, the same advantage might perhaps be derived from placing a plane glass before the good eye, and a concave glass before the distorted one. 6. The treatment of strabismus will, of course, be varied, ac- cording as the cause is more or less intimately connected with the muscles of the eyeball. A mere bad habit in the use of these muscles will probably be completely overcome by the first two means. In cases of speck of the cornea, short-sightedness, partial amaurosis, disease within the cranium, nervous irritation commu- nicated from distant organs, means suited to these different causes must be adopted. In some cases, a certain degree of success ob- tained by one plan must be followed up by another of a totally" different kind. Thus, Pellier relates the case of a girl whose squint was occasioned by a speck on the cornea consequent to small-pox. By the use of stimulating drops, he removed the speck, but the strabismus remained the same. He then began a careful system of exercise, with the sound eye covered, and by this means effected a cure.t 7. In cases of strabismus convergens, affecting both eyes, it is recommended that a pair of blinders, projecting in front of the temples, should be tried, during at least a portion of every day, with the view of attracting the eyes outwards ; and that when the blinders are laid aside, a broad green shade should be worn. Darwin employed a different plan, and with considerable suc- cess, in a case which appears to have partaken of the nature of this strabismus, and which he has related in the Philosophical Transactions. The patient was a child, of 5 years of age, exceed- ingly tractable and sensible. He viewed every object which was pre- sented to him with but one eye at a time. If the object was present- * Dissertation sur la Cause du Strabisnoe. Memoires de I'Academie des Sciences pour 1743, p. 338. 12mo. Amsterdam, 1748. t Recueil de Memoires et d' Observations, p. 410. Montpellier, 1783. 210 ed on his right side, he viewed it with his left eye, and vice versa. ■■ He turned the pupil of that eye, which was on the same side with' the object, in such a direction that the image of the object might fall on that part of the bottom of the eye where the optic nerve enters it. When an object was held directly before him, he turned his head a httle to one side, and observed it with but on& eye, viz. with that most distant from the object, turning away the other in the manner above described ; and when he became tired with observing it with that eye, he turned his head the contraryl "way, and observed it with the other eye alone, with equal faciUty ; but never turned the axes of both eyes on it at the same time. He saw and named letters, with equal ease, and at equal distances,! with the one eye as with the other. There was no perceptible difference in the diameters of the irises, nor in their contractihty/ after having covered his eyes from the light. From these circum- stances, Darwin was led at first to conclude that there was no de- fect in either eye,* but that the disease was simply a depraved habit of moving his eyes, which might probably be occasioned by the form of a cap or head-dress, which might have been too prom- inent on the sides of his face, like bluffs used on coach-horses, and might, in early infancy, have made it more convenient for the child to view objects placed obUquely with the opposite eye, till by habit tlie adductores were become stronger, and more ready for motion than their antagonists. Darwin recommended a paper gnomon to be made, and fixed to a cap. When this artificial nose was placed over his real nose, so as to project an inch between his eyes, the child, rather than turn his head so far to look at oblique objects, immediately began to view them with that eye which was next to them. The plan of cure was not persisted in ; so that, six years after, Darwin found all the circumstances of this child's mode oi vision exactly as they had been, except that they seemed estab- lished by longer habit, so that he could not bend the axes of both his eyes, on the same object, not even for a moment. By Darwin's advice, a gnomon of thin brass was made to stand over his nose, with half a circle of the same metal to go round his temples. These w-ere covered with black silk, and by means of a buckle behind his head, and a cross-piece over the crown of his head, this gnomon was worn without inconvenience, and projected before his nose about two inches and a half. By the intervention of this instrument, he soon found it less inconvenient to view oblique objects with the eye next to them, instead of the eye opposite to them. After this habit was weakened by a week's use of the gnomon, two bits of wood, about the size of a goose-quill, black- ened all but a quarter of an inch at their summits, were frequently presented for him to look at, one being held on one side the ex- * From a series of experiments which he afterwards made, he came to the condu- sion that the insensible spot at the bottom of this child's eye was four times the arei of that in the eyes of others. . 211 I tremity of the gnomon, and the other on the other side of it. As he viewed these, they were gradually brought forwards beyond the gnomon, and then one was concealed behind the other. By this means, in another week, he could bend both his eyes on the same object for half a minute together. By the practice of this exercise, before a glass, almost every hour in the day, he became in another week able to read for a minute together, with his eyes both directed on the same objects. By perseverance in the use of the artificial nose, he acquired more and more the voluntary power of directing both eyes to the same object, particularly if the object was not more than four or five feet from him, so that Darwin anticipated a com- plete cure.* i 8. In strabismus divergens, affecting both eyes, the alternate bUndfolding of the eyes is as likely to be useful as in the conver- gens. It has also been recommended to apply a piece of black s plaster on the point of the nose, which may attract the patient's ; view, and correct the divergence. Weller recommends a short funnel, made of pasteboard, with an 'oval base, to be so applied as to include both eyes, and having, at ithat part which rests above the point of the nose, an opening about an inch in diameter. Through this instrument, fixed perfectly straight and firm, the patient must look, and by and by read. He ;is obliged, by this contrivance, when he wishes to see or to read jany thing, to turn the eyes inwards and downwards.t |«ECTION V. LUSCITAS, OR IMMOVABLE DISTORTION OP THE 1 EYEBALL. ) The word luscitas, has been used in various senses by authors oa. the diseases of the eye. Plenck employs it as synonymous with ) oblique vision, or that state of the eyes, in which the patient, see- jing little or nothing when he looks directly forwards, perceives ob- jjects situated to one side, but without any distortion of the eye ; t while Beer understands by luscitas, that the eye is turned to one or other side, and is there completely fixed, so that the patient is una- ■ ble to move it.§ Luscitas, in this sense, is often confounded with ! strabismus; but in the latter affection, the patient is able to direct I the distorted eye upon any object as soon as he closes the sound : eye, while, to effect the same purpose in luscitas, he must rotate [ the head. I * Philosophical Transactions for 1778, Vol. Ixviii. Part i. p. 86. ' t Krankheiten des Menschlichen Augen. p. 234. Berlin, 1819. i i Luscitas sen visus obliquus est ocuh vitium quo segrotus objecta non directe sed '; oblique solummodo \idere potest. Differt luscus a strabone, luscus enim oculum non distorquet. Doctrina de Morbis Oculorum, p. 214. ViennsB, 1777. § Der Schiefsehende vermag es aber entweder gar nicht, oder nur mit sehr grosser , Beschwerde, den Augapfel in die seiner fehlerhaften Stellung entgegengesetzte Rich- ii tung zu bringen. Lehre von den Augenkrankheiten. Vol. ii. p. 667. Wein, 1817. 212 Causes. Palsy of the rectus internus, attended generally by a similar affection of the rectus superior, rectus inferior, and levator palpebree superioris, while the rectus externus retains its power, and rolls the eye outwards, is the most frequent cause of immovable distortion. Injuries of the muscles of the eyeball, or of the nerves, may produce a similar effect ; also, the pressure of tumours with- in the orbit, or a congenital deficiency of one of the recti. Treatment. Luscitas is often incurable. The turning of the eye outwards, in palsy of the muscles, may go off, the eye coming again to be directed forwards, merely in consequence of the palsy extending to the rectus externus. Except in cases of injury of the muscles, or their nerves, and of orbital tumours, the treatment of luscitas is that already recommended for palsy of the muscles of the eyeball. SECTION VI. OSCILLATION OF THE EYEBALL. Symptoms. In this disease, the eyeball is affected with an almost perpetual semi-rotatory motion, round its antero-posterior axis. The patient is not conscious of this motion, nor can he restrain it. The motion varies in extent, from a scarcely perceptible degree, to as much as a fourth of the circumference of the eyeball. It seems to be produced by the antagonizing action of the obliqui, the recti having lost, in a great measure, their control over the eye. Pa- tients affected with partial amaurosis often complain of all objects appearing to them in a state of tremor, but this does not seem to depend on oscillation, but probably arises from some peculiar mor- bid state of the retina. Causes. This affection frequently attends the partial amaurosis, which in many cases is consequent to deep-seated strumous inflam- mation of the eyeball. Congenital cataract, especially if of some years' standing, is always attended by oscillation. This is urged as a reason for operating at an early period of life in cases of that kind. Fatiguing employments of the sight always increase this unsteadiness of the eyes ; while it generally subsides, in some mea- sure, after a period of rest. It is often attended by short-sightedness, a sense of weariness in the eyes, and sometimes by pain deep in the orbits and in the head. Treatm,ent. Even in the most favourable cases of oscillation attending congenital cataract, this symptom diminishes very slowly after the pupils become clear, from the removal of the opaque lens. If partial amaurosis has accompanied the cataract, the oscillation continues unchanged. In cases of oscillation attending partial amaurosis, and accompanied by pain deep behind the eyes, the occasional application of leeches to the temples both relieves the pain, and lessens the oscillation. Rest of the eyes, and a course of tonic medicines, are indicated in most other cases of oscillation ;, but, it must be confessed, are rarely productive of a permanent and, complete cure. 213 SECTION VII. — NYSTAGMUS. This term is used to signify an involuntary motion of the eyeball from side to side. It is a clonic convulsion of the recti, symptoma- tic of various nervous diseases, as hysteria, epilepsy, chorea, &c. SECTION VIII. TETANUS OCULI. A fixed state of the eyeball, from tonic spasm of all, or several of •the recti, is so called. CHAPTER VIII. DISEASES IN THE ORBITAL CELLULAR MEMBRANE. SECTION I. — INFLAMMATION OF THE ORBITAL CELLULAR MEMBRANE. The fatty cellular membrane which envelopes the muscles and nerves of the orbit, and by which the eyeball is supported, is sub- ject to acute phlegmonous inflammation, ending in suppuration, and forming one of the most severe and dangerous affections of the organ of vision. Symptoms. During the first, or purely inflammatory stage, pain is felt, deep in the orbit, rapidly increasing in severity, and extending to the forehead and temple. The eyeball feels as if con- stantly pressed upon, or as if the orbit had become too small to contain it. The pain is greatly increased by touching the eye, or attempting to move it. The patient is distressed by the sensation of flashes of fire in the eye. Vision soon begins to fail, from the pressure exercised on the eyeball by the inflamed and tumefied parts by which it is surrounded, from the inflammation spreading to the optic nerve and its envelope, and from the nerve being put on the stretch by the projection of the eyeball forwards in the orbit. The eye is soon observed to be more prominent than natural. The conjunctiva becomes red and chemosed. The pupil is contracted from irritation, and in some cases the eyeball partakes in the in- flammation. This, however, is by no means constantly the case ; matter may even form behind the eye, and yet its proper textures remain apparently uninjured. When they do inflame, the iris becomes discoloured and motionless. The eyelids are red, painful, and swollen, as if affected with erysipelas, and move with difficulty. ,The secretion of tears is soon checked, from the lachrymal gland staking part in the inflammation, but till then there is epiphora. 214 The symptoms of inflammatory fever attend these local appear- ances. The pulse is hard, full and frequent. The face is flushed, The patient is thirsty, his skin hot, he rests none, and is often deUrious, especially during the night. The inflammation may . extend to the membranes and substance of the brain, and then we have all the usual symptoms of phrenitis. In the second stage, matter having formed behind, or to one side of the eyeball, it is still more protruded, and is more or less distorted. It is sometimes so much protruded, as to project beyond the eyelids, pushing them aside, and presenting the displacement called exoph- thalmos. The matter generally presses forwards to the front of the orbit, and fluctuates behind the conjunctiva, or between the edge of the orbit and one or other of the eyelids. In some cases, there are several points of fluctuation. If there is only one, it is reasona- ble to conclude, that suppuration has taken place only on one side of the eye. The eyeball, in this case, is thrown forwards in an oblique direction. Not unfrequently the eyeball is destroyed by suppuration. Matter is seen to be lodged behind and in the sub- stance of the cornea, which after a time bursts, and allows the hu- mours to be evacuated. The photopsia continues, the delirium in- creases, the pain becomes more distinctly pulsative, and is of agoniz- ing severity. Vision is totally destroyed. Even, when the eyeball has not suffered much in texture from the inflammation, the retina is left in a state of insensibility. In some cases, apoplectic and fa- tal symptoms occur before the abscess is so much distended as to point externally. Rigors generally attend the second stage. The pulse falls when the matter first begins to form, but rises again when the abscess becomes distended. If this disease be neglected or mistreated, the inflammation may spread not only to the eyeball, but to the periosteum and bones of the orbit, or the matter may make its way into the nostril, the max- illary sinus, or even the cranium.* Although, in general, inflammation of the orbital cellular mem- brane is an acute and rapid disease, in some cases it assumes a chronic form, so that matter slowly accumulates within the orbit. At length the lids become swoln and red ; fluctuation is felt ; the abscess bursts, and leaves a sinus which is apt for a length of time , to discharge matter, even when there is no affection of the bones. It sometimes happens, in consequence of this disease, that the eyeball remains permanently protruded and motionless, from the indurated and adherent state of the cellular membrane. In this case, the tears run over the cheek, the eyelids cannot close, the sur- face of the eye becomes inflamed and tender, and sometimes head- achs supervene, with iusomnolency, fever, and great anxiety. t Causes. These are confessed to be, in many cases, very ob- scure. Benedict tells us that this disease occurs for the most part in * See pp. 29, 30. t Guthrie on the Operative Surgery of the Eye, p. 1 55. London, 1822. 215 plethoric individuals, after sudden changes of temperature, and in scrofulous or otherwise disordered constitutions. Foreign bodies, hrust with violence between the edge of the orbit and the eyeball, ind even slight injuries, occurring in pecuhar constitutions, or under particular circumstances of the system, may bring on inflammation jf the orbital cellular membrane. Thus, Weller instances a case «rhich occurred in a healthy young woman, who happened, while n the state of menstruation, to receive a slight lacerated wound of ;he orbit. The fright occasioned by the injury brought on inter- •uption of the menses, and without any other apparent cause, a levere inflammation followed of the whole cavity of the orbit. The jxtirpation of orbital tumours sometimes gives rise to severe inflam- mation, ending in suppuration. TreatTnent. A vigorous antiphlogistic treatment must be had •ecourse to, in the first instance. Copious and repeated bleedings Tom the arm, a liberal application of leeches round the orbit, cold otions to the head, free purging, abstinence, rest, and darkness, are ividently indicated. Even when the constitution is not robust, this sort of treatment must be followed, if we mean effectually to save ,he vision, and, it may be, even the life of the patient. The debil- ity arising from the use of active antiphlogistic means of cure may iasily be removed, while a temporizing or timid plan of treatment nay be productive of the most serious mischief. If the conjunctiva s chemosed, it should be freely scarified, or pieces of it cut out, ^Miich will procure a considerable flow of blood. Benedict recom- mends sinapisms to tjie neck, friction of the forehead and temple Arith mercurial ointment, and large doses of calomel internally. An opening through the conjunctiva, or through the eyelid, for .he evacuation of the matter collected within the orbit, is the chief loint of the treatment in the second stage. A deep and free inci- sion is to be made wherever the fluctuation is discovered ; and even ivhen there is no distinct fluctuation, if other symptoms are present ivhich lead us to conclude that in all probability matter has formed, I is safer to plunge the lancet into the part which is swollen, and vvhere we think suppuration is most hkely to have taken place, than ,0 allow the matter to accumulate, the bones perhaps to suffer, or 3ven the brain to become affected. Of course, in opening the abscess, care must be taken to avoid the eyeball and other important parts. This incision ought to be kept open with a dossil of lint, and a poultice is afterwards to be applied. The eye is frequently to be fomented with decoction of poppies, or aqueous solution of opium. At the second or third dressing, after the abscess has been evacuated, the opening into the orbit may be cautiously examined with the probe. If it is not deep, the dossil of lint is gradually to be diminished in thickness, and pushed less into the orbit, till the sinus closes completely. If, )on the other hand, the sinus, or sinuses are deep, running back lalmost to the bottom of the orbit, a mixture of tepid water and 216 laudanum ought daily to be injected. This is to be continued till the probe is found not to pass beyond the eyeball. The lint may be introduced to this depth, and is not to be lessened till the back part of the sinus close. 1 have already explained the necessary treatment in cases where the bones of the orbit are found to be affected.* If the eyeball has suffered much, so that the aqueous chambers are distended with pus, it will be proper to open the cornea ; but if only a small quantity of matter is lodged in the anterior chamber, or between the lamellae of the cornea, we may rely on this being absorbed, if the general inflammation of the eye and orbit is once subdued. To promote the absorption of matter, it is recommended to touch the cornea once a day with the vinous tincture of opium. In four or five days after the orbital abscess is opened, all the dangerous symptoms have in general subsided, and the use of active antiphlogistic remedies may be laid aside. Easily digested food, in moderate quantities, may be allowed, and if the patient has been much weakened by the previous depletion, some such tonic may be given as is not apt to excite the vascular system. Cases. I have already stated the principal circumstances of a case related by Saint- Yves, and of another by Demours, in which this disease ended in extensive caries of the orbit.t Mr. Lawrence has related, with his usual clearness, two cases which fell under his care in an early stage of the complaint. " Some time ago," says he, " I saw two instances of this affection, in which the local and general symptoms were characterized by a degree of violence which I have hardly ever witnessed in any other case. One was that of a young man between twenty and thirty years of age ; he came to me accompanied by his wife, who told me that he had suffered such agonizing pain for the three or four preceding nights, that she was afraid he would have gone out of his mind. In this case, matter was presenting just under the su- perciliary ridge : after making a free opening, a large quantity issued out, and, upon putting in a probe, it went to the bottom of the orbit. The other case occurred in a child between three and four years old ; the local and general symptoms were equally severe ; the matter presented between the lower lid and the globe, but the quantity discharged, on making an opening, was not very considerable in this case. In both instances the globe of the eye was very much protruded, but not actually thrust out; and after the matter was discharged it receded to its natural situation ; in the child, vision was restored, but in the adult the eye, although it had not been inflamed, remained amaurotic." X A case is recorded by Mr. Guthrie, of a soldier, wounded by a bayonet, wliich penetrated into the orbit without injuring the eye, , The symptoms which ensued were trifling, until the patient con- ' * See Chapter I. Section ii. t See p. 30. t Lectures in the Lancet, Vol. ix. p. 500. Lon^ion, 1826. 217 irived, three days afterwards, to absent himself for twenty-four hours, and get drunk. On his return, the eyeball was protruded, ;he lid could not be raised so as to expose the eye, which was bighly inflamed ; chemosis had taken place, vision was indistinct, ;he iris was discoloured, the pupil contracted ; the pain was excru- Mating, both in the eye, which felt as if it were too large for the Drbit, and all over the forehead and temple of that side ; flashes of light of various colours darted through the eye, in consequence of :he surrounding pressure upon it; the swelling increased, the patient became delirious, and an abscess burst in the upper eyelid on the fourth day, without any alleviation of the symptoms. He soon afterwards became comatose, and died, probably from the formation of matter within the cranium. The eye had previously been lost by the sloughing of the cornea.* Dr. Abercrombie quotes, from Burseiius, what appears to have been an instance of inflammation of the orbital cellular membrane, terminating fatally by suppuration extending within the cranium. A woman, after suffering for a fortnight severe pain in the left side of the head, was seized with swelling and inflammation on the left eyebrow, eyelids, and cheek. After several days, the swelling suppurated and discharged much matter, and the left eye was found to be blind ; after a few days more, she was seized with convulsions, and died comatose. On dissection, the external sup- puration was found to have penetrated to the bottom of the orbit, betwixt the bone and the ball of the eye, without injury of the ball itself; internally there was an extensive collection of matter, which communicated freely with the cavity of the orbit.t SECTION II. INFILTRATION OF THE ORBITAL CELLULAR MEM- BRANE. There are several very remarkable instances recorded of exoph- thalmos, in which there appears to have existed neither inflamma- tion of the orbital cellular membrane, nor any circumscribed orbi- tal tumour. In some of th ecases to which I refer, the exophthalmos yielded after the use of internal remedies, and although it is im- possible to determine the exact nature of the cause to which the protrusion of the eye was owing, the facts are too valuable to be, on this account, passed over without notice. Saint- Yves entitles the chapter in which he gives the three cases which I am about to quote from his work, Des Amas df Hmneurs qui se font derriere le Globe de V CEil. The case which I have already quoted at page 72, from Landmann, proves, by dissection, that the eye may be pushed from the socket, by a cause quite distinct from abscess on the one hand, and on the other from circumscribed tumour. * Lectures on the Operative Surgery of the Eye, p. 146. London, 1823. + Abercrombie on Diseases of the Brain, p. 43. Edin. 1828. . 28 218 Inflammation of the periosteum of the orbit, terminating in thick- ening' of that rriembrane, might give rise to similar ss'mptoms as those produced by infiltration of the orbital cellular membrane, and might yield, peihaps. to the same remedies. Case. 1. In the first case related by Saint- Yves, he supposes the fatty cellular substance behind the globe of the eye. as well as the lachrymal gland, to have been tumefied by the efTusion of a viscid fluid. The eyeball was protruded at least three lines. Several surgeons who were consulted wished to extirpate the lach- rymal gland, in the hope that the suppuration of the wound would lead to the replacement of the eye, and dissipate the swelling within the orbit. Saint- Yves objected to this proposal, being afraid lest the disease, which appeared to him of a scrofulous nature, might degenerate into cancer. He cured it perfectly by a three months' course of cethiops mineral. Case 2. The subject of Saint- Yves" second case was a young man, who came to Paris, with the globe of the eye inflamed, af- fected with epiphora, and extremely protruded. The eyelids, pressed by the globe against the edge of the orbit, were swoln, and the upper was even beginning to be livid, as if read}^ to fall into a state of gangrene. The patient attributed his complaint to a coup de soleil. which had been followed first of all by pain deep in the orbit, and then by protrusion of the eyeball. Saint- Yve~: concluded from the symptoms; that either there was an abscess behind the eye, or that the fatty cellular membrane of the orbit was tumefied by infiltration. Had he been certain that it was ab- scess, he would have pushed a lancet through the orbicularis pal- pebrarum to the bottom of the orbit, but afraid of doing so without reason, he resolved to try the eflfect of a sorbefacient treatment. He ordered, therefore, eight grains of calomel at night, with a dose of senna, manna, and jalap next morning : and in the mean- time bled the patient from the external jugular vein. Finding that the first dose produced some good effect, he continued the calomel and the purgative mixture ; and in a few days had the satisfaction of finding the exophthalmos completely removed. Case 3. Saint- Yves relates a third case, in which the symp- toms were for a time alleviated b}' the use of remedies : but at length the pain gro\\-ing insupportable, and totall}- preventing sleep, the eye at the same time becoming disorganized, he removed the contents of the orbit. Unfortunately he neglects to give any account of their appearance on dissection, although he speaks con- fidently of the cause of the protrusion, as un amas d'humeurs visqueses* Case 4. Louis quotes, from the Medicina t^eptejitrionalis of BonetuS; the case of a girl of three years of age, whose right eye was almost entirely protruded from the orbit. Bonetus was * Nouveau Traite des Maladies des Yeus. p. 141. Paris. 1722. 219 isked whether a setoii in the neck was hkely to be useful. He observed that the child's clothes were much shorter before than be- iiind, and this led him to examine the abdomen. He found it ex- rernely tumid, tense, and hard. The child, in fact, presented the symptoms of tabes infantum, Bonetus thought that nothing could 1 36 done directly for the eye, but that the obstructed state of the bowels only should be attended to. After being purged, she was 3ut on the use of tincture of rhubarb for a month. The exophthal- 7103 gradually decreased as the abdomen fell; and by the time i;hat the digestive organs were restored to a state of health, the 3yeball had, without any other means of cure, recovered complete- y its natural situation.* (SECTION III. SCIRRHUS OP THE ORBITAL CELLULAR MEM- BRANE. I have repeatedly seen the cellular substance near the front of the ')rbit become hard and tuberculated, in consequence of slow inflam- TQation, occasioned by an injury. In one instance a piece of lime- stone struck the outer edge of the orbit, producing a lacerated wound ^ 3f no great extent, and which readily healed. Some time after a small hard swelhng formed at the site of the injury, was extirpated, md was found to contain a minute fragment of hmestone. After some months, another small tumour made its appearance in the 5arae spot, and in connexion with it another, attached so firmly to -he edge of the orbit, that it was taken for an exostosis. In a few veeks, a third circumscribed swelling was discovered running along .he lower edge of the orbit, more movable than that last mentioned, Dut firm to the touch as a piece of cartilage. The patient was ander the care of Mr. Samuel Clarke, of this town, whom I assisted it the removal of the tumours. The two which felt so like exos- oses, lay partly within the orbit, and adhered firmly to its perios- teum. On making a section of them, they presented the white striated texture of scirrhus. The extirpation was accomplished ifter a semilunar incision, running parallel to the outer and lower 3dge of the orbit, and every particle of indurated substance was carefully removed. Nearly a year has elapsed since the operation, and there has been no return of the disease. SECTION IV STEATOMATOUS AND ENCYSTED TUMOURS IN THE ORBIT. Sytnptoms. Whatev^er be the nature of a morbid growth with- in the orbit, be it steatomatous, encysted, aneurismal, or osseous, it necessarily gives rise to displacement, protrusion, and iramobilit)'' of the eye, pressure on the eyeball and its nerves so as to cause * Memoires de 1' Academic de Chirurgie, Tome xiii. p. 35D. 12mo. Paris, 1774» 220 pain, and traction of the optic nerve, which, added to the pressure, brings on amaurosis. This last is often the earhest symptomwhich attracts attention. A great degree of deformity is produced by the unnatural position of the eyeball in such cases, even when it is not at all affected in structure. There is intolerance of light, the tears run over the cheek, the pain extends from the orbit to the head, and at length the eye inflames, and is disorganized. The steatoraatous or sarcomatous tumours of the orbit are more or less of a firm consistence, and often very hard. They are more rare, and grow more slowly than the encysted tumours, but seldom reach so great a size. They appear altogether beyond the influence of sorbefacient remedies, as indeed do also the encysted tumours ; the latter, however, are, at least in many cases, susceptible of a palliative cure, while for the former there is no resource but extir- pation. When an encysted tumour contains a fluid, the cyst may be punctured with temporary rehef ; and in some instances, this has been followed by a radical cure, although it is undoubtedly the preferable plan to remove the tumour completely. The contents of the encysted tumours are very various ; sometimes limpid like white of egg, in other cases a thick bloody fluid, in others a sub- stance like pap or honey, in some rare cases a collection of the par- asitical zoophites called hydatids. No part of the orbit is exempt from becoming the seat of steato- matous and encysted tumour. They grow near the front of the cavity, so as from the first to advance before the eyeball. Their most frequent situation is below the eye and somewhat behind it. They grow above and behind the eye. Less frequently are they found by the nasal or temporal side of the orbit. In some cases, they have surrounded the optic nerve. The connexions of these tumours are very different in different cases ; sometimes loose, so that on exposing the tumour, it is easily separated and extracted, while in other cases it adheres fii'mly to the muscles and nerves, insinuates itself between these parts, in- volves the lachrymal gland, or adheres firmly to the eyeball, the optic nerve, or the walls of the orbit. They have all a tendency to advance out of the cavity of the orbit; pushing on between its walls and the eyeball, pressing the eyeball forwards and to one side, projecting the eyelids or everting them, and elevating the conjunctiva. When considerably ad- vanced, we are able to detect a degree of fluctuation in many of the encysted tumours, while the steatomatous feel sohd and resisting. The encysted are often so soft, that on pressure they seem to retire within the orbit, appearing again as soon as the pressure is removed. They are always more elastic to the touch than the steatomatous tumours. It is a fact worthy of remark, that the pressure of a tumour within the orbit will sometimes dilate that cavity, or induce inflam- mation and caries gf its walls, the eyeball continuing to resist the 221 effects of the pressure ; while in other cases, the eyeball inflames, bursts, and is destroyed. A tumour in the orbit, if altogether left to itself, may extend to a very great size, and at length prove the occasion of the patient's death by pressure on the brain. Causes. Blows on the edge of the orbit, and exposure to cold, -are the causes most frequently referred to in the cases of orbital tu- •mours on record. Treatment. 1. Extirpation of steato?natous twmours. This may occasionally be eifected by dividing merely the skin or the conjunctiva, according to the situation of the sweUing, laying hold of the tumour with a hook or pair of hooked forceps, or passing a ligature through it, dragging it forwards, and dissecting it out with a small scalpel. In other cases, it is necessary, in order to effect the extirpation of the tumour with ease, first to disunite the eyelids by an incision, carried from their outer angle towards the temple. The conjunctiva covering the tumour is thus completely exposed, and all the remaining steps of the operation effected with less diffi- culty. When the tumour lies close to the bones of the orbit, and is perhaps adherent to its periosteum, the extirpation is more readily effected by cutting through the eyelid in a direction parallel to the fibres of the orbicularis palpebrarum, and along the edge of the or- bit, leaving the conjunctiva untouched. A perpendicular division of the lid covering the tumour has sometimes been had recourse to, but ought, if possible, to be avoided. The tumour is to be extirpat- ed, if possible, without injuring the parts in its neighbourhood, or to which it adheres. They are to be separated from it by cautious touches with the point of the scalpel, with a silver knife which serves to tear rather than cut, or with the finger-nail. But if the adhesions be inseparable, the parts to which the tumour adheres must be sacrificed. Even the eyeball will sometimes require to be removed. No portion of the tumour ought to be left, else the dis- ease will be apt to be reproduced. After the tumour is extirpated, the displaced eyeball sometimes returns immediately to its natural situation, and recovers its power of motion ; but in general this is effected not at once, but slowly in the course of several weeks or even months, and may sometimes be assisted by the application of a compress and bandage. The removal of the pressure caused by the tumour is in some cases followed, more or less immediately, by restoration of the sight of the eye ; while on the other hand, I have known the sweUing and inflammation subsequent to extirpation of an orbital tumour, produce for a time a greater degree of displace- ment than had previously existed, and a total loss of vision, in an eye with which, although much displaced, the patient had contin- ued to see till the operation. The severe inflammation which sometimes follows the extirpation of an orbital tumour, may even extend to the brain or its membranes, and prove fatal. Cases. Of the numerous cases of steatoraatous orbital tumours on record, I shall select a few, so as to illustrate the most remarka- ble circumstances attending this kind of disease, and its treatment. 222 ^ - Case 1. Tumour extirpated through the conjunctiva, after disunion of the eyelids. A woman of about 40 years of age wap admitted a patient at tlie Surgical Hospital of Gottingen, under the care of Professor Langenbeck. Her left eye was very prominent; and at the same time pressed upwards and inwards. The lower fold of the conjunctiva was protruded by a hard swelling, which pressed down the lower eyelid, and surrounded the eyeball from the inner canthus to the outer, and hence to the upper edge of the orbit. This swelling was somewhat movable, and could be surrounded by the fingers, so that no firm adhesions were to be expected. The protruded eye was of natural appearance, the pupil was regular, and the iris expanded and contracted, but there was no Arision. This Langenbeck explains by supposing that the organs which produce and transmit the sensations of light were deprived of their activity by the pressure on the eye, and the elongation of the optic nerve ; while, on the other hand, the protrusion of the e5'eball did not operate so injuriously on the cihary nerves, which, from their flexuous course, could sustain a considerable degree of traction without their functions being impeded. Langenbeck began the operation by dividing the outer commissure of the eyelids and the conjunctiva. After both eyelids were separated from the swelling, it was seen to be a steatomatous tumour, connected with the eye- ball and its muscles. The separation from these parts was accom- plished partly with the cutting part of the scalpel, partly with its handle, and partly with the finger. The large opening left after the extirpation of the tumour was filled with charpie, till granula- tions appeared. The eyeball gradually retired within the orbit, and the power of vision returned so completel}^ that the patient could distinguish the smallest object before she left the hospital. The deformit}' also was entirely removed.* Case 2. Tumour extirpated through an incision of the lower eyelid — Eyeball restored to its place by pressure. One of the most interesting cases of steatomatous orbital tumour is related by Dr. Thomas Hope. The patient was a girl, eighteen years of age, who, when about eleven, began to have her left eye turned towards the temple, by a tumour betwixt the globe and the orbit. This tumour, for some years, did not appear outwardly : but, in- creasing by degrees, at last a hard swelling was perceived exter- nally, reaching from the inner almost to the outer angle, under the lower eyehd, and half an inch down on the cheek. It forced the globe of the e3^e almost out of the socket, so that the pupil of that eye was, by measure, above 3-4ths of an inch farther from the nose than the pupil of the other, while the eyeball was so prominent, that it seemed to be out upon ihe temple. It was quite immovable, but the sight, although a good deal impaired, was not lost. The patient had frequent pains in her head. Dr. Hope, having resolved t rseue Bibliothek fUr die Chirurgie und Ophtlialmologie. Vol. ii. p. 238. Hano- ver, 1819. 223 to extirpate the tumour, made an incision about an inch long, be- ginning at the inner angle, and following the direction of the fibres of the orbicular muscle, towards the outer angle. He then passed a crooked needle, armed with silk, through the middle of the tumour as deep as he could go. By this means raising the tumour, he separated with a bistoury, all its lateral adhesions, with the scissois cut the deeper attachments which he could not so well reach with the bistoury, and brought away all that the thread had hold of. This seemed to be a tough membranous substance, indepen- dent of the real tumour, which, after it was quite taken out, was found to be of a spherical figure, smooth, and even, about the big- ness of a small pigeon's-egg. Dr. H. passed the needle through the middle of it, as he had done before, and plunged a lancet into it as deep as he could, in order to let out any fluid matter that it might contain, but found nothing but a carnous substance. Lift- ing up the tumour by the thread, he cautiously dissected it, as far as he could, from the adjacent parts. In doing this, he found on the side next the eye several strong callous attachments, which felt almost as hard as cartilage, and obhged him to change two or three instruments. He then with the scissors, cut the inward adhesions at the roots, and brought the tumour away entire. On putting in his finger to the bottom of the orbit, he could feel several hard cal- lous substances still remaining. Keeping his finger upon them, he hooked them with a crooked needle and ligature, and, making an assistant raise the thread, with the scissors, he cut them away, so that he left the bottom even, and entirely free, as far as he could judge. All this while there was no great effusion from any artery, but a good deal of black grurnous blood from the varicose vessels. He dressed the wound with dry lint, which he removed on the third day, when he found a soft swelling in the eyelids and conjunctiva, wnth shght inflammation, and pain in the forehead. He applied a soft dossil dipt in common digestive and warm brandy, and ordered a warm fomentation every two hours. The pain in the forehead, and the swelling, continued for three or four days, without any ap- pearance of matter. He then touched the bottom of the wound with lunar caustic. Some hours after, there followed a pretty large discharge of blackish blood, and immediately the head was relieved and the swelling subsided. A bloody sanies continued to issue out the two following days, for which he injected warm water, with a little brandy and honey of roses, after which the wound began to heal up. The eye still continued immovable. The abductor muscle had been so long contracted and the adductor overstretched, that they had lost their use. Dr. H. observed, however, that by pressing gently with his hand upon the globe of the eye, he could bring it a good deal more into the socket, and that upon taking away his hand it returned to its former place. This made him think that a constant and gradual pressure, by some proper band- I age, might be of service to force the eye into its place, and keep it 224 there till the muscles should recover their tone. Accordingly, he procured a steel bandage, with a concave brass plate corresponding to the convexity of the eye, and which, by means of a screw, bore upon the side of the eye next the temple. He applied this bandage, first gently forcing the eye more into its place with his hand, and then putting a thick soft compress betwixt the eye and the brass plate. He then screwed it down in such a manner that it was impossible for the eye to start back again as it used to do. An assistant was left with the patient all night with instructions, if the bandage caused great pain, to ease the screw. By keeping the bandage constantly applied, day and night, and gradually increasing the pressure, in about twenty days the eye was brought entirely into its place, so as to remain there of itself, performing all its natural movements, and the patient seeing with that eye as well as with the other. In the morning, when the bandage was taken off, Dr. H, could observe that side of the eye which the plate bore upon considerably flattened ; yet this was not attended with any pain, or bad consequence. In about a month, the wound was quite healed up. A spongy carnosity had grown all along the inside of the lower eyelid, which, having been long over-stretched by the tumour, was so relaxed, that, after the operation, it turned inside out ; while the upper eyelid, having been very much extended for so many years by the globe, upon the eye returning to its place, was so relaxed, that its cartilage, on the contrary, turned inwards. For the cure of the ectropium of the lower lid, Dr. H. passed a crooked needle through the middle of the carnosity, and raising it by the thread, cut it off with the scissors. He afterwards touched the inside of the lid with lunar caustic, in order to destroy what remained of the carnosity, and giving the eschar time to be thrown off, he repeated the same twice or thrice, by which the lid, in about a fortnight, recovered its proper situation. By topical applications, the upper eyelid recovered its strength, so that he did not find it necessary to operate for the en- tropium. Dr. H. concludes his account of the case, by expressing his surprise how, after so great a degree of elongation of the optic nerve, for seven years, the patient's vision should, in a month's time, be so perfectly restored, and the muscles, after so long disuse^.- recover so soon their natural action.* ' Case 3. Tumour extirpated through a perpendicular in- cision of the upper eyelid — Disease returns. Dr. Monteath shortly states the case of a young girl, who had a tumour on the \ upper and outer side of the orbit. In order to get at it, he was^ obliged to cut through the whole perpendicular length of the upper eyelid, and dissect back the two flaps. The tumour was nearly the size of a plum, and reached as far back as the eyeball. It was slightly encysted, perfecdy organized, and of anomalous texture^ * Philosophical Transactions for 1744 and 1745, Vol. xliii. p. 194. London, 174& 225 The healing of the wound was rapici, and contrary to expectation, the eyelid re-united perfectly, and regained very nearly its natural power and extent of motion. The eyeball did so also, and the vision was perfect. The patient went to England some months after, and Dr. M. was concerned to learn that the tumour had be- gun to grow again.* Case 4. Tumour returns from not being completely extir- pated — Operation rendered difficult hy patient's resistance. Mr. Wardrop relates, that a young woman, of a robust form, had a tumour on the orbitar plate of the left frontal bone, the base of which adhered firmly to the bone, whilst the exterior portion was attached to the integuments, in which there was a small sinus leading into the interior of the tumour. The diseased mass did not exceed the bulk of an almond, but it was attended with great pain, and even cautiously touching the orifice of the sinus with a probe excited violent irritation. A tumour had been extirpated from the seat of this swelling some months previously, a portion of which adhering to the bone being left behind, gave origin to this new growth. Though she had come from a distance, deter- mined to get the disease removed by an operation, if it was con- sidered advisable, yet when the scalpel touched the integuments, she made a violent resistance. A second attempt was made, she being previously secured on a table with numerous assistants ; but such was the force and exertion she made to extricate herself whenever the operation was about to be begun, that every hope of success was abandoned. It now occurred to Mr, W. as the only resource, that if she would allow herself to be bled to a state of deliquium, the tumour might be extirpated while she remained insensible. After a few days, she submitted to this measure. A large vein was freely opened while she sat in the erect posture, in a very warm room, in which there were seven people, with the doors and windows kept shut to hasten her fainting. No less than fifty ounces of blood were drawn before she fainted, and then a complete state of syncope came on, which lasted a sufficient time to illow the tumour to be removed. The operation was accomplished with great facihty ; and in order to promote an exfoliation of the diseased portion of bone, its surface was rubbed over with kali purum. When the fainting went off, she would not believe that .he operation had been performed, until she had examined her face In a glass. She suffered little from the eflfects of the operation ; ind though she remained pale and feeble for a few days from the profuse bleeding, yet in a week she was better than most patients ire who have undergone so severe an operation.f Case 5. Tumour encircling optic nerve — Eyeball extirpated. \. young adult woman consulted Dr. Monteath on account of an * Translation of Weller's Manuel, Vol. i. p. 195. Glasgow, 1821. t Medico-Chirurgical Transactions, Vol. x. p. 275. London, 1819. 29 I 226 orbital disease of two years' standing, which had produced hideous exopiithalmos. It was found impracticable to extirpate the tumour 1 without also removing the eyeball, which was accordingly done.] The tumour exceeded the size of the eyeball, lay directly behind it,! and so completely encircled the optic nerve, that the latter was di- minished one half in thickness by the pressure. Vision had been rapidly declining previous to the operation. The tumour was ex- ceedingly hard, of anomalous texture, and surrounded by a layer of condensf^d cellular substance. The anterior surface of the tu- mour touched and pressed upon the posterior surface of the eyeball, but had no connexion with it except through the medium of the optic nerve and cellular substance. Twenty months after the ope- ration, the patient continued well.* Case 6. Inflammatioii of the bi'ain after extiipation of an orbital tumour — Death within twenty four hours. Langenbeck remarks, that on account of the neighbourhood of the brain, and the connexion which the parts contained within the orbit have with the membranes of the brain, the extirpation of orbital tumours is by no means free from danger. He instances the case of a ro- bust man of 40 years of age, from whose orbit he extirpated with- out difficulty a steatomatous tumour, which had to a considerable degree protruded the eye. After the operation, he was enabled to press the eye back into its natural situation, so that the deformity was completely removed. The patient felt so well after the opera- tion, that the most favourable termination of the case was antici- pated. When Langenbeck visited him two hours after the opera- tion, he was asleep. He did not disturb him, but returning some hours after, he found him still sleeping. On observing him, he saw that he lay with his mouth open, and his face affected with convulsive twitchings. He had torn off the bandage, and had been very restless. The sound eye was half shut. When spoken to, he returned no answer. On raising him up, he was unable to keep himself in that posture. The bandage was replaced. The patient fell again into the soporose state, tossing, however, continu- ally about, as those are seen to do who labour under inflammation of the brain. He was copiously bled, cold applications were made to his head, and he was freely purged with calomel. He became quite insensible, and discharged his faeces and urine involuntarily. In the evening, he attempted to spring out of bed, and was so un- ruly, that it was necessary again to let blood from him. Gradually he became quieter, continued soporose, and died next morning. Struck by the suddenness of this event, Langenbeck inquired mi- nutely into his previous history. He learned that he was habitual- ly a hard drinker, especially of rum, and that the evening before the operation he had come to the hospital in a state of intoxication, which had been carefully concealed. On dissection, nothing un- natural was observed in the orbit, nor were any remahis of the tu- » Translation of "Weller's Manuel, Vol. i. p. 196. Glasgow, 1821. 227 mour detected. On opening- the head, no morbid change was re- marked on the superior surface of the brain, but where the inferior surface of its anterior lobe rested on tlie orbitary plate of the frontal bone, exactly above the place of the tumour which had been remov- ed, there was discoloration, purulent exudation, and all the marks of inflammation. The tumour had had no communication with the cavity of the cranium.* Case 7. Death from erysipelas, after extirpation of an or- bital tumour. Dr. Ballingall, in a clinical lecture delivered to the students of the Royal Infirmary of Edinburgh, in March 1828, and afterwards printed for their use, states that on the 12th of Novem- ber 1827, James M'Intosh was admitted with a soft movable tu- mour impacted between the roof of the orbit and globe of the right eye. The superior eyelid was protruded outwards and considerably inflamed, as well as the conjunctiva covering the surface of the tumour ; the ball of the eye was depressed by the swelling towards the cheek. The structure of the eye appeared perfectly sound, and the vision unimpaired, except in so far as it was partially obstructed by the projection of the tumour, which obliged the patient to throw back his head, and to elevate his iixce in attempting to see objects placed before him. He was unconscious of any accident to which this complaint could be attributed, assigning its origin to exposure to cold in the month of January preceding. In July, he had been in the Infirmary, at which time the tumour was not above a fourth of the size it had attained in November. In July, it occupied the site of the lachrymal gland. He was urged to have it removed, but would not consent, although told that he would in all probability return with it at a future period, when the operation would be more difl5cult. This accordingly happened ; and in November he was solicitous for its removal. Dr. B. began by dividing the superior palpebra upwards and outwards from the external canthus of the eye. After dissecting the eyehd off from the surface of the sweUing, the tumour was with much difficulty separated from the contiguous parts ; a pedicle or neck, by which it was found adherent to the very bottom of the orbil, was then cut across with a pair of probe- pointed scissors, and some small portions of it afterwards removed. The operation was followed, in the first instance, by a very mod- erate degree of swelling and inflammation, much less, indeed, than was to be anticipated. For nearly a week the case had a very favourable aspect, but at the end of this time, the forehead and upper part of the face became involved in a violent erysipelatous inflamination, which gradually extended over the whole head, ac- companied with dehrium, his pulse rising as high as 150. It was observed, soon after the operation, that his breath was imbued with the mercurial foetor, which he attributed to some medicines taken * Neue Bibliothek far Chirurgie und Ophthalmologic. Vol. ii. p. 241. Hancver, 228 before his admission. The urgent symptoms were somewhat alle- viated by bleeding, both general and topical, by the internal exhibi- tion of antimonials and saline purgatives, the application of a blister to the nape of the neck, with the use of an anodyne fomentation to the inflamed parts. On the 22d, (Dr. B. omits to mention the date of the operation), he was found to have sunk so low, that he was not expected to live through the ensuing night ; his pulse 120, his breathing laborious, and his extremities cold, with low mutter- ing typhoid deliiium. From this state he again rallied under the use of brandy and water, beef tea, and the application of a second bUster to the nape of the neck. A copious discharge of unhealthy matter had for some days been going on from tbe affected eye, the cornea of which now ulcerated, and on the morning of the 27th, the crystalline lens was discharged through the opening. His de- lirium continued with occasional intermissions, during which he asked for and devoured food with a ravenous appetite. His pulse continued frequent and weak, his breath foetid and offensive, and his general appearance resembling that of a patient in the advanced stages of typhus. The cuticle separated in crusts from those parts of the head and face in which the inflammation had been seated ; rigors and diarrhoea latterly supervened, and he expired on the evening of the 28th. Permission could not be obtained to examine the body ; but a hasty examination was made of the head and parts concerned in the operation. A portion of the principal tumour was found still adherent to the sheath of the optic nerve, and seve- ral small melanotic tubercles imbedded in the fatty matter sur- rounding the muscles of the eye. Some serous effusion had taken place both on the surface and into the ventricles of the brain. Dr. B. remarks, that if he had been fully aware of the nature of the disease, and of the deep attachment of the tumour, he should have proceeded at once to extirpate the whole contents of the orbit ; but having succeeded in removing the bulk of the tumour with safety to the eyeball, he felt reluctant to change the plan of the operation. The inflammation immediately succeeding to the removal of the tumour was much less than was to have been expected from so severe an operation, but when the symptoms of erysipelas super- vened, it was obvious that the case became one of a very perplexing and hazardous description. The patient's system surcharged with mercury precluded the employment of mercurial purgatives, so often beneficial in erysipelatous inflammation, and it had been remarked, that even when in the hospital in Jul}', he had something of that sallow cachectic look often attendant upon internal organic disease, and which rendered him, in Dr. B.'s estimation, an unfit subject for profuse evacuations of blood. Case 8. Orbit dilated by a steatomatous tumour — Death some months after extirpation. In a lady of about thirty years of age, Langenbeck extirpated a tumour hj which the eye was considerably protruded from the orbit. The temporal side of this 229 cavity was also evidently pushed outwards. As this deformity had increased J the patient had frequently complained of violent pain in the head. The tumour was easily removed, the pain of head sub- sided, and the wound healed readily. The eye retired in some degreee into its natural place, but the protuberance in the temple remained unchanged. After some months, periodic headachs came on, and constantly increased till they reached a high degree of se- verity. At length she became soporose, and died. The body was not inspected.* 2. Puncture of encysted tumours. Encysted tumours, in dif- ferent parts of the body, and especially in superficial situations, are apt to burst in consequence of blows, or at length give way simply from distention, and discharge their contents. The cyst remains for a time, and seems to operate like a foreign substance ; inflam- mation comes on, ending in suppuration, and either separately and entire, or along with the matter and broken down into shreds, the cyst is evacuated ; and the cavity, formerly occupied by the tumour, contracts and heals up. Upon this course, sometimes followed by nature, is founded the practice of puncturing encysted tumours, and evacuating their contents. It is not a practice to be much commended. It is tedious and uncertain ; for the cyst may not come away for weeks or months, and if any portion of it is left behind, or, as is often the case, if the whole of it is left, a new col- lection of fluid is apt to take place. It may also happen in the orbit, as it has often happened in other parts of the body, that this practice of puncturing encysted tumours may give rise to a fungous growth from the inside of the cyst, attended with great pain and iiiitation. The difficulty, however, on the one hand, of completely extirpating encysted tumours of the orbit, and on the other, the total subsidence of the swelling, and the return of the eye to its natural situation after the contents of the cyst are evacuated, has occasionally led surgeons to content themselves with this palliative plan of treatment. The following is an instance of the accidental bursting of an orbital encysted tumour. A lively girl, of about 17 years of age, had a small opening at the temporal edge of the left orbit, close to the tarsus of the upper eyelid. Every morning she found the neighbourhood of this opening somewhat swoln, and by pressure evacuated through it a quantity of a whitish, pretty consistent, ropy substance, something hke half-fluid tallow. The origin of her complaint was her leaping suddenly against a door, believing it to be open, when it was shut, and which she struck violently with the left side of her head. The part immediately became swoln and livid. Fomentations and poultices were employed, and the immediate consequences of the contusion were removed. After some time, a small swelling made its appearance under the skin * Neue Bibliothek fUr Chirurgie und Ophthalmologic, Vol. ii. p. 244. Hanover, 230 of the part which had been struck. This swelhng increased, not- withstanding the use of embrocations and the hke, and much dis- figured the ghi's countenance. It had acquired the size of a wal- nut, and a day was fixed for its extirpation, when she happened by accident again to strike her head against the same door so vio- lently, that the cuticle was stript from off the part, and the tumour so much bruised that it suppurated. The alsscess was opened, the cyst gave way, and a yellowish-white substance like honey, was discharged. After which the wound contracted to the small open- ing, which existed when Dr. Schwarz, the narrator of the case, saw the patient. He did not think it necessary to urge her to have the cyst removed by operation, as the inconvenience of emptying it from time to time was but trifling.* In the three following cases, the' puncturing of encysted tumours in the orbit, proved a radical cure. Case 1. A shoemaker, aged 45 years, had the left eye promi- nent, and almost entirely ont of its orbit. This exophthalmos had come on gradually, attended with pain, but without inflam- mation. The eye was pushed out by a hard tumour, which ap- peared to be situated between the globe and the inner wall of the orbit. Several practitioners in Paris were of opinion that the tumour was cancerous. The protruded eye was not enlarged, but was deprived of sight from compression and traction of the optic nerve. Richerand proposed to the patient to extirpate this sus- pected carcinoma, although from the renitency of the tumour he had his doubts concerning its nature. After having disunited the eyelids at their outer angle, and divided the conjunctiva, he thought proper, before going on with the operation, to assure himself of the real nature of the disease by plunging into it the point of his knife. This was followed by the exit of two or three ounces of a fluid similar to white of e^g. Being now certain that the exophthalmos depended on an encysted tumour, and the eye having already, in consequence of the contraction of the C3'st, retired partly into its natural place, Richerand renounced the idea of extirpation, and contented hiujself witli applying wet compresses over the eye. Considerable inflammation followed, for which he bled the patient. The cyst suppurated, and the patient was cured after the excision of some excrescences formed by the conjunctiva.! Case 2. A woman was brought to 3Ir. Weldon, with one of her eyes considerably protruded from its usual situation in the or- bit. About two years before, she felt a fulness of the eye, and a stiffness of the eyeUds, so that they moved with difficuU)\ As these syrnptoms increased, she became sensible of a feehng of pres- sure and uneasiness in ihe ball of the eye, which gradually became painful; especially in moving it. At length the eye became im- * Grafe and Walther's Journal der Chirursie und Augen-Heiikonde, Vol. vii. p. 235. Berlin, 1825. t Nosographie Chirurgicale, Tome ii. p. 119. Paris, 1813. ' . ' J 231 movable, the sight disappeared, and the pain increased to such a degree of violence, that the patient at times became dehrious. When Mr. W. saw her, the eye was considerably protruded for- wards, and rather upwards, towards the inner angle, in a manner easily conceived by supposing a tumour in the orbit to press the eye directly forward, while the optic nerve firmly resists the pressure. The eyelids were open and immovable, and there was a general fulness of the surrounding integuments. The sight had been lost about twelve months. The iris was motionless, moderately di- lated, and had, (says Mr. W.) a number of fissures in it of various depths, some of which extended three-fourths through it. The blood-vessels of the eye were full and turgid, but not inflamed. The pain she described as being intolerable, and almost without remission, extending at times over the whole head, but, in general, pretty much confined to the globe of the eye, and the situation of the optic nerve. It was attended by a sense of pressure and great distention. On feeling the integuments that covered the orbit be- neath the eye, the sensation to the finger resembled that produced by feeling a loose fatty substance, but on examining the part more attentively, a deep-seated fluctuation was very evident. The parts were free from any tenderness or pain on pressure. With a cata- ract-knife, Mr. W. made a puncture into the tumour, from the middle of the lower edge of the orbit, and pressed out a small quantity of transparent fluid. He then extended the wound for near an inch towards the outer canthus, taking care to keep the point of the knife sufiiciently deep, and to carry it forwards at the same time, so as to open the cyst very freely. About two table- spoonfuls of a clear transparent fluid, slightly adhesive, came away, and were followed by instantaneous ease, while the eye sunk near- ly into its natural situation. The lips of the wound were kept asunder, and in five or six days, the cyst, which Mr. W. fancies to have been a hydatid, appeared in view, and was withdrawn. This coat, as Mr. W. terms it, was spherical, rather thicker than the coats of hydatids of a corresponding size usually are, and had a smooth shining surface. The discharge gradually lessened, and the wound healed without farther trouble in the course of three weeks. The pain and affection of the head totally ceased, and the eye, to a common observer, appeared as the other. The iris remained motionless, and the sight was totally lost.* Case 3. A patient came under the care of Mr. Lawrence, complaining of considerable pain and distention in the orbit, with dimness of sight. The globe of the eye was a little projecting, and on examination Mr. L. thought he could discover the existence of a tumour in the upper part of the orbit. It was represented to the patient how the case stood, and he was informed that the only effective mode of relief would be the renaoval of the tumour ; at the same time, the operation was not much encouraged from the un- * Cases and Observations in Surgery, p. 104. London, 1806. 232 certainty of its consequences. The patient went away ; but in I twelve months he returned, with a more decided projection of the jj globe, and a visible prominence under the upper lid. Mr. L. i thought he could distinguish a fluctuation in the tumour, and pro- *j posed to puncture it, and see what it contained. He did so with a i| lancet, when about a tablespoonful of clear watery fluid escaped, fl which gave relief to the patient. In about a week afterwards, Mr. ! L. observed something hanging out of the opening. He took hold of it with the forceps, and drew out a hydatid of considerable size. In a few days, more came out, after which Mr. L. injected tepid water into the aperture, and thus brought out half a teacupful of hydatids of various sizes. The cyst inflamed and suppurated, then collapsed and closed. The eye returned into the orbit, but continued amaurotic. The patient, fieed from great local suffer- ing and severe headach, regained his health and strength, and continued well.* 3. Partial extirpation of encysted tumours. This is another method of treatment which has been adopted on account of the j difficulty of removing the cyst in an entire state, and the danger of f' injuring important parts when the disease reaches deep into the orbit. The front of the tumour being exposed in the usual way, the cyst is laid hold of with a pair of hooked forceps, or any other suitable instrument, and as much of it is removed as can convenient- i ly be brought within the grasp of the scissors. The portion of the cyst which is left inflames, the external wound heals up more or less promptly, and in some cases there is no farther trouble experi- enced ; but more frequently the wound opens repeatedly, till the cyst, destroyed by suppuration, is completely discharged. Case 1. Donald M'Kinnis, aged 18 years, was admitted into the Glasgow Eye Infirmary, under the care of Dr. Monteath, on the 28th of Sept. 1827, on account of a soft tumour which, since in- fancy, had been observed to project from the right orbit, immediate- ly above the tendon of the orbicularis palpebrarum. Its projecting part w^as as large as a middle-sized gooseberry, and as far as could be judged, the tumour dipped deep into the orbit. The eyeball was not displaced, nor did the patient experience any pain, but he was anxious to have the tumour removed on account of the defor- mity, which was very considerable. The integuments were divided and dissected back, and when the anterior half of the tumour was thus exposed, it was laid hold of and excised. The cavity of the posterior half could now be distinctly seen, dipping nearly an inch into the orbit, close to its internal wall. It was evident tiiat this part of the cyst could not be removed, even by a laborious dissection. The whole cavity was therefore rubbed over with nitrate of silver, and then stuffed gently with lint, over which a compress and band- age were applied. Very httle inflammation succeeded the opera- * Lectures in the Lancet, Vol. x. p. 387. London, 1826. 233 tion. The cavity contracted from day to day, and was very soon completely obliterated, leaving no deformity. Case 2. The following case will illustrate some of the dangers attendant even on the simple operation of partial extii-pation. Agnes Crawford, aged 14 years, was admitted a patient at the Glasgow Eye Infirmary, under the care of Dr. Monteath, on the 24th October 1827. For six years, a tumour had been observed to pro- ject from the right orbit, pushing the upper eyelid before it, and most protuberant about mid-way between the tarsal border of the eyelid and the bony edge of the orbit. The greatest projection of the tumour was at the upper and inner part of the orbit, so that the eye was forced downwards and outwards. The part of the tumour which appeared externally was as large as a green- gage plum, and, from the very great displacement of the eyeball, it was concluded that the portion lying within the orbit was also large and extended deep. The skin, covering the tumour, had a dirty livid colour. On partially everting the eyelids, the inferior part of the tumour was seen bulging through the conjunctiva. The girl suffered no pain. The vision of the eye was perfect, and the tunics free from inflammation. Though the eye was turned very much to the right side, she had no diplopia. She enjoyed good health. She had never menstruated. The tumour had been re- peatedly punctured, and at one time a thread had been drawn through it and worn for some time, without producing either good or bad effects. On the 28th of October, after low diet for three or four days, and two doses of laxative medicine, the patient was laid on a table, and an incision, nearly two inches long, made in the direction of the fibres of the orbicularis palpebrarum. The integuments were dissected back with a scalpel and a blunt silver knife, till more ,han the anterior half of the tumour was exposed. This was now lut away with the scissors. An immense discharge of fluid imme- diately took place from the sac, of the appearance of dark blood. This was followed by very considerable haemorrhage from the Dottom of the orbit. Dr. M. thrust his finger to the bottom of the Drbit, and making pressure soon stopped the violence of the bleed- ing. Cold water was next injected for about a minute, by means of a syringe, deep into the orbit, which caused the bleeding to cease. Examination with the finger clearly demonstrated that the iumour had extended to the very bottom of the orbit, and even oc- cupied there much space. It was therefore impossible to dissect out the posterior part of the cyst, so that it was merely stuffed mod- erately with a strip of hnt. Another strip was placed between the lips of the wound, to prevent adhesion. A compress was laid over 'all, and the eyes shaded. Before the patient had left the operation, table, the eyeball had retreated very considerably into its natural position. Next day, the whole of the upper eyelid was red and much swoln. 30 234 The patient complained of headach, and her pulse was 112. Ten , leeches weiej ordered round the orbit ; after which, an emolUent poultice w^as applied, and she had a dose of castor oil. On the third , day after the operation, the report states that the leeches had bled freely ; but that the tumefaction having, upon the whole, increased, as well as the headach and fever, the tent of hnt was withdrawn. She had suffered much during the night, the pain being pulsating and constant, both in the eye and head. In the morning, she had been seized with vomiting. The pulse was still above 100. Tongue white. The tumefaction was now so much increased, that the ex- ophthalmos was greater than before the operation. The eyeball being chemosed, a portion of the swollen conjunctiva was excised. A probe was passed through the wound to the bottom of the orbit, but no retained blood nor pus was discharged. A small portion of sloughy matter, apparently part of the cyst, was extracted from the wound, at the mouth of Vv'hich it presented. Twelve ounces of blood were taken from the arm at noon, and six more at 7 p. m. On both occasions she became faintish. The blood was buffy. The pulse fell a Uttle, became softer, and she felt relieved. The poultice was continued, and she was ordered a dose of Epsom salts in civided quantities, which operated freely in the nigiit, and dis- turbed her sleep. She had much less pain than during the previous night. Next day, the 4th after the operation, the pulse was about 90 and soft, the tumefaction of the eyelids, of a deep red colour, and very sensible to the touch, was increased to the bulk of the half of a middle-sized apple, the greater part of the swelling being formed of the upper eyelid ; the chemosed conjunctiva projected from between the aperture of the lids ; the cornea continued trans- parent, and vision was, as yet, good. Her thirst had been immod- erate for the last three days, and still continued. She had frequent transient chiils through the course of this da)^ Upon the whole, the pain of the eye and head were less than in the preceding da)^ She was ordered a draught, with twenty-five drops of laudanum, and the poultice was continued. For two days, the tumefaction of the lids increased, particularly of the lower, which became so broad as to reach as low as the opening of the nostril. The swelling was indeed enormous, and the whole of it very tender to the touch. The cornea could with difficulty be seen, being overlapped by the chemosed conjunctiva. So far as it could be seen, it was transparent, but the pupil appeared enlarged, and that she said she could not see. From the 4th till the 8th day after the operation, the pulse va- ried from 75 to 90 ; the thirst gradually ceased; there was some return of appetite ; and the headach and pain of the eye declined, so that by the 8th day they were nearly gone. The bowels Avere gently purged with Epsom salts, and she had an anodyne each night with much benefit. On the 7th and 8th days, the wound dis-', charged matter pretty freely. Both eyehds had by this time become ' 235 i softer, and much less swollen. On the 8th clay, it was observed that pus had made its way from the bottom of the orbit, through I two apertures in the conjunctiva, where it is reflected from the lower ' eyelid to the eyeball, near the nasal canthus. For some days pre- viously to this, the poultice had been discontinued, and the eyelids covered with lint smeared with simple ointment. The draught was now omitted. On the 2Sth of January 1828, the report states that the incision had been completely closed for some time, and ' that the eye had retired more into its proper situation. The pupil, however, continued dilated, and there was no return of vision. I The patient was free from pain, and her general health was im- proving. I On the 8th of February, the eye was still more in its natural |iplace, and its power of motion increased, but no renewal of vision. 1 The patient now left the Infirmary for her home in the country, tand in a few months died of phthisis pulmonalis. 4. Total extirpatio7i of encysted tumours. The complete extirpation of an orbital encysted tumour is an operation almost [always attended with considerable difficulty. The flow of blood, the danger of rupturing the cyst, the instant escape of its contents [if it be accidentally torn or wounded, the almost impossibility of jremoving it m the collapsed state, and the great depth to which the I cyst often extends within the orbit, are the circumstances which [have led to the practices of puncture and partial extirpation. The [total removal, however, of the cyst, is much more satisfactory. This ioperatioa is generally performed by making a transverse incision j through the skin of one or other eyelid, parallel to the fibres of the prbicularis palpebrarum. This incision is not to be made freely, but cautiously, avoiding the lachrymal passages at the inner canthus, and taking care not to open the cyst, which is often almost imme- 3iately under the skin. The cellular substance beneath the orbi- jularip and the fibrous layer of the eyeUds being next divided, the annexions of the cyst are to be separated. This is best effected 3y means of a pair of blunt forceps and a silver knife ; with the burner laying hold of the cyst, and with the latter destroying its pellular attachments. This being accomphshed as completely [ ound the cyst as possible, it is to be dragged forwards, and its pos- I erior connexions divided with the knife or the scissors. The finger pught now to be introduced into the cavity left by the removal of I -he tumour, and an examination made, lest any indurated attach- I'nents or roots of the cyst have been left. These are to be laid hold ipf, and extirpated with the scissors. 1 It is the general practice to fill the cavity formerly occupied by |;he tumour with lint, but this does not appear to be necessary. We [ xiay leave it filled with the blood which flows from the parts which |we have divided. Its parietes will most probably inflame and sup- purate, and then gradually contract ; but by stuffing it with lint, iwe must excite additional irritation, the inflammation which follows 236 is likely to be more severe and extensive, the contents of the orbit may thus be made to suffer severel}^, the eye may be prevented, by the swelling of the parts, and the matting together which they are apt to suffer from the inflammation, from retreating into its natural place, or even a new and permanent degree of protrusion of the eye may be produced. Cases. — Case 1. The following case, related by Saint- Yves, is frequently referred to, and appears to have served as an encouraging example of extirpation of an orbital tumour to several of his succes- sors. The patient w^as a girl of twelve years of age. The tumour was situated below the eyeball, so that it turned the pupil upwards, and protruded the lower lid for more than half an inch. It ex- tended towards the cheek for the breadth of an inch. Saint- Yves divided the skin and the orbicularis palpebrarum by a similunar in- cision, extending the whole length of the tumour ; he then laid hold of it with a hook, separated it from its attachments with a bistoury, and removed it. With the ssissors, he next cut away its root, which was hard and coriaceous. In thirteen days, the wound was healed. The eye returned to its place, and the patient saw^ with it as with the other. The tumour presented three cavities. That which lay next the skin contained a purulent fluid ; the sec- ond was filled with a thicker matter, partly calcareous ; and the' contents of the third resembled w^hite of egg* Case 2. A laborious country-man was attacked with pain, and dimness of sight, in one of his eyes. These symptoms did not at- tract any particular attention for two or three years, when he be- came quite blind of the eye, the globe being at the same time greatly protruded, and the lower lid everted. Many surgeons, both in town and country, who w^ere consulted, dissuaded him from submitting to any operation, being apprehensive that his complaint, if not al- ready cancerous, was likely to become so by meddhng with it. He was therefore urged not to hazard the danger of any operation, see- ing that his disease did not render life intolerable, but might be sup- ported W'ithout farther inconvenience than the want of sight in the eye, and its unseemliness from being so far thrust out of its socket. He was recommended, however, to consult Mr. Ingram, a sur- geon in London, w^ho on carefully examining the^ case, imagined that he felt, on pressure, a resisting fluid under the eye, and formed the opinion that this fluid was contained in a cyst, detached from the lachrymal gland. He therefore gave encouragement to attempt the man's relief by an operation. Mr. Bromfield approved of this proposal, and with Mr. Ingram's assistance, performed the following operation. He pressed upwards the distorted lower lid, till it was brought as near as possible to its natural position. While it was thus held tight, Mr. B. cut through the integuments into the lower part of the orbit under the conjunctiva, till an aperture w'as made • Nouveau Traite des Maladies des Yeux, p. 147. Paris, 1722. 237 sufficient to peiinit the introduction of the fing-er, so as to direct a sharp-pointed scalpel, with which he perforated the tumour. Im- mediately, a thin pellucid liquor was discharged, not far short in quantity of a small wine glassful. Here Mr. B. paused, to give the patient a little water to cleanse his mouth from the blood, and ob- served, that his business was not more than half done, until he could extract the cyst which had contained the water. He therefore in- troduced two small hooked instruments to catch hold of it, and took it completely out. The wound was filled with lint, and dry dress- ings, and these were secured by a proper bandage. Within less than twenty-four hours the patient's head and neck were swelled to a prodigious size. This was, after some time, removed, by dress- ing it very lightly with dry hnt, and by a few gentle purges. Treated as a common superficial wound, in less than a month the whole was healed, and the man sent home perfectly satisfied. Mr. I. was all along, even before the operation, confident, that the over- stretched muscles of the eye would, in time, recover their natural power, that the globe of the eye itself would consequently be in- cluded within its socket without leaving any outward blemish, and that even the sight would, to a certain degree, return. Dr. Brock- lesby, who relates the case, owns that he gave not much credit to €ill this, till five months after the man went home, when, being in the country, he sent for him to satisfy his curiosity. When he saw him, he scarce knew him again ; for his eyelid had fully recovered its natural position and functions. About a month before Dr. B. saw him, the eye began to be sensible of the difference between darkness and bright sunshine, and ever since that period its power of perception had become gradually strengthened.* Case 3. Thomas Heard, a healthy-looking young man of 17, was admitted an in-patient of the Exeter Eye Infirmary, under the care of Mr. Barnes, on account of a tumour which completely obstructed the sight of his left eye. The tumour was situated beneath the eye, occupying a ver}'^ considerable portion of the orbit ; the eye in consequence was pushed into the upper part of that <-avity, so as to be almost wholly hidden behind the upper hd. On tracing it backwards, the tumour appealed to extend to a very considerable depth ; and it projected so much in front, as to con- stitute a very striking deformity. Anteriorly it was rounded in form. A superficial groove, running obliquely across its upper sur- face, formed a slight line of division between the more prominent and movable part of the swelling, and that more immediately under the eyeball. The ciliary edge of the lower tarsus, with a few scat- tered hairs in it, crossed the front of the tumour rather above its middle; the conjunctiva, drawn forwards from the eyeball, greatly stretched, but not apparently much altered in structure, investing it above ; and a thin skin of a deep red, loaded with purple vessels, * Medical Observations and Inquiries, Vol. iv. p. 371. London, 1772. 238 covering it below ; bat neither of them closel)^ adherent to it. The portion of the tumour in front, was soft, and could be moulded into different shapes by the fingers ; the posterior division felt more elastic. By an effort, the patient could raise the upper eyelid a little, but not his^h enough to discover even the lower edge of the cornea. By lifting it with the finger, a portion of the pupil might be exposed, and he could then distinguish objects partially. The eye was apparently perfect, but he had scarcely any power of mov- ing it. The swelling was first observed in early infancy, and was at that time not much larger than a pea. It incji-eased ]3ut slowly, until about four or five years before his admission into the Infirma- ry, when it began evidently to enlarge, and for some time grew rapidly. More lately it had not advanced much. It caused no pain, but as it was a great deformity, was still enlarging, and by its presence rendered the eye useless, it was thought advisable to remove it. Id the operation, a division was made of the inferior oblique muscle of the eye, which appeared stretched across the front of the tumour, having been pushed before it, in its progress from the deeper parts of the orbit. The sac adhered firmly to the outer angle, and part of the lower edge of the orbit ; in most other points, it was but loosely connected with the surrounding parts. It was found to extend almost to the bottom of the orbit, and to occupy more of it than did t!ie eye itself. As it was impossible to proceed in the dissection far within tlial cavity, without greatly endanger- ing the eye, on account of the very narrow space between it and the posterior division of the swelhng, the contents cf the latter were partially evacuated, to obtain room, and the sac cautiously separated from its deeper attachments. Towards the posterior point, on the inner side, and more than an inch from the edge of the orbit, the sac felt as if it eurbraced a shar]:) bony process, arising from about the line of junction between the ethmoid and superior maxillary bones. Unwilling to proceed at hazard, the operator cut oft' the cyst close up to this projection, that its nature and connexions might be examined before an attempt was made to remove it. It appeared to be formed of bone, terminating in a sharp point, and proiecting nearly in a perpendicular direction into the cavity of the orbit. It was slightly movable, as if attached to the periosteum only; and was removed without much difficulty, together with the remains of the sac which adhered to it. On examination, it was found to be a tooth, resembling in form and size, the supernu- merary teeth sometimes found in the palate. The part which \no- jected into the sac was conical, and covered by smooth, shining, white enamel ; the sac firmly adhered round a contracted portion at the base of the cone, resembling the neck of a tooth ; and with- out the sac, there was the appearance of a root, truncated obliquely, with a passage in the centre, evidently containing blood-vessels. It was by this part that it W'as connected with the floor of the orbit. 239 I The patient had a complete natural set of teeth, though many of them were disposed irregularly. The extirpated tumour was found to be made up of two cysts, separable by dissection, at the groove already mentioned, to some depth all round, but indissolubly united in the centre. That in front allowed the colour of its contents to be distinguished through it. The posterior sac was thicker and more vascular. The inte- rior surface of that in front was rough, with here and there a chalky matter adhering to it. It contained a compact lardaceous yellow substance. The inner surface of the posterior sac was smooth, ex- cepting a part near the tooth, where it had much the appearance of coarse skin with many pores in it. The contents were partly a whey-coloured fluid, and partly a yellow curdy substance. The eye did not in the least drop on the removal of the tumour ; and the large cavity which this had occupied, was filled with pieces of soft sponge, dipped in oil. On removing the last piece of sponge, on the seventh day after the operation, the cavity was found to be every where covered by healthy granulations. The opening con- tracted rapidly, and the eye sunk fast, so that within a fortnight it was nearly on a level with the other. The patient was discharged in the beginning of January, with the wound perfectly healed. The lower lid did not, at that time, cover so much of the eyeball as it does naturally ; and in one spot the ciliary edge was a little invert- ed. He had the power of moving it slightly, but he could not raise it high enough to bring it into accurate apposition with the upper. The lachrymal canal of each lid was pervious to fluids, which passed freely into the nose by means of a syringe. There was a considerable hollow above the eyeball ; and the eye was not quite in a line with the other, but rather above it. He could not move it at all downwards, or freely in any direction. With the exception of this inconvenience, he enjoyed with it perfect vision.* Case 4. The eye of a man, of 29 years of age, was pressed in- wards and downwards by a tumour which occupied the upper and outer side of the orbit. The tumour fluctuated, and was very prominent. In consequence of previous inflammation, the cornea was opaque, and the eyelids were united to the eyeball. Langen- beck divided the upper lid, over the tumour, which, as soon as it was laid bare, presented the appearance of a shining transparent cyst. He removed it perfectly entire. It was about the size of a pigeon's egg, and filled with fluid. The edges of the wound were brought together, and after it was healed, the morbid union of the lids to the ball of the eye was divided, so that the eye was restored to its natural place and power of motion.t * Medico-Chirurgical Transactions, Vol. iv. p. 316. London, 1813. t Neue Bibliothek fur die Chirurgie und Ophthalmologic. Vol. ii. p. 40. Hano- ver, 1819. 240 SECTION V. ORBITAL ANEURISMS. 1. Orbital Aneurism hy Anastomosis. The disease, so admirably described by Mr. John Bell, under the name of aneurism from anastomosis, does not appear to arise from any original malformation, such as we observe in nsevus ma- ternus, although this congenital structure is apt, as has been already explained,* to assume, in a considerable measure, the characters of this kind of aneurism. The disease described by Mr. Bell, often begins in apparently healthy adults, from sudden and hidden causes ; it is not confined to the skin, or subcutaneous cellular membrane, but affects indiscriminately all parts of the body, and brings on complicated morbid phenomena even among the viscera. Several cases are now recorded, in which aneurism by anastomosis has arisen within the orbit, characterised by pain in the eye and head, a peculiar sensation compared to a snap or crack, followed by a whizzing noise in the head, blindness, protrusion and pulsation of the eye, and pulsatory or aneurismal sweUings between the eye and the orbit. The instances which have occurred of this disease in the orbit have been too few, to permit us to describe from actual observation its ultimate effects and termination ; but reasoning from the history of aneurisms by anastomosis in other parts of the body, we cannot doubt that the progress of the disease would be equally rapid in this situation, the bleedings, if the complaint were neglected, alarming and dangerous, and the issue fatal. Mr. Abernethy has related an interesting case of neevus mater- nus of tlie upper eyelid, in which the disease extended also into the orbit, and of which a cure was effected by the simple abstraction of heat, by means of folded hnen, wet with a saturated solution of alum in rose water, and kept constantly applied over the tumour.t This mode of treatment, however, and also that of pressure on the aneurism, are evidently quite inapplicable when this disease is situ- ated deep within the orbit. Neither can excision be had recourse to in such a case, unless we resolve at once to remove the whole contents of the orbit ; and even were the patient ready to submit to this operation, could we with safety attempt it, knowing, as we do from the recorded histories of many aneurisms by anastomosis, the innumerable sources by which such tumours are supplied with blood, the great dilatation which the neighbouring blood vessels commonly present, and the difiiculty which has often been expe- rienced in arresting the heemorrhage attendant on attempts to ex- tirpate tumours of this nature. The only other m^ode of treatment likely to impede the progress of an anastomotic aneurism within the orbit, is diminution of the force * See p. 127. t Surgical Observations on Injuries of the Head ; and on Miscellaneous Subjects p. 228. London, 1815. 241 of the circulation through the tumour, by applying a ligature on the common carotid artery. We owe the first proof of the efficacy of this plan, not only in preventing the increase, but even in effect- ing the cure of this disease, to Mr, Travers. His example has been followed by Mr. Dalrymple of Norwich, who has published a second highly interesting instance of the efficacy of the operation ; while, still more recently, Mr. Wardrop has demonstrated that similar good effects may be expected from tying the carotid, in cases of extensive neevus occupying the external parts of the face.* The cases by Mr. Travers and Mr. Dalrymple are valuable, not only as proofs of the efficacy of the mode of treatment, but as illustra- tions of the origin, progress, and effects of the disease. I shall therefore quote them, almost without abridgment. At the same time, there is a suggestion made by Mr. Hodgson,t which is worthy of notice, namely, that in similar cases it would be advisable to aid the process of cure after the operation, by depletion and abstinence. In Mr. Travers' patient, the diminution of the tumour was very remarkable after violent discharges of blood from the uterus. A very spare diet, and the avoidance of all violent exercise, in con- junction with repeated blood-letting, have been known to prove successful in the cure of a carotid aneurism, + and the observance of a similar legimen must be highly proper after the application of 1 a ligature on the carotid in any case of aneurism by anastomosis. Case. Frances Stoffell, aged 34. a healthy active woman, the mother of five children, on the evening of 28th of December, 1804, being some months advanced in pregnancy, felt a sudden snap on the left side of her forehead, attended with pain, and followed by a copious effusion of a limpid fluid into the cellular substance of the eyelids on the same side. For some days preceding, she had com- plained of a severe pain in the head, which was now increased to so great a degree, that for the space of a week she was unable to raise it from the pillow. The oedematous swelling surrounding the orbit was reduced by punctures ; an issue was set in the temple for a smart attack of ophthalmia which supervened, and leeches and cold washes were applied. She now first perceived a protrusion of the globe of the eye, with dimness of sight, and the ap- pearance of a circumscribed tumour, elastic to the touch, about as large as a hazel-nut, upon the infra-orbitary ridge. Another softer and more diffused swelling arose at the same time above the tendon of the orbicularis palpebrarum. The lower tumour communicated both to the sight and the touch, the pulse of the larger arteries ; the upper gave the sensation of a strong vibratory thrill. The swellings grew slowly, and the skin between the eyes and that of the lower eyelid became puffed and thickened. The globe of the eye was * See p. 133. t Treatise on the Diseases of Arteries and Veins, p. 446. London, 1815. t Memoires de I' Academie des Sciences,' pour 1765. Tome xxxvii. p. 758. Am- Bterdam, 1771. 31 242 gradually fciced upwards and outwards, and its motions were consideraiily impeded. She had a constant noise in her head, which, to her sensation, exactly resembled the blowing of a pair of bellows. Tlie pulsatory motion of the tumours was much increased by agitation of mind, or strong exercise of body, but the most dis- tressing of her symptoms was a cold obtuse pain in the crown of the head, occasionally shooting across the forehead and temples. She was compelled to rest the left side of her head on her hand when in the recumbent posture, and found the beating and noise to increase sensibly when her head was low and unsupported. Such was the substance of the patient's report, when Mr. Travers was recjuested to see her. He found the skin in the region of the ■■ orbits morbidly thick and wrinkled, the eyebrow of the diseased side pushed two or three lines above the level of the opposite one, and the hollow of the orbit lost from the elevation of the globe of the eye. The upper half of the inner canlhus was filled by the thrilling tumour, which afforded a loose woolly sensation to the touch, was very compressible, and when firmly compressed, was felt slighily to pulsate. The veins of the upper lid and on the sides of the nose were varicose, and the skin was much pursed over the lachrymal sac. The lower tumour, which projected above the infra-orbitary foramen was of a conical shape, firm, but elastic to the touch. It could be emptied, or pressed back into the orbit, but the pulsation then became violent; and from the increased pressure of the globe upon the roof and side of the orbit, the pain was insup- portable. Careful compression of the temporal, angular, and max- illary arteries, produced no effect on the aneurism. Upon applying the thumb to the trunk of the common carotid, Mr. T. found the pulsation to cease altogether, and the whiz of the little swelling to be rendered so exceedingly faint, that it was difficult to determine whether it continued or not. The recent increase of puffiness in the skin over the root of the nose, and below the inner angle of the opposite eye, had given alarm to the patient and her friends, who feared, not without some appearance of reason, a similar affection of the ri^ht orbit. Mr. T. felt persuaded that this disease could be no other than aneurism by anastomosis. Indeed, it bore so strong a resemblance in its principal features to several of Mr. John Bell's cases, and in particular to that communicated by Mr. Freer, of Birmingham, whose patient, refusing assistance, expired of haemorrhage, that Mr. T. considered the sensible growth of the disease an argument of sufficient force to justify any rational attempt to repress it. From the character of similar cases, and the idea which he had formed of this, it was to be expected, that although it had been slow in its formation, it would be rapid in its increase ; and, unlike the aneurism of trunks, would resist control as it acquired size. He first tried the effect of pressure, but, although moderate, it could ' be borne only for a very limited time, by reason of the pain attend- 243 irig the exasperated action of the arteries. Cold applications had been already made use of without any evident advantage, but in- deed the duration and aspect of the disease made this remedy appear trifling. Excision, the only method, of which, in similar cases, experience had confirmed the success, was clearly imprac- ticable without extirpation of the eye ; and from the great displace- ment of the globe, and the obvious origin of the disease within the orbit, Mr. T. considered the result of such an operation to be most precarious. Being satisfied of the increase of the disease, knowing from the happy precedent of Sir Astley Cooper's first case of carotid aneurism, tiie perfect practicability, and, under favourable circum- stances, the moderate risk of placing a ligature on the carotid artery, and particularly reflecting that the obstruction of such a channel, must, at all events, be followed by a sensible and permanent dimi- nution of the impulse of blood destined to the disease, Mr. T. tied the carotid on the 23d of May, L809. After exposing the artery, a cuiTed-eyed probe, carrying a stout round ligature, was passed beneath it, and upon compressing the vessel with the fingei., as it lay over the probe, the pulsation of the lower tumour immediately ceased. The probe being cut away, the ligatures were drawn apart from each other, and tied. Before she quitted the table, the patient observed that the pain was numbed, and that the noise in her head had entirely ceased. The small tumour over the angle of the eye was still thrilling, but very ob- scurely. The ligatures came away on the 21st and 22d days. Few symptoms of general irritation followed the operation. By the fifth day, the pulse, vi'hich had risen to 130, had fallen to 84 ; her headach had subsided ; and she felt comfortable in every respect. The following are the principal changes which followed the ope- ration. In the evening of the same day, Mr. T. was concerned to find, that the lower tumour had already acquired the thrilling motion of the upper. On the third day, the tingling or thrilling sensation was experienced in both tumours, upon li^ht contact of the finger ; if firmly compressed, a pulse was perceived in the lower. On the fifth day, the tumours were very considerably diminished, and the eye less prominent; the globe of the eye com- municated a slight pulsation ; her sight was short, and objects appeared to her larger than natural, and misty. On the 21st day, she found no inconvenience from sitting iip, and working all day, and was astonished to find that she could read small print, and do fine work with her right or sound eye, which she had been unable to do for years. By the end of the fifth week she could perform all the duties of her situation as well as before the operation, and expressed herself well satisfied with the obvious diminution of the tumour, the decrease of the pulsation, and the total freedom she enjoyed from pain, which liad distracted her for years. Four months after the operation, the tinnours were evidently smaller, and their motion materially diminished ; the eye was less project- 244 ing ; the cold dull pain, formerly uninterrupted, was now but rarely felt ; the artery of the left side was distinguished beating very feebly below the angle of the jaw, while the carotid of the opposite side contracted with more than ordinary force. On the 28th of October, she miscarried at the period of about ten weeks after conception. The haemorrhage was so considerable as to induce syncope, and left her in a state of extreme debility. On the succeeding morning, it was observed that the upper tumour was flattened, and the pulsation had altogether ceased. On the 30th, she felt pain in the affected side of the head, and was feverish. In the course of a few hours, the cellular substance of the orbit was filled with a serous fluid, precisely as at the commencement of the disease. The pain was reheved, and the oedematous swelhng, and heat of the surface, were reduced by a cold lotion. In the course of November, the pain in her head had entirely subsided, but owing to her extreme debility from loss of blood, she was subject to occasional palpitation of the heart, and giddiness. The upper tumour, and the folds of the integuments between the eyebrows, had totally disappeared. The eye projected less ; the lower tumour was inelastic, and had no preternatural pulsation. In May, 1811, a knob, of the size of a large pea, over the inner angle of the eye, was the only vestige that remained of the disease.* Nearly five years after the operation, Mr. Hodgson had an opportunity of examining this patient. She was then in perfect health, and the cure of the aneurism so complete, that it was impossible to discov- er that disease had existed in the orbit.t Case 2. On the 24th of November, 1822, Dinah Field, aged 44 years, of a delicate and sickly habit of body, came to Mr. Dai- ry mple, of Norwich, with a complaint in the left eye. She said, that about five months before, being then pregnant of her sixth child, she was seized in the middle of the night, with an intense pain in the left eyeball, accompanied by a whizzing noise in the head, which grievously distressed her. The attack was instanta- neously sudden. Hearing a noise, as of the cracking of a whip, and feeling at the same moment an extraordinary kind of pain in the globe of the left eye, she awoke in great alarm, and leaped out of bed. About ten or twelve hours afterwards, the eye became in- flamed, and the eyelids so much swelled, as to project considerably beyond the level of the upper and lower orbitary ridge. She also felt acute pain over the whole of the left side of the head ; while in the left eyebrow, and at the bottom of the orbit, her anguish was scarcely to be borne. In the succeeding night, the extreme violence of the pain abated, but the swelling of the eyelid seemed rather to increase ; and she thought she felt as if the globe of the eye was forcibly drawn upwards towards her forehead. No partic- ular alteration took place in the next seven weeks, at the end of * Medico-Chirurgical Transactions, Vol. ii. p. 1. London, 1813. i Treatise on the Diseases of Arteries and Veins, p. 446. London, 1815. 245 which she was delivered. During her labour, which she said was very severe, there was projected between the eyelids a bright red tumour, of an oblong form, which, for seven or eight days, gradu- ally enlarged, until it occupied, in a vertical direction, almost the whole space between the superciliary ridge and the lower edge of the ala nasi, reaching horizontally from the external angle of the left eye, across the root of the nose, to nearly the internal canlhus of the right eye. In the course of her confinement, this tumour was punctured, in several places, by a surgeon who then attended her. It bled freely, became smaller, and of a strikingly darker colour. A week afterwards, it was again punctured, and with sim- ilar results ; and although the operation was repeated four other times, the latter incisions afforded no relief. About two months previous to the appearance of this swelling, the patient lost all power over the levator muscle of the upper eyelid ; but if the swell- ing was depressed, and the lid raised, she could see as well as ever. She soon, however, became totally blind on this side. Three or four months after Mr. D. first saw her, he found that her general health had sensibly declined, and that the local affec- tion, now marked by very decided characters, was distinctly aneu- rismal. She had constant and acute pain, referred chiefly to the bottom of the orbit ; but her severest suffering was occasioned by the increasing noise in her head, which she compared to the rippling of water, and which became absolutely insupportable, when, b}^ any accident, her head fell below a certain level. The left eyeball was immovable ; and either enlarged, or thrust with so much force against the upper eyelid, as to cause this part to project, in a convex form, considerably beyond the superciliary and infra-orbitary ridges. The eyebrow, also, of the affected side, rose somewhat above the level of the other. The external surface of the tumid eyelid was, for the most part, soft and elastic to the touch, but its cuticle was remarkably coarse, as was, indeed, the texture of the skin generally in the vicinity of the orbit. Deep seated within the integuments of the eyelid, a little towards the inner canthus of the eye, there was a cluster of small tumours, of a firm and dense structure, causing great pain when compressed, and communicating to the finger a pulsatory thrill. Interposed between this cluster and the lower edge of the eyebrow, precisely in the course of the frontal branch of the ophthalmic artery, there was a hard tubercular substance, which rose somewhat higher above the general surface of the eyelid, and pulsated still more dis- tinctly than the smaller swellings. The texture of this substance was particularly hard and compact, and the slightest pressure upon it occasioned intolerable pain. The lower eyelid was everted, and formed a bright red convex tumour, following in its outline the di- rection of the inferior edge of the orbit, and reaching from the ex- ternal commissure of the eyelids to a little way beyond the tendon of the orbicularis. At its upper part it was covered by an overlap- 246 ping- of the upper eyelid which was paralytic, and entirely conceale( the globe of the eye. The most depending part of this tumou reached to within a line of the infra-orbitary foramen. Like thi tumours at the upper part of the orbit, this sweUing communicate( to the touch an aneurismal thrill, which also becanie evident to th( sight whenever the force of the circulation was increased. In ad dilion to these appearances, immediately above the nasal third o the superciliary ridge, the integuments were gently elevated into i soft ill-defined tumour, occupying very exactly the situation of cer tain branches of the frontal artery, and pulsating siinultaneousl) with the artery at the wrist. A similar elevation of the skin wa; perceptible at the root of the nose, giving a faint tremulous motior to a finger placed upon it. When the globe of the eye was un covered, it appeared, at first, to be enlarged, but a closer inspectior showed it to be forcibly thrust forwards, in a direction somewha outwards and upwards. A multitude of enlarged vessels could b( traced from the surface of the lower tumour to that portion of thf conjunctiva which covers the sclerotica. The cornea retained it- natural lustre and transparency, but there was a total loss of powei in the iris, and the pupil, much dilated, was slightly irregular. Be hind the lens a fawn-coloured appearance was observed, similar tc that represented in the second plate of M]\ Saunders' posthumous work. The cutaneous veins of the face generally were very fuL of blood, and gave to the skin of the left side of the face the com- plexion of a person strangled. When strong pressure was made upon the conunon carotid arter}', the tremulous motions of the tu- mour, situated at the lower part of the oi'bit, ceased entirely, but the pulsations of the upper swellings continued in some degree. The force of the stroke was, indeed, much weakened, but no pressure which the patient was able to bear, could entirely suppress it. At noon, on the 7th of April, 1813, J\Ir. D. tied the common trunk of the left carotid artery. The effects of the operation were immediate and decisive. As soon as the ligatures were tied, the pulsatory motions of the tumours on the forehead and cheek en- tirely ceased : but a slight thrilling w^s still perceptible in the tumid upper eyelid. The red sw'elling of the lower eyelid became paler, and its surface shrivelled. A few minutes after the patient wa; placed in bed, she was quite free from pain, and the noise by which she had been so long tormented having also ceased, she declared that her head no longer felt like her old head. At .5, p. m. there was no pulsation in any of the tumours. Next day the upper eye- lid, for the first time during several months, was movable. The day after, the tumour over the inner part of the eyebrow was entirely gone ; the swelling of the upper eyelid was much smaller, its tex- ture much softer, and it was less painful when compressed ; the globe of the eye also had considerably retired within its orbit. By the Loth of April, great changes had taken place in the tumours;'' the globe of the eye had completely retired within its orbit, the gen- eral prominence of the upper eyelid had sunk proportion ably, and 247 ■ not the slightest pulsatory orthrilhng motion was perceptible in any of the diseased parts. By the 17th of May, the tiimouis had all 'disappeared, and the patient's general health seemed re-established ; iyet the wound was not entirely closed, although the ligatures had iconie away, the upper on the l8lh of April, and the lower on the 4th of May. On the evening of the 3d of July, Mr. D. was called in great haste, in consequence of a bleeding which had taken place at the lower part of the wound. The haemorrhage had ceased be- fore he could reach the house. The colour of the blood was florid, land the quantity lost 10 or 12 ounces. A similar discharge took iplace on the evening of the 9th of July, but, like the former, ceased spontaneously, and happily proved the last of a series of incidents, not unlikely to disappoint the hopes which the earlier circumstances lof the case had inspired. From this period the course of events was prosperous ; and on the 19th of July, which, reckoning from the iiTiorning of the operation, comprises a period of 103 days, the wound swas firmly healed, and the patient's recovery secured. After a lapse of nearly two years, her cure appeared complete, with the exception I of her sight, which seemed irrecoverably lost. With respect to the state of the local circulation, there was no pulsation to be felt in any :of the branches of the left temporal and facial arteries ; but, as in the icase treated by Mr. Travers, the carotid might be distinguished I beating very feebly below the angle of the jaw, while a very brisk action of the collateral branches lying near the surface, was visible in the vicinity and along the course of the cicatrice.* 2. Aneurism of the Ophthalmic Artery. \ liike the internal carotid by the side of the sella turcica, the an- terior cerebral, and other arteries within the cranium, the ophthal- mic artery within the orbit is subject to true aneurism. Mr. j Guthrie states, that he saw a case of this kind, in which both [ophthalmic arteries were dilated, and which terminated fatally. iThe symptoms were similar to those of aneurism by anastomosis, ;but no tumour could be perceived. The eye was gradually pro- (truded until it seemed to be exterior to the orbit, but vision was : scarcely aflfected. The hissing noise in the head could be distinctly ; heard, and was attributed to aneurism. On the death of the pa- tient, an aneurism of the ophthalmic artery was discovered on each side, of about the size of a large nut. The ophthalmic vein was greatly enlarged, and obstructed near where it passes through the sphenoid fissure, in consequence of a great increase of size which the four recti muscles had attained, accompanied by an almost car- , tilaginous hardness, which had been as much concerned in the protrusion of the eye as the enlargement of the vessels. The di- sease existing on both sides prevented Mr. G. from proposing any operation on the carotid, to which indeed, he thinks, the patient would not have submitted.! * Medico-Chirurgical Transactions, Vol. vi. p. 111. London, 1815. t Lectures on the Operative Surgery of the Eye, p. 158. London, 1823. 248 CHAPTER IX. INJURIES OF THE EYEBALL. In the first section of Chapter lY., we have considered the injurii of the muco-cutaneous membrane, which covers the anterior third! of the eyeball. We have now to turn our attention to the injuries which affect its proper textures. ^ SECTION I — INJURIES OF THE CORNEA. 1. Contusion of the Cornea. Foreign bodies, of small bulk, impinging with violence against the cornea, and immediately flying off, are sometimes followed by very severe inflammation, ending in ulceration of the part struck, infiltration of matter between the lamellee of the cornea, and other i dangerous effects. 2. Foreign Substances adhering to the Cornea. Foreign particles frequently adhere to the surface of the cornea, i The irritation created is generally so considerable, that the patient \ is led to make immediate application for rehef : and if the foreign body has not become imbedded in the substance of the cornea, in consequence of the patient's rubbing the eye, and forcibly winking and shutting the eyelids, the removal of the cause of irritation is easily effected, with the point of a picktooth. It sometimes hap- pens, however, that the irritation does not attract suflicient attention, so that the foreign substance is left for days or even weeks, bring- ing on inflammation or even ulceration, without any attempt being made to discover the cause or to remove it. Morgagni relates a case where an insect having darted into the eye, one of its wings was left sticking to the cornea, where it created an ulcer, which immediately got well when the wing was removed. The foreign bodv, adhering to the cornea, may even be mistaken for the pro- duct of disease, and no direct attempt made to remove it in conse- quence of this mistake. Thus. Wenzel relates a case where the husk of a seed adhered for four months to the cornea of a child. A round yellowish spot was perceived on the cornea, elevated above its surface, and which from its resemblance to a pustule had been treated as such. From this spot proceeded a number of vari- cose vessels diverging like radii from a centre. It turned out to be the hard skin of a millet seed, which had stuck on the cornea in such a manner that its sharp edge and concave side adhered, whilst its smooth convex surface formed an elevation like a minute pustule. 3. Foreign Substances im^bedded in the Cornea. It is a very common occurrence for minute, hard, angular, and sometimes ignited particles to be projected with such force, as to 249 penetrate at once into the substance of the cornea ; for instance, a spark from the anvil, a minute fragment of stone, or a particle of glass. The presence of even a very small body of this description, so small, indeed, that it may be with difficulty that we are able to detect it, produces a constant flow of tears, spasm of the orbicularis palpebrarum, and speedy inflammation of the external tunics of the eye. These symptoms do not, in general, subside until the foreign substance is either removed by art, or comes away by a tedious and painful process of suppuration. In a few hours after the extraneous substance becomes imbedded in the cornea, its ad- jacent portion becomes opaque, and the opacity extends according to the violence of the inflammatory symptoms which succeed. The conjunctiva and sclerotica become more or less vascular, and the pain is varied in kind, and more or less severe, according as the one or the other of these tunics is chiefly affected with inflam- mation. If the conjunctiva is the chief seat of the increased vas- 3ularity, the eye feels rough, and as if filled with sand ; if there is considerable sclerotitis, nocturnal circum-orbital pain is excited, [ritis may even be brought on, if the case continues to be neglected, ending in effusion into the pupil. In the meantime, the part in contact with the foreign particle, killed perhaps by the impetus vvith which it was struck, or scarred by the ignited state of the mrticle, is gradually reduced to the state of a slough, and loosened Dy the processes of ulceration and suppuration, so that at length, 1 1 drops out along with the foreign substance, and leaves an ulcer )f the cornea, more or less deep, and often of a brownish colour, vhich in general heals up readily, leaving a cicatrice or leucoma. Occasionally it happens that the inflammation of the cornea is very ;evere, and gives rise to infiltration of matter between its lamellae. ■ I the foreign body is removed, and the inflammation abated by antiphlogistic means, the matter is absorbed ; but if the case is still [leglected, the purulent effusion may increase, hypopium may be lidded to the onyx which already exists, and the eye will, in all ' )robability, be entirely destroyed. This result is particularly apt follow, when rude attempts are made by common work-people, remove particles of wliinstone and iron, which have become fixed n the cornea. I could quote several lamentable cases of this sort "roiTi the journals of the Eye Infirmary, in which a conceited me- :hanic, with a common penknife, having in various instances ittempted the removal of a Jire or ignited particle of iron, fixed in he cornea, violent inflammation followed, ending in extensive ilceration, onyx, hypopium, staphyloma, and of course entire loss if vision. It is sometimes the case, after a foreign body has lain imbedded 3r a time in the cornea, that a layer of new substance is formed iver it, so that the inflammation at first excited by its presence eases, and it remains through life without giving rise to any 32 250 farther irritation. We see this frequently happen to grains of gun- powder. In other cases, the shape of the foreign substance, or the manner in which it is fixed in the cornea, may prevent it from either drop- ping out, or becoming invested in the manner now mentioned ; it will continue, therefore, to produce irritation and inflammation, which may prove destructive to vision. I shall have occasion, under the head of penetrating wounds of the cornea, to quote a case which occurred in Mr. Wardrop's practice, which will illustrate this point. The best instrument for removing foreign particles fixed on the surface of the cornea, or slightly imbedded in its substance, is a straight cataract needle. The edge of the instrument near its point, rather than the point itself, is to be used for dislodging the offending body. This is not accomplished in many cases, without fairly pressing the edge of the needle under the particle of iron or stone, so as to dig or lift it out of the cornea. This cannot be done so safely \vith the point of the needle ; for should we attempt it with the point, we may readily enough miscalculate the force we employ, so that the needle passes through the cornea into the anterior chamber. An assistant, standing behind the patient, must support the head, raise the upper eyelid, and prevent the eyeball from rolling upwards, when we proceed to the operation. If no assistant be at hand, we fix the head of the patient against the wall, and separate the lids with the fingers of the hand which does not hold the needle. When the extraneous body is removed by art, it leaves a depression in the cornea, which in general is soon filled up ; and the surrounding opacity is gradually removed. It is often the case that a considerable portion of its conjunctival cov- ering is abraded, in removing foreign particles fixed in the cornea, but that covering is reproduced perfectly transparent, unless acetate of lead is afterwards used in solution, as it often unfortunately is, for bathing the eye. This application renders the cicatrice opaque. Nitras argenti and murias hydrargyri in solution have not the same effect. The former is often useful, in such cases, in pro- moting cicatrization ; but, in general, a little warm milk and water will serve as a sufficient collyrium, employed three or four times a day. If the spasm of the orbicularis palpebrarum does not speedily subside after the removal of the foreign particle, a warm poultice made with decoction of poppy-heads, and enclosed in a linen bag may be laid over the eye. Bleeding with leeches, or from a vein of the arm, is highly beneficial, and must on no account be neglect- ed when much iiTitation has been produced ; the patient should be purged, and should remain at rest, without attempting to use the eyes, till all danger of inflammation is past. Although it generally happens that when the cornea heals over any minute fragment of foreign matter imbedded in its substance, all irritation ceases ; yet this is not always the case. I remember 251 Dr. C, Jaeger presenting a case for consultation at Professor Beer's house, of a foreign body which had remained for five years in the cornea. It was said to be a spicula of glass. The lower half of the cornea was somewhat opaque, the opacity was gradually in- creasing, and the eye was affected with frequent stinging pain. The foreign substance was of a pyramidal form, very slender, stretching from the lower edge towards the centre of the cornea, and partly from its own transparency, partly from the haziness of the cornea, it was perceived with difficulty even on close examina- tion. From the consideration that the woman was daily losing her sight more and more from the increasing opacity of the cornea, it was agreed that an attempt should be made to extract the piece of glass, and a discussion took place, whether the instrument with which the incision was to be made should be carried before or be- hind the body to be extracted. With the cataract knife, Dr. C. J. made an incision through the lower part of the cornea. Unfortu- nately, however, he happened to touch the sclerotica before enter- ing the knife into the cornea, so that the eyeball was covered with blood from the conjunctiva, and further, the patient turned her eye forcibly upwards and inwards, so that the incision was, in a con- siderable degree, made in the dark. As soon as the incision was completed, the patient became faint, and it was not till after the faintness went off, that the foreign substance could be sought for. I heard it distinctly touched by Daviel's spoon. A pair of for- ceps was then employed for its removal ; but neither with the for- ceps, nor with a delicate probe, could it again be felt. It had prob- ably given way, from its extreme tenuity, on being touched with Daviel's spoon. Some particles of it might have been washed away by the blood and aqueous humour, while others might have slipped behind the wound into the anterior chamber. The wound healed readily, and the pain which had been felt previous to the operation was relieved. I am unable to state any thing regarding the effects of the operation on the opacity of the cornea. 4. Punctured Wounds of the Cornea Are apt to be followed by violent inflammation, and, what is very remarkable, by a dragging of the pupil towards the puncture, even when the wound has not passed through the whole thickness of the cornea, so as to reach the anterior chamber. Of the latter effect, Demours has narrated and figured an instance. The cornea is represented as nebulous round the point which had been touched by the instrument of injury, and the pupil drawn up into an acute angle opposite to the seat of the puncture.* Cases of punctured wounds of the cornea must be watched with great care, as the inflammation which follows is sometimes rapidly destructive. I have seen a prick with a needle produce, in the * Traite des Maladies des Yeux. Planche 52. Fig. 3. Paris, 1818. 252 course of a few days, during which the case was neglected, such a degree of infianiraction, as ended in a copious deposition of lymph and pus between the lamellae of the cornea, and in the anterioi chamber. The liberal application of leeches, bleeding at the ami; purgatives, the use of belladonna so as to oppose closure of the pu- pil, rest, and a strict antiphlogistic regimen, will be required, along "with the use of calomel and opium, blisters, &c. The calomel and opium, and the belladonna, are directed against the inflamma- tion of the iris, which is apt to arise, and end, if neglected, in closure of the pupil. 5. Penetrating Woimds of the Cornea — Loss of the Aqueous Humour — Prolapsus of tho- Iris. As the wounds which penetrate through the cornea into the an- terior chamber var}- much in their nature, being either clean-incised or lacei-ated. — in their extent, from a mere puncture to the whole t breadth of the cornea. — and in their situation, being sometimes at the edge, and in other cases near the centre of the cornea, — so their effects are very different in different instances. AVe meet with penetrating wounds of the cornea, so small and so obhque, that they give rise to no discharge of aqueous humour, and heal by the first intention, leaving scarcely any visible cicatrice ; in some cases, the wound, for weeks, permits the aqueous humour to ooze through it. but at length unites, and perhaps leaves the eye with- out any serious permanent defect ; while in others, the wound in- flames, suppurates, and leaves an opaque unseemlj^ cicatrice, which interferes more or less with vision, according to its situation, rela- tion to the pupil, and extent. In nine cases out of ten, penetrating wounds of the cornea are followed by the instantaneous escape of a considerable portion of aqueous humour, and a protrusion of the iris. The latter consequence is much more apt to occur if the opening in the cornea is situated near its edge. It results partly from the iris losing the support of the aqueous humour which has been evacuated, partly from the push made by the rest of that fluid to escape also by the wound. The pupil is dragged towards the prolapsed portion of iris, and, as but too often the prolapsus remains unreduced, the iris unites to the hps of the wound, and the defor- mity is permanent. The loss of the aqueous humour, although regarded by the an- cients as equivalent to the loss of vision, is speedily repaired b}" the re-secretion of that fluid. The replacement of the prolapsed iris is a matter of much greater difficulty. It is often impossible to effect this replacement : indeed, Mr. Lawrence states he has never seen it accomphshed.* We may, however, occasionally succeed, by the following means, if they be employed within an hour or two after the accident, and especially if it is the pupillary portion of the iris Lectures in the Lancet, Vol. X. p. 482. London, 1826. i 253 which is prolapsed. We find the eye ah-eady inflamed, intolerant ! of light, and probably acutely painful. The cornea will, in general, i be more or less flaccid, and, on attempting to fix the eye, there is I apt to follow a farther discharge of aqueous humour. The first ( means to be had recourse to is gentle friction of the eye through the eyelid, continued for the space of about half a minute, and then , sudden exposure of the eye to a bright light. If this does not suc- ceed, we may endeavour, with a small blunt probe, to lift one edge ! of the wound, and push the iris into the anterior chamber ; and I then, whether we succeed or not with the probe, repeat the friction I of the eye and the exposure to bright light. If we still fail in ac- jicomphshing the reduction, and if the wound is so situated between I the centre and the edge of the cornea, that it is the pupillary por- tion of the iris which is prolapsed, we may next have recourse to [belladonna, smearing the extract on the eyebrows and lids, and idropping a filtered solution of it upon the eyeball. In the course of from fifteen to thirty minutes, the influence of the belladonna will have probably operated on the unprolapsed portion of the iris, so as to dilate the pupil, and perhaps to drag back into its natural place the prolapsed portion. But if the wound is close to the edge of the cornea, belladonna ought not to be employed, as it only tends, in this case, to produce a greater degree of prolapsus. After the belladonna has been applied a sufficient length of time, our attempts by friction, and with the probe, are to be renewed. If we are successful, some recommend the wound to be freely touched with a sharp pencil of lunar caustic, so as to form a minute slough, which may act as a plug, and prevent any farther discharge of the aqueous humour. Should all our attempts to reduce the prolapsed portion of iris fail, we have still a choice left of snipping it off with the scissors, or of leaving it slowly to contract, and disappear. The former is certainly the preferable practice ; for if left to itself, it long proves the cause of irritation, and leaves a broader cicatrice than if it had been removed. If the patient refuses to permit this to be done, the prolapsed portion may be touched every second day with nitras ar- genti. Under this treatment, it gradually shrinks, becomes covered with a lymphatic effusion, and at length disappears, the pupil being left permanently disfigured, and vision more or less abridged ac- cording to the size and situation of the cicatrice. The penetrating wounds of the cornea of which we have been speaking are those effected by foreign substances which are imme- diately withdrawn, as the point of a penknife, fork, or pair of scis- sors, sharp pieces of wire or wood, splinters of metal or stone pro- jected against the eye, and the like. It sometimes happens, how- ever, that the body with which the injury is inflicted, is left sticking in the cornea. The following is the instance of this sort to which I have referred at page 250. A patient applied at Mr. Wardrop's hospital, under the following circumstances. On the temporal edge 254 of the left cornea there was an opaque spot ; the pupil was irregular, and adhered to the opaque spot of the cornea ; and there was coi> siderable redness of the white of the eye, and great intolerance oi light. Fourteen weeks before, when twisting a piece of gold wire, a small portion of it broke off and struck the eye. Three days after the accident, intense inflammation came on, with severe pain, which continued for five weeks, and resisted active depletion. From: this period, the pain became less acute. A few days after applying at the hospital, a portion of gold wire v;as observed projecting be- yond the surface of the cornea, and a considerable portion seemed to be impacted in the opaque spot. It was easily extracted by means of a pair of forceps, and was followed by a discharge of the aqueous humour. The portion of wire was fully three lines in length, and one extremity had penetrated into the anterior chamber. The patient felt much relieved immediately after the extraction of the foreign substance, and the inflammation and opacity soon sub- sided.* In many instances of penetrating wound of the cornea, the for- eign body enters completely into the anterior chamber, and there remains till we extract it. We sometimes find that it has fallen to the bottom of the anterior chamber, more frequently that it is fixed in the iris or in the lens, rarely that it has passed behind the iris so as to lie in the posterior chamber. In all these cases we proceed immediately to its removal, unless it be of a very small size. A grain of gunpowder, for example, which, passing through the cor- nea, is fixed on the anterior surface of the iris, or perhaps even a particle of metal of the same size, we should allow to remain. It has repeatedly happened that the point of a cataract knife or needle, breaking off in the anterior chamber, has been left there, and has become oxidized and dissolved.! Larger and rougher metaUic frag- ments we cannot calculate on being removed in this manner. If they are fixed in the iris, or if they are impacted between the cornea and the iris, although without any laceration of the latter, they will almost certainly bring on iritis ; and even if merely in contact with the chrystalline capsule, without this part being divided, cata- ract is the invariable result. Remove a metallic fragment from these several situations, and iritis and cataract may be prevented. In doing this, however, there is a danger of wounding the iris, of touching the capsule so as to admit the aqueous humour into con- tact with the lens, which will cause cataract, and of the iris pro- lapsing after the foreign body is removed. The extraction of a foreign body from the anterior chamber may sometimes be accomplished by means of a small pair of forceps, introduced through the wound of the cornea already present ; but in other cases, this cannot be done, and the cornea must be opened -* Lancet, Vol. x. p. 475. London, 1826. t Lawrence's Lectures in the Lancet. Vol. ix. p. 53L London, 1826. 265 with the cataract knife, about the tenth of an inch from the edge of the sclerotica. If the incision be made closer to the sclerotica than this, protrusion of the iris is very likely to occur, and will in general be found irreducible. I have seen the application of bella- donna, in a case in which an angular fragment of steel was im- pacted between the iris and the cornea, dilate the pupil and carry the foreign body along with the iris to the very edge of the cornea; but I do not consider this as a practice to be followed preparatory to extracting the foreign substance by an incision of the cornea, as, I think, it favours prolapsus of the iris. Not unfrequently it hap- pens that as soon as the incision is made through the cornea, the foreign body rushes out along with the aqueous humour, so that we are saved from any trouble of extracting it with forceps. 6. Burns of the Cornea. I have seen several cases in which the cornea being touched with hot pieces of metal, its conjunctival covering w^as raised like a iblister, and considerable fear entertained lest vision should be lost. The conjunctiva, however, has been regenerated perfectly transpa- rent in some of these cases, and in others with only a slight degree ! of obscurity. It has been very different with injuries of the cornea from sul- phuric acid and from quicklime. Deep ulceration of the cornea, with hypopium, and total opacity of the front of the eye, have fol- lowed in such cases. SECTION II, INJURIES OF THE IRIS. These are, in the first place, punctures and lacerations through the cornea ; in the second, displacement ; and thirdly, separation of the ciliary edge of the iris from the choroid. Punctures and lacerations of the iris are apt to be followed by dilatation of the aperture, so as to form a false pupil. Inflamma- tion is to be guarded against in such cases, and combated by the means hereafter to be recommended for iritis. Blows on the eye, (for instance, with the fist,) are not unfre- 'quently followed by displacement of a considerable portion of the iris. The pupil is greatly enlarged, and one-half, perhaps, of the iris is thrust out of sight, so that the pupil extends on one side to the very edge of the cornea. This accident is generally attended by effusion of blood into the eye, and by amaurosis. 1 The connexion between the iris and the choroid is much less <;firm in man than in quadrupeds, and the consequence is that 'smart blows on the human eye are apt to separate the one of these j membranes from the other, so as to form a false pupil exterior to the circumference of the iris. The stroke of a whip, a horse's tail, or the twig of a tree is frequently the cause of this accident. 256 We have no means of bringing back the iris to its former situation.!^ Belladonna dilates the false pupil as well as the natural one, nar- rowing the portion of iris between them. The vision of the eye is, in general, much debihtated after this sort of accident. ! SECTION III. INJURIES OF THE CHRYSTALLINE LENS AND CAPSULE. Punctures of the capsule, by means of pointed or cutting instru- ments pushed through the cornea, are followed by the admission of the aqueous humour into contact with the lens, which produces opacity or cataract. The edges of the puncture or wound of the capsule are apt to inflame and become of a chalky white colour. If they unite, so that the aqueous humour is no longer admitted into contact with the lens, the progress of the cataract will be ar- rested. If the wound of the capsule is considerable and does not heal, the whole lens becomes coagulated and opaque, and in a young or middle-aged person is gradually dissolved, so that the pupil clears and a certain degree of vision is recovered. Blows on the eye sometimes rupture the capsule, so that the lens escapes. "When this is the case, the lens generally passes forward through the pupil, and lodges in the anterior chamber, causing great pain and irritation, and bringing on inflammation. When this happens, the cornea is to be opened, as in common extraction of the cataract, taking care, however, to pass the knife behind the dislocated lens, especially if some weeks or months have elapsed since the accident. The use of this direction is to prevent, if pos- sible, the lens from slipping back through the pupil, and sinking into the vitreous humour, which, in consequence of the injury which it has sustained, in injuries of this sort, we generally find in a dissolved state. The retina is also rendered almost always in- sensible by the blow which produces the dislocation of the lens. In some neglected cases of this accident, I have known the opaque lens lie for years in the posterior chamber, where it was seen bobbing about, on every movement of the eye or head, but occa- sionally passing through the pupil into the anterior chamber, and returning again into the posterior, till on some particular occasion more irritation being excited by its presence in the anterior cham- ber than usual, iritis has come on with great pain in the eye and head, contraction of the pupil, and an impossibility of getting the lens to retire, as it had been wont to do, into the posterior chamber. Under these circumstances, however unfavourable for an operation, the extraction of the dislocated lens must be resorted to, that the patient may be freed from the severe pain attending the iritis, and the sound eye saved from the danger of sympathetic inflammation. Another accident to which the lens and its capsule are subject in ' consequence of blows on the eye, is separation of both from the 257 vitreous humour, so that the capsule, enclosing the lens, becomes entirely insulated. In this case, the capsule thickens, the lens co- agulates and dissolves, and the cataracta cystica which is thus formed moves in the posterior chamber, and occasionally comes forward, like the lens in the former case, into the anterior chamber. If we extract this kind of cataract, we do so not to restore vision, for the eye is uniformly amaurotic, but to save the patient from pain. SECTION IV. WOUNDS OP THE SCLEROTICA AND CHOROIDEA. Incised wounds of the conjunctiva and sclerotica, are instantly followed by a protrusion of the choroidea, which we have no other means of repressing, than by directing the patient to keep the eye- lids as much shut as possible, so as to give a degree of support to the eyeball, till the wound heals. This it never does without leaving a considerable cicatrice, the space between the edges of the wounded sclerotica being filled up by an effusion of lymph which gradually assumes the appearance and texture of a membrane. The conjunctiva sometimes heals in cases of this kind, while the sclerotica continues open, with the choroidea projecting through it. Where both sclerotica and choroidea are divided, the vitreous humour immediately issues from the wound, which also bleeds profusely. The vitreous cells become injected with blood, and form a fungus-hke protrusion from the wound. This case is to be treated hke the former. Besides antiphlogistic means, the eyelids must be kept shut, unless the injected protrusion of the hyaloid membrane prevents this from being accomplished. A warm bread and water poultice is to be laid over the lids. Most frequently vision is entirely destroyed by the loss of vitreous humour, the in- jury done to the retina, and the violent inflammation of the eye which follows the accident. I SECTION V. PRESSURE AND BLOWS ON THE EYE. |j Beer relates the following instance of the bad effects of sudden pressure exercised on the eyeball. " Some years ago," says he, "I was called to a man, who had previously enjoyed excellent sight, but, a short time before I saw him, had in an instant become to- tally Wind in both eyes. He happened to be in a company of friends, when suddenly a stranger stepped behind him, and clapped bis hands upon his eyes, desiring him to tell who stood behind 'him. Unable or unwilling to answer this question, he endeavoured jto remove the hands of the other person, who only pressed them ,Lhe firmer on the eyes, till at length withdrawing them so as to al- low the eyes to be opened, the man found that he saw nothing, i 33 258 and continued ever afterwards blind, without any apparent lesion of the eyes." * Blo\\ s on the eye are often productive of amaurosis, without any- visible change being produced in the organ : whence Ave may con- clude that the blow has affected the retina by concussion, conges- tion, extravasation, or laceration. It is unfortunate that cases of traumatic amaurosis are often oeglected, till the bhndness is com- pletely confirmed ; for much may be done for their relief, if they are taken in proper time. The following case will illustrate the danger of neglect, and the good effects of appropriate treatment. ISlr. N. applied to me on the ISth of January 1S29, on account of the effects of a blow which he had received, eight days before, with a prett)^ heavy piece of metal, on the temporal side of the left eye. He was a man of about 40 years of age, of sound constitu- tion, and his eyes had been good till this accident. Any inflam- mation or irritation produced by the blow had already subsided. although almost nothing had been done in the way of treatment. The vision of the eye was lost, except when he turned it very much to the left, so much indeed as to look almost behind him. When he did so. he saw indistinctly any object situated to his left. For- wards or to the right he saw nothing, every thing being darkened by the appearance of a thick gauze or mist. A bright light, as a gas flame, was the only object capable of producing a sensation,, when the eye was directed forwards. This amaurosis was so con- siderable, and had been neglected for so many days, that I pro- nounced a very doubtful prognosis, but urged the adoption of activer measures. Thirt}' ounces of blood were taken from the arm on the evening of the ISth. He took two of the following pills, and was ordered two three times a day : R aloes gr. ii.. massee pilulse hydrargA'ri gr. iii.; misce ; fiat pilula. On the 19th. he thought he saw objects somevrhat less indistinctly, but still only when he looked much to the left hand. "When he looked forwards, he saw as if gauze-threads were moving before him. and the lamp appeared of various colours. Twenty-four leeches were apphed round the eye. On the 20th, his vision was so far improved, that he could make out the large characters on the back of a quarto book, when he looked at it sideways. He could recognise any ordinary object, as a teacup, held towards his left side, but lost sight of it entirely as it was moved in front of him. A blister was applied to the left temple and behind the left ear. On the 22d, there was a great unprovement in vision. He could now tell the hour on a watch, even when he looked straight forwards, and compared the apparent impediment to vision to branches of trees, whereas it formerl}" had the appearance of a imiforra cloud. The mouth being considerably affected by the pills, they were omitted. The blister was re-applied. On the 24th, the bhster was discharging well, the mouth was very * Pflege gesunder und geschwachter Augen, p- 10. Frankfort, 1802. 259 sore, and the vision much improved. He could read a newspaper with the left eye, and said that the branches of trees, which appear- ed before him, were now broken, and looked like grains of sand separated one from another. On the 26th, he stated that he knew an increase of vision daily. The mouth was still very sore. The blister was repeated. After this, the vision continued progressively to improve, and by the middle of February was all but perfect. If it were necessary, I could quote similar cases from the journals of the Eye Infirmary, showing the good effects of depletion, coun- ter-irritation, and mercurialization, in amaurosis consequent to those blows on the eye, which are probably productive of congestion of the choroid and retina, but unattended by any other considerable lesion of these important structures. I have already, in the preceding sections of this chapter, had occasion to notice some very serious effects of blows on the eye, as displacement and separation of the iris, bursting of the capsule with escape of the lens, and dislocation of the lens enclosed in the cap- sule. Effusion of blood into the aqueous chambers, dissolution of the vitreous humour, and laceration of the retina, are among the most common effects of heavy blows on the eye. We also fre- quently meet with laceration of the sclerotica, with or without rup- ture of the conjunctiva, and of the choroid : and sometimes, though not so frequently, we meet with laceration of the cornea. From the cases which have come under my care, I could describe an almost infinite variety of effects arising from blows on the eye, with the fist, with sticks, with stones, and other implements thrown at the eye, and from falls on the eye. In the whole of such cases, the prognosis is unfavourable. Even when there appears to be nothing more than an effusion of blood into the aqueous chambers, we generally find, that after the blood is absorbed, the pupil remains dilated and immovable, and the retina insensible. If we puncture the cornea in cases of this kind, there is, in general, a profuse dis- charge of bloody watery fluid ; if the puncture is small, it heals in twenty-four hours, and may be repeated from time to time without any ill effects. The cornea is more resisting than the sclerotica. The conjunctiva, from its laxity, sometimes escapes, while the sclerotica, owing to the tension produced by its contents, is unable to withstand the effects of a blow, and consequently gives way. I have seen the sclerotica and choroid ruptured, and the lens at the same time propelled through the lacerated opening in their tunics, so as to lie immediately under the conjunctiva, which remained entire. What rendered this case the more remarkable, the iris had been partly separated from the choroid by a former injury, so as to form a false pupil, and yet a considerable degree of vision was ultimately retained, as much, indeed, as, in many instances, is recovered after an operation for cataract. I removed the lens by an incision through the conjunctiva, some time after the lacerated sclerotica and choroid had closed. 260 In cases of bursting of the eye from a blow, whether the lacera- tioa is through the cornea, or through the sclerotica, considerable haemorrhage takes place, especially wlien the clioroid has also given way. The humours are also often partly, and sometimes almost wholly, evacuated, so that a dwarfish deformed eyeball is left after the lacerated part heals up. SECTIOX VI. GrXSHOT WOUNDS OF THE ETE. Under this head, I may notice some of the effects of gunpowder exploded into the eye. It is generally the lower portion of the cornea which suffers most from this accident, but in an instance which came under my observation, as the person was in the act of stooping to the ground when the powder exploded, only the upper half of each cornea received the injury, and was left opaque. I have repeatedly seen grains of powder propelled through the cornea into the lens, so as to cause cataract. Small-shot not unfrequently pass through the coats of the eye. Demours has represented a case in which a grain of small-shot passed through the cornea, detached the iris from the choroid, and produced opacity of the lens.* Amaurosis is generally the effect of grains of shot entering the eyeball ; and Mr. Lawrence mentions that he once saw complete blindness caused by a single grain, which merely struck the sclerotic obliquely and did not enter.t The eyeball is most frequently found to be burst in cases where it has been struck by musket-shot ; but occasionally it escapes, and the ball penetrates between the eye and the orbit. Exophthalmia, or inflammatory disorganization of the eye, with protrusion, is very apt to follow in either of these cases. When this symptom does occur, either the humours should be evacuated by a free and deep incision, so as to allow the eyeball to shrink and become quiet ; or, if it has become solid from thickening of its coats, it ought to be extirpated. If such practice is not followed, the patient is generally doomed to suffer extreme pain for a length of time : and the en- larged eyeball is even apt, by pressure, to produce absorption of the roof of the orbit, and fatal inflammation of the dura mater and brain. SECTION VII. DISLOCATION OF THE EYEBALL. I have already had occasion to quote two cases of dislocation of the eyeball, produced by foreign substances thrust between the eye and the orbit ; t and I have explained that by being dislocated is to be understood that the eyeball is extruded beyond the fibrous layer of * Traite des Maladies des Yeux. Planche 52. Fig. 1. Paris, 1818. t Lectures in the Lancet, Vol. is., p. 531. London, 1826. t See pages 13 and 15. 261 ihe eyelids. The optic nerve, when the eye is in that state, is put very much on the stretch, vision is lost till reduction is accomplish- ed, and the lids can no longer be brought together. If the foreign body by which the dislocation has been produced be still in the orbit, it must, of course, be removed before reduction be attempted. After this is effected, the eye is to be pressed steadily back into its place. The pressure being continued for some time, the eyeball will generally be found to start suddenly back through the aperture in the periosteal edging of the orbit, and vision to be immediately restored. From the obliquity of the base of the orbit, it is evident that to- wards the temple the eyeball stands in a considerable degree exte- rior to that cavity ; and hence it is that a severe blow on the eye, for instance, with a racket ball, is capable of producing dislocation. Covillard, in his Observations latro-chnurgiqiies^ relates a case of this sort. He tell us that the dislocation was so complete, that when he came to visit the patient, immediately after the accident, he found one of his friends with scissors in his hand, ready to cut the eye away. Covillard reduced it, and the patient's vision was pre- served.* SECTION VIII. EVULSION OP THE EYEBALL. The eyeball is often blown out by musket-shot ; but cases of its being torn out of the socket by other accidental means are rare. A remarkable instance of this, however, is related in the first volume of Grafe's Journal. A cart-wheel went over the side of the head, and tore out the eyeball, along with seven lines' length of the optic nerve, the muscles of the eye being left behind, and the orbit unin- jured. The patient, a man of 75 years of age, recovered without any bad symptom. CHAPTER X. THE OPHTHALMIiE, OR INFLAMMATORY DISEASES OF THE EYEBALL. SECTION I. THE OPHTH ALMIjE IN GENERAL. Under the term inflammation, a very considerable number of different phenomena are included. There is included, first of all, that state of parts which is recognized by increased redness, un- natural heat, swelling, and pai7i. This, indeed, is strictly ia- * See Memoire sur plusieures Maladies du Globe de I'CEil, par Louis ; in the Memoires de I'Academie de Chirurgie, Tome xiii. p. 266. 12mo. Paris, 1774, 262 flammation, characterized by its four distinct primary phenomena. The morbid changes which I shall presently enumerate, may be regarded as so many secondary phenomena, apt to succeed, but which do not necessarily succeed to this, the first stage of every in- flammatory disease. So long as the part affected exhibits nothing else than increased redness, unnatural heat, swelling, and pain, and so long as these continue to augment, the disease is merely devel- oping itself. An inflammatory attack before, or even when it has reached the greatest degree of violence of which this first stage is susceptible, may, without any new local phenomena being mani- fested, gradually subside through the means employed for its cure, or by the natural resolution of the disease. On the other hand, the disease may go on, and manifest with greater or less rapidity, one or more of the following seven secondary phenomena of in- flammation ; namely, effusion, of red blood, of colourless blood, or of fibrin ; adhesion ; suppuration, from a secreting surface, or in the form of abscess ; ulceration ; mortijication ; grariulation ; and cicatrization. The part inflamed may pass through several of these states in succession, or several of them may exist together at the same time. Inflammation, in whatever part of the body, and consequently in whatever part of the eye, it exists, may terminate in any of the processes now enumerated. It is also well known that the secon- dary phenomena of inflammation are always modified according to the structure of the part affected. Every different texture of the eye, as it possesses both physical and vital properties peculiar to it- self, must suffer differently from these several processes of inflam- mation. In many cases, the modifications of inflammation from differences of texture in the j)arts affected, are displayed with much distinctness in the e5'^e ; in other cases, these modifications can be judged of only from their consequences, and by a very minute ob- servation of the derangement which remains in the organization or in the function of the part which had suffered ; while in other cases, from the delicate texture of the part or its hidden situation in the eye, the modifications in question may altogether escape ob- servation. The conjunctiva, sclerotica, cornea, iris, chrystalline capsule, and retina, present a series of the modifications of inflammation, to which I have just now referred, sufficiently distinct to convince the most sceptical of the truth of what I have been asserting, and suf- ficiently striking to rouse the most inattentive to research. The muco-cutaneous conjunctiva secreting a flood of purulent matter, as in the ophthalmia of newborn children — the fibrous sclerotica af- fected for months with rheumatic inflammation — the transparent fibro-cartilaginous cornea becoming opaque, or being destroyed layer after layer by a penetrating ulcer — the erectile iris losing all power of executing its motions of expansion and contiaction — the chrys- talline capsule pouring out coagulable lymph from its serous surface. 263 and this lymph forming the medium of morbid adhesions — the nervous retina, too deeply seated to be observed immediately, but in a few hours losing its inconceivably delicate sensibility — these are facts in which are displayed the modifications of inflammatory action and the various consequences of inflammation, fully as dis- tinctly and as strikingly as they are manifested in any other, nay in all the other parts of the body put together. There are other circumstances besides differences of texture which modify the inflammatory affections of the eye, -and which render this subject very extensive in the discussion, and cause the diseases to be occasionally very perplexing in the treatment. They are under the influence of peculiarities of constitution, of constitu- tional diseases, and of certain artificial states of constitution ; and they are subject to innumerable variations from the influence of those inscrutable connexions called sympathies. Scrofula, syphilis, gout, and that state of the system which we may call mercurialism, are each of them either capable of exciting inflammation in differ- ent parts of the eye, or at least of communicating to an inflamma- tion, excited by other causes, such differences in character as shall often render it difficult to recognise a disease with which we were well acquainted in its simple or idiopathic form. By the influence of local sympathy, inflammation of one texture of the eye never takes place without extending in some degree to the textures with which the first affected is in contact ; by the same influence, an inflammatory disease originating in one tex- ture of the eye shall be communicated to several of the other tex- tures, the inflammation of the superficial tunics being communi- cated to those more deeply seated, and conversely that of the in- ternal parts spreading outwards ; and, while each texture obeys its own laws of morbid action, the whole organ in this way maj?" become involved, by what had at first a very limited [existence, and perhaps a very trivial aspect. When we jeflect, then, on the innumerable combinations which may take place among the inflammatory diseases of the eye, and the many causes by which these diseases may be modified, we shall be convinced, I think, that of all the subjects requiring de- scriptions and explanations of morbid actions and changes, there can be few more difl&cult than those diseases which have been swept together with so indiscriminating a hand, under the name of oph- thalmia. To consider these actions and changes individually, and only in a single texture of the eye at once, may seem to lessen the difficuliy ; for instance, to consider inflammation of the cornea, and to exhibit to ourselves in order, effusion of serum, eflTusion of coagulable lymph, secretion of pus, formation of abscess, ulceration, mortification, and cicatrization, according as each of these processes manifests itself in the cornea. But to do all this, is to consider and to exhibit what never takes place separately in nature. Unless this be kept in mind by those who begin to study the inflammato- 264 ry diseases of the eye, they will be not a little perplexed bj'' tha diversified complications of morbid phenomena, which they will meet at every step of their progress. The knowledge of the inflammatory diseases of the eye has been greatly retarded by the practice of confounding them all under the name of ophthalmia, and thus overlooking both the seat of the disease, and the peculiar nature of the inflammation. The consequence of thus viewing all these diseases without discrimina- tion, has been a method of treating them equally preposterous. In fact, in the practice of those who have had no opportunities of studying the diseases of the eye, one routine of remedies continues to be used in every case in which the eye appears inflamed, and it often happens, that it is not till this routine is exhausted, and the eye in some of its essential parts becoming seriously disorga- nised, that a suspicion arises of there being somethiog specific or peculiar in the case. Even from the slight view which we have akead}'' taken of this subject, it is evidentljf impossible that the in- flammatory affections of parts so widely differing in structure and function as do those which are assembled in the eye, can be treated at ance indiscriminately and successfully. We find, for example, that the remedies which in the course of a few days are sutficient completely to remove inflammation of the conjunctiva, only aggra- vate inflammation of the sclerotica or iris, while the plan of treat- ment which speedily cures sclerotitis or iritis, if trusted to in con junctivitis, would expose the eye to almost certain destruction. Great advantages will accrue, then, from the adoption of an accu- rate classification of the ophthalmiee. One advantage of no incon- siderable moment will be, that we shall conduct our examinations of the inflammatory diseases of the eye which may come under our care, with much more accuracy than we could possibly do, were we to employ the vague nomenclature commonly used upon this subject. Having noted exactly the disease which is before us, we shall be able bc^h to ascertain to our own satisfaction, the ef- fects of the remedies which we employ, and to communicate our experience to others ; which, without a just classification and per- spicuous nomenclature, it is utterly impossible to do. 1 have admitted into the following table of the ophthalmiee none, the distinct and separate existence of which I have not either as- certained in the course of my own observations, or beenxonviuced of upon indubitable authority. I. CONJUNCTIVITIS. I. Conjunctivitis PuRO-MrcosA. 1. Catarrhal. 2. Contagious or Egyptian, 3. Leucorrhoeal, or Ophthalmia Neonatorum. 4. Gonorrhoeal. II. Conjunctivitis Scrofulosa. 265 1. Phlyctenular. 2. Pustular. III. Conjunctivitis Erysipelatosa. IV. Conjunctivitis Variolosa, V. Conjunctivitis Morbillosa. VI. Conjunctivitis Scarlatinosa. II. SCLEROTITIS. 1, Rheumatic. III. CORNEITIS. 1. Scrofulous. IV. IRITIS. 1. Rheumatic. 2. Syphilitic. 3. Scrofulous. 4. Arthritic. V. CHOROIDITIS. VI. RETINITIS. VII. AdUO-CAPSULITIS. VIII. ANTERO-CHRYSTALLINO-CAPSULITIS. IX. POSTERO-CHRYSTALLINO-CAPSULITIS. X. VITREO-CAPSULITIS. XI. CHRYSTALLINITIS. Appendix. 1. Traumatic Ophthalmiae. 2. Compound Ophthalmiae, as the catarrho-rheumatic, pus- tulo-catarrhal, &c. 3. Intermittent Ophthalmiae. section ii. — remedies for the ophthalmiae. Before proceeding to describe the different inflammations of the eye, and explain the treatment peculiarly required for each, it may not be improper to offer a few rules of universal application in the treatment of these diseases, and to make some general remarks on the classes of remedies employed for their cure. 1. It is a general rule of great importance in the treatment of any ophthalmia, to discover the cause whence it has arisen, and, if possible, to remove that cause, if it is still in operation. The cause may be purely local, or it may be constitutional ; but in either case, if it be allowed still to operate, it is evident that every thing in the way of remedy must prove comparatively or entirely ineffectual. 2. The eye, and the body at large, must be defended from new causes of irritation. The original cause may be removed, but still the disease may continue, being kept up by other causes of a nature very different from the original one, but equally detrimental. The primary cause is often local, and the secondary causes constitutional. After the first is removed, the second are too often overlooked. 34 266 The remedies which may occasionally be required for the cure of the ophthalraise are very numerous ; those which are most frequent- ly used, and in general with complete success, are few and simple. 1. Bloodletting. Openiv:r a vein of the arm, the apphcation of leeches round the eye, and division of the inflamed conjunctiva, are the three modes of taking away blood generally had recourse to in this class of diseases. Opening the temporal artery, the external jugular vein, or the nasal vein, or cupping the temples, is seldom necessary. The three modes of bleeding first enumerated, cannot be substituted one for another, and we should often run a risk of losing the ej'e, were we to attempt to cure by local what will readily yield to general bleeding, or vice versa. For instance, bleeding at the arm. by depressing the general strength of the patient, rather aggravates than alleviates the scrofulous ophthalmias, v.'hile bleeding with leeches, by removing local turgescence, greatly relieves them ; a check is readily put to most of the internal ophthalmiee by gene- ral blood-letting, while local has comparatively but little effect ; in chronic puro-mucous conjunctivitis, much more good is done by scarifying the inside of the eyelids, than could be accomplished by leeching or phlelxttomy. Neither is it unimportant in what succes- sion we employ these three modes of taking away blood. Leech- ing, for example, when considerable synocha is present, produces much more effect if preceded by general bleeding ; and especially if .the leeches are applied within a few hours after the impetus of the circulating system has been moderated by bleeding from the arm. I know of no inflammatory disease of the eye which is curable by bleeding alone ; and I look on the attempts to cure the conta- gious or Egyptian ophthalmia by taking away very large quantities of blood, till the inflamed membrane grows pale from depletion, as the veriest of folly ; first, because even were this paleness pro- duced, it could be no test of the disease being subdued ; secondly, because a degree of blood-letting suflacient to produce even an ap- proach to such an effect, would leave the patient in a state of great and unnecessary debility : and thirdly, because the disease could be cured by a much milder plan of treatment. AU the ophthalmise require other remedies besides the taking away of blood ; and, there- fore, while we value this means of cure veiy highly, we must by no means trust to it alone in any case. In taking away blood from the arm in any inflammatory disease of the eye, the opening should be made large, so to ensure, if pos- sible, a consideral^le effect on the impetus of the circulation. The quantity removed will vary from ten to thirty or forty ounces, ac- cording to the constitution of the patient, and the circumstances of the disease. Leeches ought to be appUed, in general, not on the loose sub- stance of the eyelids, but on the temple, forehead, and side of the nose. The number applied will vary from one to twenty or more. In infants, we often find much good effected by one leech to the 267 middle of the upper eyelid. In some chronic cases of inflamed and thickened conjunctiva, one or two, fixed on the internal surface of the lids, will be found useful. I by no means deny the efficacy of opening the temporal artery, or taking away blood by scarifying and cupping the temples ; but these modes are more difficult of execution, and are attended with a greater degree of irritation and pain than simple venesection, and the application of leeches. They also preclude, in many instances, the use of other means which are likely to be useful ; as, blisters to the temple and behind the ear. The tight bandage necessary after arteriotomy is also objectionable in cases of ophthalmiee, as it produces a degree of pressure, and a development of heat, which are apt to increase the uneasiness of the eye and head. Scarification of the conjunctiva of the eyelids, and sometimes of that covering the eyeball, is a valuable means of cure in certain cases. One or two deep incisions being made along the whole length of the inner surface of either eyelid, a very considerable dis- charge of blood will probably take place, and if the lids be proper] y managed, blood will continue to flow for a considerable time. F or this purpose, the lid ought neither to be held everted till the bleeding ceases, nor allowed to fall back into continued contact with the eyeball, in either of which ways little blood will be obtained ; but the lid ought to be alternately everted and permitted to return to its natural position, by which means the divided vessels are re-filled, and thus a continued flow of blood is produced. Along with scarification, we may class the snipping across of individual enlarged vessels running over the surface of the eyeball,, which is often useful. The mode which I adopt, is to raise a small fold of the conjunctiva with the forceps, and snip it'away wadi the scissors. This fold rarely contains the enlarged vessel which w^e wish to cut across, but it is now exposed ; wath a small hook it is easily raised from the surface of the sclerotica, and divided. The practice of removing with the scissors a circular portion of the conjunctiva round the edge of the cornea, as was advised by Scarpa, appears to be almost laid aside. Evacuating the aqueous humour, as a mode of depletion in cer- tain kinds of ophthalmia, was highly recommended by Mr. Ward- rop ; but has never come into general use. 2. Purgatives act in two ways in the cure of the inflammatory disease of the eye ; namely, as depletory, and as sympathetic means. They reduce the quantity of circulating fluid, as well as remove the contents of the bowels ; and from the continuity of the investing membrane of the eye with the lining membrane of the digestive organs, they prove a very effectual remedy in almost all kinds of ophthalmia. An active purge of calomel and jalap is often suffi- cient of itself to check an attack, when employed early. In the course of diseases of this class, occasional laxatives are always necessary ; while in many cases, especially in children, nothing but a continued use of purgatives will effect a cure. 268 3. Emetics are of essential service in the treatment of various inflammatory affections of the eye, not only when there is reason to suppose that an overloaded state of the digestive organs is con- cerned in keeping up irritation, but as a means of lowering the circulation, and relaxing the skin. In chronic cases, the sorbe- facient effects of this class of remedies are also highly useful, pro- moting the absorption of unhealthy depositions, and thus assisting in restoring the transparent media of the eye to their natural condition. 4. Diaphoretics are useful in lowering inflammatory action in the eye, especially when suppressed perspiration has been, as it often is, the exciting cause of an ophthalmia. The eye, being invested by a continuation of the integuments, partakes in the good effects of a renewed secretion from the skin. We seldom, indeed, think of treating any ophthalmia by diaphoretics alone ; but, after depletion, we employ this class of remedies as valuable adjuvants in the cure. 5. Alteratives. Of this class mercury is the chief; and without the aid of this medicine, we might regard the internal ophthalmias, and especially inflammation of the iris, as incurable. It is as a sorbefacient that mercury proves so useful in the internal ophthal- mise, powerfully promoting the removal of effused coagulable lymph, by an increased action of the absorbents. Whether it accomplishes this directly, by actually stimulating the absorbents, or merely favours their action, by abating in some unknown mode, the in- flammation, in which the effusion originates, we are unable to say ; but the sad result of the ophthalmiee of this class when neglected, and the admirable effects of mercury, in preserving the open and transparent state of the pupil, in these diseases, are placed beyond all doubt. In the diseases to which I have alluded, we employ mercury so as to affect the constitution, and in this way to operate on the eye ; but in other cases we use it in smaller doses, in the expectation of deriving benefit from its well known effects on the secretory organs concerned in digestion. 6. Tonics. The scrofulous ophthalmiee, and almost all others in the chronic stage, are benefited by this class of medicines, of which cinchona is by far the most powerful. The treatment of the scrofulous opthalmise with sulphate of quina is an improvement in ophthalmic medicine, perhaps scarcely less important than the treatment of iritis with mercury. The former diseases are- much more frequent in their occurrence than the latter, and not less dan- gerous in their effects upon the transparent parts of the eye. The mineral acids, and the chalybeates, are also highly valuable tonic remedies for certain kinds and stages of the ophthalmiae. 7. Narcotics. We are naturally led to employ narcotics in the hope of assuaging the severe pain attending many of the ophthal- miee ; but this is perhaps not their most important effect. Two of 269 tlie most painful ophthalmise are the rheumatic and catarrho-iheu- matic. Laudanum, rubbed on the forehead and temple, does much to reheve the pain ; or if opium be taken internally, considerable alleviation will be procured ; and much more good will be effected if this medicine be administered internally, combined with calomel. I regard the form of calomel with opium as almost specific in the rheumatic and catarrho-rheumatic ophthalmiee. Either remedy by itself is much less efficacious. The opium appears to act as much as a dirigent as a narcotic. Opium, in vapour, and in fomentation, is employed directly to the eye in certain states of inflammation. A very peculiar set of narcotics, of inestimable value in ophthal- mic medicine, consists of belladonna, hyoscyamus, and stramonium, which have the power of dilating the pupil. They are used in a variety of ways, but chiefly in extract smeared on the eyebrow. As in all the internal ophthalmiee there is a disposition to closure of the pupil, one of these narcotics is applied once or oftener in the twenty-four hours to oppose this tendency. If severe inflammation is already present in the iris, they have little effect ; but if the at- tack is incipient, or if it be already yielding to the influence of mercury, the pupil is speedily expanded. 8. Refrigerants. Prom the feeling of unnatural heat which attends most of the ophthalmiee, the application of cold water may be regarded as a remedy to which the patient is prompted by in- stinct. It undoubtedly relieves for a time, yet in the internal oph- thahniee it is positively injurious, while in many, or even in most other cases, there follows its use a degree of reaction which is det- rimental. Incipient inflammation of the external covering of the eye may sometimes be checked by the application of cold lotions ; but even in these cases, the same good may be obtained from tepid applications, without the risk of any hurtful re-action ; exactly as the skin in fever is cooled with less risk by the tepid, than by the cold affusion. A tepid lotion soothes and relaxes the inflamed membranes of the eye, and being evaporated at the expense of the superabundant heat of the parts, acts in fact as a refrigerant. Hence it is that I scarcely ever employ cold applications or refrige- rant solutions in the treatment of the ophthalmise. Nitre is occasionally employed as an internal refrigerant in some ophthalmise. Its diuretic effects may perhaps prove serviceable. 9. Astringents. I have almost entirely dismissed from my prac- tice the acetas plumbi, and sulphas zinci, being convinced, from numerous observations, of their almost uniform bad effects, especi- ally if they are allowed to come into contact with the cornea in an abraded or ulcerated state. The nitras argenti and murias hydrar- gyri, in solution, may be substituted in place of almost all other astringent lotions or drops. Even the sulphas cupri and lapis di- vinus may be laid aside, except in a few peculiar cases. 10. Stimulants and escharotics. Under this head we include 270 a valuable set of remedies ; as, nitras argenti, murias hydrargyri, red precipitate, subnitrate of mercury, vinum opii, &c. In the in- ternal ophthalmise, the application of most of these is destructive, while in conjunctival inflammations, more is effected by. their means than by almost any other kind of remedy. The nitras argenti and murias hydrargyri are to be employed in solution, never in the form of ointment. No doubt a nitras argenti ointment has been recommended by Mr. Cleoburey and others, but as it is perpetually imdergoing a new degree of decomposition, it forms a remedy of variable strength, concerning the effects of which no certain con- clusions can be drawn.* The red precipitate, again, and the sub- nitrate of mercury, are used only in the form of salves. The vinum opii is applied either pure or diluted, and in certain chronic inflam- mations of the eye proves highly useful. Any attempt to employ it, or indeed any other single remedy, as a panacea in the ophthal- miae, would manifest a total ignorance both of this class of dis- eases, and of the uses of remedial agents. 11. Counter-irritants, including rubefacient hniments, blisters, and issues, are of much service in the treatment of the ophthalmiee, especially in the chronic stage. Having thus gone over the chief classes of remedies employed in the treatment of the ophthalmiee, I may mention that much is to be effected also, in the cure of these diseases, by dietical regulations, using dietical in its original and extended sense, and comprehending under it every particular in the mode of life. Thus, attention to cleanliness, by the removal of morbid discharges from the eyes, e>zclusion from an improper degree of light, exposure to pure air frequently renewed, early going to rest, quiet sleep, repose of body and mind, a properly regulated diet, and regulated exercise ; all these, and many similar observances, are in a high degi'ee conducive to recovery, while a neglect of one or more of these rules is often the cause of prolonged and severe attacks of inflam- mation, in different textures of the e3'e. SECTIOX III.- — CONJUNCTIVITIS IN GENERAL. It may here be proper io recall to mind the extent and relations of the conjunctiva, that it lines the internal surface of each eyelid, * The following note is taken from the preface of the original edition. Notwithstanding this objection, which, in a pharmaceutical point of view, is im- portant, I have been induced to try a salve composed of five grains of nitrate of silver, rubbed into an impalpable powder, and mixed with an ounce of lard; and, in chronic cases of the puro-mucous ophthalmia, have found it highly beneficial. In the acute stage of these diseases, the aqueous solution still appears preferable. The fact that lard slowly decomposes nitrate of silver, of course renders it expedient to prepare this ointment only in small quantity as it is wanted. At first it consists simpl}' of nitrate of silver in fine powder diiTused in lard, but afterwards the nitrate is slowly reduced, by the action of the animal substance, to the state of an oxide. The salve is apphed once a-day to the inflamed conjunctiva, and generally produces very considerable pain for abou;, a quarter of an hour. 271 covers the anterior third of the eyeball, passes over the cornea, although differing considerably in texture at that part from what it is in the rest of its extent, that it insinuates itself into the excretory ducts of the lachrymal glaud, forms a semilunar fold at the inner angle of the eyelids, covers the caruncula lachrymaUs, invests the Meibomian follicles, enters into their apertures, and passes into the lachrymal canals by the puncta lachrymalia. This muco-cutaneous membrane is occasionally affected \nth in- flammation like that by which the other parts of the mucous system are commonly attacked ; a puro-mucous, blenorrhoeal, or catarrhal in- flammation ; and in other cases, it is affected with diseases evidently partaking of the nature of cutaneous eruptions. It thus resembles the membrane of the fauces, which sometimes is affected with catarrhal inflammation, and at other times with aphthae ; or the continuation of the lining membrane of the urethra over the glans penis, wiiich in one case we see affected v»'ith gonorrhoea, and in another with a pustular eruption. There are certain marks by which we distinguish an inflamma- tion of the conjunctiva from one of the sclerotica. The vessels of an inflamed conjunctiva are comparatively large, and tortuous, they are more of a scarlet colour, anastomose freely with one another, and form a net-work over the w hite of tire eye ; whereas the vessels of an inflamed sclerotica are small and hair-like, never very tortu- ous, but run like radii towards the cornea, forming thus a halo or zone, and not a net-work, and are generally more of a pink or rose, than of a scarlet colour. The vessels of an inflamed conjunctiva can be shoved, or drawn aside, by pressing or dragging the eyelids, and they shift under the rotatory motions of the eyeball ; whereas those of the sclerotica are not susceptible of any of these changes of place, but whatever position the eye assumes, maintain the same relation to the membrane on which they run, and to the cornea, although the conjunctiva is easily made to slide over them. Here a question naturally occurs. Does the conjunctiva remain un- inflamed in sclerotitis 7 We answer, No. Neither does the sclerotica in conjunctivitis. A common occurrence also in conjunctivitis, and occasionally in sclerotitis, is an effusion into the cellular membranes connecting the tv.'^o tunics, so that the conjunctiva is elevated from the sclerotica, which by this means is completely hid from view, so that in determining the genus of the ophthalmia, in this chemosed state of the eye, we must be led by other signs than merely the appear- ances or arrangement of the inflamed blood-vessels. We take into account the original seat of the inflammatory action, and consider which is the part the functions of which are principally aflfected. There is undoubtedly a sympathy of contiguity which prevents a conjunctivitis, or a sclerotitis, or an iritis, from existing entirely insulated, and without some participation of the surrounding parts, while at the same time it is evident that the inflammation begins in one part only, and continues through the whole course of the 272 disease, to affect that part with much greater severity. We shall see immediately also, that there are certain subjective signs by which we can readily determine the genus of any ophthalmia, whether conjunctivitis or sclerotitis, even although we were not allowed to inspect the inflamed membranes at all. SECTION IV. PURO-MUCOUS CONJUNCTIVITIS IN GENERAL. There are certain symptoms characteristic of the genus conjunc- tivitis puro-mucosa, whether it arise from the influence of a cold and moist atmosphere, or from contagion, and whether the conta- gion be derived from this disease existing in the eye of another per- son, or from the appUcation of puriform matter from other quarters, as that of leucorrhoea or gonorrhoea. All these are capable of ex- citing puro-mucous conjunctivitis, and the last mentioned causes produce a much more severe disease than the first. The charac- teristic symptoms of puro-mucous conjunctivitis are analogous to those which attend the blenorrhoeal or purulent inflammation of other mucous membranes, as of the Schneiderian membrane in catarrh, or the lining of the urethra in gonorrhoea. Besides the primary phenomena of inflammation, there is a suppression of the natural mucous secretion of the inflamed conjunctiva, and a conse- quent feeling of dryness and itching in the eye ; nest follows a thin and irritating discharge ; then, a copious puriform discharge, which, after continuing for a longer or shorter space of time in different instances, gradually diminishes, becomes thin, and at last ceases entirely, leaving the conjunctiva in a more or less altered state, and with a greater or less disposition to the re-secretion of pus. The most striking character of this genus is, no doubt, the puri- form discharge. I need scarcely say that the pus is secreted by the conjunctiva; it is merely an increased and changed discharge of mucus, and not the effect of ulceration. It is also almost superflu- ous to mention, that the inflammation of the conjunctiva, although ficculiar, is still sufficiently distinct, and that we should form an erroneous idea of the diseases which I am now about to consider, were we to regard any of them as a mere flux of humours, and not as inflammatory affections. The pain in all the puro-mucous ophthalmise is distinctive, and is compared by the patient to the feeling excited by sand in the eye. Puro-mucous conjunctivitis, as I have already mentioned, at length wears itself out, and subsides ; but before this happens, the eye may be entirely destroyed, the cornea having grown opaque, or having become infiltrated with pus, ulcerated, and given way. 273 SECTION V. CATARRHAL OPHTHALMIA.* There are three ophthalmise, which are frequently excited, es- pecially in adults, by atmospheric influences ; namely, the catarrhal, the rheumatic, and the catarrho-rheumatic. The first of these is a puro-mucous or blenorrhoeal inflammation of the conjunctiva ; the second is an affection of the fibrous sclerotica ; while in the third, both the conjunctiva and sclerotica are attacked, and the symptoms of the catarrhal are united to those of the rheumatic ophthalmia. Symptoms. The inflammation in the catarrhal ophthalmia, which is by far the most common disease of the eye in adults, is ahnost entirely confined to the conjunctiva and Meibomian folHcles. The mucous secretion of the membrane is increased in quantity, and occasionally becomes opaque, thick, and purifoim ; but in many cases remains transparent, and by its superabundant quan- tity renders the eyelids merely more than usually moist and sUp- pery ; while the Meibomian secretion, also increased in quantity and changed by disease, concretes on the edges of the lids and amongst the eyelashes, and binds them together during the night. In mild cases, the redness is chiefly in the conjunctiva lining the eyelids. On the white of the eye, the vessels are arranged in a network ; and can be moved in every direction, by pressing the eyelid against the eyeball with the finger, showing that they reside in the conjunctiva. Not unfrequently we observe spots of extrava- sated blood beneath the" conjunctiva. In severe cases, chemosis, takes place, even to a great extent ; so much so, that if only gene- ral treatment be employed, as blood-letting and purging, while local means are neglected, the cornea may lose its vitality, become infil- trated with pus, burst, and slough, and thus vision be destroyed. I have been led to attribute the destruction of the cornea in severe cases of catarrhal ophthalmia, as also in the contagious or Egyptian ophthalmia, and in the ophthalmia of newborn children, not en- tirely to a vital, but partly to a mechanical cause ; not altogether to excessive inflammatory action in the cornea itself, but partly to the pressure caused by the enormously distended conjunctiva of the eyelids and eyeball. Other causes, no doubt, concur, in the puro- mucous inflammations of the conjunctiva, to produce opacities of the cornea, detachment of its conjunctival covering, and ulceration ; and, in particular, the maceration of the cornea in a flood of puru- lent fluid, not sedulously removed by injections. But the destruc- tion of the cornea by infiltration of pus and sloughing, I am dis- posed to refer in no small degree to the pressure of the chemosed conjunctiva, and the consequent mechanical death of the cornea. Diagnosis. In the catarrhal ophthalmia, the patient uniformly complains of a feeling of roughness of the eye, of sand, hot ashes, or broken glass under the upper eyelid ; a sensation which never * Conjunctivitis Puro-mucosa atmospherica. 35 274 attends the pure rheumatic ophthahnia, and may therefore be re- garded as strikingly diagnostic. ^Jor^over. in the catarrhal ophthal- mia, the patieLt is generally free from hendach ; v.'hereas in the rheumatic, one of the most remarkable symptoms is supra-orbital or circum-orbital pain, severely aggravated during the night. When headach does attend catarrhal ophthalmia, it is seated across the forehead, and is felt most in the morning. So distressing, even at the beginning of an attack of catan-hal ophthalmia, is the sensation as if sand or some other foreign body were under the upper eyelid, that I have repeatedly been requested to visit patients, in whom this disease was commencing, who sup- posed that some particle of dust had actually got into that situation ; and in one instance I was called to visit a medical gentleman, who was so convinced, from the feelings which he experienced, that this was the case, that he had made various attempts, with his dressing probe to free himself from the imaginary ofifending substance. Causes. Atmospheric changes, and especially exposure to cold and wet, are the exciting causes of this disease. Night- watching, and exposure to the night-air, after being much heated, or in a state of intoxication, are frequently the occasions which give rise to catarrh- al ophthalmia. Wet feet is a cause which some of my patients have particularly mentioned. An individual who has once labour- ed under this disease, is more likely to be attacked again : one of my patients had three attacks between ^lB.y and January. Epidemic, In many instances the catarrhal ophthalmia has been known suddenly to attack a great number of persons, who happened to be exposed to the same general exciting causes. As- salini, for example, relates, tha,t in May, 1792, several battalions of the duke of Modena's troops arrived at Reggio, in order to quell some riots. These troops passed the first night after their arrival under the spacious porticoes of a convent looking to the north, in the lowest part of the town, and near the trenches of the citadel. Many of these soldiers contracted a violent catarrhal ophthalmia, which was attributed to the dust of the straw on which they had slept ; and not to the moist and cold air of the place, which no doubt was the true cause, and which was so much the more likely to prove hurtful, as these men had been accustomed to close and comfortable quarters.* The catarrhal ophihalmia has been known to spread itself still more extensively, attacking a great proportion of the inhabitants of a town or district, so as to obtain the name of epidemic ophthabnia. In 1778, it attacked the whole neighbourhood about Newbury, in Berkshire : and, in the same year, it prevailed in several of the English caiTips, where it was known by the name of the ocular dis- ease. In 1S06, an epidemic ophthalmia of this kind prevailed ia Paris, and was, in many instances, attended by an affection of the • Manuals di Chirurigia. Parte ii. p. 117. jNIilano, 1812. 275 mucous membrane of the air passages ; a complication which I have repeatedly observed in the sporadic cases of this country. The same disease prevailed in 1808, at Vicenza, in Italy. It has been mentioned by some authors, that this disease is more common in summer and autumn. In this town and neighbourhood, it is com- mon at all seasons. Prognosis. If the catarrhal ophthalmia be neglected, or treated only with general remedies, or with improper local ones, it wiii con- tinue for many weeks, and become the cause of much febrile ex- citement and constitutional illness, as well as local distress and dan- ger. Amongst other bad effects of neglect, the conjunctiva, particu- larly where it lines the upper eyelid, becomes sarcomatous and rough, and by rubbing in this state against the cornea, brings on a vascu- lar and nebulous state, or it may be, even a dense white opacity, especially of the upper half of the cornea. The discharge from the conjunctiva is more apt, also, under neglect or improper treatment, to become puriform, and to assume the power of propagating the disease by contact. Contagious. I regard it as scarcely admitting of doubt, that the discharge in catarrhal ophthalmia, especially when distinctly puriform, if conveyed from the eyes of the patient to those of others, by the fingers, or by the use of towels and the like in common, will excite a conjunctivitis still more severe, more distinctly puri- form, and more dangerous in its effects on the transparent parts of the eye. than was the original ophthalmia. This is the conclusion at which I have arrived, from the observation of many instances, in which, as far as it was possible to come to the facts, this disease, having arisen in one member of a family from atmospheric expo- sure, several others of the family have become affected without any such exposure that could be ascertained ; and while, in the first affected, the disease was comparatively moderate, and scarcely pu- riform, in the latter the symptoms were more violent, and the dis- charge thick, abundant, and opaque. I think it probable, that the ophthalmia which attacked the British and French armies in Egypt was an atmospheric puro- mucous conjunctivitis, but that it afterwards degenerated into a contagious, perhaps infectious, disease, that is to say, that it was propagated by actual contact of the discharge, and perhaps by mi- asmata from the discharge floating through the air. Nor is this idea inconsistent with what is generally admitted regarding conta- gious and infectious diseases. If we admit such a thing as conta- gion or infection at all, we must also admit, I should apprehend, that diseases, originally excited by external influences, w^ere propa- gated only in the second and succeeding instances, by their conta- gious or infectious power. I know of no experiments in which the discharge from an eye affected with simple catarrhal ophthalmia, or puro-mucous conjunc- tivitis arising from atmospheric influence, has been applied to a 276 sound eye. Dr. Guillie's experiments, indeed, may have been performed with matter of this description. He took the puriform mucus from the eyelids of some children affected with puro-mucous conjunctivitis, in the hospital for sick children at Paris, and intro- duced it under the eyelids of four blind children belonging to the institution for the blind. These children were amaurotic, but the external surface of their eyes was healthy and entire. In all four a regular puro-mucous conjuctivitis was produced.* In the next section, I shall have occasion to refer to one or more striking instances of catarrhal ophthalmia spreading by con- tagion. Treatment. The catarrhal ophthalmia yields readily to a very simple treatment, chiefly of a local and stimulating kind. I was first struck with the truth of this fact, in the successful manage- ment of this disease by Professor Beer, at Yienna, in 1817 ; and I was confirmed in this view, by an attentive consideration of the cases detailed in an excellent Report by Mr. Melin, pubhshed in the London Medical and Physical Journal for September, 1824. The results of my own practice, both in private and at the Eye Infirmary, some account of which I submitted to the profession in 1826,t have amply borne me out in the belief, that general reme- dies in this disease are inferior in importance to local ones ; that violent general remedies are absurd, and worse than useless ; and that a local stimulant treatment may almost entirely be relied on. 1. I very rarely find it necessary to take away blood in catarrhal ophthalmia, either from a vein or by leeches. When there is more than usual constitutional irritation, the taking away of from twelve to twenty ounces of blood from the arm, will no doubt prove useful ; but this will rarely be necessary if the disease has not been neglected for a number of days, or mistreated. 2. Scarification of the conjunctiva of the eyelids is necessary only in cases in which there is some degree of chemosis, and a distinctly puriform discharge. In such cases, it proves a valuable means of cure, if performed according to the directions aheady given at page 267. 3. A brisk dose of calomel and jalap may be ordered at the com- mencement, with occasional doses of neutral salts during the course of the disease. 4. Determining to the skin is also usefid. This may be done by the warm pediluvium at bedtime, and by small doses of spiritus Mindereri, or of any other mild diaphoretic, in combination with diluent drinks. 5. In severe cases, a blister to the back of the neck will be found useful, or blisters behind the ears, kept open. • Bibliotheque Ophthalmologique. Tome I. p. 81. Paris, 1820. t Medical and Physical Journal. Vol. Ivi. p. 327. London, 1826. 277 6. Even weak solutions of acetate of lead, or of sulphate of zinc, appear to be prejudicial in this disease, aggravating the in- flammation, increasing the sensation as if sand were in the eye, favouring the formation of ulcers on the cornea, or if ulcers be al- ready present, leading to opaque cicatrices. 7. On the contrary, the feeling of sand is uniformly relieved, and the inflammation abated, by the use of a solution of nitrate of silver. The solution which I employ contains from two to four grains of the nitrate in one ounce of distilled water. A large drop is to be applied to the eye once a-day, by means of a camel hair pencil. The instant that it touches the eye, the salt is decomposed, and the silver precipitated over the conjunctiva in the state of muriate. I have sometimes alarmed other practitioners, by proposing to drop upon the surface of an eye highly vascular, affected with a feeling as if broken pieces of glass wei'e rolling under the eyelids, and ev- idently secreting purulent matter, a solution of lunar caustic ; and I have been not a little pleased and amused at their surprise, when, next day, they have found all the symptoms much abated by the use of this application. 8. As a coUyrium, I am in the habit of employing a solution of one grain of corrosive sublimate in eight ounces of water. This being made milk-warm, is to be used thrice a day for fomenting the eyelids, by means of a linen rag. In mild cases, a few drops are then allowed to flow in upon the eye ; but, in severe cases, in which the discharge is copious and puriform, this coUyrium must be injected over the whole surface of the conjunctiva, and especially into the upper fold of that membrane, by means of a syringe, so that the whole morbid secretion may be removed, and the diseased membrane touched immediately by the solution. 9. At bedtime, about the size of a hemp-seed of red precipitate ointment, melted on the end of the finger, is to be smeared along the edges of the eyelids. This ointment must be prepared in the manner specified at page 114. 10. The inside of the lids, and especially of the upper, ought daily to be inspected. If there is any tendency to a rough and sarcomatous state of the conjunctiva, it ought to be alternately scarified or leeched, and touched with the solid sulphate of copper or nitrate of silver, as I shall explain more particularly under the head oi granular conjunctiva. I have treated many hundred cases of catarrhal ophthalmia ac- cording to the plan above detailed, and with uniform success. In almost no case, (indeed, I may say in no case in which struma did not modify the symptoms), in which the above simple remedies were had recourse to previously to ulcer or opacity of the cornea, did any ulcer or opacity ever occur ; nor did the symptoms ever fail speedily to subside. On the other hand, I have repeatedly had occasion to see cases of this disease which had been much aggra- vated by trusting altogether to general treatment, and especially 278 to bleeding ; or by the use of acetate of lead, or sulphate of zinc, as local applications. I have been led to attribute to these salts the detachment of the conjunctival layer of the cornea, and at any rate the forn,atioa of opaque cicatrices ; whereas, superficial ulcera- tions of the cornea, treated with the solution of nitrate of silver, have uniformly healed without opacity. Modified hy struma. The catarrhal ophthalmia occurring in strumous habits, and especially in children of that constitution, is very liable to degenerate into the phlyctenular ophthalmia, here- after to be described. The strumo-catarrhal is one of the compound ophthalmiae, which are apt to prove puzzhng to the inexperienced practitioner. The treatment, in cases of this sort, must partake of the remedies above mentioned, and of those hereafter to be re- commended for strumous conjunctivitis. SECTION VI. CONTAGIOUS OPHTHALMIA. This disease is essentially the same with that described in the last section, only much more severe, and excited in a different way, namely, by contagion, and perhaps by infection. It is a common and most afflictive disease in warm climates, as Egypt, Persia, and India. From having passed, along with the British troops from Egypt to this country, in 1800, 1801, and 1802, it is often spoken of under the name of the Egyptian ophthalmia. Symptoms. These succeed each other with different degrees of rapidity, and present veiy different degrees of severity, in differ- ent individuals w^ho are suffering at the same time, in the same place, and from the same infection. These differences depend on the constitution of the patients, on their state of health when they become affected, and upon incidental and minute circumstances of situation. In w^omen, for instance, the disease is said to be milder than in men. It has also been remarked, that as the age is near to puberty, on either side, the disease is in general more fatal in its effects. In scrofulous persons, it is always tedious, and more likely to destroy the eye. This disease is also much more severe in one instance of its oc- currence than in another. In 1806, it raged with greater rapidity and severity in the 54th than in the 52d regiment. It never was so severe in the Mihtary Asylum at Chelsea, as in the latter regi- ment. It appears to have been much more severe in the Military Asylum in 1809 than in 1804. These differences appear to be owing to the climate and situation where the disease occurs, the temperature, the season of the year, and other general causes. The purely inflammatory stage of this disease, though often shorter in its duration, appears never to surpass thirty hours. At ♦ Conjunctivitis Puro mucosa contagiosa, vel Egyptiaca. Ophthabio-blenorrhoea. Purulent ophithalmia. 279 the end of that time, purulent matter is always formed by some portion of the conjunctiva. In most cases, the purely inflammatory stage is so slight and rapid, as not to come under the observation of the surgeon. So early does the formation of purulent matter take place, that even when the inflammation has extended no fartUer than the palpebral conjunctiva, pus is seen on everting the eyelids, although its quantity is not yet sufficient to be observed unless this mode of examination be adopted. The disease appears to commence soon after the application of the contagious or infectious matter to the conjunctiva ; but in many cases it advances to the secretion of purulent matter, before the patient is aware that he is affected with any inflammation. It often happens that he makes no complaint till his attention is ex- cited by finding his eyelids adhering in the morning, or till the sensation of some extraneous body in the eye has become distress- ing. A sudden attack of darting pain through the eyeball or in the forehead, is sometimes the first thing which attracts his atten- tion, while in other cases, the disease advances till there is such vascularity of the conjunctiva as cannot fail to be observed by others. In all these cases, the disease has unquestionably existed for some time, but it has been unobserved by the patient himself, or if observed, concealed. When this disease breaks out in a family, or in any larger community of individuals, those first attacked, ignorant of the previous existence of the disease in others from whom they might receive it, and ignorant of its nature, will seldom demand advice till urged by the violence of the symptoms. When once the plan is adopted, as it should always be, of daily inspecting the healthy individuals of any community in which the disease is likely to appear, it will be the fault of the surgeon if he ever meets with a new case in which the disease is so far advanced as to be attended with any other symptom than an increased vascularity of the conjunctiva of the eyelids. The right eye is more frequently attacked by this disease than the left. It is also, in general, more severely affected, and the sight of it is more frequently lost. In some instances only one of the eyes takes the disease, but, commonly, both suffer from it, although there is often an interval of several days before the second becomes inflamed. When the symptoms succeed each other with moderate rapidity, the following is the order in which they arise. A considerable degree of itching is first felt in the evening, or suddenly there arises in the eye the feeling as if a particle of dust were between the lids and the eyeball. This is succeeded by a sticking together of the lids, principally complained of by the pa- tient on awaking in the morning. The eyelids appear fuller ex- ternally than they ought to do. Their internal surface is inflamed, being tumefied and highly vascular ; and the semilunar membrane and caruncula lachrymalis considerably enlarged and redder than 280 ijisual. The swelling of these parts is soft, somewhat elastic, slip' pery, and easily excited to bleed. We have here all the symptoms of the purely inflammatory stage, and even the symptoms of commencing suppuration. The itching, which is one of the earliest symptoms, indicates a suppres- sion of the natural mucous secretion of the conjunctiva of the eye- lids, and of the Meibomian secretion. Such suppression appears to be the constant and earliest effect of inflammation upon every mu- cous membrane, and secreting organ of the body. In the course of a few hours, a thin acrid secretion takes place from the conjunctiva. This gives the slipperiness to the internal surface of the e3^elids ; and the Meibomian secretion being now increased above its usual quantity, concretes among the eyelashes, and causes the eyelids to adhere during sleep. The sensation of sand in the eye is owing merely to the dilated state of the conjunctival vessels. In about twenty-four hours after the first symptoms make their appearance, the mucous discharge from the internal surface of each eyelid is considerable in quantity. It is still thin, but somewhat viscid, and begins to be opaque. It lodges at the inner angle of the eye. On everting the lids, their internal surface is observed to be much more vascular and tumid. There is also epiphora present, especially when the patient exposes his eye to a current of air. He complains of a sensation as if the eye were full of sand, but seems to experience but little uneasiness from the light. Not unfrequently, a considerable discharge of blood takes place from the conjunctiva, after which the swelling of the membrane diminishes for a time. This is sometimes repeated several times before the profuse puri- forra discharge sets in. It does not appear to arise from the rup- ture of vessels, but rather to come from the exhalents of the con- junctiva, dilated by red blood, or by a mixture of red blood with the transparent fluid which they usually carry. The inflammation now extends to the whole internal surface of the eyelids. The secretion from the palpebral conjunctiva is much augmented, aud becomes more distinctly puriform, being yellowish and thick. In many cases it is so abundant, that on the patient opening his eyes, the matter instantly flows over the cheeks. It irritates the skin, and even excoriates it. The swelhng of the con- junctiva of the lids, and especially of the upper, increases with the discharge ; partly from a serous effusion immediately under the membrane, partly from an unnatural and inflammatory develop- ment of its vascular structure, partly from a similar enlargement of its mucous cryptee, and of the Meibomian follicles, giving rise to a sarcomatous appearance of the internal surface of the eyelids. The disease may not proceed farther over the conjunctiva but remain in the state descrilsed for weeks or even months, and how- ever severe it may appear to another person, give but little un- easiness to the patient. The purulent secretion may then diminish^ and recovery gradually take place. 281 In other cases, the inflammation spreads rapidly to the conjunc- tiva of the eyeball. Its vessels are distended with red blood, forming a thick net-work over the sclerotica, interspersed, in some instances, with small spots from extravasation. The membrane itself becomes speedily thickened, and a serous effusion taking place into the cellular membrane which connects it to the sclerotica, it is raised, so as to form a pale-red and soft elevation or chemosis. In some cases, this inflammatory osdema exists only at particular spots, though the vascularity of the conjunctiva is considerable and extends even to the cornea. It commonly happens that the che- mosis gradually spreads from the lids over the surface of the eye towards the cornea, with its advancing edge accurately defined, leaving for a while a circle round the cornea which is gradually intruded on by the swelling, till closely surrounded, and at last completely buried and overlapped, scarcely can even its centre be perceived. This chemosis is sometimes so great, that the conjunc- tiva of the eyeball protrudes considerably from between the lids. The chemosis is accompanied by redness and swelling of the skin of the eyelids, sometimes extending to a considerable distance from the eye, and resembling very much in colour and general appearance the redness and swelling which surround the cow-pox pustule between the 9th and 12th day after inoculation. This swel- ling of the hds is often as sudden in its appearance, as if it had been owing to the stinging of an insect, or some other immediate irritation. It sometimes continues to increase almost by sensible degrees, and attains its utmost height in a few hours ; at other times, it increases gradually during several days. The sudden swelUng of the lids renders them almost quite im- movable. It also occasions at first a degree of inversion, from the cartilages not yielding with facility ; but as the disease advances, the lids become everted. This happens especially to the lower, but occasionally to the upper also. The sensations produced by this enlargement of the external parts of the eye are by no means severely painful, scarcely surpassing a sense of stiffness and weight, along with a feeling of uneasiness occasioned by the accumulation of matter secreted by the conjunctiva. The sensation of gravel in the eye is now less troublesome. If light be excluded, and the eyes kept at rest, the patient does not complain much of pain. After the conjunctiva of the eyeball takes part in the disease, the flow of puriform fluid is greatly increased ; varying, however, from time to time, in quantity, colour, and consistence, as does the dis- charge in gonorrhoea. Dr. Vetch estimates its quantity as exceed- ing several ounces in the day. It partly escapes from between the lids, partly lodges in their folds, and in the pit formed over the cornea by the chemosed conjunctiva. In this last situation, the purulent discharge is sometimes allowed, from carelessness, to re- main so long, that it assumes the appearance of a thick membrane, so that one unacquainted with the symptoms, on seeing this piece 36 282 of matter drop from the eye, is apt to suppose that the whole orgaa is destroj'ed. and that it is the cornea itself in the state of a slough which has separated. The puriform secretion may continue without much change for twelve or fourteen days, or even a longer period. The swoln con- junctiva of the eyeball, in the meantime, becomes sarcomatous, but never to the same extent as that of the lids. At length the che- mosis begins to shrink, and the fluid secreted to diminish in quan- tity, and gradually to lose the characters of pus, becoming thin and gleety. The internal surface of the eyelids, the semilunar mem- brane, and caruncula lachrymalis, which were the parts first affected, are the last in which the disease disappears. Not unfrequently the internal surface of the lids remains in a sarcomatous state^ seemingly from the morbid state of the mucous cryptee of the con- junctiva, and of the Meibomian follicles. These, instead of sub- siding to theh natural size, become indurated, and form a granular, scabrous, or mulberry surface, which constantly rubbing against the cornea, keeps up a chronic inflammation in its investing mem- brane, which becomes covered with red vessels, and loses in a great measure its transparenc}*. Such may be looked upon as a favourable case of this disease. We must be prepared to meet with much more destructive termi- nations of it. In some cases, the primary inflammation extends to the layer of conjunctiva which covers the cornea. That layer becomes- thickened, detached in some measure from the cornea, and more or less opaque. The patient's vision is much diminished by these changes ; and very frequently the opacity and consequent diminu- tion of vision continue after all the acute symptoms of the disease have disappeared. Superficial ulceration frequently attacks the cornea in the course of this disease, giving rise to opaque cicatrices of various sizes, and often producing a partial flatness, or rendering the cornea irregular on its surface, and permanently unfit for dis- tinct vision. Even when the ulceration has not penetrated through the corn3a, the iris sometimes advances and adheres to its internal surface, opposite to the ulcerated part. In other cases the inflammatory process is still more severe, at- tacking the whole substance of the cornea, and even extending to the internal textures of the eye. The patient is now subject to deep-seated pulsative pain in the eye, coming on sometimes in par- oxysms, in other instances continuing with scarcely any remission in its violence till the cornea gives way. The varieties, indeed, in regard to the pain, are exceedingly^ remarkable, depending no doubt in a considerable measure on the part which the several tex- tures of the e3'e take in the disease. For the most part, the attacks of pain are sudden. Occasionally they are preceded by chillness and slight nausea, or by a peculiar sensation about the head. Fre- quently the pain, with a remarkable increase of heat, occurs around 283 the orbit, in a degree no less excruciating- than in the eye itself. The space over the frontal sinuses, the temples, and the face, are its frequent seats, or to speak more correctly it affects the branches of the fifth pair of nerves, distributed to these parts. Sometimes it occurs immediately above the eye, commencing about the supra- orbitary foramen. This supra-orbital or circum-orbital pain is in- dicative of the inflammation extending to the sclerotica, cornea, choroid, and iris. Inflammation of these textures always excites sympathetic pain in the fifth pair of nerves. The pain round the eye is aggravated by pressure, and occasionally a circumscribed swelling suddenly takes place over the part affected. When such a swelling appears in the face, it partakes of an oedematous nature, and though equally sudden in its accession, does not subside so rapidly during an intermission, as the swellings which rise under the same circumstances on the forehead and temple. At all times, the eye is the most frequent seat of the pain. It is described to be, in the eye, of a darting or shooting kind. Sometimes it is compared by the patient to what might be felt if the eye were stuck full of needles, and always appears to be of almost insufferable severity. It is generally confined to one eye at a time, though it frequently shifts from the one to the other. The apparent absence of all uneasiness from the presence of light, during the paroxysms, is probably owing to the patient's at- tention being engrossed by the violence of the pain. The duration of the paroxysms, and their recurrence, do not observe any great regularity. The more common duration appears to be from three to four hours. Sometimes they do not continue longer than two hours, and sometimes they extend to six. They appear to come on most frequently from 10 to 12 in the evening. During the pain, the secretion of tears is more copious, and the purulent dis- charge, on the contrary, almost uniformly diminished. This intermittent type of the pain is a remarkable circumstance, and might appear inexplicable, were we not acquainted with the fact, that pain in and round the eye, aggravated during certain hours of the night, is an invariable attendant on sclerotitis. It has already been mentioned, that in many cases there is no entire in- termission, and scarcely any remission in the violence of the pain. Dr. Vetch (to whose excellent account of this disease I am indebted for many of the facts stated in this section) tells us, that in those patients who were of a habit particularly robust, or who had been exposed to some strongly exciting causes, or who were of a shape favourable to a determination to the head, there was no entire in- termission, and scarcely eve; any remission in the violence of the pain.* It is only when the disease assumes its most violent form that it is accompanied by the frequent occurrence of the paroxysms of * Account of the Ophthalmia which has appeared in England since the return of the British Army from Egypt, p. 117. London, 1807. 284 pain above described, and under these circumstances the rupture of the cornea frequently takes place, an event which is almost always followed by staphyloma and loss of sight. The period at which this happens varies exceedingly in different patients. In some the daily occurrence of these paroxysms has continued for a number of weeks before rupture of the cornea is produced. In others, this is effected under the second or third attack, and gives a temporary relief. I say terti'porary, for even this melancholy event does not afford a termination to the disease, and often scarcely checks its progress. The severe pain is seldom present in both eyes at the same time, and although it occasionally happens that the attacks of pain alternate from the one eye to the other, the rup- ture of the one is generally produced before the severe pain affects the other. In some cases, where both eyes are destroyed by rup- ture of the cornea, the patient has no recurrence of the pain for some time after the rupture of the first ; while in other cases, the pain almost instantaneously shifts to the other eye. It has been known that while the second eye was suffering rupture of the cornea, the first eye, by cicatrizing, was only becoming liable to the same accident again, and this second rupture of the cornea has been preceded by as much pain as was the fij'st. Rupture of the cornea generally happens when the disease is at the height of its violence, and when the swelling of the external parts is so great, as to prevent an examination of those immediately concerned in this event. From the distinct sensation, however, which the accident uniformly communicates to the patient, accom- panied by a copious discharge of hot fluid, we seldom remain ignorant of the event having taken place. In other instances, the swelling of the conjunctiva and of the eyelids is not so great as to prevent the inspection of the eye at the time of its rupture. In these cases, the progress of disorganization may be observed. The surface of the cornea is seen to be first whitish, and then, from matter infiltrated into its substance, it becomes yellow. Its lamellae are, no doubt, detached by this infiltration from one another. It swells, and advances gradually out of the pit formed around it by the chemosed conjunctiva. Its surface becomes ulcerated in one or more points. The ulcers rapidly deepen and spread, and at last the cornea gives way. Through the opening, or openings, thus formed, we may sometimes see the yet clear lens lying in its cap- sule. It rarely happens that there is any formation of pus, or de- position of coagulable lymph in the chambers of the eye in this disease ; and hence, when the cornea is destroyed, the internal parts of the eye appear natural. The patient is sometimes able even to see objects pretty distinctly after the cornea has given way, and is apt to believe his eye to be nearly cured, or at least out of danger. The iris is pushed forwards into the opening or openings of the cornea, union takes place between the iris and cornea, and partial or total staphyloma is the result. In some cases, the iris, 285 after the eye recovers, remains protruding at different points, scarcely covered by any pseudo-cornea, but presenting a number of dark- coloured prominences, like the grains of a brambleberry, a state of the cornea and iris which is styled stapliylom,a racemosum. In some cases at least, it would appear that the cornea is rup' tured under one of those violent paroxysms of pain of which I have spoken, before it has undergone much disorganization. Dr. Vetch minutely describes a case, in which, on examining the eye after the patient had felt the peculiar sensation indicating the rupture of the cornea, and the discharge of scalding fluid had taken place which attends this accident, he found merely a small hne extending across the lower segment of the cornea, and which remained with- out any alteration after the eye was washed with tepid water. As any attempts to ascertain the nature of this line, gave uneasiness, its examination was left to next day. In the meantime, the patient saw better than he had done before the rupture took place. Next day, the line was more visible along its whole extent, from a shght opacity which accompanied it, and which daily increased, till the greater part of the cornea was not only opaque, but projected in an irregular cone, and as this alteration went on, vision, which for some time after the rupture continued more correct than before, became totally obstructed. It would thus appear that in certain cases, the aqueous humour escapes by a division of the cornea, nearly as <:lean as if made with a knife. Were the disease to subside immediately after such a rupture of the cornea, this accident would in all likelihood be at- tended with little permanent injury to the sight. But, besides the obstacles which the presence of the disease occasions to the healthy reunion of the cornea, the same causes which produced the first rupture continue to operate, so as to produce a second or a third, the disorganization and deformity increase, and the termination with respect to vision is proportionably unfavourable. As Dr. Vetch relates one case of this kind of rupture of the cor- nea with much minuteness, and tells us that he has seen several others of the same kind, I cannot think that he has been mistaken concerning the fact. Yet I am convinced that this kind of rupture, far from being the manner in which th« cornea generally gives way, occurs but very rarely. Ulceration, commencing on the sur- face, and gradually penetrating into the cornea, is one mode in which this important part is destroyed ; infiltration of matter into its substance, presenting at first the appearance denominated onyx, and at length forming complete abscess of the cornea, followed by rupture and ulceration, is another, and, I believe, the most fre- quent. In many cases, the progress of the disease does not cease with the bursting of the cornea. In a few hours, ulceration attacks the capsule of the lens, the capsule bursts as the cornea formerly did, the lens escapes through the ruptured capsule and cornea, more or 286 less of the vitreous humour generally follows, and sometimes almost the whole contents of the eyeball are evacuated. In this case, a small deformed eyeball is left deep sunk in the orbit, over which the lids fall in, become concave externally, and remain ever after- wards closed. Although this ophthalmia proves most contagious in warm weather, it is greatly aggravated by the patients exposure to cold and moisture. The symptoms are also more severe in females for some days previous to menstruation, and on this evacuation taking place they are as constantly veiy much lessened. The external symptoms of this disease, and the pain by which it is attended, cease at very uncertain periods. After the severe pain has entirely subsided, the vascularity and sarcomatous tumefac- tion of the conjunctiva generally remain stationary for a considerable length of time, and then rapidly diminish. In others, this process goes on slowly and gradually. The external tumefaction of the eyelids commonly disappears first, and then the chemosis gradually subsides, that part of the conjunctiva which immediately surrounds the cornea first assumingits natural appearance, and presentingaring of white similar to what was formerly seen in the advancement of the disease. The white space graduall}'^ enlarges till the swelling and vascularity are confined to the semilunar membrane and its neigh- bourhood, and to the bottom of the folds between the eyeball and eyelids. The eyelids have now a gaping and relaxed appearance from the subsidence of the tumefaction, and a little matter still forms on their internal surface. In this state, which may continue for months, any irritation of the eye or of the system is sufficient to cause a relapse as violent as the original attack, and the patient still continues capable of infecting others. The rapidity with which the opacities of the cornea caused by this disease frequently disappear, when their removal once begins to take place, is a remarkable circumstance. In many cases of opacity of the cornea, which had been supposed to be perfectly hope- less, the patients have speedily recovered such a degree of vision as to be of considerable use to them. Dr. Vetch relates a very remark- able illustration of this fact. During the convalescence of a man from this disease, some pectoral symptoms, to which he had long been subject, suddenly assumed the appearance of pulmonary con- sumption, which proceeded rapidly towards its last stage. Five days before his death, he was seized with a violent aggravation of the hectic fever and other symptoms, so that his death was hourly expected. At this time, to the surprise of his attendants, the opaci- ties, by which the vision of both eyes had long been obstructed, disappeared with amazing rapidity, so that a short time before his death, his sight became nearly as distinct as ever. On examining his eyes after death, the remains of the opacity were found to extend to the internal surface of the cornea, which was at the opaque part slightly corrugated. There was also a very partial adhesion of the 287 iris to the cornea in both eyes, which had not been discerned during hfe. In many cases, and especially in those who have suffered re- peated relapses, the symptoms which are the latest to disappear are the enlarged and indurated state of the mucous cryptse of the con- junctiva of the eyelids, and of the Meibomian follicles, and the vas- cular and nebulous state of the cornea depending on the constant irritation produced by the friction of the diseased eyelids upon the eyeball. The state of the conjunctiva of which I am speaking has gene- rally received the name of Granular Conjunctiva. If by granu- lar, those who employed this term meant merely that the conjunc- tiva was extremely irregular on its surface, the name would not be unexpressive nor very improper. It has evidently been used, how- ever, to signify a state of granulation. We have even heard of removing the granulations of the conjunctiva. That the promi- nences in question are not granulations is proved both from the nature of the conjunctiva and from the history of this symptom itself. No mucous membrane is known to throw out granulations, without having been previously ulcerated upon its surface. But in this dis- ease, no ulceration of those parts of the conjunctiva which are affected with this granular appearance has ever existed. If these prominences were really granulations, adhesion between the eyelids and the eyeball would be extremely frequent, whereas this is a very rare occurrence, and so far as I have observed never takes place, without a previous and distinct ulcer either of the cornea, of the conjunctiva of the eyelids, or of that of the eyeball. The granular prominences in question appear to be principally the acini of the Meibomian glands in a state of enlargement. It is a fact particularly worthy of notice, that a patient may re- main for many months with the conjunctiva of the eyelids in the granular state, his cornea probably vascular and nebulous, but without any puriform discharge, and after a fit of intoxication or some other irregularity, the inflammation shall suddenly return in its original form, and with its original propagative power. Hence it may happen that a soldier, discharged in the state described, re- turning home into the country, and there from intoxication becom- ing affected with a relapse, may give rise to an ophthalmia which shall spread through many families, and present all the symptoms and the severity of the true Egyptian disease. Constitutional symptoms. The system does not appear to be in the smallest degree primarily atFected in this disease ; the early stage is entirely local. But as the local symptoms grow in severity, the constitution begins to suffer. The pulse becomes frequent, and sometimes sharp ; but commonly continues soft. The skin is sel- dom hot. The tongue is white, but rarely furred. Thirst is sel- dom remarked. The appetite for food is rather keen than other- wise. The bowels are slow. The blood drawn is not, in general, 288 buffy. All these circumstances denote how little the constitution participates in the early stage of the disease. Varieties, no doubt^ must occur in this respect. Judging from the accounts given by Dr. Vetch and Sir Patrick Macgregor, we should conclude, that children labouring under this disease are subject to more constitu- tional irritation than adults. At last, however, there is always much general uneasiness, and sleep is prevented by the paroxysms of nocturnal pain. Great debility comes on, especially when the patient has suffered repeated relapses. Sir James M'Gregor states that in Egypt the disease very often"continued two or three months, that it much impaired the general health, that it often terminated in diarrhoea or dysentery, and that sometimes the patients became hectic* Causes — Propagation of the disease from person to person. I have already explained my views regarding the propagative power assumed by the common catarrhal conjunctivitis of this country ; and have hinted that probably the ophthalmia which arose in the British and French armies in Egypt, and with which they returned to Europe, had a similar oiigin. Assalini attributes the disease as it occurred among the French, to the vivid light and excessive heat of the country as predisposing causes, and suppressed perspiration as the occasional cause ; or, in other words, considers it as a catarrhal ophthalmia. This inflammation of the conjunc- tiva, arising where or how it may, appears speedily to acquire, if it does not from the first possess the power of producing by contagion a disease similar in nature to itself, but much more se- vere. It is undeniable that the return of the Egyptian expedition intro- duced a severe contagious ophthalmia into this country, which af- terwards prevailed extensively in regiments which had never served in Egypt, and which accompanied the British troops to almost every foreign station to which they were sent. For many ages this oph- thalmia has prevailed in Egypt. It is more frequent among the natives of the country than among strangers, owing to the freer intercourse of the former with each other ; and for the same reason it is more common among the lower than the higher classes of society, and more in cities than in the country. But it does not take its origin in Egypt alone, or other warm countries. It has been known to arise among a ship's crew, far from land. It is only the coldness of this climate, and our attention to cleanliness, which prevent the common catarrhal ophthalmia, which we see every day,, from degenerating into the contagious disease of the same kind. Whether this disease be capable of propagating itself by infection,, that is to say, whether the mere miasmata arising from the eyes of those affected with it, floating through the air, be capable of excit- ing the same disease in the eyes of others, is a point which still re- * Medical Sketches of the Expedition to Egypt from India, p. 151. London, 1804. 289 mains in doubt ; for in every case in which this ophthalmia has spread through a regiment, a school, or a family, there has been a suspicion of actual contact, by means either of the fingers of the patients, or of the towels or other utensils which they were in the habit of using in common. Speaking of soldiers, Dr. Yetch says, " Each company has a separate room, in which the intercourse among the men is necessarily great. Many things are used in common ; nor are they even over-scrupulous in washing their faces in the same water ; and however attentively some may avoid this, they are all under the necessity of having recourse to the same towel." The same author observes, that " all the attendants on the sick, who were particularly careful in avoiding such intercourse as might communicate a local disease, escaped without exception," The experiments of Dr. Guillie, to which I have referred at page 276, fully demonstrate that this disease, is, in the strict sense of the term, contagious, in other words, that the matter taken from an eye affected with this ophthalmia, and applied to the healthy conjunc- tiva of another eye, will produce the same disease. Sir Patrick Macgregor has recorded several interesting cases of accidental inoculation with the matter from the conjunctiva in this disease. In one of these, a nurse of the Military Asylum Hospital, about nine o'clock, a. m. when occupied in syringing the e)'es of a patient, who had much swelhng of both eyelids, with a profuse purulent discharge, found that some of the matter mixed with the injection had spurted into her left eye. She was directed to bathe her eye immediately with luke-warm water. She did so for several min- utes ; but, notwithstanding this precaution, about seven o'clock in the evening, the left eye began to itch to such a degree, that she could not refrain from rubbing it. When she awoke next morning, the eye was considerably inflamed, the lids were swelled, and when she moved the eyeball, she had a sensation as if sand was lodged between it and the eyelids. In the course of the day, purulent mat- ter issued from the eye, and other symptoms followed, which were similar to those in the children under her care. The disorder, how- ever, subsided under the usual treatment in fourteen days, the right eye remaining sound during the progress of the disease in the left. Another nurse, about eight o'clock, a. m. while washing with warm water the eyes of a boy suffering severely frem purulent ophthalmia, inadvertently applied the sponge which she had used to her right eye. She immediately mentioned this circumstance to the other nurses, but took no means to prevent infection. Between three and four, p. m. of the same day, great itching of the right eye took place, and before she went to bed, it was considerably inflamed. Next morning her eyelids were swoln, she complained of pain on moving them, and the whole anterior surface of the eyeball was much inflamed. A purulent discharge also began to trickle down the cheeks from the inner canthus. The symptoms increased in 37 290 severity, an-'^. notwithstanding the means thai were used for her relief, the eyeball burst in front of the pupil, on the fourth day after the application of the purulent matter. The sight of the eye was irrecoverably lost, and the inflammation continued for upwards of three months ; but the left eye did not become affected,* The following I regard as a striking, and indeed fearful in- stance of puro-mucous conjunctivitis, excited by atmospheric influ- ence, spreading by contagion. The French slave-ship Rodeur, Captain B , of 200 tons bur- den, left Havre on the 24th of January, 1819, for the coast of Africa, reached her destination on the i4th of March, and cast an- chor off Bonny. The crew of 22 men. enjoyed good health the whole voyage, and during their stay at Bonny till the 6th of April. No trace of ophthalmia had been observed among the inhabitants of the coast, and it was not till 1.5 days after the Rodeur had put to sea, and was nearly on the equator, that the first symptoms of this frightful disease were perceived. It was observed that the negroes, who w^ere 160 in number, and crowded together in the hold, and between decks, had contracted a considerable redness of the eyes, \v'hich soread with rapidity from one to another. At first, however, the crew paid nogier.t attention to ihis apoearance, imngining that it was occasioned merely by want of fresh tur in the hold, and by the scarcity of water ; for they al- ready limited the allowance of water to iight ounces a-day, and some time ufter they could allow only half a glass a-day. it was thought sufficient to make use of an eye-water made from an infu- sion of elder flowers, and, following the advice of the person who acted as ship-surgeon, to bring up the negroes in turns upon deck. This salutary measure, however, they v;e.e obliged to abandon; for the poor Africans, torn from their LaLive home, and heart-v;rung by the horrors of th^ir situation, as well as by the recollections of their lest freedom, c nbracing each other, threw themselves into the sea. The disease, which had spread amongst the negroes in a fright- ful and rapid manner, now began to threaten even the crew. The first man of the crew attacked was a sailor who slepc under deck, close to the grated partition which communicated with the hold. Next day, a lad was affected with the ophthalmia ; and, in the course of the nest three days, the captaiii, and almost all the crew, were seized. In the morning, on awaking, the patients experienced a shght prickling and itching in the edges of the eyelids, which became red and swoln. Next da}', the sweUing of the eyelids was increased, and attended with sharp pain ; in order to lessen which, they ap- plied to the eyes poultices of rice, as hot as they could bear them. On the tliird day of the disease, a discharge of yellowish matter * Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, Vol. iii. p. 52. London, 1812. I 291 took place, rather thin at first, but which afterwards became viscid and greenish ; and was so abundant, that the pa'ients had only to open their eyes every quarter of an hour, when the matter fell in drops. From the commencement of the disease, tiiere v.-eie considerable intolerance of light, and discharge of tears. When the rice failed, bciled vermicelli was used for poult'ces On the fifth day, blisters were applied to the nape of the neck of some of the patients ; but, as the canthaiides were soon exhausted, luey endeavored to supply their place by the use of pediiuvia containing mustard, and by exposing' the swoln eyelids to the steam of hot v/ater. Far from diminishing under this treatment, the pain increased from day to day, as well as the number of those who lost their sight ; so that the crew, besides fearing a revolt among the negroes, were struck with terror lest they should not be able to manage the vessel till they should reach the Carribbee Islands. One sailor only had escaped the contagion, and upon him their whole hopes depended. The Rodeur had already fallen in with a Spanish ship, the Leon, whose whole crew were so atfected with the same disease, that they could no longer manage their ship, but begged the aid of the Rodeur, already almost as helpless as themselves. The seamen of the Rodeur, however, could not abandon their own ship, on account of the negroes ; nor had they room to receive the crew of the Leon. The difficulty of nursing so many patients in so narrow lc space, and the want of fresh provisions and of medicines, made the survivors envious of those who died : a fate which teemed to be fast coming upon all, and the thought of which c? sed gen- eral consternation. Some of the sailors made use of brandy, which they dropped be- tween their eyelids, and from which they experienced some relief; which might have suggested to the surgeon the propriet}^ of a local stimulating treatment. On ihe twelfth day, the sailors who had experienced some relief came upon deck to relieve the others. Some were thrice attacked with the disease. The tumefaction of the eyelids having subsided, some phlycte- Dulae were observed on the conjunctiva of the eyeball. These the surgeon had the imprudence to open : a step which proved hurtful in his own case, for he remained blind, without any possi- bility of recovering his sight. On reaching Guadaloupe, on the 21st. June, the crew was in a de-^lorable state ; but. very soon after, from the use of fresh pro- visions, and by simple lotions of spring water and lemon juice, re- commended by a negress, they became sensibly better. Three days after coming ashore, the only man who, during the voyage, had escaped the contagion, was in his turn seized vith the same s}' mptoras : the ophthalmia running its course as it had done on board ship. 292 Of the negroes, thirty-nine remained totally bhnd, twelve lost each one eye, and fourteen had specks, more or less considerable, of the cornea. Of the crew, twelve men lost their sight ; one of these was the surgeon. Five lost each one eye, and amongst these was the cap- tain. Four had considerable specks, and adhesions of the iris to the cornea.* The history given by Sir Patrick Macgregor of tlie spread of puro-mucous ophthalmia in the Mihtary Asylum at Chelsea, (an extensive institution for the education of soldiers' children,) in 1804, appears sufficiently demonstrative of its being propagated from person to person. " In the beginning of the month of April, 1804," says he, " two boys, brothers, were brought to the Infirmary with their eyes in- flamed, but in so shght a degree, as not to require their being ad- mitted. They were made out-patients, and by using the common remedies, got well in eight or ten days. In the end of this month, six boys with ophthalmia were brought to me ; three of them had it in a violent degree, and were admitted into the Infirmary ; the other three were ordered to attend daily for advice. " In the month of May, no less than forty-four boys, and five girls, affected with ophthalmia, were brought to the Infirmary. The worst cases were admitted ; but there was not room for all, and even some of those that were admitted, were necessarily mixed with other sick. " On the morning of the fourth day after their admission, two boys who were in the same ward, labouring under other com- plaints, were attacked with inflammation of the eyes, and in the course of that week the nurse took the disease. She had it so violently, as to be deprived of sight for several days, and rendered unable to do the duty of her situation for about three weeks. About the same time, her son, a boy twelve years old, who had been in attendance on the sick, and a few days after, her two younger children, were attacked, as were several of the sick in the same ward. " In June, fifty-eight boys and thirty-two girls were 'attacked. It was in general observed, that they had the disease in a more violent degree, than those attacked in May. In the course of this month, the nurse of the Girls' Hospital caught it, and her husband, an in-pensioner of Chelsea Hospital, who came daily to see her, was also seized with it, as likewise were two occasional nurses. Upon inquiry, I found, that the above-mentioned pensioner was the only person at this time affected with ophthalmia in Chelsea Hospital. " The wife of a field-officer was at this time on a visit at the Military Asylum. She had a son between five and six years of • Bibliotheque Ophthalmologique, par M. Guillie. Tome i. p. 74. Paris, 1820. 293 age, who used to play with the other boys. He caught the oph- thalmia, and on the fourth or fifih day after it appeared, his sister, a child two years old, was seized, and some days alter this the lady herself took it. " These circumstances gave alarm, and particular attention was paid to the immediate separation of those who had any symptoms of the disease, from the other sick, and the olher means usually adopted for checking the progress of contagion were had recourse to. ^' In July, the ophthalmia continued to spread, and several of those children who had already had it, and were recovered, took it a second time. Sixty-five boys and thirty girls were attacked this month. They appeared to have the disease more severely, and did not so readily get well, as those affected in the preceding months, although treated in the same manner. The weather was much hotter than it had been the month before. " In August, sixty-nine boys, and twenty-one girls, caught the disease ; a boy and a girl, brought by their mother from Scotland, arrived at the Asylum one evening in the end of this month, and were immediately admitted. The children w'ere put by the nurse, without my knowledge, into a ward occupied by patients affected with ophthalmia ; on visiting the Infirmary next forenoon, I direct- ed the children to be immediately removed into another ward. This was accordingly done ; yet on the third morning after their arrival both the children had symptoms of ophthalmia, which in no respect differed from what were observed in the others. " All the boys from five to six and a half years of age are formed into one company. It was observed that in the course of the last, and present month, almost the whole of this company took the ophthalmia. Its progress could in their dormitories be traced from one bed to another, in the order in which they were placed, until nearly the whole were affected. The two nurses attached to this company always slept in their w^ards, and were the only nurses belonging to the Institution, (those connected with the Infirmary excepted), that suffered from the disease. About the middle of this month, I caught it myself; and though the inflammatory symptoms subsided in ten days, I did not recover from its effects in five or six weeks. " In September, sixteen boys and four girls took the disease ; in October, sixteen boys and seven girls ; in November, nine boys and six girls ; and from the twenty-second of this month to the end of December, only two instances of it occurred, and these were in two boys, brothers, who had slept together, and had laboured under the disease in the month of August in a violent degree. " From the above statement of the progress of this ophthalmia, there is much reason to suppose that it was contagious. For if the disease had been first produced, and afterwards kept up, by any general cause, (as a peculiar state of the atmosphere), the girls would have been as subject to it in the first instance, as the boys, 294 and the officers, Serjeants, and nurses of the institution, generally, would have been as Hable to it, as the persons of tlie same descrip- tion, that were immediately about the sick. But thiis was not the case ; it had prevailed among the boys for near a month before the girls were attacked, and, as appears by the preceding statement, all the adults, who did not mix with the sick, escaped the disease, while those who were connected with them all suffered from it, the assistant-surgeon excepted. " The disease sometimes shewed itself as early as the third day after exposure to infection. This was clearly proved in the cases of the two children from Scotland. '• It would appear also, that closer connexion with the affected person was necessary to produce it, than what is requisite in most other contagious diseases. This may be inferred, from the ser- vants of the Infirmary, and the two nurses that attended the little boys, taking it so readily, while the other servants of the institution escaped it. " It was influenced by the state of the atmosphere, being much more severe in its attacks, and of longer duration, in hot sultry weather, than during cold or moderate weather. This was clearly seen in July, August, and September, when the disease was un- usually severe, and of longer duration, than before or after those months. " There is reason to think, that it was most contagious in its early stage, w^hen the inflammation was active, and there was a considerable purulent discharge." * Treatment. 1. Blood-letting. When we have the charge of the patient from the very beginning of the disease I beheve it may, in general, be cured by the treatment already recommended for ca- tarrhal ophthalmia. Should we be later of being called in, and especially if chemosis be already present, bleeding from the arm to the extent of from 10 to 40 ounces, according to the age and con- stitution of the patient, followed by leeches round the eye, will be necessary, and ma}^ be repealed according to circumstances. The blood from the arm should be taken from a large orifice, while the patient si'.s or stands up, so as to ensure syncope. The leeches, in number from 6 to 24, should be applied within two hours after the bleeding from the arm. They ought not to be set on the lids, es- pecially if the integuments are already swoln and red, as in that case the bites are apt to fester. We ought neither to delay the abstraction of blood, if the symp- toms are smart, and the case of some days' standing ; nor ought we, on the other hand, to indulge in the absurd expectation that profuse blood-letting is to check the disease completely, without the use of local apphcations. 1 hold any notions of this kind, which some may have entertained, as crude and irrational, and their * Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, Vol. iii. p. 31. London, 1812. 295 practice as perhaps the most destructive which could be followed. By very profuse blood letting, the patient is too much reduced, and the eye rendered more susceptible of disorganization. We must not for a moment indulge in the fancy that the stream of blood is to be allowed to flow, till the redness of the eye fades under our view, nor are we even to make the cessation of pain in the eye the condition for stopping the bleeding. These effects might not be obtained by abstracting 50 or 60 ounces of blood, whereas the same real benefit will follow in the course of an hour or two, if not more than 20 or 30 be taken, the patient will be less debilitated, and the course of the disease will with greater certainty be abridged. Bleeding from the arm may with propriety be repeated, if in the course of 24 or 36 hours after the first venesection, the symptoms have not abated, or have increased in severity. Afterwards, also, should there be any signs of a renewal of inflammatory action, more blood is to be taken away. It is chiefly in cases where there is pulsative pain in the eyeball, and circum-orbital pain, coming on in nocturnal paroxysms, that repeated general blood-letting is ne- cessary. Besides venesection, and the application of leeches to the temple, scarification of the conjunctiva of the eyelids, and even of the eye- ball, is to be employed. This may be repeated every second or third day. In the swoln and fleshy state of the conjunctiva which attends this disease, deep incisions may be made ; they will bleed very copiously, and greatly allay the symptoms. I am disposed to place scarification of the conjunctiva among the most effectual means of combating the contagious puro-mucous ophthalmia. 2. Diet. The patient is to remain at rest, in a well ventilated apartment, his eyes shaded from the light, and to adhere strictly to the antiphlogistic regimen. 3. Purgatives. In mild cases, blood-letting, at least general blood-letting, will not be necessary ; but in all cases pui'gatives are to be used. A dose of calomel and jalap may be given at first, and either repeated from time to time during the course of the treatment, or changed for some of the neutral salts. Purgatives operate not merely by depleting, but have a strong sympathetic effect upon the conjunctiva. Emeto-purgatives, as tartar emetic with sulphate of magnesia, will be found highly useful. 4. Diajihoretics. As soon as the active inflammation is sub- dued, much advantage will be derived from promoting the action of the skin. For this purpose the warm pediluvium is to be used at bedtime ; after wliich the patient may take from 10 to 20 grains of Dover's powder. The action of these remedies may be assisted by draughts of tepid diluents, and during the day by small doses of antimony or acetate of ammonia. 5. Alteratives. Nexi to copious venesection, no remedy will be found more useful in severe cases, attended by nocturnal circumorbital pain, than calomel with opium. Two grains of the former with 296 one of the latter, may be giveu in the form of pill every evening at bedtime, till the rnouth is sore. 6. Bark and other tonics are to be tried only in the chronic stage. They are then highly useful. Local treatment. If no local remedies are employed, or only improper ones^ the eyes may be lost, notwithstanding the "best directed general tieatment. It may to some appear paradoxical, that the local applications in this disease ought to be alternately soothing and stimulating. Were we to trust to either sort alone, we should endanger the eyes. Soaking them constantly with tepid water, or laying emollient cataplasms over them, would be almost certain destruction : and, on the other hand, a perpetual succession of stimu- lating solutions and salves would be not less detrimental. The bad effects of a continued soothing or emollient local treatment, are well illustrated in the history already quoted of the Fi-ench slave- ship at sea, while the good effects of stimulants are shewn by the rapid improvement which followed the negress's prescription of lemon-juice, on the patients going on shore at Guadaloupe. Ap- plications which smart the eye are also employed by the native Africans in their own country for the cure of this ophthalmia.* The Egyptians employ urine for the same purpose. Sea water, and a solution of common salt have been found useful. 1. Cleaning the eyes. The first point in the local treatment is to clean away completely and frequently, in the course of the day and night, the puriform discharge. This is to be done with a small syringe, the fluid employed being sent over the whole surface of the conjunctiva with considerable force, but especially into the fold between the eyeball and the upper eyelid. The fluid which I recommend is a tepid solution of one grain of corrosive sublimate in eight ounces of water. This not only cleans the eye, but acts also as a gentle a,stringent. 2. Astringents. With regard to other astringents, my experi- ence leads me decidedly to condenm sugar of lead and sulphate of zinc. They increase the pain, do not abate the discharge, and are apt, as 1 have already stated, to injure the cornea. On the con- trary, the solution of nitras argenti allays the painful feeling of sand in the eye, lessens the discharge, and never renders the exco- riated cornea opaque. I have tried this solution in various degrees of strength; even to 10 grains, as recommended by Dr. Ridgway,t but 4 grains to the ounce of distilled water appears to answer best, applied once, or at most twice in the 24 hours. We generally find a very marked improvement in the course of a few days, under the use of this application. Should it disappoint our expectations, and the purulent discharge run on unabated for a week, a solution of 6 grains of the sulphate of copper in an ounce of water may be sub- * See Yv'inferbottom's Account of the Natii-e Africans in the neighbourhood of Sierra Leone, Vol. ii. p. 129. London, 1803. t See the London Medical and Physical Journal, Vol. liii. p. 122. London, 1823 297 stituted, and used as an injection over the whole surface of the cornea. 3. To prevent the lids from adhermg-. This is effected by the use of the red precipitate ointment, or of the citrine, melted on the end of the finger, and rubbed along the edges of the lids at bedtime. These applications fulfil not only the indication here stated, but operate in subduing the inflammation. Indeed. Sir Patrick Mac- gregor states in his first paper, that of all the remedies that were employed in the Military Asylum, the citrine ointment was found the most frequently successful. 4. Counter-irritants are highly serviceable in this disease, and ought always to be employed. There is generally a marked change in the quantity and appearance of the discharge from the eye, as soon as a counter-discharge is established by blisters on the nape of the neck, or behind the ears. 5. Opiate fomentations^ and friction. Considerable relief to the pain of the eye is sometimes obtained from allowing the steam of hot water with laudanum, to rise into the eyes from a teacup ; or from fomenting the eyes with warm decoction of poppy-heads. Rubbing the head with warm laudanum when the circum-orbital pain threatens to commence, is also highly useful. 6. Evacuation of the aqueous humour has been adopted as a means of relieving the severe pain of the eye and head, and of preventing bursting of the cornea. This is a practice of which I can say nothing from my own experience ; nor do I conceive it will often be required, if the remedies already recommended be had recourse to. Sir Patrick Macgregor expresses his conviction that many have lost their sight from rupture of the cornea in front of the pupil, whose eyes might have been saved by a timely and ju- dicious performance of this operation. Within two years he had performed it in 23 instances, with a degree of success which strongly induced him to recommend it. The iris knife appears the best in- strument for the purpose. The incision need not exceed the tenth of an inch in length, and ought to be about the same distance from the sclerotica. 7. Vinwni opii. When the purulent discharge is gone, this proves an excellent appUcation to the relaxed conjunctiva. Granular conjunctiva and nebulous coriiea, two important se- quelae of contagious ophthalmia, I shall consider in a separate sec- tion. Of the eversion of the lids, which occasionally proves a troublesome attendant on this ophthalmia, I have already treated at page 145. Preventives. To military suigeons especially, the means of preventing this destructive disease are of high importance, 1. Supposing that troops were sent to any of the countries where this disease prt ails, it would be necessary to guard them, as much as possible, against the exciting causes of catarrhal ophthalmia, in which it appears that the contagious originates. It is found in 38 298 Egypt that exposure to the night air is extremely apt to bring on the ophthalmia of the countr}'. Soldiers on guard, then, or at bivouac, should, during the night, cover their head well ; and if in moist and cold situations, they should avoid currents of air as much as possible. Dr. Yetch mentions that of four officers who slept in the same tent, in Egypt, tv\'o had the precaution to bind their eyes up every night, when going to rest, and the two others did not ; the latter were in a very short time attacked by the disease, while the other two escaped. 2. As soon as there are any appearances of puro-mucous ophthal- mia in a regiment, a daily and minute inspection by the medical offi- cers, of every individual belonging to it, laecomes a duty of the first moment, both for the sake of those who may have caught the dis- ease, and for the sake of their comrades. 3. Those in whom the disease is detected should instantly be separated from the rest, and must not be allowed to join their com- panies till perfectly cured. 4. Excessive crowding of the men together, especially in their dormitories, must be carefully avoided, as this of itself appears very much to promote the contagious power and the spread of the dis- ease. 5. Those who are exposed to the disease ought to be made ac- quainted with the fact of its contagious nature, and warned against the modes in which it is hkely to be communicated : as, touching the e3"es of the diseased person and then touching inadvertently their own, using the same towel with those affected with the ophthal- mia, and the like. Barrack-towels must afford a constant medium for the communication of this disease, and ought, therefore, to be entirely laid aside. 6. It will be found a salutary practice, frequently to parade the men in theh respective companies, wi\h separate vessels of water, while an officer attends to see their faces and eyes carefuUy washed. SECTION VII. OPHTHALMIA OF NEW-BORN CHILDREN. Infants, soon after birth, are subject to a puro-mucous inflamma- tion of the conjunctiva, commonly denominated ophthalmia neo- natorum, or the jyurulent oj^hthalmia of infants. We have reason to believe that this disease is, in general, an inoculation of the conjunctiva hj leucorrhoeal fluid, during parturition ; and that, therefore, it may be prevented, in almost all cases, by carefuUy washing the eyes of the infant with tepid water, as soon as it is removed from the mother. This is too seldom attended to : the child is allowed to open its eyes, the nurse sitting down with it on a low seat before the fire, or in a draught of cold air from the door^ and nothing is done to the child for perhaps half an hour or longer. 299 Exposure to^the light, to the heat of the fire, or to the cold draught from the door, are all likely enough injuriously to excite the eyes of the new-born infant ; and, accordingly, some have been led to attribute the purulent ophthalmia which so frequently shows itself about the third day after birth, to these causes. It will, in general, be found, however, that when the child becomes affected with this ophthalmia, the mother has had leucorrhoea before and at parturition, and that the eyes have not been cleaned for some time after birth. To this the ophthalmia seems to be owing, for, like a disease communicated by contagion, it is sudden in its at- tack, and much more violent than we almost ever see catarrhal ophthalmia ; so that it resembles in this respect the Egyptian, or the gonorrhoea! inflammation of the conjunctiva. That some of the cases of purulent ophthalmia, in infants, are catarrhal, is by no means unlikely ; occasionally they may arise from the application even of gonorrhoeal matter from the mother ; but by far the greater number, I believe to be the consequences of leucorrhceal inoculation. SytniHoms. It is commonly on the morning of the third day after birth, that the eyelids of the infant are observed to be glued together by concrete purulent matter. On opening them, a drop of thick white fluid is discharged, and on examining the inside of the lids, they are found extremely vascular and considerably swollen. If neglected, as this disease but too often is, or treated with some such useless application as a httle of the mother's milk, the swell- ing of the conjunctiva goes on rapidly to increase, the purulent dis- charge becomes very copious, and the skin of the lids assumes a dark red colour. In this state the eyes may continue for eight days, or a few days longer, without any affection of the transpa- rent parts, except perhaps slight haziness of the cornea. About the twelfth day, however, the cornea is apt to become infiltrated with pus, its texture is speedily destroyed, it gives way by ulcera- tion, first of all exteriorly to the pus effused between its lamellae, and then through its whole thickness, and this either in a small spot only, or over almost its whole extent, so that sometimes we find only a small penetrating ulcer, with the iris pressing through it, in other cases the whole cornea gone, and the humours protrud- ing. It is melancholy to reflect on the frequency of destroyed vision from this disease, especially as the complaint is completely within control, if properly treated. The attendants unfortunately are not alarmed sutficiently early, by what they consider as merely a httle matter running from the eye ; and but too often it happens, that medical practitioners are also betrayed into the false supposition, that there is nothing dangerous in the complaint, till the cornese burst, and the eyes are for ever destroyed. Many children have been brought to me in this state ; but the most deplorable instance which I have witnessed of the effects of this disease, when neg- lected or mistreated, was that of two twin infants, from Perthshire, 300 for whom I was consulted, some lime ago. One of the children had lost the sight of both eyes totally, while the other retained a very partial vision with one eye. That this disease is a puro-mucous or blencrrhoeal conjunctivi- tis is sufficiently evident. It is scarcely necessary to spend time in refuting Mr. Saunders's notion of its being an erysipelatous inflam- mation. His opinion regarding the mode in which the cornea is destroyed in this disease appears of more importanc and equally incorrect. He maintains that it is by sloughing, notb}' suppuration and ulceration, that the destruction of the cornea is effected. The opportunities which I have had of watching the progress of the affection of the cornea have convinced me of the conti'ary. Onyx or infiltration of pus between the lamellae of the cornea is the uni- form harbinger of destruction : the lamellee exterior to the pus give way by ulceration ; the ulcer spreads and deepens, till the cor- nea is penetrated, and often almost altogether destroyed. Any thing like mortification, or sloughing, I have never seen. The coming away of the purulent infiltration, exposed by ulceration, must have given rise to Mr. Saunders' notion of successive sloughs. Infants labouring under this ophthalmia are fretful and uneasy, and rest ill during the night. The tongue is white, and bowels deranged. If the disease is neglected, the flesh wastes away, and the integuments become loose and iU-coloured. Prognosis. When a child is brought to us with this disease, our first business is carefully to clean and examine the eyes, ex- plaining to the nurse the manner in which she is to remove the purulent discharge from time to time, and stating plainly what is hkely to be the result of the morbid changes already present in the corneae. If these important parts are only free from ulceration, and from purulent infiltration, however violent the inflammation may be and profuse the discharge, our prognosis may be favoura- ble — the sight is safe. If there is superficial ulceration, without onyx, probably a slight speck may remain. If the ulceration is deep, an indelible opacity must be the consequence. If the iris is protrading through a small penetrating ulcer, the pupil will be per- manently disfigured, and vision more or less impeded. If the ulcer is directly over the pupil, the probabihty is that the pupillary edge of the iris wiU adhere to the cicatrice, and vision be lost until a lateral pupil be formed in after-hfe by an operation. If there is a considerable onyx, we can promise nothing, for although under proper treatment, the matter may be absorbed, this is by no means a certain result ; the purulent exudation may, on the contrary, in- crease, the cornea burst, and the eye become partially or totally staphylomatous. Whenever the person who brings the child to me announces that the disease has continued for three weeks, I open the lids of the infant with the fearful presentiment that vision is lost, and but too often I find one or both the corneae gone, and the iris and humours protruding. In this case, it is our painful duty to say that there is no hope of sight. 801 Treatment. 1. As it is of the utmost importance to remove the purulent discharge, from time to time, in the course of the day, I may perhaps be excused for explaining minutely how the eyes are to be cleaned. The surgeon lays a towel over his knees, on which to receive the head of the child, whom the nurse, sitting before him, lays across her lap. The fluid for washing the eyes is the tepid solution of one grain of corrosive sublimate in eight ounces of water. The lids are opened gently, and, with a small bit of sponge, the purulent discharge is removed. The lower lid, and then the upper, are next everted, and wiped clean with the sponge. The upper lid has a tendency to remain everted, especially if the child cries. This is overcome by pushing the swoln conjunctiva into its place, and bringing down the edge of the lid. All this ought to be repeated three or four times, or oftener, in the twenty-four hours, by the nurse. 2. The corrosive sublimate coUyrium, used in cleaning the eyes, tends gently to repress the discharge. Alone, however, it is not suf- ficient for that purpose, and we have recourse, therefore, to astringent apphcations of more power. The solutions of nitras argenti and sulphas cupri are those which I have found most useful. Once, or at most, twice a day, I apply, with a large camel-hair pencil, the solution of four grains of the former, or six of the latter, in an ounce of distilled water, to the whole surface of the inflamed conjunctiva, immediately after having cleaned it as above described. Not only the local, but even the constitutional good effects of removing and restraining the purulent discharge are very remarkable. The first night after the use of the collyrium and drops, we generally find that the infant has been much quieter than it had been when the disease was neglected. 3. To prevent the eyelids from adhering during the night, the red precipitate ointment is to be applied along their edges at bed- time. 4. The above remedies are perfectly sufficient to remove this disease, if had recourse to within two or three days after the first symptoms have shown themselves. I have seen two applications of the nitras argenti solution, viz. on the third and fourth days after birth, or first and second days of the disease's showing itself, re- move the complaint completely, although thick white matter had been secreted by the conjxmctiva. In cases attended by a discharge less distinctly puriform, the use of the red precipitate salve at bed- time has sometimes been sufficient. In cases, again, which have been neglected for perhaps eight or ten days, it is necessary to take away blood from the inflamed conjunctiva by scarification, or from the external surface of the upper eyelid by the application of a leech. The latter may be had recourse to in the first instance, and unless followed by marked abatement of the redness and swelling on the inside of the lids, the conjunctiva may next day be divided with the lancet. The taking away of blood in either of these ways is 302 productive of much benefit, and ought by no means to be omitted, if there be any tendency to cheraosis or any threatening ^of haziness of the cornea. A more profuse loss of blood than can be ob- tained by the methods here recommended, I do not consider neces- sary. 5. A remedy of great service in this disease is the application of blisters behind the ears, or to the back of the head. Cantharides plaster spread on a bit of candle-wick, and laid between the head and the external ear, is a convenient mode of breaking the skin ; and by continuing this apphcation either constantly, or several hours daily, a continued discharge will be procured. As soon as there is a discharge of matter from the blistered parts, we find an amendment in the affection of the eyes ; but if the ears are allowed to get well, we often observe a renewal of the inflammation of the conjunctiva, and a more copious flow of puriform matter, which again subside if the blisters are re-applied. 6. An occasional dose of castor oil will be found useful. 7. Recovery from this disease is often tedious. For weeks, we continue the treatment above recommended, and although there is no change for the worse, nor any affection of the cornea, and per- haps but little purulent discharge, still the conjunctiva continues inflamed, and the symptoms on the whole stationary. Under these circumstances, I have found small doses of calomel highly useful. From a quarter to half a grain daily will be sufficient. 8. In threatened disorganization of the cornea, Mr. Saunders has strongly recommended the extract of cinchona. The sulphate of quina will probably answer better, and be more easily admin- istered. Half a grain may be given twice or thrice daily. 9. The relaxed conjunctiva, after the purulent discharge has entirely subsided, may be advantageously touched once a day with viimm opii, in place of the metalhc solutions. I have sometimes treated cases with the vinum opii throughout, but I consider this remedy as more applicable for the chronic stage of the complaint than for the acute. SECTION VIII. GONORRHCEAL OPHTHALMIA. Different views have been entertained of the purulent inflam- mation of the conjunctiva, which is frequently found to attend, or succeed to gonorrhoea. 1st, This ophthalmia has been ascribed to inoculation with matter from the urethra ; 2dly, It has been supposed to be metastatic ; and 3dly, It has been considered to be, at least in certain cases, an effect owing to irritation merely, with- out either inoculation or metastasis. It is quite possible that there may be three varieties of this ophthalmia, one from contagion, a second from suppression, and a third from irritation. The ex- istence of the first I consider to be beyond all doubt ; that of the second and third is somewhat problematical. 303 Some, while they have admitted that facts have fully demon- strated that this disease occasionally owes its origin to inoculation, have expressed their surprise that it is not more frequently pro- duced in this way, considering- how common gonorrhoea is, and how careless many of those of the lower ranks are of cleanliness. We should expect, say they, the finger to be in many more cases the conveyer of the matter of the gonorrhoea to the conjunctiva, than it actually appears to be. The instinctive closure of the eye- lids when the finger approaches the eye, making it actually difficult for a person to touch his own conjunctiva, unless with one finger he draws down the lower lid, and attempts to touch his eye with another finger, will serve in some measure to explain the rarity of this kind of inoculation. Women are much less frequently the subjects of gonorrhoea! ophthalmia than men. In general, it is only one eye which is affected with this disease, especially when it arises from inoculation. 1. Gonorrhmal Ophthalmia from Inoculation. Case 1. A patient was brought to me some time ago from the country by a gentleman under whose care he was, and who had formerly been one of my pupils, with his left eye violently inflamed and chemosed, the chemosis of a pale red colour, the conjunctiva discharging a large quantity of purulent fluid, the lower lid greatly everted, and the cornea, from lymph, and probably pus effused be- tween its lamellae, totally opaque. This patient was affected with gonorrhoea, and thirteen days before I saw him, while engaged in removing the discharge from the urethra, a drop of the gonorrhoea! fluid was by mischance thrown fairly in upon his left eye, and excited the severe puro-mucous ophthalmia under which he was labouring. The gonorrhoea still continued when I saw liim. The inflammation of the eye subsided under appropriate means, the cornea cleared to a degree far beyond my expectations, and a considerable share of vision was preserved. The right eye was not at all affected. Case 2. Mr. Allan relates the foUov/ing interesting case of con- tagious gonorrhoeal ophthalmia. " I was consulted," says lie, " by a young gentleman of 17 years of age, on account of a gonorrhoea recently contracted, but by no means severe. In a few days after his application to me, the eyes became violently arid suddenly in- flamed, the eyelids much tumefied, and there took place a profuse discharge, similar to that of gonorrhoea, excoriating the cheeks, and accompanied by great pain, considerable fever, and general restlessness; the discharge from the urethra did not at once disap- pear, notwithstanding the violence of the ophthalmia. In a few days, his younger brother, a boy 14 years of age, who never had been exposed to any venereal complaint contracted by sexual inter- course, and wlio slept in tlie same room, was similarly affected ; 304 and the disease in both eyes was equally severe as in those of the elder brother. I called Dr. Monro and Mr. J. Bell into attendance ; but notwithstanding every means that could be devised, the elder brother lost the sight of both his eyes, and the younger brother of one eye. If it be said," adds Mr. Allan, " that in the elder brother the ophthalmia might arise from a consentaneous connexion or sympathy betwixt the urethra and the conjunctiva, and not from the direct application of the virus, still this explanation will not at all apply to the younger brother, who had no gonorrhoea, but who must have contracted the disease from actual contact ; as by using the same towel or wash-hand basin with his brother, wiping his face with the same handkerchief, or in some less obvious manner, and in whom it was equally severe." * Case 3. Astruc relates, that a young man had been in the habit of every morning bathing his eyes with his urine while it was yet warm, in order to strengthen his sight. Although he had con- tracted a gonorrhoea, he did not abstain from this custom, appre- hending no harm from it ; but the urine partaking of the infectious matter, quickly communicated the same disease to the tunica con- junctiva of the eye and eyelids. The consequence was a severe ophthalmia, attended with an acrid and involuntary discharge of tears and purulent matter, but which yielded to the same remedies which removed the gonorrhoea.t Case 4. A healthy young woman happened to wash her eyes with some sugar of lead water and a sponge which had previously been used by a young man affected with gonorrhoea ; the conse- quence was, that she immediately contracted a severe ophthalmia, which rapidly destroyed one eye, and brought on swelling of the lymphatic glands about the neck, for which she underwent a course of mercury. J So similar is the discharge from the eye in gonorrhoeal and in Egyptian ophthalmia, to that which runs from the lu-ethra in gon- Qrrhoea, that some have gone the length of concluding that gonor- rhoea has been originally an inoculation of the urethra by the mat- ter coming from the eye in Egyptian ophthalmia ; while others are of opinion that this last disease is nothing else than the etfects of an inoculation of the conjunctiva with matter from the urethra in gonorrhoea. Both parties have referred to experiments in favour of their own opinion. Little can be drawn from negative experi- ments on this subject. It is demonstrated beyond all doubt that the matter from the urethra in gonorrhoea, applied to the conjunc- tiva, excites a severe puro-mucous ophthalmia, and a similar in- flammation of the urethra has unquestionably been brought on by inoculation with the matter coming ffom the conjunctiva in the * System of Pathological and Operative Surgery, Vol. i. p. 153. Edin. 1819. t De Mortis Venereis, p. 192. Lutetiae Parisiorura, 1736. t Chirurgie Clinique de Montpellier, par le Professeur Delpech. Tome i. p. 318, Montpellier, 1823. 305 Egyptian ophthalmia ; but experiments of this kind have also sometimes failed, and from such failures conclusions have been drawn that are altogether unwarrantable. For example, Dr. Vetch tells us that in the case of a soldier, received in a very advanced stage of the Egyptian ophthalmia, he attempted to divert the dis- ease from the eyes to the urethra, by applying some of the matter taken from the eyes to the orifice of the urethra. No effect followed this trial. It was repeated in some other patients, all labouring under the most virulent state of the Egyptian disease ; and in all, the application was perfectly innocuous. But, in another case, where the matter was taken from the eye of one man, labouring, under purulent ophthalmia, and applied to the urethra of another, the purulent inflammation commenced in thirty -six hours after- wards, and became a very severe attack of gonorrhoea. From the result of these experiments. Dr. Vetch, while he admits that gonor- rhoea! matter taken from one person and applied to the conjunctiva of another, will excite a highly purulent ophthalmia, regards him- self justified in no longer admitting the possibility of infection being conveyed to the eyes from the gonorrhoeal discharge of the same person. He adds that the impossibihty of this eflfect, was rendered decisive by an hospital-assistant, who, with more faith than pru- dence, conveyed the matter of a gonorrhoea to his eyes without any affection of the conjunctiva being the consequence.* It is remark- able, that Dr. Guillie has fallen into the same error of reasoning with Dr. Vetch, only that his negative experiments have led him to the very opposite conclusion. He applied the matter taken from the conjunctiva of one patient to the urethra of another ; no effect followed, and hence he concludes that the notion of some, regarding the propagation of puro-mucous inflammation from one mucous membrane to another in different individuals, is unfounded.t The first case which I have related would have been sufficiently convincing to me of the reality of gonorrhoeal ophthalmia by inoc- ulation, had I entertained any doubt upon the subject. The man had a profuse gonorrhoea, but his eyes were perfectly well ; shaking away the discharge from the penis, and stooping at the time, a drop went fairly in on the left eye, violent inflammation imme- diately set in, was all along confined to the eye which had been inoculated, and produced the results already stated, while the gon- orrhoea continued to run its course. Diagnosis. There are no marks which can be absolutely de- pended on, by which to distinguish gonorrhoeal ophthalmia, pro- duced by inoculation, from the Egyptian or contagious ophthalmia. The symptoms of the former are not less rapid and severe than those of the latter ; and the danger of losing the eye, by destruc- tion of the cornea, greater perhaps than in any other ophthalmia. There is a great degree of chemosis, and a profuse discharge of * Practical Treatise on the Diseases of the Eye, p. 242. London, 1820. + Biblioth^quc Ophthalmologique. Tome i. pi 83. Paris, 1820. 39 306 matter, varying in colour like the discharge in gonorrhoea. The external surface of tiie hds is perhaps not so rnucli swoln, nor of so dark a red colour, as in the Egyptian ophthalmia. In the early stage, it will also be observed, that in the latter disease, the inflam- mation commences on the inside of the hds : whereas in gonor- rhoeal ophthalmia, it attacks the whole conjunctiva at once. The history of the two diseases will perhaps afford the best ground for diagnosis. Treatment. This ought to be exactly the same as in the Egyp- tian ophthalmia. Abstinence from all stimulants ; blood-letting, both general and local : and the exhibition of purgatives, or emeto- purgativeS; and diaphoretics, are to be had recourse to in the early stage. The discbarge is to be frequently and carefully removed with the muriate of mercury coUyrium, the conjunctiva is to be touched once or tvace a day with the nitras argenti solution, and the lids are to be prevented from adhering by the use of the red precipitate salve. Oounter-kiitation ought to be employed from the very first, by means of sina,pisms and blisters to the neck, be- tween the shoulders, or tehind the ears. If either the pain of the eye is pulsative, or the circum-orbital region affected with noctur- nal paroxysms of pain, calomel and opium are to be given, till the mouth is sore. Warm fomentations, the vapour of laudanum, opiate Mction of the head, and the like, will serve to moderate the pain ; but our chief rehance must be placed on depletion, counter- irritation, scarification, and smarting applications to the conjunctiva, for removing the disease. Snipping out a portion of the chemosed membrane, so as to procure a considerable flow of blood, is highly serviceable. Bleeding alone must not be depended on. " The inflammation produced," says Mr. Bacot, " in the four instances that have come under my observation, is of the most violent and intractable des- cription, and has produced the total destruction of the organ of vision, in the space of two or three days, notwithstanding the most vigorous employment of general and topical blood-letting, and other antiphlogistic means." * The acetate of lead and the sulphates of zinc and copper, at least in the early stage, will be found to aggravate the symptoms. These are the local remedies recommended by Mr. Allan ; and the case already quoted, the pubhcation of which does great credit to his candour, shows how httle adapted these applications are to this dis- ease. 2. Gonorrhceal Ophthalmia from Metastasis. The doctrine of related diseases, or of the conversion of one disease into another, is at once one of the most important and difli- cult, in the whole science of medicine. * Observations on Syphilis, p. 46. London, 1821. 307 Perhaps the most famihar example of a metastasis, or conversion of disease, is swelled testicle following suppressed gonorrhoea ; but no one supposes that in this case, there is actually a translation of matter from the urethra into the testicle. The most dangerous, as well as the best-proven, translation is that which attends the inflammation of veins. For instance, caus- ' tic potass was directed to be applied on the outer side of the leg, below the knee, for the purpose of forming an issue. By mischance, it was applied over one of the branches of the external saphena. The eschar fell out and was found to have penetrated into the vein, which immediately bled profusely. A bit of sponge was applied, and kept in its place by a roller. The vein inflamed, violent fever ensued, and the patient died. Before his death, a considerable swelling, communicating to the hand a peculiar kind of crepitation, had formed under one of the pectorales majores. On dissection, this swelling was found to consist of a large collection of pus. Within the veins, purulent matter was traced from the external saphena to the commencement of the inferior vena cava. The ex- planation which has generally been adopted of metastatic cases like this, is that the pus, mingling with the blood, is circulated through the body, and by its presence, excites inflammation in parts remote from the seat of the original injury. In various parts of the body, and among others in the eye, in- flammation, ending in suppuration and sometimes in ulceration, has been known to arise from inflamed veins. A highly interesting case of this kind occurred to Mr. Earle. He had removed a por- tion of a varicose vein of the leg. This was followed by great con- stitutional disturbance, inflammation of the vein, deep-seated ab- scesses in the opposite leg, in both forearms, and in one of the lungs. The day before the patient's death, the corneee were observed to have become opaque, and their surface rough, the vessels of the conjunctiva were injected, and the patient lay with his eyes con- stantly closed. On dissection, destructive changes were found to have taken place within the globe of the right eye, the chrystalline lens was so soft as to v\e\d to the shghtest touch, the vitreous hu- mour was of a reddish yellow colour, and red vessels were distinctly seen traversing its membrane. The retina was of a deep red col- our. The nerve of the third pair on the left side was evidently flat- tened, and softer than that on the right. The nerve of the fifth pair on the right side iiad undergone a similar change to a greater ex- tent.* This, then, appears to have been a destructive inflammation of the eye, arising from the transmission of pus into the circulation, A similar case is recorded by Mr. Arnott, in his valuable paper on the Secondary Effects of Inflammation of the Veins, published in the fifteenth volume of the Medico-Chirurgical Transac'ions. A young man had a hgature placed on the left .carotid artery, for * London Medical Gazette, Vol. ii. p. 284. London, 1828, 308 an aneurismal disease of one of its branches. Considerable diffi- culty was experienced in passing the needle round the vessel. Ven- ous hsemorrhage took place during the operation, recurred at night, and occasionally afterwards, for nine or ten days. On the fifth day after the operation, the patient had a severe rigor, succeeded by heat of skin, and general febrile symptoms. These increased, the pulse rose to 120, and the constitutional disturbance assumed a very violent character. About the tenth day, the vision of the left eye became impaired, and was quickly lost, the pupil was contracted, the iris immovable, and the cornea had a somewhat hazy appear- ance ; effusion took place under the conjunctiva, and the lids were greatly swoln, producing an appearance as if the globes were much protruded. There was, at the same time, a degree of deafness, considerable stupor, and occasionally slight delirium. In the course of a few days, the coats of the eye sloughed at the upper part, and its contents w^ere evacuated. While these changes were going on in the eye, collections of matter formed, without pain, in different parts of the body, on both shoulders, above the insertion of the del- toid muscles, over the sacrum, &c. The constitutional disturbance abated, and the collapsed eye healed over ; but the patient never recovered his health. He died five months after, labouring under lumbar abscess, and worn out by hectic. On examination of the body, a portion of the jugular vein, to the extent of two inches, was found wanting ; the upper and lower ends next the lost part being shrunk, hgamentous, and gradually lost in the cellular substance. On opening the head, pus was found effused in great quantity be- tween the tunica arachnoidea and pia mater, along the base of the brain, and the w^hole length of the spinal cord. The intermuscu- lar cellular substance of the loins was loaded with pus. Mr. Arnott asks, when we consider the circumstances of this case, the venous haemorrhage, constitutional disturbance, formation of abscesses, and appearances presented on dissection, and compare them with the consequences which have been observed to follow inflammation and suppuration of a vein, and the occurrences in Mr. Earle's case, whe- ther we can doubt that the affection of the eye. in this instance, arose from the inflammation of the jugular vein, and from the en- trance of an inflammatory secretion, probably pus, into the blood. I have quoted these facts, both as interesting in themselves, and as illustrative of the doctrine of metastasis. It is evident that if a destructive inflammation of the eye can be excited in consequence of the suppuration of a remote vein, a metastatic ophthalmia from suppurative inflammation of the urethra must be regarded as not so improbable an event as some have been disposed to consider it. There is a set of cases, however, in themselves highly important, and still more confirmatory of the possibility of a metastatic gonor- rhoea! ophthalmia. A disease of the eye, similar to that observed in the two cases above mentioned, occurring in the puerperal state, has been described by Dr. Hall and Mr. Higginbottom, in a paper pub- 309 lished in the thirteenth volume of the Medico-Chirurgical Transac- tions, under the title of " Cases of Destructive Inflammation of the Eye, and of Suppurative Inflammation of the Integuments, occur- ring in the Puerperal State, and apparently from Constitutional Causes." In all of these cases, six in number, the affection of the eye took place in from five to eleven days after delivery. It was preceded and accompanied by serious indisposition, in every instance terminating fatally, and under symptoms of extreme exhaustion. The affection of the eye was characterized by redness of the con- junctiva, intolerance of hght, and contracted pupil, rapidly followed by opacity of the cornea, and excessive chemosis. In two of the cases, the coats of the eye gave way ; and in one of these, where the process was observed, the rupture took place by ulceration of the coats round the cornea. In both of these cases, the collapsed globe had healed over previous to death. In each instance only one eye was affected, and in five of them it was the left. In the case communicated by Mr. Ward, it does not appear which eye was the seat of the disease. With the disease of the eye, there also took place an inflammation of the integuments, first observed on the hand, but on careful examination, found in the inferior, as well as the superior extremities, and under which, matter quickly formed. In one case only, there was no such inflammation. The authors of the paper conjecture, that the morbid affection of the eye had a constitutional origin. No examination after death seems to have been made in any of the cases. Mr. Arnott, in his comments on these cases, asks, whether, considering the circumstances under which the affection of the eye took place, its character, and the depositions of pus under the integuments of the body, and com- paring these with the known consequences of inflammation of veins, and the frequency of inflammation in the veins of the uterus after parturition, we may not be justified in attributing the disease of the eye to inflammation of the uterine veins, and the introduction of pus into the circulation. He cautions us against supposing him to regard the matter deposited in different parts of the body, under such circumstances, to be actually that which has been brought into the circulation from the inflamed vein or veins ; stating that the question is no longer one of a translation of matter merely, but one which involves the very difficult subject of the pathology of the blood. Indeed, in these cases, although inflammation, ending in suppuration, occurred in the extremities, no deposition of pus appears to have taken place in the inflamed eye. I owe to Mr. James Brown of this city, the opportunity of seeing a case of puerperal ophthalmia, which I have now no doubt was of the nature of the cases recorded by Dr. Hall and Mr. Higgin- bottom. The patient was a slender scrofulous woman, about 30 years of age, of irritable temperament, sedentary habits, and mel- ancholy disposition. She had been seven times pregnant, and the following numbers indicate the months during which each utero- 310 gestation was continued ; viz. 9, 7, 5, 9, 9, 7, 4. She had formerly- been subject to discharge from the vagina, probably leucorrhceal, but not immediately before the abortion in the fourth month, which led to her last illness. There was nothing remarkable about the labour. The lochial discharge was scanty, and did not continue above a week, at the end of which time she began to complain of pain in the back and groins, accompanied with slight colds and heats, and little, if at all, relieved by blood-letting and purging, both of which were copiously used. Some fifteen or eighteen days after delivery, she was seized with very severe rigors, followed by great pain in the head, back, and abdomen ; the pain in the abdomen being complained of chiefly on pressure. The affection of the eye, which, as in the cases already referred to, was the left, came on about twenty-eight or thirty days after the former symptoms had been apparently subdued by the usual means, although during all this time, the general state of the patient had been by no means favour- able. The affection of the eye was ushered in by new rigors, which were followed by a good deal of fever, rather of a remittent type, and occasional feelings of sinking. The pulse continued from the first quick, irritated, and by no means strong. The eye was highly inflamed, the conjunctiva much chemosed, the hds swoln, and the lower lid everted. There was severe pain in the eye and head, and excessive intolerance of light, so much so that she was obhged to keep her face covered with a handkerchief, although the window- shutters were kept constantly closed. At first tears ran from the eye, and, after a time, purulent matter. The cornea became opaque, but the eye did not burst. Her mind was all along very desponding. For some days she was shghtly incoherent, on coming out of sleep, but when roused was sensible to the last. No abscess formed near the surface of any part of the body. She died about eight weeks after the abortion. It is to be regretted that neither the eye nor the body was permitted to be examined. It is far from being my intention to draw, from these facts, any other conclusion, regarding gonorrhoeal ophthalmia by metastasis, than this, that they render such an affection somewhat less prob- lematical. The facts themselves are valuable, nor could 1 omit giving an account of them under some head or other. Saint- Yves appears to have been the first to speak of gonorrhoeal ophthalmia from metastasis. His account of it is very short. He describes the conjunctiva as becoming hard and fleshy, the disease having commenced by an abundant discharge of white or yellowish matter. He states that, in most cases, the ophthalmia began two days after the commencement of the gonorrhoea, the latter discharge having at that period suddenly ceased, and thus caused a metas- tasis to the eye. He recommends blood-letting from the first, mer- cury, purgatives, and the warm bath. As local applications, he advises brandy and water, and a decoction of rosemary, sage, hys- sop, and roses in red wine.* * Nouveau Traite des Maladies dea Yeux, pp. 187, 209. Paris, 1722. 311 Succeeding writers have adopted Saint- Yves's view of the sub- ject with too Uttle hesitation, and appear to have investigated suf- ficiently neither the probability of the ophthalmia having arisen rather from inoculation than from metastasis, nor the chance of there being no connexion between the two diseases, but merely a concurrence in the same individual. The causes of the suppression of the gonorrhoea, to which the rise of metastatic gonorrhceal ophthalmia is attributed, are exposure to cold, violent exertions of the body, the abuse of spirituous liquors, and the employment of astringent injections into the urethra. The following may serve as a specimen of alleged metastatic gonorrhcEal ophthalmia. A captain in the army, aged 29, was ordered to mount guard at court, in the month of January, when he had a violent gonorrhoea. The day was excessively cold, and he was forced by his duty to remain a long time exposed to the air during the day and night. Towards midnight he began to feel the most violent pain in both eyes at once, which very soon increased to such a degree that he could not endure any kind of light. Next day, these s3rmptoms were attended by a discharge of puriform matter from both eyes, and the albuginea appeared very much inflamed and swelled. A physician w^as sent for, unfortunately very ignorant, who ordered general remedies, as bleeding, purgatives, See a case of Staphyloma Scleroticae successfully treated, by repeatedly tapping- the Eye ; by Richard Martland, M.D., in the Edinburgh Medical and Surgical Jour- nal, Vol. xxiii. p. 59. Edin. 1825. t Ophthalmitis interna idiopathica propria sic dicta of Beer. 387 other texture appearing to be congenitally weaker or stronger than the otliers, so that the same exciting cause, operating on a number of persons, shall produce in one, inflammaiio;i of the conjunctiva; in another, sclerotitis ; in a third, iritis; in a fouilh, inflaniiviiiuon of the retina. On the other hand, the nature of the cause ieads in one case to external, in another, to internal ophihnhma. Cold, ope- raiing on the eye, will bring on inflammation of the conjunctiva or sclerotica, while the sudden and direct reflection of a strong light into the eye will be apt to produce an inflammation of which the retina is likely to be the focus. The inflammatory action, however, is seldom, if ever confined to the part first affected. We have al- ready seen how inflammation, originating in the iris, spreads to the sclerotica, and to the choroid ; and how choroiditis affects the tex- tm^es both within and without the choroid. In the same way, in- flammation commencing in the retina is likely to spread inwards to the vitreous humour, to the capsule of the lens, and to the lens it- self, all which parts are fed by branches from the central artery of the retina ; and outwards, to the choroid and iris to the sclerotica and cornea, and to the conjunctiva. Thus an inflammation of the whole eyeball may arise from a very limited point of origin. Nor is this a fanciful picture of disease. Although a retinitis, ending in general ophthalmitis, and arising from causes of very limited and transient action, is rare ; yet it occasionally occurs, es- pecially after long continued straining of the sight in the examina- tion of very snjall, perhaps microscopical objects, under a strong light, reflected into the eye, either immediately from the object of examination, or from a speculum. In such cases, however, there are commonly certain predisposing causes, which ought not to escape observation ; such as plethora in and near the organ of vision. Unexpected and vivid flashes of lightning sometimes excite in- flammation of the retina, and this disease has frequently been ex- cited by imprudently viewing an eclipse of the sun. Prisoners, who have been long confined to the darkness of a dungeon, have been seized with intlamniation of the retina on being brought suddenly forth into the full glare of day. Travelling over a long tract of coimtry covered with snow, has been known to produce the same effect. Saint-Yves notices the case of a man who became blind in consequence of going too close to (he light and heat of a strong fire, in attempting to tie a string to a fowl, turning on the spit ; and an- other of a workman in the mint, who lost his sight from the bril- liant flashing to which he was exposed, while pouring metal into a red-hot crucible. Both of these accidents were probably owing to retinitis. The Esquimaux, who inhabit Hudson's Bay, are well aware of the loss of vision which arises from exposing the eyes to the con- stant vie.v of a country covered with snow. They make use of a kind of preservers, which they term snow eyes. These consist of 388 two pieces of wood or ivory, so formed as to fit the eyes, which they completely cover, and are fastened behind the head. Each piece presents a narrow slit, through which every thing is distinctly seen. This invention preserves them from the snow-blindness, which is apt to be occasioned by the strong reflection of the sun's rays ; and which, it is probable, is the effect of inflammation excited in the retina.* Blinding persons by producing retinitis was, and still is, in some countries, a mode of punishment. The person is compelled to look steadily on a concave mirror of polished steel, held opposite to the sun. This would excite speedy inflammation of the retina, and certainly end in a greater or less degree of insensibility to light. Some such method must be employed in India at this day, as many of the native princes, who have been condemned to the loss of sight by the jealousy of their rivals, but are suffered to live in a state of captivity, are said to have no appearance, at a little distance, of being blind. Chronic cases of retinitis not unfrequently present themselves to our observation, under the designation of weakness of sight, and are characterised by a morbid sensibility to hght and slight obscu- rity of vision, followed after a lapse of time by gradual contraction of the pupil, immobility of the iris, and amaurosis. Watchmakers, jewellers, and those who spend great part of the day and night in reading and writing, are apt to be affected in this way. Such cases are often injured by stimulant and tonic treatment, while on the other hand, they are greatly benefited by leeches round the eye. Dr. Mirault has published a paper on inflammation of the re- tina,! in which he describes under this name, the common strumous or phlyctenular ophthalmia, maintaining that the excessive intoler- ance of hght which accompanies this disease, can be attributed only to retinitis. This, however, is a mistake. We see an equal de- gree of intolerance of hght brought on, in an instant, by the pres- ence of a particle of dust between the eyeball and upper eyelid ; and there can be no doubt, 1 think, that conjunctivitis, not retinitis, is the cause of the same symptom in strumous ophthalmia. The following are the symptoms of sudden and severe retinitis. The patient first complains of a general feeling of pressure and tension in the whole eyeball. To this there succeeds an obtuse, deep-seated, pulsating pain, which seems to inciease every moment, and soon extends to the eyebrow and cranium. The power of vision is already sensibly diminished, and every hour becomes more and more feeble. At the same time, the pupil is observed to have * These instruments also increase the powers of vision, so that the Esquimaux are so accustomed to their use, that when they are desirous of ^dewing any thing at a dis- tance, they mechanically apply them to their eyes. Different accounts are given of the slit or slits in these instruments, for some tell us there is only one in each eye-piece, and that it is long and narrow, while others say that there are two, about a quairterof an inch long. This is probably regulated by the fancy of the wearer. ♦ Archives Generales de Medecine. Tome xx. p. 477. Paris, 1829. 389 lost its glancing blackness, and to have become much contracted. Without becoming angular or deviating from its natural situation, it at length completely closes, the iris having reached its greatest possible degree of expansion, and seeming no longer to be perforated b}^ any central opening. Long before the pupil is closed, the sen- sibility of the retina seems extinct ; and yet, even when the pupil is closed, and there is no longer any trace of perception of light from without, the patient experiences a troublesome sensation of fiery spectra with every oscillation of the internal blood vessels of the eye. While these changes are taking place, the iris loses its natural colour, becoming greenish or reddish according to its original hue. The anterior chamber is strikingly diminished in size, the iris hav- ing advanced towards the cornea. By the time that this advancing of the iris is first discerned, which is generally when the pupil is still of considerable size, the whole sclerotica is rose-red. The con- junctiva some time after presents a pretty thick net-work of blood vessels, and the cornea loses much of its natural lustre without be- coming absolutely opaque. The last mentioned symptoms make their appearance under severe inflammatory sympathetic fever, along with insufferable and almost maddening headach. Some- times it happens that during this first period of the disease, the pu- pil, though much contracted, does not completely close ; but it is cloudy, and on looking at it through a magnifying glass, or even by merely concentrating the light upon it, is seen to be reddish-gray, while the power of vision is totally lost. So severe are the sympathetic fever and headach which attend retinitis, that ii sometimes passes with medical men who have not studied the diseases of the eye, for phrenitis or brain fever, the char- acteristic symptoms of this ophthalmia, from which the affection of all the other parts arises, not being sufficiently prominent to arrest attention. The oculist generally finds retinitis so far advanced in its progress, as to be almost altogether beyond control. The pain of the eye now becomes unequal ; it is still pulsative, but is now attended by a feeling of cold and weight in the part. Shiverings take place, and there suddenly appears a quantity of pus at the bottom of the anterior chamber. This matter presents a horizontal surface and is sometimes seen to change its position on the head being moved from side to side. It constantly increases in quantity, till it not only reaches the pupil, but at length fairly fills the anterior chamber. It may accumulate to such a degree, especially in neglected cases, that the cornea projects, assumes the appearance of an abscess ready to burst, and at last gives way un- der insufferable pain. The eye then collapses, and the pain grad- ually subsides. If the pupil has not completely closed by the end of the first stage, we see, just at the moment when the hypopium begins to form, fine whitish filaments of lymph shooting from the edge of 390 the pupil towards its centre. Viewed through a good lens, these have the appearance of a dehcate cobweb. After the pus has cov- ered the pupil, and reumined perhaps long unabsorbed, this cob- web-iike pseudo-membrane becomes whitish-yellow from little par- ticles of the pus lodging in its interstices, and sometimes a single piece of what appears to be thickened purulent matter, attached to this membrane, projects through the pupil, intimately connected also with the pupillary edge of the iris. But if the pupil has closed completely in the first stage, of course nothing of this spurious cat- aract is observed. Prognosis. The prognosis in retinitis is not unfavourable, if a proper method of treatment be commenced before the pupil is much contracted, or the power of vision greatly lessened. If vis- ion seems already extinguished, the prognosis is extremely unfa- vourable. Beer, indeed, had in two cases seen vision return with the arrest of the inflammatory symptoms, but in both a very con- siderable weakness of sight remained during life, and the patients could read large print only with much difficulty, and small print not at all. If the pupil be once closed, even before the retina ap- pears to have become insensible, there is no longer any hope of preserving sight ; for even should the pupil re-open in some degree, as it occasionally does on the inflammatory symptoms being ar- rested, yet it remains small and motionless, and the eye is still blind. If retinitis be completely misunderstood in the commence- ment, neglected or mistreated, it proceeds rapidly on to a dangerous inflammation of the whole eyeball. In the second stage the pi'ognosis is always bad. For before the disease has advanced so far, vision is irretrievably lost. All that can be done is to endeavour to save the form of the eye, by limiting the suppuration as much as possible. If this disease has been misunderstood at the commencement or mistreated, so that it has gone on to a complete ophthalmitis, attended with chemosis, there is much danger that in the second stage not even the form of the eye will be saved. Treatment. Complete rest of the eyes and of the whole body, darkness, abstinence, and active depletion, followed by the rapid introduction of mercury into the system, are the means to be de- pended upon in the first stage of retiniiis. Copious blood-lettmg from the arm is to be immediately followed by a plentiful cipoiica- tion of leeches round the eye. Should the pain of the eye and head still continue, the jugular vein or temporal artery ought to be opened, and a considerable quantity of blood abstracted. Calomel with opium ought to be given in frequent doses, till the mouth is yffected. Belladonna is to be applied in the usual way. In the second stage, the preservation of sight is out of the ques- tion. A warm emollient poultice is to be laid over the eyelids. If only a small quantity of matter be present in the anterior chain- 391 ber, we must on no account let ourselves be induced by that to open the cornea, for the purpose of evacuating it ; but trust to the sorbefacient effect of the mercury, assisted by blisters behind the ears or on the back of the neck. Beer recommends the eye in that state to be touched repeatedly in the course of the day with vinuni opii, by the careful use of which, in combination with the internal employment of opium and sometimes of cinchona, he had seen collections of pus in the anterior chamber completely disappear. Should the hypopium increase, so that the anterior chamber is filled, we cannot trust to its absorption, but must give exit to the matter by opening the cornea with the extraction knife. In such circumstances, the natural appearance of the cornea and iris is completely lost, the eyeball sometimes remaining flattened in the situation of the cornea, while in other cases it becomes staphyloma- tous. SECTION XXIV. AQ.UO-CAPSULITIS. By the term aquo-capsulitis is meant inflammation of the car- tilaginous membrane, generally considered as serous, which lines the internal surface of the cornei. When this membrane is in- flamed, it becomes more or less opaque ; thers is at the same time a rauddiness in the anterior chamber, and occasionally an appear- ance as if the eyeball were unusually full and prominent. This arises from an increase in the quantity of the aqueous humour, the balance of action being suspended, which naturally exists be- tween the exhalents and absorbents of that fluid. In more severe cases, coagulable lymph is effiised from the lining membrane of the cornea, and if the iris be at the same time in an inflamed state, this eff'usion may become the medium of adhesion between the iris and the cornea. Besides the diffiised muddiness, there are often present in this disease one or more milk-hke spots on the internal surface of the cornea, which even the least experienced may readily distinguish from any of the common superficial opacities of that part. The spots in question give the cornea a mottled appearance, and form by far the most characteristic mark of this ophthalmia. Mr. Wardrop has accurately described their more opaque central points as surrounded by a kind of disk, resembhng what is called the eye of a pebble. He seems to ascribe the whiter point in the centre to opacity of the substance of the cornea, and the disk to that of the lining membrane. This mottled appearance I have seen very distinctly in two cases ; and what was very remarkable, in one of these, the spots appeared and disappeared at different points of the internal surface of the cornea, even in the space of a few hours, so that the patient saw worse in the morning when most of the spots were observed, 392 and better towards the evening when those at the upper part of the cornea had greatly diminished. There accompanied this sin- gular case, a general turbid ness in the morning. The whole ap- pearance of the anterior chamber, and of the spots in question, resembled very much the effect which might be supposed to be produced, were a quantity of minute drops of ammoniated oil min- gled with the aqueous humour. This state of the cornea was the consequence of pretty severe inflammation, about nine months be- fore, in a patient who had long been troubled with rheumatism. The appearance of the redness in aquo-capsulitis, so far resem- bles that in iritis, that there is a circular zone of minute vessels seen on the anterior part of the sclerotica. Sometimes one or more distinct blood vessels are seen traversing the inflamed mem- brane. Some vessels of the conjunctiva also are frequently en- larged. These appear as insulated trunks, and can be raised on the point of a needle from the sclerotica. The vessels on the white of the eye are of a bright red colour during the active stage of the inflammation, and gradually assume a more crimson hue as the symptoms subside. There sometimes attends this disease an increased flow of tears, but the patient in general suffers very little from exposure to light. Vision is more or less dim ; and what is particularly to be noted, is a sensation of distension and fulness in the eyeball, accompanied with a dull aching pain, generally in the forehead, sometimes also in the back part of the head ; symptoms which Mr. Wardrop as- sures us are instantly and permanently relieved by evacuating the aqueous humour. The constitutional symptoms vary much in their degree of se- verity. Sometimes the pulse is very frequent and hard, the skin hot and dry, the tongue loaded, and the functions of the alimentary canal disordered. In other cases, the disease almost from the com- mencement, assumes a chronic form, and after continuing a certain period, participates in any peculiarity of the patient's constitution, and becomes thereby modified. During the continuance of the inflammatory symptoms, there is generally so much muddiness diflfused over the whole anterior chamber, that no distinct portions of eff"used lymph can be distin- guished, unless they be of large size ; but when this turbid state goes off", flakes of lymph may sometimes be perceived, and in other instances, the whole surface of the inflamed membrane is left cov- ered by a thin layer of it. In some cases, the effused lymph floats in the anterior chamber, appearing like a thick cloud ; in other cases, it is deposited in streaks, so as to present a reticulated ap- pearance ; and in others, it resembles a purulent fluid. If the eff'used lymph be not afterwards absorbed, it is apt to be- come organized ; and not unfrequently red vessels can be seen ramifying through it. This is a much more frequent appearance than that to which I have already referred, of a red vessel or vessels 393 running along the internal surface of the cornea without any effu- sion of lymph. Treatment. Little else is known regarding the effects of rem- edies in this rare ophthalmia, than what is mentioned by Mr. War- drop, in his paper on Evacuation of the Aqueous Humour, in the fourth volume of the Medico-Chirurgical Transactions. In the cases there recorded, benefit appears to have been derived from cupping the temples, purging, fomenting, and the application of such stimulants as murias and nitras hydrargyri in solution, red precipitate salve, and sulphuric ether. Mr. Wardrop, however, places most reliance on the evacuation of the aqueous humour, stating that there is no inflammation of the eye, where so much benefit is derived from that operation, as when the disease affects the internal layer of the cornea. He had never found it fail in procuring immediate relief of the pain of the head, and instanta- neous restoration of the transparency of the anterior chamber. The opening through the cornea, by which the aqueous humour is to be discharged, may be made with any of the knives common- ly used for extracting the cataract, or with a broad iris-knife. It is sufficient that the point of the instrument be introduced so that it makes a puncture into the anterior chamber ; this should be done near the junction of the cornea and sclerotica, at any part of the circumference. When the knife has penetrated into the anterior chamber, it may be withdrawn a little, and the blade turned on its axis, when the aqueous humour will readily escape. It is better not to remove the instrument altogether, till the fluid is observed to be discharged ; for if the incision be not sufficiently large, and the knife taken away before the aqueous humour flows out, the elasticity of the cornea closes the wound, and either hinders the evacuation from being so sudden, and consequently so efficacious, or the closure of the wound entirely prevents its escape. The operation, therefore, which is necessary to discharge the aqueous humour, is merely the first step of the section of the cornea, made in extracting the cata- ract, or what is called the puncturation. The chief difficulty in performing the operation, arises from the pain occasioned by the necessary pressure on the eyeball, whilst keeping open the eyelids ; but until a sufficient portion of the cor- nea is brought into view, and the movements of the eye completely under the management of the operator, the introduction of the knife should not be attempted. The upper lid should be elevated by the fingers of the assistant, or by Pellier's speculum ; while the operator, with the fore and middle fingers of the hand which does not hold the knife presses down the lower lid, and applies their points over its edge, in such a manner that they touch the eyeball, and can apply any degree of pressure upon it which may be neces- sary. After the assistant raises the upper hd, the patient should be 60 394 directed to look downwards ; and then the assistant employs a suf- ficient pressure, to keep the eye in that position. The operator now makes the puncture ; but as the patient is very apt to start when he first finds the instrument coming in contact with his e)'e, it is useful merely to touch the cornea repeatedly with the back of the knife till all risk of starting is over ; and as soon as its extremity rests on the part where the puncture is to be made, the knife may readily be raised on its point, and thrust into the anterior chamber.* It is probable that a variety of other remedies besides those men- tioned by Mr. Wardrop might be useful in aquo-capsulilis ; es- pecially cinchona, turpentine, and mercury. Of these, however, nothing can be said from experience. SECTION XXV. INFLAMMATION OF THE CRYSTALLINE LENS AND CAPSULE. Common lenticular cataract appears to be a consequence of the impeded nutrition which attends the advanced period of life ; while opacities of the capsule are probably in all instances the result of inflammation, and thus resemble specks of the cornea. Capsular and capsulo-lenticular cataracts generally present themselves to our observation after the inflanamation in which they have originated has subsided ; bat in other cases, we may be fortunate enough to meet with the disease in its acute stage. The appearances which are then presented to observation, have been minutely described by Professor Wallher,* and I have had more than one opportu- nit)'' of verifying, to a certain extent, the accuracy of his descrip- tion. He states that inflammation of the crystalline capsule generally occurs about the middle of hfe, and in subjects of a slight cachectic disposition. This is certainly true, although in more than one in- stance I have seen such severe inflammation of the capsule in young children, that the part appeared completely loaded with red vessels. This disease occurs oftener in light eyes than dark, and is always accompanied by a slight chaoge in the colour of the iris and form of the pupil, the iris becoming a little darker, and the pu- pil oval or irregular. The motions of the iris are at first lively and extensive, but subsequently become sluggish and very hmited. The pupil is smaller than in the sound state, and there usually appears a black rim of irregular breadth all round its edge, arising from the pigmentum nigrum of the posterior surface af the iris com- ing into view. Along with these symptoms, a number of red vessels appear in • Medico Chirurgical Transactions, Vol. iv. p. 153. London, 1813. * Abhandlungen aus dem Gebiete der practischen Medicin. Vol. i. p. 53. Land' shut, 1810. 395 the pupil itself, the largest of which are visible to the naked eye, but the greater number distinguishable only by the aid of a magnifying glass. What at first merely appears a red point, assumes under the glass, the appearance of a delicate tissue of vessels. The lens used for this microscopical examination of the eye should be one of a very short focus, and the patient should be so placed with respect to the light that the parts within the pupil be well illuminated, and not shaded by the glass nor by the head of the observer. In order to have the pupil as large as possible, the other eye should be closed during the examination, and a little of a filtered solution of extract of belladonna in water should be dropped upon the affected eye an hour previously. In inflammation of the capsule of the lens, the sensibility not being much increased, the patient can bear exami- nation of the eye in a strong light and with a dilated pupil, without much uneasiness. The red vessels observed in the pupil during inflammation of the anterior hemisphere of the capsule always constitute a sort of vascular wreath, situated at about a quarter of a line's distance from the pupillary edge of the iris ; this wreath forms a concentric circle within the pupil, and is found on examination to consist, not of one or a few vessels circularly disposed, but of a number of vas- cular arches. To this vascular wreath there run in a radiated form, numerous vessels from the circumference of the capsule. Other vessels seem to extend from the pigmentum of the iris ; but such are not constantly present. It is only in cases where the disease has lasted some considerable time that they appear. In other cases, according to Professor Walther, vessels seem to be pro- longed rather from the capsule into the posterior surface of the iris. Those which run from the iris to the capsule, never aiise from the edge of the pupil, but at a little distance from it, on the posterior surface of the iris, so that nearly a hue's breadth next the pupillary edge is free from these vascular sproutings. From the vascular wreath already mentioned, vessels are seen spreading towards the centre of the anterior capsule, and these again forming clusters and arches. The continuation between the vessels seen indifferent parts of the pupil seems interrupt- ed at some points, yet there can be no doubt of their being continuous; although from their extremely minute size they can be distinguished only where enlarged and clustering together. Posterior to the red vessels seen in the capsule, there appears in some cases a network of more delicate vessels, which seem to be seated in the lens itself The larger trunks of this network are not always derived from the circumference of the lens, but evidently come, says Professor Walther, from its posterior surface, directly forwards, and then divide into branches. The presence of these vessels in the lens, he has repeatedly and distinctly observed. He states that they present one of the most beautiful phenomena, and that the only things which come near them are the finest injections 396 of the choroid, such as those which are in the possession of Soem- mening, and have been represented by him in his work on the anatomy of the eye. Professor Walther is of opinion thai the existence of these vessels passing into the substance of the lens is entirely morbid, and he compares it to what occurs in inflammation of the thorax, when vessels are prolonged from the pleura to the pseudo- membrane formed on its surface. He says that as the vessels of the anterior hemisphere of the capsule shoot forwards into the posterior surface of the iris, so they shoot backwards into the lens itself; and that the same holds good with respect to the posterior hemisphere of the capsule, which being more copiously supplied with blood vessels, it is explained how the largest vessels of the lens are seen to come from behind forwards. It would appear also that all inflammations of the lens begin in the capsule, a fact which Professor W. con- siders as analogous to the spread of inflammation to the capsule from the ciliary processes or from the iris. At the apparent terminations of several of the vessels in the cap- sule, there are distinctly perceived httle knots of a whitish-grey semi-transparent substance. This is evidently coagulable lymph, and Professor W. considers its presence as disclosing the manner in which inflammation of the capsule and lens produces opacity of these parts. The anterior hemisphere of the capsule, where the vessels are very numerous, sometimes assumes a peculiar velvety or flocculent appearance, and in one or more spots of its extent presents a grey or brownish colour. These brownish spots appear in some instances to be nothing more than effused lymph ; but in other cases they probably owe their origin to the iiis having been united to the capsule by partial adhesions, which being separated either by more extensive spontaneous motions of the iris, by me- chanical violence, or by the sudden influence of belladonna or some similar narcotic, part of the pigment of the iris has remained ad- herent to the anterior surface of the capsule. It is a fact strongly confirming the accuracy of Professor Wal- ther's account of inflammation of the crystalline capsule, that in anterior capsular cataract, the specks or streaks generally radiate from the edge of the anterior hemisphere of the capsule towards its centre ; while in posterior capsular cataract, they evidently branch out from the centre of the posterior hemisphere, following thus both the natural course of the arteries, and the directions of the inflamed vessels, as represented by Professor Walther. As to the state of the patient's vision who is affected with in- flammation of the lens and capsule, where the disease is severe, vis- ion is indistinct and confused, particularly when the eye is directed towards distant objects. Those objects which are nearer are seen as if through a fine gauze. This does not seem red, nor are objects tinged of that colour. This ophthalmia always observes a chronic course. It proceeds 397 very slowly, and is attended with little or no pain. When pain does attend this disease, it is seated at the bottom of the orbit, in the forehead, or in the crown of the head. When the disease has con- tinued for some considerable time, the blood vessels in the lens and capsule become varicose and remain so permanently. Professor W. observed the vessels of the lens in a middle-aged man. to remain in a varicose state for a whole year, without undergoing the least al- teration. In one case, I have seen this disease followed by incom- plete amaurosis, with tremulous iris. Effusion of fluid between the lens and capsule, and dissolution of the former, are not unfrequent consequences of inflammation of these parts ; while in other in- stances, this disease would appear to go the length of suppuration, for we must consider inflammation as the cause of that variety of cataract which is called cataracta cum bursa, the opaque state of the lens and capsule being combined with the presence of a cyst contained within the capsule and filled with pus. The causes of this ophthalmia have not been sufficiently inves- tigated. In one case which came under my care, it affected the right eye of a keen sportsman, and might perhaps be connected with the over-excitement which the eye may have undergone year after year at the shooting season. Inflammation of the lens and capsule approaches nearer to iritis than^to any other ophthalmia. It is, however, much less acute in its character, and greatly less under the influence of treatment. Depletion, counter-irritation, and alteratives, are the remedies which suggest themselves as most likely to do good in the early stage of this disease, and tonics in the latter stages. I must confess, however, that this ophthalmia has in my hands proved the most obstinate of any. Even mercury, which, in the inflammatory affections of the eye the most similar to this, proves almost specific, appears to have scarcely any power over the inflamed vessels of the crystalline capsule. SECTION XXVI. INFLAMMATION OF THE HYALOID MEMBRANE. The morbid states in which we meet with the vitreous humour, naturally give rise to the supposition that it occasionally suffers from inflammation. Its synchesis or dissolution, dropsical increase, state of atrophy, unnatural viscidity, change of colour, loss of transpa- rency, and ossification, are so many morbid changes, which lead us to suspect the hyaloid membrane to be susceptible of inflammation. The vessels of the posterior hemisphere of the crystalline capsule are derived from the central artery of the vitreous humour, and we can scarcely suppose the former to be affected with inflammation, without the latter participating in the same disease. Inflammation of the hyaloid membrane, however, has not been observed with sufficient accuracy ito admit of description. 398 SECTION XXVII. TRAUMATIC OPHTHALMIA. We have now seen how each texture of the eye suffers, in its own way, from intJammation, excited without any evident mechanical or chemical injury ; the conjunctiva suffering puro-mucous and eruptive diseases ; the sclerotica, rheumatic disease ; the iris under- going adhesive inflammation ; the cornea losing its transparency, and becoming the seat of purulent infiltration and of ulceration j the choroid falling into a state of extreme varicosity ; and the retina losing its sensibility to light ; every texture, in fact, suffering differ- ently. Now, the inflammation which is excited by the evident mechani- cal or chemical injuries, the direct effects of which we have already considered,* may attack one or several of these textures. We may have traumatic conjunctivitis, traumatic corneitis, traumatic iritis, &.C., and it is remarkable, that traumatic inflammation, in any of the textures of the eye, imitates, so to speak, the oph- thalmiae which we have already considered. We meet with puro-mucous conjunctivitis, excited by injury, and we very often see pustular or phlyctenular conjunctivitis, brought on by the same cause. Traumatic iritis, the iritis, for example, which is so apt to occur after the operations for cataract, very closely resembles rheu- matic iritis. The cornea, by traumatic inflammation, is rendered opaque, or becomes affected with onyx, or with ulceration ; the lens also loses its transparency from the same cause, and the retina its sensibility. This observation, if duly considered, will throw a great degree of light on the treatment of the traumatic ophlhalmise. Puriform inflammation of the conjunctiva, arising from injury, is to be treated, in fact, exactly as we treat catarrhal ophthalmia. In traumatic iritis, the three great indications, to abate the inflamma- tory action by depletion, to dilate the contracting pupil by bella- donna, and to promote absorption by mercury, are to be followed out exactly as in rheumatic or syphilitic iritis. For these reasons, I thought it proper to say nothing of the traumatic ophthalmia, till we had finished the consideration of the varieties of inflammatory disease, which are excited in the different textures of the eye by atmospheric and constitutional causes. Without a knowledge of these varieties of ophthalmia, we should be but httle able to understand the inflammatory effects of evident mechanical and chemical injuries upon the several structures com- bined in the eye ; but with such a knowledge, both the symptoms and the treatment of the traumatic ophthalmiae become perfectly simple. The symptoms vary, no doubt, ad wjinitum, in regard to severity, while in one case, a single texture, and in other cases, several textures of the eye will sufffer; still, the invariable and • See Section 1 of Chapter IV, and Chapter IX. 399 peculiar physical and vital properties of each texture serve to pro- duce, under wiiatever circumstances, or by whatever causes inflam- mation may be excited, the same essential phenomena. The most important general rule regarding the treatment of the traumatic ophthalmia, is, that we should be on our guard against effects which are apt to be produced, but which may not yet be present, and against effects implicating the interior textures of the organ, although the injury has appeared to be merely superficial. A considerable part of our treatment must be preventive. We must not wait to take away blood, till severe sclerotitis, with acute circum-orbital pain, sets in. We ought to bleed from the moment of a severe injury. We must not wait till the pupil is evidently closing ; but apply belladonna, and prevent it. We must not wait till the iris grows discoloured, or lymph is effused into the pupil; but from the very first put the patient on calomel and opium, if we apprehend from the nature of the injury, that iritis is hkely to be the result. We sometimes meet with severe sympathetic inflammation in the eye which has not received the injury. It is not unworthy of observation, that after all the other symp- toms of severe inflammation of the eye following mechanical or chemical injuries have been removed by depletion, counter-irritation, mercurializalion, &c. a very troublesome and obstinate intolerance of light, with epiphora, is apt to remain, not so much apparently from irritation arising from the state of the eye, as merely from continued and now habitual excessive activity in the hds and lach- rymal gland. In such cases, in addition to the remedies recom- mended for epiphora at page 76, I have derived advantage from the internal use of the extract of stramonium. SECTION XXVIII. COMPOUND OPHTUALMIjE. Strictly examined, few instances of ophthalmise will be found absolutely simple. Many are strikingly compound ; for example, the catarrho-rheumatic, already described. Strumo-catarrhal oph- thalmia is also very common, beginning as a slight puro-mucous conjunctivitis, but soon manifesting the signs of phlyctenular oph- thalmia. In other cases, we meet with pustules of the conjunctiva, combined from the commencement with blenorrhoeal inflammation of that membrane. Phlyctenular conjunctivitis with strumous iritis, strumous corneitis with iritis, and many other compound ophthalmise might be enumerated. The treatment of such diseases will, of course, consist in the combined use of the means, which are ascertained 1o be effectual in removing the separate or simple ophthalmiae. The treatment necessary for strumous ophthalmia will be combined, therefore, with that for catarrhal conjunctivitis, in the Btrurao-catarrhal cases ; 400 while in the catarrho-rheumatic ophthalmia, the remedies for rheu- matic inflammation of the sclerotica will be required alon^ with those for blenorrhoeal inflammation of the conjunctiva; and so on, in the other compound ophthalmiee. SECTION XXIX. INTERMITTENT OPHTHALMIA. Although several interesting cases have been recorded of oph- thalmiee recurring in the same individual after longer or shorter intervals of time, yet I doubt whether there is sufficient ground to admit the existence of any disease of this kind so regularly peri- odic in its accession, as to warrant the appellation of intermittent ophthalmia. The pain which attends many of the ophthalmise, is undoubtedly subject to regular nocturnal exacerbations, but this does not entitle these diseases to the appellation of intermittent. By an intermittent or periodical ophthalmia, I should understand one which recurred with considerable regularity at intervals of weeks or months, and apparently not from accident, but from con- catenation with the revolutions of time ; whereas, if we examine the cases which are recorded as being of this kind, we shall find that they are nothing more than instances of some particular oph- thalmia recurring more or less frequently in the same individual, in consequence of his repeatedly exposing himself to the same, or to some similar exciting cause. The strumous ophthalmia, being that which is most apt to be renewed on slight exposures, will also more frequently than any other inflammatory disease of the eye appear to be periodic. The rheumatic, catarrho-rheumatic, and catarrhal will also be subject, from their ready occurrence in eyes once affected with them, to the same suspicion. 1 have frequently treated patients who at intervals of three or four months, or once a year nearly about the same season for several successive years, had suffered an attack of rheumatic iritis ; but in every case of this kind, I have been able to trace the return of the disease to some new imprudence. In arthritic inflammation of the eyes, the periodic tendency will also appear to be very decided, for every attack of that sort leaves the eyes worse than before, and with a strong disposition to suffer again from renewed causes of excite- ment. These remarks, will, I think, be confirmed by a careful perusal of the interesting narratives of Dr. Curry and Dr. Bostock, both of whom had suffered from repeated attacks of severe ophthalmise.* * History of a Case of Remitting Ophthalmia, and its successful Treatment by Opium ; by James Curry, M. D. in the Medico-Chirurgical Transactions, Vol. iii. p. 3^. London, 1812. — Case of a Periodical Affection of the Eyes and Chest ; by John Bostock, M. D. in the same work, Vol. x. p. 161. London, 1819. 401 CHAPTER XL DISEASES CONSEQUENT TO THE OPHTHALMI.E. Some of the consequences of the ophthahniae are immediate, while others are more or less remote. Onyx, for example, or effusion of matter between the lamellae of the cornea, is an immediate conse- quence of severe inflammation of the exterior textures of the eye ; hernia of the iris is a remote consequence, which cannot take place till the cornea is penetrated by ulceration ; while staphyloma of the iris and cornea is still more remote, never being produced till these two parts are united by inflammation, and, in many cases, not for a considerable number of weeks or months after such union is effected. In all the cases falUng under the head of diseases consequent to the ophthalmise, it is a question of importance, Is the ophthal- mia subdued ? If it is not, then the remedies which are indicated in the particular species of ophthalmia, which is still present, how- ever long it may have continued, and however much it may have been neglected or mistreated, are, in all probability, the most likely means to remove also the consequences which the ophthalmia has produced. If, on the other hand, all active inflammatory symp- toms are gone, and merely certain sequelae remain behind, it is often necessary to try some mode of treatment totally different from what might have been pursued with advantage, had the disease still existed in the inflammatory stage. To recur again to onyx and staphyloma, as illustrations, we have frequent opportunities of witnessing the complete dispersion of the former by the employ- ment of proper antiphlogistic means, while the latter is totally beyond the control of any such mode of treatment. SECTION I. ONYX, OR ABSCESS OP THE CORNEA. The name onyx is highly expressive of the state of the cornea to which it is applied ; namely, a collection of matter in the sub- stance, or between the lamellae of that part. Such an abscess generally makes its appearance at the lower edge of the cornea, and, however small, may easily be distinguished from commencing hypopium, by its exact similarity in form to the small white spot seen at the root of the nails, whence the name.* Even when the quantity of pus between the lamellae of the cornea is more consid- erable, this disease may always be known by its superior limit being circular, and by its remaining unchanged in form and situ- ation, whatever be the position of the patient's head ; whereas hy- * Ovu|, the nail. 51 402 popium always presents a horizontal limit superiorly, when the patient has been for some time at rest in the erect position, although, upon motion, this form may be somewhat changed, by the matier gravitating to one or other side, according to the direction in which the head is moved. Onyx is apt to take place chiefly in acute and neglected cases of puro-miicous ophthalmia, and especially in the ophthalmia of new-born children. It occurs, not uufrequently, in catarrho-rheu- matic ophthalmia, and in variolous ophthalmia : occasionally in strumous ophthalmia; very rarely in ony of the others. Under the use of the remedies most applicable to the particular ophthalmia in which it originates, onyx is frequently removed by absorption, in the course of a lew days, or even in a few hours. But, in neglected cases, more and more matter is effused, mount- ing gradually from the lower edge of the cornea till it covers the pupil, separating the lamellae, or, perhaps, rather infiltrating the substance of the cornea, till at length this part of the eye is com- pletely put on the stretch, and looks like an abscess ready to burst. As the onyx thus increases, the pain of the eye and head is severe- ly aggravated. At length, occasionally the posterior lamellee give way, and the matter is thrown into the anteiior chamber, so as to form a spurious hj'popium ; but more frequently ulceration com- mences on the external surface of the cornea, and over the middle of the onyx ; in the progress of ulceration, the cavity containing the pus is opened, and slowly the matter is discharged. As the onyx increases, the pupil uniformly contracts, and becomes filled with lymph. Not unfrequently, the ulcer which has served to open the onyx goes on to penetrate completely through the cornea, so that the aqueous humour is discharged, the iris falls forward into contact with the ulcerated cornea, adhesion between them ensues, and the case ends in staphyloma. The result, however, of the bursting of an onyx externally, is not always so- unfortunate. It not unfrequently happens, tliat as soon as its contents are dis- charged, the inflammation begins to subside, the pupil clears, and, although some degree of leucoma is always left, it may be very limited, so that a fair degree of vision shall be preserved. Although the lower edge of the cornea is by far the most fre- quent seat of incipient onyx, it sometimes happens that pus is col- lected in a circumscribed spot over the pupil, or at any other part of the cornea, while, in other cases, we see onyx commencing, per- haps, above the centre of the cornea, and diffusing itself irregularly over a large extent. This is particularly the case with onyx orig- inating in a variolous or strumous pustule, which has burst into the cornea, and not through its exterior lamellae. Such an onyx is generally absorbed after a considerable length of lime, the lamellae which were separated by its presence come together again, adhere by means of effused lymph, and present a peculiar variety of albu- go, which seldom entirely disappears. 403 Treatment. The remedies most likely to subdue the ophthal- mia ill which the onyx has originated, must be carefully employed. Nuuseants, purgative.^, counter-irritation, and mercurialization, he- sides their antiphlogistic powers, frequently appear to act favourably by promoting the absorption of the purulent effusion in these ab- scesses of the cornea. Belladonna ought to be used to counteract the tendency to contraction of the pupil. Ought abscesses of the cornea to be evacuated by the knife? All agree that this ought never to be ventured on, when they are small, that is to say, when, having commenced at the lower edge of the cornea, they have, perhaps, not mounted higher than oppo- site to the lower edge of the pupil, in its medium state of dilatation. Larger onyces than this I have repeatedly opened with the lancet, and in every case in which I have done so, staphyloma has been the unfortunate result. I have, on the other hand, left onyces un- touched, although they were so extensive as to cover the pupil completely, and have sometimes had the satisfaction of witnessing an almost perfect recovery of the eye. The following is a case which I treated on this plan, at the Eye Infirmary. John Ferrie, aged 47, was admitted on the 22d of May, 1826, on account of catarrho-rheumatic ophthalmia of the left eye, with which he had been affected for about three weeks. For eight days he had had severe orbital pain during the night. There was an onyx, extending from the lower edge of the cornea go high as to cover the pupil, and over the middle of the onyx there was a small ulcer. The conjunctiva and sclerotica were very vascular. Vinum opii was dropped upon the eye, and extract of belladonna smeared on the eyebrow and lids. He was ordered to rub the forehead and temple every night with tincture of opium, to bathe his feet in hot water, and to take two grains of calomel with one of opium, on going to bed. On the 24th, he felt the eye better, although there was not much evident change in its appearance. The iris was discoloured, and there was a lymphatic effusion into the pupil. He was ordered to take the calomel and opium morning and evening, to apply a blister to the nape of the neck, and to continue the other remedies. On the 27th, the mouth was affected, but the onyx had increased. Eight leeches were applied to the left temple ; the morning dose of calomel and opium was omitted. On the 31st, the pupil appeared to be contracting. On the 2d of .Tune, the up- per part of the cornea was observed to be nebulous, and the eye felt more uneasy. The nitras argenti solution was applied in place of the vinum opii. By the 5th. the exterior laminae of the cornea had given way, and a considerable quantity of matter had been dis- charged from the onyx. The pupil was still more contracted. He complained of a feeling of sand in the eye. He was ordered an aqueous solution of extract of belladonna, as a collyrium. On the 7th, the blister was reapplied. By the 9th, the aqueous humour had evacuated itself, and the iris fallen forward into contact with 404 the cornea. The matter of the onyx had almost entirely disap- peared, and he said he saw a httle better. On the 12th, the pupil, still in contact with the cornea, appeared clearer, and vision was more distinct. On the 14th, a little aqueous humour was present between the upper part of the iris and cornea ; the ulcer of the cor- nea was covered with lymph ; and all the pus gone. On the 26th, the pupil was considerably larger, and clear ; more aqueous hu- mour was present between the iris and cornea. By the 30th, the pupil was clear, and of considerable size. A minute adhesion be- tween the slight leucoma on the cornea and the lower edge of the pupil was observed, when the eye was examined laterally. The vision of the eye was good. In this case, then, I left the abscess of the cornea to itself, and certainly no case could have been more alarming in its progress, nor more unexpectedly favourable in its results. The success which attended this case, I attributed in a great measure, to the sorbefa- cient influence of the calomel over the effusion into the pupil, to the continued use of belladonna, and to the gradual and natural pre- paration of the cornea for its giving way, and for its healing up — a preparation which would have probably been altogether defeated, had I ventured to open the onyx with the lancet. In cases, however, where the abscess does not incline to open of itself, but appears to be about to involve the whole cornea, an artifi- cial exit must be afforded to the matter, were it merely to save the patient from the continuance of the violent pain which attends this symptom. The incision may be made conveniently with the iris- knife, and ought to comprehend only the external laminse of the cornea. At the moment of making the incision, no pus is in gen- eral discharged, but it forms in the course of some minutes a small drop, which is to be wiped away from the cornea. The operation, in most cases, requires to be several times repeated, before the onyx is entirely evacuated, and ought to be held out to the patient more as a palliative for the pain, than as a means of saving the sight, which, in such circumstances, is generally lost. The effect of evacuating the aqueous humour in the early stages of onyx does not appear to be ascertained. Although by no means disposed to regard that operation as one frequently called for in the treatment of the ophthalmise, nor as one altogether free in itself from danger, I am willing to acknowledge that it must, at least for a short time, relieve the tension which attends severe inflammations of the eye, and that as onyx makes its appearance only in severe cases, the evacuation of the aqueous humour in the mode described at page 393, might have a good effect upon this dangerous symp- tom. To trust, however, almost solely to this, or to any other local means, without assiduously combating, by general means, the ophthalmia in which the onyx has originated, would be highly im- proper. 405 SECTION II. — hypopidm; 1. By true hypopium is meant a collection of matter within the chambers of the aqueous humour, and most frequently within the anterior chamber, secreted by some portion of the parietes of these cavities, as the lining membrane of the cornea, the iris, the capsule of the lens, or the ciliary processes. The most frequent sources of true hypopium appear to be the iris and the cornea. In this variety of abscess, the purulent matter is always observed first at the bottom of the anterior chamber, and so long as the patient remains at rest in the erect position, its su- perior limit constantly presents a horizontal line. In some cases it is seen to shift its position, on inclination of the head from side to side ; while, in other instances, it is so thick and glutinous, that it undergoes no change of this kind. It may increase gradually till it not merely covers the pupil, but completely fills the anterior chamber. If the case be neglected, the prominence of the cornea increases, it becomes conical, presents exactly the appearance of an abscess, and at last, under a scarcely supportable degree of pain, gives way ; the pain now ceases, the iris falls forward and adheres to the cornea, and staphyloma is the result. It is but rarely that we meet with true hypopium, uncombined with some affection of the cornea, and still more rarely does it pro- ceed, unless complicated with onyx or ulcer of the cornea, to such a degree as to give rise to rupture of the cornea. Most frequently the collection of purulent matter remains nearly the same in quan- tity, not only for several days, but even weeks ; during which time the iris becomes more and more inflamed, its motions more and more impeded, and at last, when the matter is absorbed, the pupil is found to be almost entirely obliterated. When onyx, or ulcer of the cornea, is present along with true hypopium, there is much danger of the cornea being destroyed, and the case ending in sta- phyloma. 2. The name spitrious hi/popium is applied to a collection of pus in the anterior chamber, arising from the bursting of an abscess of the iris or of the cornea into that cavity. Abscess of the iris I have already described at page 360, and abscess of the cornea in the last section. Hypopium of this sort seldom, if ever, reaches higher than the lower edge of the pupil. When onyx, however, exists along with true hypopium, and bursts into the anterior cham- ber, this cavity may become completely filled with pus. Treatment. The remarks, in the last section, on the treatment of onyx, apply, almost without any variation, to that of hypopium. The inflammation must be combated by general means, and in its subsidence we must chiefly trust for the removal of the purulent effusion. The giving exit to the matter of hypopium, by an incision of the cornea, is plainly advisable in every case in which the chambers 406 are completely filled, for we can never depend, in such a case, on absorption ; while, by delay, we should risk the bursting-, and complete destruction of the eye. Under such circiuiistances, we must regard the opening of the cornea as notliing more than a means of freeing- the patient from excessive pain, and of preserving such a form of the eyeball, as may afterwards permit the application of an artificial eye. When the hypopium does not amount to such a quantity of mat- ter as to fill the chambers of the eye, and especially when severe inflammation of the iris is present, it might seem improper to prac- tice an opening of the cornea. Such an operation appears likely to aggravate the intlammation, increase the secretion of purulent matter, and expose the eye to protrusion of the iris. Notwith- standing these apparent objections. Mr. Wardrop has recommend- ed evacuation of the aqueous humour, as a remedy of much service, in the early stages of hypopium ; and in cases of iritis, and of ulcer of the cornea, combined with hypopium, we have the testimony of Dr. Monteath in favor of a similar prac- tice. One of the apparent objections to it is easily removed, even by theoretical considerations, namely, the dread of protrusion of the iris ; for, in hypopium, the iris is always in a state of inflammation, with a tendency to contraction of the pupil, which will, 1 believe, prevent any protrusion from taking place. Dr. Monteath recommends the incision to be made with the iris-knife, and to be two or three lines in length. This extent of incision is necessary, on account of the purulent exudation being thick, and sometimes even adherent, so that it will not flow out, but require to extracted by forceps, or a small blunt hook. Dr. M. mentions, that, after opening the cornea, and laying hold of a small filament of the matter, he has often been able to extract the whole en masse, which, previously examined through the cornea, had every appearance of pus, but when extracted and examined, was in every respect similar to the exudation of puriform 13'mph, on the surface of an inflamed pleura or peritmieum. He observes, that when the hypopium is considerable, the operation, repeated again and again if necessary, checks the suppuration and ulcera- tion of the internal surface of the cornea which invariably takes place when the collection mounts as high as the centre of the pupil, and which is so apt to end in bursting of the cornea, and destruc- tion of the eye,* SECTION III. ULCERS, DIMPLE, HERNIA, AND FISTULA OF THE CORNEA, AND HERNIA OF THE IRIS. 1. There are two distinct varieties of ulcer of the cornea, the su- perficial and the deej). * Glasgow Medical Journal, Vol. ii. p. 122. Glasgow, 1829. 407 The former generally extends over a considerable portion of the surface of the cornea, appearing often to destroy merely its conjunc- tival covering. The deep ulcer is commonly much less extensive, but aflects the proper substance of the cornea, and often penetrates completely through it, so as to open into the anterior chamber, and give exit to the aqueous humour. The superficial ulcer occurs much more frequently in catarrho-rheumatic ophthalmia, than in any other ; the deep is generally the result of the bursting of a stru- mous phlyctenula or pustule. The superficial, however, sometimes arises from slight mechanical or chemical injury, while the deep is occasionally owing to more severe injury of the same kinds. Onyx bursting externally also gives rise to deep ulcer of the cornea. The superficial ulcer of the cornea discharges only a thin clear kind of matter, its surface is slightly rough, its edges are, in general very irregular, and so little raised above the level of the ulcer, that in many cases merely the conjunctival layer of the cornea appears as if abraded. The cicatrice which follows such an ulcer is usually quite transparent, so that, at least for some time, the appearance is as if a portion of the cornea had been sliced off. The deep ulcer, on the other hand, is small, circular, and, by penetrating the laminee of the cornea, one after the other, comes to present a funnel-shape. Its surface is usually ragged and covered with a sloughy-like matter, which assumes a white colour if touched by any lotion, or other preparation, containing sugar of lead. 'J'he same happens to the superficial ulcer, which becomes covered by an opaque cicatrice in consequence of the use of saturnine applications. Hence, in every case of ulcer of the cornea, these applications ai"e totally inadmissable. The cicatrice which follows the healing up of a deep ulcer of the cornea is always opaque. 2. There is one pecuhar appearance on the cornea which must not be confounded with these ulcers ; namely, that state of it which follows the absorption of a phlyctenula or pustule. The result of such absorption is a transparent dimple, smooth, and covered in fact by the conjunctiva, which has fallen down into the little depression, formed by the removal of the contents of the phlyctenula or pus- tule. 3. Occasionally it happens that the progress of a deep ulcer is ar- rested by the lining membrane of the cornea, or that this mem- brane, after having been penetrated by the ulcer, heals up, but, in either case, being unable by itself to resist the pressure of the aque- ous humour, it is protruded through the ulcer in the form of a vesi- cle, constituting what is termed hernia of the cornea. This pro- trusion sometimes takes place to a very great extent, assuming a conical form, and rising so far above the natural level of the cornea, as with difficulty to be covered by the eyelids. In such cases, we are obliged to remove it with the scissors, or destroy it by the csppli- cation of lunar caustic ; and what is very remarkable, a similar pro- trusion is apt to return again and again, even in the course of a few 408 days after we have completely removed the preceding, till at length the cicatrized cornea attains a degree of firmness sufficient to resist the pressure of the aqueous humour. 4. When an ulcer fairly penetrates through the cornea, the aque- ous humour is suddenly discharged, the iris falls forward, and but too often becoming engaged in the ulcer, protrudes through it, forming a little black point like the head of a fly, whence the name, myo-cephalon, which is bestowed on this hernia of the iris. The bit of iris which protrudes speedily adheres to the ulcer, and should violent inflammation of the eye continue after this accident, the iris and cornea are very apt to become agglutinated together in a great part of their extent, and ultimately to become staphylomatous. 5. It may not be improper here to notice, what is termed fistula of the cornettj although it very rarely resuks, except from perforat- ing injuries of the part. An artificial wound of the cornea, such as the section made for extraction of the cataract, sometimes remains long open, and threatens to become callous and fistulous ; a perfor- ating ulcer of the centre of the cornea may also fall into a similar state, and allow the aqueous humour to drain away for a number of days. These may so far be considered as instances of fistula of the cornea : but the most remarkable affection of this sort occurs when a perforating wound, close to the edge of the sclerotica, and entering the anterior chamber, becomes closed by the conjunctiva healing over it, although the cornea continues imperfect, so that the aqueous humour flows out under the conjunctiva, and elevates it in the form of a vesicle. If this swelling be removed with the scissors, a large quantity of thin fluid escapes, and at the bottom of the opened cj'^sty an orifice will be detected, leading directly into the anterior cham- ber. If nothing further is done, the conjunctiva heals, but the fis- tula corneae remains, and the vesicular sweUing returns.* Both kinds of ulcer of the cornea, but especially the deep, are usually attended by much intolerance of light, and a gush of burn- ing tears on opening the eyelids. The subjects of ulcer of the cornea, and especially of the deep ulcer, are rarely robust or in a good state of general health. On the contrary, they frequently present the indubitable signs of great weakness, and sometimes even of inanition, so that I have occa- sionally been led to compare their state to that of the dogs in Ma- gendie's experiments, which being fed, or rather starved, on white sugar and distilled water, died from exhaustion, their death being preceded by perforating ulcer of the cornea and evacuation of the humours.t The girl, whose case I have related at page 327, was * See a Case of Fistula Corneae, which I treated at the Eye Infirmary, reported in the London Medical Gazette, Vol. v. p. 224. London, 1829. t Memoire sur les Proprietes nutritives des Substances qui ne contiennent pas d' Azote, p. 7. Paris, 1816. — See a Case of Ulcerated Cornea, from Inanition: by Joseph Brown, M.D. in the Edinburgh Journal of Medical Science, Vol. iiL p. 218» Edinburgh, 1827. 409 in a state of great debility in consequence of over-depletion. With- in 24 hours, the tonic plan of treatment arrested the progress of a deep ulcer on one of her cornese. Treatment. In all cases we endeavour, of course, to check the ulcerative process, by those measures which are fitted for subduing the inflammation in which the ulcer took its origin. So long as there is an appearance of activity in the inflammatory disease, and much pain of the eye, local blood-letting must be employed. The bowels must be kept freely open, and opium administered in such a combination as shall be likely to operate on the skin. In stru- mous cases, sulphate of quina operates very advantageously. In chronic superficial ulcer, calomel, given so as to affect the mouth, is sometimes necessary. In almost all cases of ulcerated cornea, counter-irritation will be found useful. As the inflamed state of the eye abates, the patient finds the pain greatly relieved^ and we observe the ulcer clearing and beginning to contract. It frequently happens, however, that the ulcer itself proves a principal cause of prolonging the inflammation. The flow of acrid tears, and the motions of the eyelids, constantly irritating it. keep it from healing, and greatly augment the attending ophthalmia. In this case, there is one method of treatment which is eminently useful, and that is the coating of the ulcer in such a way, that it shall, for a time at least, become insensible to the irritations in question. This is effected by the application of lunar caustic, either in solution or in substance. This kills the surface of the ulcer, and renders it able, for a time, to withstand the friction of the eye- lids and the influence of the tears. This treatment is much su- perior, as an anodyne, to any sedative lotion, or even to any narcotic taken internally. In the interval of prevented irritation, the heahng process is allowed to go on, and before the thin slough is thrown off, which is formed by the application of the caustic, we find that the ulcer has contracted. Were we to leave the case here, the ulcer would, in all likelihood, begin again to spread and to penetrate into the cornea. As soon, then, as we observe that the tears are producing renewed irritation, and the ulcer assuming a new degree of obscurity and irregularity, the caustic must be reapplied. In cases of superficial ulcer, the best means of applying the caustic is by touching the diseased surface with a hair-pencil dipped in a solution of from 2 to 4 grains of the nitrate of silver in an ounce of distilled water. The deep ulcer is better managed, in general, by sharpening a pencil of caustic, and touching the diseased surface with it for an instant. During this application, the upper lid is to be kept ele- vated by Pellier's speculum, and before it is allowed to fall, a httle water is to be injected over the cornea. The caustic is to be applied in the same way if hernia of the cornea be present, or if the cornea be completely penetrated, and 52 410 hernia of the iris has taken place. In fistula of the cornea, also, after snipping off the projecting portion of conjunctiva, the opening is to be touched with the lunar caustic pencil. When the hernia of r[j8 cornea or of the ins projects much, it may also be removed with the scissors, and then the caustic applied. The contact of the caustic is, in these cases also, to be continued only for an instant. If the surface of the ulcer, or the piece of protruding substance, be just whitened by the action of the nitras argenti, it is enough. We ought never to continue the contact, so as to cause a slough of any considerable thickness. In cases of deep ulcer over the pupil, it has been thought advi- sable to evacuate the aqueous humour near the edge of the cornea, and to touch the ulcer with the solution of lunar caustic. Dr. Monteath; however, has recommended a different practice. " A deep scrofulous ulcer of the cornea," says he, " nearly pene- trating into the anterior chamber, at which stage there is ahnost always pretty acute inflammation, assuming the vascular character, is very apt to induce iritis, and secretion of pus into the anterior cham- ber, forming hypopion. This is a state of considerable danger to vision, particularly if the ulcer be nearly opposite to the pupil ; but, wherever it may be situated, I hardly ever fail to excite a healing action in the ulcer, and to give an immediate check to the hypopion and inflammation of the iris, by the following treatment. The iirsL and most important step, is to perforate the remaining layer, or layers, of the cornea, at the JDOttom of the ulcer, with an iris-knife, and allow the aqueous humour to flow out, and the anterior cham- ber to collapse. The second, is to give a full dose of calomel and opium each night, till the mouth is, in the slightest degree affected. The very first night after the puncture, the patient sleeps soundly, which he had been prevented from doing for several previous nights by violent supra-orbital and hemicranial pain. In a day or two after this trifling operation, the ulcer is completely filled with co- agulable lymph, which even overlaps its border, so as to put on the appearance, to an inexperienced surgeon, of the ulcer being much increased in size, whereas, it is the most favourable circumstance that could happen, because the redundant lymph is removed by absorption in a very few days. In proportion as the lymph, de- posited in the ulcer, becomes organized, the integrity and natural size of the anterior chamber are restored. From the combined ef- fects of the evacuation of the aqueous humour, and of the mercury, the iritis is rapidl}^ removed, and the case now requires merely the ordinary treatment of scrofulous ophthalmia, attended with an ul- cer on the cornea, which is one of the most common occurrences in ophthalmic practice." * I regard it as an essential part of the treatment in all cases of deep ulcer, and even in the more severe cases of superficial ulcer, * Glasgow Medical Journal, Vol. ii. p. 133. Glasgow, 1829. 411 near the centre of the cornea, to apply belladonna, so as, if possible, to dilate the pupil. If (his is neglected, the iris may readily ad- vance into contact with the cornea, even when the ulcer is yet far from penetrating into the anterior chamber, and becoming adherent, may thus give rise to partial staphyloma. The good effects of bel- ladonna in freeing the iris, even after it had become involved in an ulcer of the cornea, are well illustrated by the case of James Tassie, which I have related at page 327. In cases, however, where the iris protrudes to one side of the cornea, belladonna appears rather to favour a farther prolapsus, and ought, therefore, to be avoided, when the ulcer is not over the pupil. Prognosis. In all cases of deep ulcer, we ought to forewarn the patient of the opacity of the cicatrice, and the consequent de- formity, and, it may be, abridgement, or even loss of sight. Even when the ulcer is superficial, it is proper to pronounce a dubious prognosis ; for, though the conjunctiva of the cornea is usually re- generated, so as not to impair the cornea's transparency, this is by no means always the case. SECTION IV. SPECKS OR OPACITIES OF THE CORNEA NEBULA^ ALBUGO LEUCOMA. Specks of the cornea are distinguished by different names, ac- cording to the degree of opacity and density which they present, and according to the mode of their formation. 1., Nebula is the slightest degree. It resides most frequently in the conjunctival layer of the cornea ; occasionally it has its seat in the lining membrane of the cornea ; rarely between its laminae. Nebula is supposed to be sometimes the consequence of pressure merely, from preternatural increase of the aqueous humour. In some cases it appears to be the result of serous effusion into the substance of the cornea ; in others to arise from fibrine deposited in the substance either of the lining membrane of the cornea, or of its conjunctival covering. Nebula includes only those opacities of the cornea which are cloudy or hazy. This kind of speck is usually also extensive, and undefined, becoming less and less opaque towards its edges, and often affecting the whole cornea. Nebula is a frequent consequence of puro-mucous ophthalmia, but the most common cause of this opacity is scrofulous corneitis. The inflammation produced by inverted or supernumerary eye- lashes, or inverted eyelids, and that arising from sarcomatous or granular conjunctiva, are also abundant sources of nebula. De- pending on the latter causes, this opacity will require for its removal, the cure of the disease of the eyelid, and will not be at all benefited by any remedies directed against the state of the cornea merely. 2. Whenever the effusion of lymph into any part of the cornea is so dense as to present a pearly or chalk-whits appearance, the name of nebula is changed for that of albugo. 412 This sort of speck has its seat most frequently under the con- junctiva of the cornea. The lymph effused forms an opaque spot, generally circular or oval, more dense usually in the centre than towards the circumference, but in some rare cases presenting the appearance of a ring. The common source of albugo is a phyctenula or pustule on the cornea, which has receded without bursting. Like every other abscess, these pimples may be regarded as cavities formed by the exudation of coagulable lymph, and containing pus. The sphere of lymph which surrounds the pus appears to be formed in order to limit the extent of the disease. When the pustle disappears with- out bursting, the contained matter being absorbed, the sphere of lymph remains for a time, or it may be, continues to form a per- manent speck. Another source of albugo is where the pus of an onyx is either absorbed or evacuated by the knife. Onyx or abscess of the cornea is always attended by more or less lymphatic effusion ; and after the pus is dispersed, the laminse of the cornea which w^ere separated by its presence are reunited by the process of adhesion, which can- not be accomplished without a new secretion of lymph. Albugo may sometimes be observed with numerous red vessels running into it from the conjunctiva, and is extremely apt, when this is the case, to spread over the cornea. This vascular albugo is occasionally very obstinate. It is somewhat elevated above the level of the cornea, and the conjunctiva corneae through which the red vessels run is much thickened. In some cases, these vessels are so numerous, as to make the albugo appear red, with patches of white in the interstices. We meet with this variety of albugo in stru- mous adults, and sometimes in children. The shrinking and dis- appearance of the red vessels which feed it afford ground to believe that the albugo will cease to spread ; but it is rarely the case that the speck itself totally disappears. 3. A third sort of speck is called leucom-a, and is always the re- sult of cicatrization. A loss of substance in the cornea by ulcera- tion, and a partial filling up of that loss by granulation, always precedes the formation of leucoma, which indeed is synonymous with opaque cicatrice. Leucoma may in general be known by its contracted and cir- cumscribed appearance. Albugo is more diffused. Leucoma is often flat, and is frequently combined w4th partial adhesion of the iris to the cornea. Prognosis and treatment. All the three kinds of speck, nebu- la, albugo, and leucoma, have a natural tendency to disperse, as soon as the disease upon which they depend begins to subside, and that whether they depend on primary inflammation spreading to the cornea, or secondary inflammation of that part arising from the irritation of inverted eyelashes or granular conjunctiva. We must, then, in every case endeavour to remove the ophthalmia, or the 413 mechanical irritation on which the opacity depends, assured that if we succeed in this, nature by the process of absorption will, sooner or later, accomplish the whole amount of recovery whicli is possible. In children and young persons many very dense and extensive specks are removed in the natural progress of the growth of the cornea, which would be quite immovable in adult life. Demours is of opinion that the cornea grows from its circumfer- ence, and relates, in support of this idea, the case of a child, who, at the^ age of six months, had a violent inflammation of the eye followed by abscess of the cornea, evacuation of the aqueous humour, and adhesion of the iris to the cornea, near the edge of the scleroti- ca. At the age of eight years, this adhesion was at the distance of a line only from the centre of the cornea, whence it follows that the growth of the cornea had taken place between the adhesion and the edge of the sclerotica.* We are able, by various applications, to hasten the action of the absorbents in the removal of specks, especially if the applications in question be employed at the proper time. If we commence their use too soon, that is to say, before the cause of the opacity be sub- dued, we shall not merely torment the patient unnecessarily, but actually impede the cure. For instance, suppose that in a case of albugo, arising from scrofulous corneitis, and still attended by con- siderable vascularity, the practitioner forthwith began to attack the opacity of the cornea with stimulating powders, and solutions of irritating or caustic substances, not only would he fail in effecting his object, but run a great chance of rendering his patient totally Wind. But if he began by attacking the strumous inflammation which still hngered in the eye, aad that chiefly by constitutional remedies, not merely would he witness the dispersion of the redness, but he would find that the cornea would begin to clear, and that day after day, a little more of the effused lymph being removed, the patient's vision would proportion ably improve. It may be remarked that, in general, the internal and constitu- tional remedies which do good in cases of specks of the cornea, are those which operate in removing the ophtlialmiae in which the opacities have originated ; and the same observation holds good in regard to the local remedies also. At the same time, there are both general and local means peculiarly adapted for hastening the absorption of opaque depositions in the cornea. Mercuiy is a gen- eral remedy of this kind. Some opacities yield only after the use of country air and generous diet. When we find that the process of clearing has begun and is going on, we may often greatly assist it by such local nieans as the following ; a solution of from two to four grains of lunar caustic, three or four grains of sulphate of zinc, sulphate or ammoniaret of fiopper, or from one to two grains of corrosive sublimate in an ounce * Traite des Maladies des Yeux. Tom. i. p. 54. Paris, 1818. 414 of distilled water ; the vinum opii, pure or diluted ; the red precipi- tate salve; a finely levigated powder, consisting of one drachm of red precipitate and an ounce of white sugar. This last is to be blown into the eye through a quill ; the salve is to be introduced behind the upper lid, and rubbed into the cornea by moving the lid with the linger in various directions for some minutes ; the so- lutions may either be dropped in by means of a camel-hair pencil, or injected over the surface of the eye with a syringe. One only of these applications is, in ordinary cases, used daily ; but when the eye is less sensitive to stimulants than common, one of them may be applied in the morning, and another at bedtime. The solution of lunar caustic is regarded by many as specific for all those specks, which are at all removable by excited absorp- tion, so that they keep this solution ready by them for all such cases. It will be found advantageous, however, to change the stimulus, after it has been continued for some time. In all our endeavours to remove opacities of the cornea, it is ne- cessary to bear in mind that the points of importance are the pe- riod of the disease at which stimulants are hkely to prove useful, and the regular and frequent employment of the stimulating sub- stance or substances selected. There are few cases of speck, which are not benefited by a blis- ter kept open behind the ear, or on the back of the neck, and by repeated scarifications of the conjunctiva of the lids. I have generally found vascular albugo to be intractable, unless the vessels running into the speck are divided, and the gums af- fected by the administration of mercury. The best mode of divid- ing the fasciculus of vessels is to lay hold of a fold of the conjunc- tiva with a small pair of hooked forceps, and snip it off with the scissors. If the enlarged vessels have escaped division in this way, a small hook may now be easily introduced beneath them, so as to raise them within grat;p of the scissors. Considerable bleeding follows this operation, and ought to be encouraged by warm fomen- tations. The vulgar have a notion that specks can be removed by opera- tion. This is impossible, except when the opacity is merely a crust of oxide or carbonate of lead deposited on the surface of an ulcer of the cornea, in consequence of a solution of acetas plumbi having been employed as a collyrium. It sometimes happens that such a crust remains after the ulcer is cicatrized, and I have re- peatedly succeeded in lifting it away with a sharp end of a probe, leaving the cornea beneath nebulous merely, and susceptible of clearing completel}^ under the continued application of vinum opii. 415 SECTION V. GRANULAR CONJUNCTIVA.* In treating of the puro-mucous ophthalmise, I have repeatedly had occasion to refer to the thickened, fleshy, and rough state of the hning membrane of the lids, and especially of the upper lid, which is known by the name oi granular conjunctiva. At page 287, I have made some remarks on the sense in which the term, granular is here to be taken, and on the impropriety of calling the prominences of the conjunctiva which exist in this disease, gra7iulatio7is. I have stated, also, that I consider the prominen- ces in question to be principally the acini of the Meibomian follicles in a state of enlargement. This conclusion I have come to, not merely from the seat of this affection, w^iich is chiefly the internal surface of the upper hd, where these follicles are most abundant, but from what 1 have observed on drying portions of granular con- junctiva which I had removed with the scissors. In such portions, I have distinctly perceived the acini of the Meibomian follicles. The conjunctiva in the indurated and granular state, which is so apt to continue as a sequela of the puro-mucous ophthalmise, rubbing against the cornea, keeps this part in a state of constant irritation, so that it becomes vascular and nebulous, particularly in its upper half. Should the case be neglected, great thickening, with roughness, and total opacity of the cornea, may at length be the result. Prognosis. Although by sufficient clothing, proper diet, re- striction from intemperance, good air. and judicious medical treat- ment, the granular state of the lids, and opacity of the cornea, may be removed, and vision restored ; yet, if the patient be guilty of intemperance, or be insufiicienlly protected from cold winds, or damp cold weather, a relapse will almost certainly take place, at- tended by renewed inflammation of the conjunctiva and puriform discharge. Frequent relapses may at last render this disease in- curable. Treatment. The treatment which I have found most success- ful consists in scarification of the conjunctiva, the application of escharotics, and the use of counter-irritation. The eyelids being everted, so as completely to expose their in- ternal surface, the scarification is to be conducted as has been stated at page 267. Next day, or two or more days after the scarification, according to circumstances, the lids being again everted as before, and dried from any of the gleety mucus with which they may be covered, the lunar caustic pencil is to be brought into a single rapid contact with the prominences which we wish to remove. Before allowing the Uds to be replaced, a little warm water may be squirted over "* Trachoma ; Pladarotes. — Hie afFectus etiam sycosis seu palpebra Jicosa dicitur, quia interna palpebra superficies ficus discissi adinstar granulosa evadit. Plenck de Morbis Oculorum, p. 30. Vienna, 1777. 416 the surface which has been touched with the caustic. It is advan- tageous after a time to change the lunar caustic for the sulphate of copper, which may be more hberally apphed. The scarification and the caustic are to be employed alternately at intervals of two or three days. Escharotics and stimulants in solution, or in ointment, are also useful ; as, the lunar caustic solution, the expressed juice of the root of the holcus avenaceus, the red precipitate salve, &c. These assist in trlearing the cornea, as well as repressing the sarcoma of the conjunctiva. During the employment of these remedies, a blister is to be kept open on the nape of the neck. By continuing this plan of treatment with regularity for some weeks, I have often succeeded in removing granular conjunctiva after it had resisted a variety of other less methodical modes of treatment. The cure will be greatly promoted by attention to the dietetical adjuvants mentioned under the head of the prognosis. When tliis state of the conjunctiva has proceeded to a very great degree of exuberance, and continued for many months, notwith- standing a careful trial of the plan of treatment now explained, it may be necessar}" to have recourse to a more speedy and effectual method of removal, namely, by the knife.* The eyelid to be ope- rated on is to be evened as completely as possible, a small and very sharp lancet-shaped knife is to be laid flat at the root of this layer of indurated conjunctiva, which is then to be pared off by a steady motion of the instrument onwards, sawing as little as possible. In performing this operation, which is generally attended by very considerable pain, it is necessary to beware of removing more than the mere layer of indurated conjunctiva. If more than this is taken away, hard and irregular cicatrices are left on the internal surface of the lids, the effects of which on the corneee are scarcely, if at all, less prejudicial than those of the disease which has been removed. SECTION VI. ANCHYLO-BLEPHARON AND SYM-BLEPHARON. A union of the edges of the eyelids or anchylo-hlepharon, and a union of the eyelids to the globe of the eye or sym-hlepharon, are two diseased states which may occur either separately or to- gether. The edges of the lids may unite in (heir whole length, or only in part of their extent, and that generally at their temporal extrem- ity. There is always more or less of an opening at their nasal angle. Sym-blepharon may also be complete or incomplete ; the conjunctiva of the eyeball being united with the whole conjunctiva of one or of both eyelids, or a similar connexion existing only in a small extent. These modifications have considerable influence upon the prognosis and method of cure ; less, however, than the following. " Sir William Read's Short but Exact Account of all the Diseases incident to the Eyes, page 96. London, 1706. 4\1 It sometimes happens that the injured edges of the eyeUds, or the surfaces of the excoriated or ulcerated conjunctiva, being left for a time in immediate and constant apposition, a close and inti- mate union takes place, Much more frequently, however, a con- siderable quantity of coagulabl6 lymph is effused between the two edges, or between the two surfaces, and becoming organized forms the bond of these morbid connexions. When the lids are united in this manner, we find a whitish, uninterrupted, firm membrane, occupying and obliterating their natural opening ; and when the eyeball is united to one or both lids in this way, the organized coagulable lymph which forms the union, presents itself in bundles of an almost tendinous texture, stretching from the one part to the other. These bundles may be compared in some respects to those partial adhesions which are so frequently met with between the pleura which covers the lungs and that which lines the ribs ; but in one respect they are essentially different, namely, that as the pleura is a serous membrane, these adhesions in the thorax may take place upon the slightest inflammation, whereas the conjunctiva, following the laws to which all other mucous membranes are sub- ject, will never adhere in the manner described, so long as it con- tinues entire. Were mucous membranes under the same law as serous membranes in this respect, the dangers to which life is ex- posed would be greatly increased, as adhesions between the oppo- site sides of all the hollow viscera would be continually taking place. Nature has therefore wisely provided that no mucous mem- brane can become adherent, so long as its surface continues entire ; and accordingly we find that till it is wounded, or till it becomes excoriated or ulcerated, the conjunctiva of the eyeball never con- tracts adhesions to that of the eyelids. Indeed, ulceration of the cornea precedes almost every case of sym-blepharon. Causes. The causes of anchylo-blepharon and sym-blepharon are to be found chiefly in such traumatic inflammations as arise from burns, or from the influence of escharotics ; although any other ophthalmia, productive of excoriation or ulceration of the edges of the eyehds or of the conjunctiva, may give rise to these consequences. They occur most frequently in those whose eyes have been injured by boihng fluids, concentrated acids, or quick- lime, and in those who, labouring for a great length of time under puro-mucous ophthalmia, and being unable to withstand the hght, or to procure medical assistance, have lain buried for weeks in some dark corner with their eyelids constantly closed. Prognosis. The prognosis is extremely various, and depends upon the possibihty of completely separating the morbid adhesion?, the chance of preventing them from returning, and the advantage the patient is hkely to gain if they were removed. The operation for anchylo-blepharon can be performed with a reasonable hope of success, only when the union of the edges of the eyelids is not complicated with union between the eyeball and 53 418 the eyelids ; or if the latter union be present, when it is inconsid- erable in extent, and does not involve the cornea. There are various means for ascertaining the facts. One is to take hold of a fold of the upper eyelid, and drawing it from the eyeball, desire the patient to move about the eye as much as he can. By this means we shall not merely discover the existence, but ascertain prci/.y coriectl}^ the extent, of any adhesion between the eyeball and eyelids. A second means is the introduction of a small probe at the nasal angle of the lids. If there be no sym-blepharon, the probe passes on with ease to the temporal angle, whereas when adhesion exists, we ascertain its situation and extent by the oppo- sition which it gives to the point of the instrument. A good deal may be ascertained also, by observing the degree of sensibihty to light which remains. If the patient, with the lids in the state of anchylo-blepharon be able to distinguish all the gradations of light^ the adhesion does not involve the cornea, which to a certainty re- mains transparent. If he distinguishes only the more considerable changes of light, while the slighter gradations escape him, we must operate in a degree of uncertainty regarding the state of the cornea. Perhaps it may not be adherent, but probably it is in some mea~ sure opaque. If there is no sensibility to light, we may conclude either that the adhesion extends to the whoL surface of the cornea, and probably includes even a considerable portion more of the sur- face of the eyeball, or at least that the cornea, by the same inflam- mation which produced the anchylo-blepharon, has been rendered completely opaque, and that therefore the great object of an ope- ration cannot be obtained, namely, the restoration of sight. We will; of course, recommend the patient to undergo an ope- ration, when the case appears to be a simple anchylo-blepharon \ when there appears to be not only no sym-blepharon present, but when we judge that the surface of the eyeball has either not suf- fered at all, or suffered but httle, from the inflammation in which the anchylo-blepharon has originated. On the contrary, when the sensibility to light is extremely indistinct or altogether wanting, or, even though the sensibilit}' to light be pretty distinct, if the eyeball feels to the finger, through the eyelid, larger or smaller, harder or softer, or quite irregular on its surface, we will be cautious in recommending any operation, as the patient would thank us but little if we jnerely brought into view a useless and destroyed eye which had formerly been concealed. There is one reason, however, which may sometimes lead us to operate for sym-blepharon, altogether independent of any" hope of restoring sight. If the one eye is sound, and the other affected with this moibid union, the patient on at'empting to look from side to side, experiences a disagreeable or even painful feehng of dragging in th'= ey 3 affected \vith sym-blepharon which restrains, in some measure, the exercise even of the sound eye. To relieve this, and with no view of restoring the sight, I have been solicited to separate the eyeball from morbid connexions with the eyehds. 419 It sometimes happens that we meet with sym-blepharon combined witli staphyloma, and here also we may be obHged to operate with- out any reference to restoration of vision, which in such circum- stances is entirely out of the ques<^\on. The hds, bound down tothe cornea, resist the grov^^ing staphyloma, and thereby cause a great degree of pain, which we are sometiuies led to I'elieve for a time by puncturing the eye; but the puncture soon closes, the staphyloma again presses against the lids, the pain and fever return, and lO give permanent relief, we are forced, first, to operate for the sym-biepha- roa, and immediately after to remove the staphyloma. Treatment. The operation for anchylo-blepharon requires to be performed somewhat differently, according as the eyelids are united immediately, or through the medium of a pseudo-membrane. If they are united immediately, the assistant takes hold of the upper lid between his finger and thumb, so as to form a perpendicular fold, which he raises as much as possible from the eyeball, while the operator, with his left hand, does the same to the lower lid. With a scalpel the operator now divides the fold, which is thus form- ed, by a transverse incision, three or four lines long, exactly in the course of the natural opening of the lids. Through the incision thus made, a small grooved director is to be passed and run along to the nasal angle of the lids, which is almost always open, and where the extremity of the director will appear. The incision is now continued to the inner canthus, and then to the outer. After the central opening is made in the manner described, the rest of the operation may be performed with scissors, with which instrument, the separation at the temporal angle of the lids, v.nll always be most easily effected. When the union of the edges of the lids is through the medium of a pseudo-membrane, we perform, first of all, an operation similar to the above, only that we make the incision close to the edge of the upper eyelid, leaving the whole of the pseudo-membrane at- tached to the lower eyelid. Then laying hold of the membrane with a pair of forceps, we remove it completely with the scissors. This may appear a very precise sort of operation ; but the pre- cision of the operation is nothing, compared with that which it is necessary to observe in the after-treatment. Our care may be said to commence at the moment when the operation is finished, for its success depends entirely upon our preventing the reunion of the separated lids, or, in other words, upon their edges becoming quickly skinned over, without much inflammation or suppuration. If this does not take place they unite again, either immediately, or by a new pseudo-membrane. In order to prevent this, we ought to perform the operation pretty early in the morning, after the patient has had a good night's rest, in order that he may be able to remain the longer without sleep after the operation, and thus any long-continued approximation of the eyehds be prevented. The edges ought to be alternately washed with a tepid coUyrium of ace- 420 tate of lead in rose-water, and besmeared with tutty ointment. An assistant should sit by the patient during the first night after the operation, and frequently repeat these applications. With all this care, some re-adhesion is still apt to form in the temporal angle, to prevent which, the patient should be awakened repeatedly during the night; and made to open his eyes as widely as he can, and this he should also do frequently in the course of the day. When a case of sym-blepharon presents itself, it is not difficult to determine whether we can undertake an operation with hopes of success. We see distinctly in what condition the cornea is, and can judge what will be the effects of dividing the morbid adhesions. If the union be immediate, the assistant draws the upper eyelid upwards, and from the eyeball as much as possible, while the ope- rator draws the lower eyelid downwards, in order that the whole ex- tent of the united places being brought into view, and put on the stretch, they may be the more easily and accurately divided. This is to be accomplished with a small scalpel. The external edge of the union is always the firmest part, the interior parts being much looser. During the separation, we must carefully avoid injuring thd cartilages of the eyelids on the one hand, and the sclerotica and cornea on the other. If the sym-blepharon exists through the medium of bundles of organized coagulable lymph, after putting the conjunctiva on the stretch as in the last case, we must endeavour to cut away the bands as close to the conjunctiva of the eyelids as possible, and then lay- ing hold of them with a pau' of hooked forceps, dissect them cau- tiously from the eyeball. All that has been said respecting the habihty of anchylo-ble- pharon to recur after the operation, is applicable to the present case, only that here it seems almost impossible by any contrivance to prevent the contact of the two raw surfaces. One of my pupils suggested to me an artificial eye, as the substance most likely to answer the purpose of preventing reunion. I am afraid, however, that not even this could be borne, and that we must trust to the use of the coUyrium and ointment above mentioned, and to very frequent motion of the eye. We need never think of performing the operation for sym-blepharon without the formation of some new bands of coagulable lymph, which will require to be removed by a second operation. Celsus honestly confesses, that he never saw any one cured by the operation ; and states that Meges, who had tried it many times, avowed that he had never succeeded, but that the eyehd had constantly become again adherent to the eye- baU." * De Re Medica ; Lib. viL Cap. 1. Sect. 2. 421 SECTION VII. SYNECHIA. The term synechia is employed to signify any moibid adhesion of the iris. When the adhesion is to the cornea, it is termed syne- chia atiterior ; when to the capsule of the crystalline lens, syne- chia posterior. The former is the result of a penetrating wound of the cornea, or of severe inflammation of that part, generally in- deed of ulcerative inflammation, ending in perforation into the an- terior chamber, and escape of the aqueous humour. The latter is the frequent consequence of iritis. It is the dread of such results which makes us anxious in the treatment of the ophthalmia, knowing that once formed, these morbid adhesions can scarcely ever be separated. In some in- stances of partial synechia anterior, and of synechia posterior even when complete, which last is almost always attended by closure of the pupil, vision may be restored by the formation of an artificial pupil. SECTION VIII. OBLITERATION OF THE PUPIL. It has been fully explained in the sixteenth and following sections of the last chapter, that in consequence of inflammation of the iris, the pupil is apt to become narrowed, misshapen, fixed, and filled with coagulable lymph, a state of the parts to which the terms atresia] iridis, and synizesis^X have been applied. No operation can open up the natural pupil, but in many cases of this sort an artificial pupil may be formed with advan- tage. The use of belladonna in cases of closure of the pupil ought not to be hastily abandoned. The filtered aqueous solution, dropped upon the conjunctiva every second day, and continued for several months, is often followed by some degree of dilatation, and consid- erable improvement in vision. SECTION IX. CATARACTS OR SPECKS OF THE CRYSTALLINE CAPSULE AND LENS. The origin of these sequelae of ophthalmia has been fully explained in those sections of the last chapter, which treat of iritis, and in- flammation of the crystalline lens and capsule. When once fair- ly confirmed, no means of cure are of any avail, except the removal of the opaque body by an operation. * 2uvf;tH*, continuity. t From a. negative, and "r/Testa, to perforate. t ^uvt^Ho-ii) a running together. 422 SECTION X. DISSOLUTION OF THE VITREOUS HUMOUR. This has been styled synchesis,* and is in fact a disorganization and solution of the hyaloid membrane. It is totally incurable, and sooner or later is accompanied by amaurosis. It remains to be as- certained by dissection, whether the boggy state of the eyeball, re- ferred to at page 374, depends on dissolution of the hyaloid mem- brane, or merely diminution of its contents. When the vitreous capsule is dissolved, it by no means necessarily follows that the eye should feel soft or boggy. On the contrary, it often feels harder than natural, owing probably to a superabundant quantity of aque- ous fluid, occupying the place of the vitreous humour. SECTION XI. — ATROPHY OF THE EYE. Severe ophthalmise, and especially severe internal ophthalmiae, excited by injuries in strumous subjects, are apt to be followed by an absorption of the contents of the eyeball, and shrinking of its coats. When it goes to a great length, this state is termed phthisis oculi. In all degrees of atrophy of the eye, the prognosis is unfa- vourable. Operations upon eyes which have shrunk to less than their natural size are rarely attended with any success. SECTION XII. STAPHYLOMA. Various protrusions from the front of the eye have received the name of staphyloma, from the resemblance which they occasionally bear to a grape.t 1. Staphyloma of the Iris, or Staphyloma racemosum.X It sometimes happens that the cornea is perforated by ulceration, not in one point alone, but in many, and that through the open- ings thus formed, the iris protruding gives rise to an appearance somewhat like a cluster of berries. These protrusions continue of a dark colour, and are scarcely covered by any pseudo-cornea. One or more of them occasionally become very thin, give way, and allow the aqueous humour to escape. The staphyloma conse- quently becomes flat, and sometimes disappears altogether, the cor- nea cicatrizing over the seat of the former protrusion. In other cases the staphyloma of the iris degenerates into staphyloma of the cornea and iris. Prognosis and Treatment. If any considerable portion of the cornea be in a natural state, it may be possible to form an artificial pupil behind that portion, after the staphyloma of the iris is re- * 'Xuy^va-ti, confusion. + Srst^xx, a grape, t From raceTTMs, a bunch of grapes or berries. 423 moved, which is sometimes effected by puncturing the individual protrusions with the point of a cataract-needle, and touching them with the lunar caustic pencil. If more considerable, they may be snipped off, and the place touched in the same way. When the whole cornea is affected, nothing can restore vision. The staphy- loma may be punctured occasionally, or removed entirely by the knife, exactly as a total staphyloma of the cornea and iris is re- moved, which will be followed by a flat and opaque pseudo-cornea^ adherent to the capsule of the lens. 2. StaphyloTna of the Cornea and Iris Is styled partial or total, according as it involves a portion only, or the whole of these parts. The most evident symptoms are opacity and projection of the cornea, but an essential part of the disease is adhesion of the iris to the portion of the cornea which is affected, and consequently diminution or total obhteration of the anterior chamber. It has been maintained by some, that the secreting organ of the aqueous humoiu' resides principally, if not entirely, in the posterior chamber, while the absorbing organ of that fluid resides in the an- terior chamber.* I do not regard this as a point which is estab- lished, but I must confess that the phenomena Avhich attend the disease now under consideration go a considerable way in its sup- port. In staphyloma of the iris and cornea, the anterior surface of the former is either partially or throughout its whole extent glued by adhesive inflammation to the posterior surface of the latter, so that the anterior chamber is abridged or annihilated, and the func- tions of the membrane which lines that cavity proportionally inter- rupted. The posterior chamber, on the other hand, remains in most cases entire, the functions of its lining membrane are, so far as we know, left unimpaired, and if this membrane possessed in an equal degree both a secreting and an absorbing power, the quan- tity of aqueous humour ought to continue the same. This is not the case. Much more aqueous humour is secreted than is ab- sorbed, and the consequence is the formation and constant enlarge- ment of that projection of the united cornea and iris, to which w© give the name of staphyloma. It is remarkable that when the cornea merely gives way by ul- ceration, and then cicatrizes, forming a leuconja, this cicatrice i& sufficiently strong to resist the pressure of the aqueous humour ; but when, in addition to the leucoma, there is extensive adhesion be- tween the iris and the internal surface of the cornea, these parts in union are insufficient to resist that pressure, and are projected by it into a staphyloma. This fact seems explicable only upon the sup- position above mentioned, that the absorption of the aqueous hu- *• Memoire sur les Proces Ciliaires, par F. Ribes ; Memores de la Societe Medi- cate d'Emulation. Tome viii. p. 859. Paris, 1817, 424 mour is carried on chiefly in the anterior chamber, while its secre* tion goes on principally in the posterior ; and that as by the union of the iris to the cornea, the absorption must be impeded, while the secretion continues as in health, the quantity is superabundant in relation to the cavities in which it is deposited, and must therefore tend to dilate them at such part of their parietes as is weakened by disease. The dilatation occasionally goes on to a very great ex- tent, so that the staphyloma becomes excessively thin, and at last gives way : in which case the aqueous humour escapes, and the tumour for a time subsides, but on the rupture healing, it gradually returns to its former size. Causes. Onyx, hypopium, and ulceration of the cornea are precursors in almost all cases of staphyloma. Small-pox pustules on the cornea being extremely apt to end in bursting of the cornea and adhesion of the iris, staphyloma was a much more frequent oc- currence before the general introduction of vaccination than it is at present. Tlie ophthalmia of new-born children, the contagious or Egyptian ophthalmia, and severe strumous ophthalmia, are the common causes of staphyloma at the present day. 1. Partial staphyloma, being generally the result of an onyx, occupies, in nine cases out of ten, the lower part of the cornea. In those cases where it does not cover nor involve the pupil, the patient is able to see with more or less distinctness those objects which are placed above him or on a level with his eye, but he is generally affected with epiphora, and painful sensibility of the or- gan. In more unfortunate cases of staphyloma, the whole edge of the pupil is adherent to the opaque and projecting portion of the cornea, and the patient can recover a degree of vision only by the formation of a lateral artificial pupil. Partial staphyloma is sometimes confounded with leucoma, al- though by a careful examination of the eye this mistake may al- ways be avoided. To the whole extent of the partial staphyloma the iris is firmly adherent, so that the anterior chamber is much diminished in size ; whereas, in leucoma, the iris is either not at all adherent to the cornea, or adheres to it in a mere point. In partial staphyloma, the whole cornea partakes in some measure in a conical form, the termination of the cone being at the centre of the staphyloma ; whereas in leucoma, the general spherical form of the cornea remains unaltered, the leucoma being scarcely percep- tibly raised above the level of the rest of the cornea, and not unfre- quently depreesed. The very considerable degree of vision which patients with par- tial staphyloma often possess, may readily be lost, either by inat- tention on their part, or by injudicious attempts to remove or lessen the disease. Wlien neglected, the tumour is apt to increase in size till it projects from between the eyelids, so that it is constantly irri- tated, and soon becomes inflamed, from contact with their edges, the eyelashes, and foreign bodies. In such circumstances, the pa- 425 tient ought to submit to such a treatment as, if carefully conducted, shall not only improve very materially the form of the eye by les- sening the staphyloma, but save the remaining sight. The pa- tient, however, must be informed that notwithstanding the removal of the partial staphyloma, it will be impossible for him to recover I the transparency of the cornea in the part affected. There, after I the most successful treatment, a very visible, white, but flat cica- trice, will remain. If, either from closure of the pupil, or from the partial staphyloma being situated over it, and consequently involving it, no vision ex- i ists, we must, first of all, direct our attention to the diminution of the staphyloma, and removal of the pain and irritation by which i its increase in size is attended; and then determine whether, by ! an operation for artificial pupil, we are likely to gain for tiie pa- ; tient some restoration of sight. It is only by means of a gradual, moderate, and repeated inflam- [ matory process, that a partial staphyloma can be removed, without i endangering the general form of the eye and the remaining degree 1 of vision. The inflammation is to be excited by the cautious use I of escharotics, continued till such a firm cohesion is produced in I that part of the cornea which is adherent to the iris, that it shall be able to resist the pressure of the aqueous humour. The eschar- otic most frequently employed for this purpose is that preparation of the muriate of antimony called butter of antimony. The point . of a camel-hair pencil being dipt in this pieparation, and the eye- lids held widely separated, the apex of the staphyloma is to be touched with the pencil till a small white eschar forms. Before allowing the lids to close, the surface of the staphyloma is to be washed with a large camel-hair pencil dipped in milk. The re- petition of the caustic is not to take place till the eschar shall have separated, and the inflammation caused by the former application subsided. 2. Total staphyloma appears under two different forms, the discrimination of which is necessary both for the prognosis and the technicism of the operation which total staphyloma so frequently requires. In the one, the tumour is spherical ; in the other, it has the form of a blunt cone. There is this remarkable difference in the structure of these two varieties of total staphyloma, that in the spherical^ there exists an adhesion between the cornea and the iris, but none between the iris and the capsule of the lens ; whereas in the conical, not only are the cornea and iris united, but also the iris and the capsule of the lens. In the spherical staphyloma, the anterior chamber is abol- ished ; the posterior continues to exist. In the conical, both cham- bers are obliterated. As by the abolition of both chambers, the secretion of the aque- ous humour must be entirely prevented, we can easily explain, in the first place, why the conical staphyloma never reaches that great 54 426 size which is frequently attained b)"" the spherical. In the latter, the posterior chamber remaining entire, that portion of the secreting organ of aqueous humour which is lodged in that cavity, and which, if the conjectures already stated are correct, is the chief por- tion of that organ, continues its functions, and by its overbalancing supply of aqueous humour forces the united iris and cornea to ex- pand into a spherical and constantly more and more extenuated tumour ; whereas when the cornea, iris, and capsule of the lens are all glued together by adhesive inflammation, as they are in con- ical staphyloma, there can be little, if any, secretion of aqueous hu- mour, so that when once a staphyloma of this kind has formed, it will ever afterwards 'iiaintain nearly the same size. Another circumstance explained by this morbid anatomy of staphyloma, is the rarity of the conical variety, in comparison of the spherical. The cases in which inflammation extends its influence so deeply as to unite the cornea, iris, and capsule of the lens, must evidently occur less frequently than those in which merely the cor- nea and iris are affected. This morbid anatomy of staphyloma serves to explain a third fact, namely, the frequency, or rather constancy with which conical staphyloma is accompanied by varicose dilatation of the blood-ves- sels of the eye, which is a rare attendant on spherical staphyloma. The inflammation which produces the former, attacks the eye much more deeply and generally, and arises more frequently from syphi- lis, scrofula, or some other dyscrasia, than the inflammation which terminates in the latter. Hence it is, that along with the conical variety of staphyloma, the whole vascular systems of the eye are left in a state inclining to varicose degeneration. The actual exist- ence of this state manifests itself, not merely by enlarged vessels scattered over the surface of the eyeball, but by a dirty blue colour of the sclerotica, and after a time, by a circle of dark blue varices of the choroidal vessels, shining through that tunic, which has be- come extenuated from their pressure. As to the size which is attained by spherical staphyloma, that depends very much on the degree of activity possessed by the source of the aqueous humour, which resides in the posterior chamber. We conclude that the less that this source has suffered from the preceding inflammation, the greater will be the quantity of aqueous humour secreted, and the greater consequently the expansion of the united iris and cornea. We not unfrequently see spherical staphyloma become so thin and transparent, from distention and interstitial absorption, that the patient is able to distinguish a num- ber of objects around him, and is sometimes led to entertain hopes of a conaplete recovery of his sight from the operator. This ap- pearance is always the forerunner of the bursting of the staphylo- ma, which is followed by a sinking awa}^ of the tumour for a day or two, but is soon succeeded by its re-appearance in its former shape, and with its former dimensions. 427 There is another circumstance regarding spherical staphyloma which merits attention, namely, that when it attains a large size, the iris, (unable to expand to the same degree as the cornea, and its texture much more frail,) becomes torn into threads, so that when we examine the internal surface of such a staphyloma, after death, or after it has been removed by an operation, we find the iris which adheres to the cornea, broken and reticulated ; whereas the internal surface of a staphyloma which has not reached a great size exhibits the iris still entire.* Prognosis. There is no possibility of restoring sight to the patient affected with total staphyloma, even in cases where there can be no doubt that the lens, vitreous humour, and retina, are perfectly sound. All that we can do in the way of relief is to re- move a tumour which is extremely unsightly, frequently very pain- ful, and even dangerous if left to itself. If a total staphyloma be combined with an advanced varicose state of the eye, if the tu- mour be of such size that it can no longer be covered with the eyelids, but is in continual contact with the eyelashes, and con- stantly exposed to the air and substances floating through it, if in consequence of these causes the cornea becomes inflamed, and the integuments of the lower lid excoriated, then, the most trifling bruise or other injury may bring on inflammatory disorganization and protrusion of the whole eye, especially if the staphyloma is of syphilitic, scrofulous, or arthritic origin. It is proper, therefore, to remove as soon as possible every considerable total staphyloma. Treatment. Many proposals have been made for removing total staphyloma without operation. The application of the mu- riate of antimony has been particularly tried, in consequence of the recommendation of Richter. It was also supposed that by mere incision of the staphyloma, passing a thread through it, or excision of a small part of it, so that the eye v:as kept for a certain time in a state of evacuation, the cure of this disease could be accom- plished.! All these means have been found to fail ; and in many cases, especially when escharotics w^ere tried, they were found to excite the eye into a state terminating in exophthalmia. Beer, on the other hand, mentions that he had removed 216 staphylomata by operation, and that in not a single instance had any dangerous accident followed. J Operation. The operation for total staphyloma consists, first, in the formation of a flap with the knife, and secondly, in the re- moval of that flap with the scissors. While the assistant keeps the upper eyelid raised by means of Pellier's speculum, a pretty large hook is to be passed through the centre of the staphyloma. In the hand which does not hold the * Beer's Ansicht des staphylematosen Metamorphosen des Auges. Plate 1. fig. 1 & 2. Wien, 1805. t Celsus de Re Medica, Lib. vii. Pars ii. Cap. i. Sect. 2. t Lehre von den Augenkrankheiten. Vol. ii. p. 216. Wien, 1817. 428 hook, the surgeon takes the staphyloma-knife, which is nothing; more than the cataract-knife somewhat enlarged. With the cut- ting edge directed upwards, the staphyloma is to be penetrated at its temporal edge, close to its basis, and at such a distance below its transverse diameter that two-thirds of the tumour shall be in- cluded in the incision to be made with the knife. The point of the knife ought to be passed perpendicularly into the staphyloma. Having penetrated through the cornea and iris, the handle is to be carried backwards till the instrument is brought into a position par- allel to the basis of the staphyloma. The knife is now to be carried onwards till it reaches the point of exit, which ought to be in a horizontal line with the point of entrance. The flap is completed by the progressive motion of the knife, till it fairly cuts itself out. The operation is instantly to be completed, by dividing with the curved scissors that part of the circumference of the staphyloma which remains in connexion with the sclerotica. At the same mo- ment, the assistant lets fall the upper eyelid, which must not again be raised for eight days. During the whole of the operation, and especially towards the end of it, care must be taken that the eyeball is not iiregularly and forcibly pressed, as this might readily give rise to the loss of the lens and vitreous humour, which, in oil cases, at least of spherical staphyloma, may and ought to be preserved. In cases of conical staphyloma, it is scarcely possible to avoid the loss of the lens, and part of the vitreous humour ; and not unfrequently the whole con- tents of the eye are evacuated. This is owing to the adhesion which subsists in this kind of staphyloma between the capsule of the lens and the iris, so that the knife actually passes behind the lens and tLrciigh the vitreous humor. If the sclerotica has taken a considerable share in the disease, anct ihere are a number of dark-blue varicose protuberances round the Gtaphylomatous cornea, rather than confine the operation to the removal of the cornea and iris merely, it is better to take away the anterior third of the eyeball ; an operation which though oc- casionally followed by shrinking of the remains of the eye to a very small size, in general leaves it sufficiently large to support an artificial eye. After the operation for staphyloma, strips of court-plaster are to be applied so as to keep the lids of both eyes from moving. If the vitreous humour, and more especially if the lens, has been preserved, we generally find on examining the eye eight days after the operation, that a greyish, semi-transparent, and flat pseudo- cornea is already produced, through which the patient, were we to allow him, might be able to distinguish a number of objects. Gradually this membrane becomes opaque, till at last the place of the staphylomatous cornea presents a firm cicatrice, with bluish or brownish streaks. The eyeball has, as to its form, lost only the projection of the cornea, having there become flat. When it has 429 completely recovered from the operation, an artificial eye may be applied, by which a high degree of illusion may be produced. It occasionally happens, especially in cases of staphyloma attend- ed with varicosity of the internal vessels of the eye, that either im- mediately, or some hours after the operation, haemorrhage takes place both from the eye and into the vitreous cells. Injected with blood, the vitreous humour protrudes to such an extent from the wound, that it is impossible to keep the eyelids shut. The eyeball is painfully distended, while the conjunctiva and lids become greatly ecchymosed. The haemorrhage into the eye gives rise in some cases to agonizing pain, and may even bring on convulsions. Under such circumstances, it may not be improper to cut away with the scissors, the protruding hyaloid membrane, which presents a solid and dark-purple mass, hanging from the front of the eye. After this is done, the bleeding ceases, and the pain abates. Left to itself, the protrusion dies away in the course of a few days. The eye is apt in either case to shrink below the usual size of a staphylomatous eye after operation. Violent inflammation sometimes supervenes to the operation for staphyloma, ending in suppuration, both within the eyeball and in the surrounding cellular membrane. This must be combated by a strict antiphlogistic plan of treatment, opiates will be required to abate the severity of the pain, a poultice is to be laid over the eye, and any abscess which may form is to be immediately opened with the lancet. It occasionally happens that the opening into the eye, formed by the removal of the staphylomatous cornea and iris, is long of closing, no pseudo-cornea being present when we open the lids on the eighth or tenth day, and even for weeks the clear humours lying uncovered behind the gap in the front of the eye, till at length the aperture contracts and cicatrizes. 3. Staphyloma of the Choroid and Sclerotica. I have nothing to add to what has been said on this head, in the twenty-second section of last chapter,* except that when a staphyloma of this sort on the front of the eye is very prominent and insulated, I see no reason why it should not be removed like a staphyloma of the cornea and iris. SECTION XIII.— -VARICOSITY OF THE EXTERNAL AND IN- TERNAL VESSELS OF THE EYE. Two sets of blood-vessels belonging to the eye are apt to be left in a state of varicose distension, after certain of the ophthalmiae ; namely, the visible arteries of the sclerotica, after arthritic iritis, and the vasa vorticosa of the choroid, after choroiditis. ♦ See p. 381. 430 Little can be done, and nothing directly, to remove this state of the vessels, which is not only in general beyond cure, but affords a very unfavourable index of the condition of the humours and retina. Glaucoma and amaurosis, in almost every case, are sooner or later added to varicose distension of the blood-vessels of the eye. SECTION XIV. AMAUROSIS. Complete or incomplete insensibility of the retina to light is a frequent consequence of inflammation, especially when it has af- fected the internal textures of the eye ; as, the retina, the choroid, or the iris. When the inflammation has been completely subdued, but the amaurosis continues, recovery of sight may be regarded as hopeless. SECTION SV. OSSIFICATION IN DIFFERENT PARTS OF THE EYE. Ossification, or calculous deposite, certainly occurs as an occa- sional sequela of long-continued ophthalmia ; and, indeed, it may be suspected that in all instances, and in w^hatever texture of the body an unnatural formation of osseous substance takes place, it is preceded by a certain kind or degree of inflammatory action. 1. Ossification of the cornea. Yoigtel mentions, that in the Walterian Museum at Berhn, there was a piece of cornea preserved, which had been converted into bone. It was three hues long, two broad, and weighed two grains.* Mr. Wardrop relates, that in dissecting an eye of which no his- tory could be obtained, he found several gritty particles and inequal- ities on the internal surface of the cornea. He also states that on maceration of an eye which was changed in form, and the cornea opaque, a piece of bone, weighing two grains, oval shaped, hard, and smooth, was found between the laminae. A piece of bone was present between the choroid coat and retina of the same eye.t 2. Osseous DejJosite in the Anterior Chamber. Mr. Anderson, surgeon at Inverary, communicated to Mr. Ward- rop, that on examining the right eye of a woman of 31 years of age, he observed a substance of a whitish appearance, arising from the inside of the sclerotic coat, and extending upwards behind the cor- nea, over a great part of the iris, to very near the pupil. It had produced much irritation in the eye, with inflammation, severe pain, an almost constant flow of tears, inability to bear the light, and a considerable diminution of vision. The eye was less in size than * Handbuch der Patholorischen Anatomic. Vol. ii. p. 92. Halle, 1804. t Morbid Anatomy of the Human Eye. Vol.i. p. 74. London, 1819. 431 the other. The complaint was the consequence of a fall, fifteen years before, at the root of a tree, by which the patient struck the eye, but did not cut any part of it. From this period, the substance seen through the cornea had begun to grow, and had gradually in- creased in size. The pain and other symptoms had been suffera- ble until about nine months before Mr. Anderson saw her, when the complaint became more violent. He made an incision into the cornea, in the manner recommended for the extraction of the catar- act, raised the flap of the cornea with a flat crooked probe, and with the same instrument turned out a small piece of bone. The upper part of it was as thin as a piece of paper ; at the under part, it was thicker, porous, and brittle, and of an irregular semilunar form. The upper part was quite detached, the under part shghtly adhered to some part of the globe out of sight ; but it was easily extracted, without requiring the knife to separate its adhesions. From the un- steadiness of the patient, it was impossible to discover from what part the ossification originated.* Mr. Wardrop, in his second volume, mentions that a case similar to Mr. Anderson's had come within his own observation, thin lam- inae of bone having been discharged at several times from the an- terior chamber, through ulcers formed in the cornea; and that he also had had an opportunity of examining a case under Mr. Wis- hart's care, where that portion of the capsule of the aqueous humour which is reflected over the iris, was almost entirely converted into a bony shell.! 3. Ossification of the Choroid Coat. Voigtel has described various preparations belonging to the Wal- terian Museum, in which the choroid coat was more or less com- pletely ossified. In one, the posterior half was so affected ; in oth- ers, the anterior part ; in some, the whole choroid. He also quotes from Giinz, an instance of ossification between the lamellae of the choroid coat.+ Mr. Wardrop, under the head of ossification of the choroid, men- tions that he had met with a few instances of a thin cup of bone between the sclerotic coat and the retina ; that the retina was in immediate contact with the interior surface of the bone, but that be- tween the sclerotic coat and the ossification there was a very thin, tender, and pale-coloured membraneous expansion, the only vestige of the choroid ; and that at the bottom of the cup, there was a small round perforation, through which the retina passed to expand on the interior surface of the osseous shell.§ It may be doubted whe- ther such cases were not rather ossifications of the membrana Jaco- biana, than of the choroid. * Ibidem, p. 75. t Ibidem. Vol. ii. p. 18. London, 1818. t Handbuch der Pathologischen Anatomic. Vol. ii. p. 97. Halle, 1804. § Morbid Anatomy of the Human Eye. Vol. ii. pp. &i and 272. Lond. 1818. 432 4. Ossification of the Retina. Morgagni, Morand, and others, have recorded instances of cup- like ossifications within the choroid, and whicii have generally been accounted as situated in the retina. Morgagni says, that in the case which fell under his observation, instead of the retina, there was a thin bony lamella under the cho- roid universally.* In Morand's case, the proper retina, by which I understand the medullary and vasculo-cellular layers of that membrane, appears to have been enveloped by the osseous substance, so that we may con- clude that it was, partly at least, the membrana Jacobiana, or ex- ternal layer, which was ossified, along with the hyaloid membrane. The patient had been blind of the eye thus affected for twenty years ; when about fifteen, he had had a violent inflammation of that eye, followed by the formation of a yellow cataract, which seve- ral oculists had offered to remove by operation, but the patient would never consent.t 5. Ossification of the Hyaloid Membrane, Crystalline Cap- sule, and Crystalline Lens. Many examples have been recorded of ossification of the crys- talUne lens and capsule ; and in some of these, the hyaloid mem- brane has been more or less affected in the same manner. " In one case," says Mr. Wardrop, " besides the capsule of the lens being ossified, I found several large, but thin scales of bony matter, dispersed in an irregular manner throughout the vitreous humour, which, in all probability, were ossifications of the hyaloid membrane." + Ossification of the capsule appears to be much more frequent than of the substance of the lens. In one case of capsular cataract, I found the anterior hemisphere of the capsule hard and gritty un- der the needle. The disease had originated in iritis, followed by contracted pupil and lymphatic exudation. The cataract was de- pressed, and a tolerable share of vision was restored. In some cases, the whole capsule is converted into a thin shell of bone, containing the lens in an opaque state. In other cases, the lens had been previously absorbed in part or completely, so that the ossified capsule has a less regular form, having become shrivelled previous to being converted into bone. In an eye sent to Mr. Wardrop by Mr. Allan Burns, the central portion of the lens was found converted into a hard bone. This is the only instance which Mr. W. had met with, in which ossifica- tion of the lens was unattended by ossification of the capsule. The ossified centre of the lens was of a deep brown colour, and exhibited a laminated structure.§ * De Sedibus et Causis Morborum. Epist. li. Art. 30. t Memoires de 1' Academie Royale des Sciences, pour 1730, p. 467. Amsterdam, 1733. X Morbid Anatomy of the Human Eye. Vol. ii. pp. 128 and 271. London, 1818. § Ibidem, pp. 96 and 261. 433 Pellier relates an interesting case, in which the cornea of an eye, which, for twenty years, had suffeted more or less from inflamma- tion, at length gave way, and allowed an ossified lens to be seen and felt. A crucial incision was made through the cornea, and a portion of calculous substance of the size of a kidney-bean was ex- tracted. Part of the ossification was still left in the eye, the pa- tient having become so restless that it could not be removed. Pel- lier seems to think that the whole contents of the eye were in an ossified state. The piece extracted was rough and irregular.* A careful perusal of the cases recorded of ossification in different parts of the eye, will confirm, in a very striking manner, the re- mark with which I commenced this section, namely, that this morbid change has generally been the consequence of long-contin- ued inflammation. As for the diagnostic signs of this state of the eye, they must be obscure, for the pupil is generally contracted in such cases, and the eye atrophic. CHAPTER XII. ADAPTATION OF AN ARTIFICIAL EYE. When the eye and eyelids have been destroyed, or removed in consequence of disease, a painted imitation of these parts has some- times been applied over the front of the orbit, and kept in its place by means of a steel-spring going round the temple to the opposite side of the head ; t but by an artificial eye is generally meant a hollow plate of enamel, made to resemble the front of the natural eye, and introduced behind the eyehds. Enamelled plates of gold were formerly used for this purpose, but at the present day artificial eyes are generally made altogether of enamel. An artificial eye ought to be perfectly smooth, and of such a form and size as to cover the remainder of the natural eye without pres- sing much on it, or irritating it in any way. Its edge ought not to be sharp, but rather thick and round. The internal surface of the middle portion, which represents the cornea, ought to be con- cave, and neither flat, nor, as we even sometimes find it, convex, which forms must necessarily give rise to pressure on the eye, un- less it be much shrunk. Want of attention to these particulars is often the cause of the pain which patients feel from the introduc- tion of an artificial eye, and which often leads them to resign all thoughts of continuing its use. * Recueil de Memoires et d' Observations. Obs. 139. Montpellier, 1783> t CEuvres d' Ambrose Pare ) Liv. xxiii. Chap. i. 55 434 Thinness and lightness are indispensable requisites of an artifi- cial eye. When the remains of the natural e5"e are large, unless the artificial eye is thin, the lids are too much pressed out, and are prevented from executing their usual movements. If the remains of the eye are irregular in form, the artificial eye must be made so too, lest it press unequally and injuriously against any part. When the upper eyelid, for example, is partially adher- ent to the remains of the eyeball, the diameter of the artificial eye from above downwards must be shorter than common, or it must have a notch in its edge opposite to the point of adhesion. The particular hue of the white of the eye, the appearance of the vessels strewed over it, and the size and colour of the iris, ought to be exactly imitated from the sound eye. The pupil ought to be represented at its medium degree of expansion, and the appearance of an anterior chamber ought to be given. I have observed, how- ever, that the iris looks darker, when the eye is introduced behind the eyehds, than it does when examined in the hand. If the defective eye, which the patient is desirous of covering from view, is not larger than the natural size, an artificial eye may be worn without an)' previous surgical operation. If. on the other hand, there is staphyloma present, this must first be removed. The injur}' which has rendered the application of an artificial eye desirable, or any operation which has been performed on the eye, must first be completely cured, and an additional space of some months must have elapsed before the artificial eye can with pro- priety be tried. In some cases, indeed, from the great irritability of the patient, causing a tenderness and epiphora which cannot be subdued, or from the nature of the disease in which the loss of the eye took place, giving ground to dread that irritation might bring on perhaps some malignant disease within the orbit, we are obliged to resign all thoughts of applying an artificial e3^e. If there is no inflammation, no fungous excrescence from the eyeball or eyelids, no pain or irritation present, we may begin with a small pldin enamel eye, about three quarters of an inch long and half an inch broad. The mode of introducing an artificial eye, is to lay hold of it by its lower edge with the thumb and forefinger of the right hand, dip it in water, with the left thumb raise the upper e3'elid, intro- duce the upper edge of the aitificial eye under this lid, and press it up into the upper fold of the conjunctiva, till its most prominent partis hid behind the hd, turn this part of the artificial eye towards the outer canthus, allow the upper lid to descend over the artificial eye, w^hich is now to be supported with the right thumb, while with the left fore-finger, the lower eyehd is to be forcibly drawn downwards, which allows the artificial eye to slide behind it into the lower fold of the conjunctiva. For some days, the artificial eye is to be worn only during a few hours. It is withdrawn with the aid of a gold or silver probe, of 435 the thickness of a knitting needle, the end of which is rounded off and bent into the form of a hook. With the fore-finger of the left hand, the lower hd is to be depressed, so as to allow the hook to be introduced behind the edge of the artificial eye, which by its means is to be raised till it is no longer grasped by the lower lid ; the ar- tificial eye immediately glides from the upper fold of the conjuncti- va, and is to be laid hold of by the left hand. The eye is to be im- mediately washed in clean cold water to free it from the mucus which adheres to it, and laid aside till next day. The patient is soon able to introduce and withdraw the artifi- cial eye without assistance. While withdrawing it, he leans over a bed, in order that if it should fall it may not be broken. If the eyeball shrinks to a very small size, or if it be removed, the eyelids lose that support and elasticity necessary for the per- formance of their motions ; the consequence is, that they soon be- come entirely motionless, and sink into the orbit, while the folds of the conjunctiva, which in the natural state of the parts extend over the anterior third of the eyeball, gradually become contracted, and at last almost abolished. The superabundant tears and mu- cus cannot be properly excreted, being no longer pressed forward by the convexity of the eyeball, but gather behind the hds and adhere to their edges and angles, while the nostril of the same side feels dry. These symptoms are in general greatly lessened by the use of an artificial eye, which affords to the lids a new sup- port, restores to them the elasticity necessary for their motions, and expands again the folds of the conjunctiva ; while the renewed action of the lids serves to convey the tears and mucus to the puncta lachrymalia, as in the state of health. In such cases, we must commence with a very small artificial eye, and employ larger ones, proportionally as the folds of the conjunctiva will admit. We need not be afraid thaL a very small eye will in such circum- stances fall out from between the lids, for v/e may observe that the lids are enabled to open only in proportion to the size of the eye which is placed behind them. I have said that we may begin with the use of a small plain eye ; by which I mean one without any representation of the iris. A series of such eyes ought to be kept by the oculist, and em- ployed till the patient becomes accustomed to their use. The hds cannot in general be easily moved at first over an artificial eye, so that it remains exposed to the foreign matters driven through the air, and both from this cause, and from the first attempts of the patient to remove and replace it, is apt to become scratched, which very soon destroys its appearance. Every two or three days, a larger eye ought to be introduced, till at length the lids shell ap- pear to have reached nearly their natural degree of expansion. The artificial eye ought always to be somewhat smaller than the natural size. The iris and pupil of the eye which is to be used permanently must correspond in direction with those of the sound 436 eye, and must not be placed nearer to either canthus, else the pa- tient will appear to squint with the artificial eye. Some artificial eyes are made for the right or left side only, and have more scle- rotica above than below the iris, others are intended to be used on either side, and have the iris placed midway between the upper and lower edges of the eye. In all artificial eyes, there is more sclerotica on the temporal than on the nasal side of the iris. A properly adapted artificial eye performs the same motions as the sound eye, especially if the remains of the eyeball over which it is placed are considerable, and are moved with facility by the recti. The motion of the artificial eye, however, does not depend upon this alone, but also on the motion of the conjunctiva and its folds, into which the artificial eye is received, and which possess a simultaneous movement w*ith the eyeball and eyelids. Hence it is that if the artificial eye is of a proper size, neither too small so as to escape the influence of the conjunctiva, nor too large so as to prevent that influence, we find that it performs all the ordi- nary motions of the eye, even when the stump which is covered is very small. An artificial eye soon begins to suffer from the influence of the tears and mucus, so that the cornea becomes dim from the enamel losing its pohsh. It has been supposed that it is the Meibomian secretion which is chiefly detrimental. The polish is never com- pletely preserved for longer than three or four months ; and gen- erally in six months the whole surface of the enamel is rough and hazy. The rapidity with which this process goes on, varies in different individuals, depending on the peculiar qualities of the se- cretions. This is a circumstance which puts it completely out of the power of any but those in easy circumstances to use artificial eyes. Others must submit to conceal the defective eye behind a dark coloured glass, or if its appearance is very unsightly, to hide it wnth a shade. They ought never to adopt the practice of cov- ering it closely up with a piece of black plaster, which heats the eye too much, and renders the parts inflamed and cedematous. Enamel eyes which have lost their polish, prove hurtful, their roughness exciting the conjunctiva to inflammation, excoriation, and the growth of fungous excrescences. When an artificial eye, therefore, is observed to have become dim, and to be producing ir- ritation, it must no longer be used, any irritation already present must be calmed, and when the parts are again perfectly free from pain or inflammation, a new artificial eye may be applied, but it will generally be necessary to begin with a small one, as at the first. When we wish an artificial eye made expressly for any particu- lar person, it is necessary to send to the enameller a front view of the sound eye, representing accurately the colour and other appear- ances of the iris, along with a model in wood or lead of the size and form of the artificial eye which is to be made, taking the con« 437 vexity of this model from the sound eye, and marking on it the place and size of the iris and pupil. The drawing and models ought to be kept by the enameller, so that at any future time the patient can have an eye made after them, and sent to him, without further trouble. In the use of an artificial eye, the strictest regard to cleanliness must be observed. Every twelve hours the eye must be taken out and freed from the mucus which adheres to it, and accumulates in its cavity. The eyelids and orbit must at the same time be bathed with tepid milk and water, and should there be any considerable relaxation of parts, with a tendency to puro-mucous inflammation, a slightly astringent collyrium may be employed, the lunar caustic solution apphed to the conjunctiva at bedtime, and the edges of the lids smeared with a httle red precipitate salve. CHAPTER XIII. PARTIAL AND GENERAL ENLARGEMENTS OF THE EYEBALL ; EFFUSIONS AND TUMOURS WITHIN ITS COATS. SECTION 1. CONICAL CORNEA,* In some individuals, the cornea, as appears to have been first ob- served by Leveille, the French translator of Scarpa on the Diseases of the Eye,t instead of its natural spherical shape, presents the form of a cone, more or less acute. Viewed from one side, the cornea in this state looks like a solid piece of glass, projecting from the front of the eye. The cone in some cases is pointed, in others, al- though it projects more, its apex is rounded off. The apex of the ~cone is generally in the centre of the cornea, but sometimes to one side of it. In certain positions of the eye, the point of the cone ap- pears less transparent than the rest of the cornea, and in some cases is actually nebulous or opaque. On placing the patient directly opposite to a window, the projecting centre of the cornea, instead of transmitting the light, reflects it with such force as to produce a sparkling effect. As this takes place precisely in front of the pupil, which is of course contracted from the direct exposure to the light, it necessarily follows, that the patient can distinguish objects only confusedly. He probably sees them as a person with a healthy eye would do, when looking through a plano-convex lens. In the early periods of tliis disease, short-sightedness is the prin- cipal effect which it produces on the vision ; when more advanced, nothing is seen by the patient through the centre of the cornea ; all the sight which he enjoys is either over the nose or towards the * Staphyloma pellucidum. t Traite Pratique des Maladies des Yeux. Tome ii. p. 179. Paris, 1802. 438 temple, and ia its sphere is extremely limited. Still, however, by strongly compressing the eye with the half-closed lids, and liringing the object close towards one or other side of the eye, generally toward the temporal, the patient is sometimes able even to read. Beyond two or three inches, vision becomes very indistinct, and at a few feet, the patient, in general, can judge neither of the dis- tance nor form of objects, so that he is rendered nearly as dependent as if he were totally blind. One of Mr. Wardrop's, patients, with conical cornea, observed that when she looked at a luminous body at a distance, such as a candle, it was multiplied five or six times, and that all the images were more or less indistinct.* This, I beheve, is generally the case in conical cornea. When Dr. Brewster examined the eye of Mr. Wardrop's patient, he observed, that in every aspect in which the cornea could be viewed, its section appeared to be a regular curve, increasing in curvature towards the vertex ; a form, he remarks, which could produce no derangement in the refraction of the incident rays. As the disease was evidently seated in the cornea which projected to an unnatural distance, it did not seem probable that there was any defect in the structure of the crystalline lens. He was, therefore, led to believe, that the broken and indistinct images which appeared to encircle luminous objects, arose from some emi- nences on the cornea, which could not be detected by a lateral view of the eye, but which might be rendered visible by the changes which they induced upon the image of a luminous object that was made to traverse the surface of the cornea. He, therefore, held a candle at the distance of fifteen inches from the cornea, and keeping his eye in the direction of the reflected rays, observed the variations in the size and form of the image of the candle. The reflected image regularly decreased when it passed over the most convex parts of the cornea ; but when it came to the part nearest the nose, it alternately expanded and contracted, and sutfered such derange- ments as to indicate the presence of a number of spherical eminences and depressions, which sufficiently accounted for the broken and multiplied images of luminous objects. Mr. Wardrop states, that Dr. Brewster had afterwards examined a great variety of cases of conical cornea ; and that in all of them, without exception, he had detected inequalities in the superficial conformation of the cornea. It does not appear to have been yet ascertained by dissection; whether the cornea in this disease is merely protruded into the conical form which it assumes, or actually thickened, so that the cone is solid. The external appearance would certainly lead us to think that the latter was the case ; and accordingly Sir WiUiam Adams has described this disease as a morbid thickening and growth of the substance of the cornea. f Mr. Wardrop, however, states that the irregular portion at the apex of the protrusion which * Morbid Anatomy of the Human Eye. Vol. i. p 131. London, 1819. t Journal of Science and the Arts. Vol ii. p. 403. London. 1817. 439 is sometimes clouded and opaque, is generally very thin ; and that in one case, a gentleman with this disease receiving a blow on the eye, the cornea burst. This disease generally begins first in one eye, and after a time attacks the other also. It has been met with in almost every stage of life : like common short-sightedness, it appears most frequently about the time of puberty, or at least advances rapidly about that period. In one instance, Mr. Wardrop met with it in a boy of eight years of age. Sir W. Adams had seen it in patients from 16 to 70 ; much more frequently, however, in women than in men, and in young tban in old persons. The progress of this disease is unattended by inflammation, pain, or feeling of distension. It is not likely that it depends on any pressure of the aqueous humour. More probably it is an effect of some inordinate or irregular action of the nutrient vessels of the cornea itself Treatment. It is generally agreed that evacution of the aqueous humour is of no use in this disease. Pressure, astringents, and all other local means, appear also to have failed in arresting its pro- gress. Mr. Travers says he has found repeated blisters, and the more powerful tonics, as steel or arsenic, decidedly serviceable.* As it is evident, however, that he confounds conical cornea with aqueous dropsy,t it is impossible to know whether the benefit accruing from these remedies occurred in the former, the latter, or both of these diseases. The same author states, that the confusedness of vision is greatly lessened by the patient's looking through an opening of the size of the pupil, formed in a piece of black wood, and of about a quarter of an inch or more in depth. This affords more aid in correcting vision than any form of lens. Indeed, notwithstanding Dr. Brewster's opinion, that the injuiious effects of this disease upon vision may, within certain limits, be removed by glasses, and by preventing the image from being formed by rays passing through any part of the corrugated surface of the cornea, such as he dis- covered in Mr. Wardrop's case, I have never learned that any patient has actually derived the slightest benefit from concave or other glasses. Sir W. Adams, from the opinion which he had adopted, that the conical form assumed in this disease was the effect of a morbid growth of the cornea, and that the short sight of the patient was to be attributed to the increased refractive power of the part, which, together with that of the crystaUin^ lens, brought the rays of light to a point far short of the retina, suggested, that as it was impos- sible to remove the morbid state of the cornea, without rendering it unfit for the transmission of hght, a useful degree of vision might * Synopsis of the Diseases of the Eye, p. 286. London, 1820. + Ibidem, p. 124. 440 be restored by removal of the crystalline lens. His opinion in favour of this plan was confirmed by what happened in the case of a woman of nearly seventy years of age, vviio placed herself under his care, labouring under this disease accompanied with cataracts. These he successfully removed, and had the gratifica- tion to find that the patient was capable of seeing much more dis- tinctly without convex glasses than it is usual for those to do who have undergone the operation for cataract. The favourable result of this case determined him, at the earliest opportunity, to try the effect of removing the crystalline lens, as a remedy for blindness produced by conical cornea. A favourable case presented itself the following year, in a young woman, who, during six years had found her sight gradually decreasing, and at the expiration of that period, became so blind, from this disease, as to be unable to continue her employment as a servant. The cornea of each eye had assumed the conical form in a great degree, attended b}^ a slight opacity in the apex of each cone, but none whatever in the crystalline lens. She could walk without a guide, and could see at the distance of three or four feet, so as to avoid running against any person, but had entirely lost the power of reading or perceiving minute objects, however near to the eyes. Sir William effected the removal of the crystalline lens of one of her eyes, by the operation of division. The patient, however, re- turned to the country before the eye had entirely recovered from the operation, and Sir William did not again sfee her until nearly twelve months afterwards, when he was in the highest degree gratified to find her capable of discovering minute objects, and reading the smallest sized print, without the assistance of a glass, while holding the book at the usual distance of ten or twelve inches from the eye. The usual cataract spectacles for near objects, of two inches and a half focus, confused her sight nearly in the same manner as it had been before the crystalline lens was removed, while with those of nine or ten inches focus, her capability of seeing minute objects was somewhat improved. Objects at a distance she saw better without than with any glass which could be found. I am ignorant whether the plan of obviating the effects of con- ical cornea, by removal of the crystalline lens, has been tried by any other oculist. SECTION II. HYDROPHTHALMIA. OR DROPSY OF THE EYE. Dropsical affections of the eyeball sometimes depend entirely on local causes ; in other cases, they are connected with some cachec- tic state of the system, as the scrofulous, or that which attends chlorosis. Rarely does it happen that hydrophthalmia either forms part of a general dropsy, or is combined, in point of origin, with any other local dropsical affection. 441 1. Dropsy of the Aqueous Humour Is the most common variety of hydrophthalmia. Following an injury of the eye, or of the surrounding parts, (blows, for example, on the edge of the orbit, or lacerated wounds of the eyelid and eyebrow), it is generally hmited in its extent, and combined with a paralytic and tremulous state of the iris, and partial amaurosis. But when constitutional in its origin, it sometimes proceeds till the anterior chamber is greatly dilated. Symj^toms. 1, At first, the cornea is merely more prominent than natural, but after a time, it evidently increases in diameter. This increase may even go on till the cornea is twice, thrice, or four times its natural size, before it bursts, and before it loses much of its transparency. It always appears in advanced cases a little cloudy. 2. The iris loses its motion, even from the commencement of the disease, and always appears darker than it should be. The pupil is generally in the middle state between contraction and dila- tation. In some cases, its edge is bent back towards the lens, so that the iris presents the form of a funnel. 3. The patient complains of pressure and distension in the eye ; scarcely ever of pain. 4. In the commencement, the eye is unnaturally far-sighted, but this changes into an amaurotic weakness of sight, never reach- ing to complete blindness. 5. The motions of the eye are performed with more and more difficulty, in proportion as it increases in size. It at the same time becomes harder to the feeling, and the sclerotica, necessarily forced to partake in the extension of the cornea becomes thin, and blue, as in young children. Causes. Except when this disease results from such injuries as have already been mentioned, its causes are obscure. The sudden suppression of cutaneous eruptions has been mentioned as a cause. Prognosis. Arising from any cachexia, this disease is apt to degenerate into general dropsy of the eye. When it originates in any more limited cause, as an injury, or the suppression of an erup- tion, it never has been observed to go the length of bursting the cornea, and may frequently be cured. Treatment. 1. When this affection of the aqueous humour is the result of an injury, much advantage will be derived from a suc- cession of blisters to the temple, and behind the ear ; and from the use of mercury combined with purgatives. 2. When this disease forms part of a general dropsical affection, or appears to depend on the same cause as any other local dropsy present at the same time, diuretics may be employed with some hope of success. In other cases of hydrophthalmia, they are of no avail. 3. If the suppression of an eruption, especially one to which the 56 442 patient has long been subject, and which has been attended by a discharge, be tlie suspected cause, the "xcitement of an artificial eruption, by friction with tartar emetic ointment, is plainly indicated. 4. In the incipient stage, and especially when the disease is of local origin, friction round the eye with mercurial ointment has been found useful. 5. If the disease is advanced, and vision much affected, but the sclerotica not yet aiscoloured from partaking in the distension and extenuation of the front of the eye, paracentesis oculi ought to be employed. An incision may be made at the low^er part of the cor- nea, two lines long, and at the distance of half a line from the sclerotica. Beer recommends, not merely that an evacuation of the aqueous humour should be made in this way, buu that the wound should be re-opened every day, for a number of successive days, or even w^eeks, so that the aqueous cavities may be maintained in a void state. More than once, he had observed general remedies to have a good effect after this operation, although they had had none before. If it is not successful in curing the disease, it proves at least an excellent palliative ; and if too large an opening is not made, may be frequently repeated with temporary advantage. 2. Sub-Sclerotic Dropsy. As the internal surface of the sclerotica is connected by fine cel- ular membrane to the external surface of the choroid, and as nu- merous vessels and nerves pass bet^veen these tunics, it is evidently incorrect to talk of any serous cavity existing betw^een them. Thin fluid, however, may accumulate there, constituting what we may term sub-sclerotic hydrophthalmia. The symptoms of this disease wHll in some respects resemble those arising from a dropsical effusion betv/een the choroid and the retina ; and will, like them, derive relief from the operation of punc- turing the eye, and allowing the collected fluid to escape. 3. Suh-Choi^oid Dropsy. I have already* had occasion to state, that a Avatery effusion be- tween the choroid and the retina, is by no means an uncommon result of inflammation of the former of these membranes. I need not repeat what I have said regarding the symptoms of choroiditis, which in general will be found to have preceded, or to accompany, sub-choroid h yd roph th almia. Examples cf this disease, in which it had proceeded so far as to cause the absorption of the vitreous humour, and the compression of the retina into a cord extending from the optic nerve to the back of the lens, have now been described by many observers.! The t See page 382. t Zinn, Descriptio Anatomica Oculi Humani, p. 25, Gottingse, 1780. — Scarpa delle Malattie degli Occhi, Vol. ii. p. 172. Pavia, 1816. — Ware's Observations on the TreatrL-^nt of the Epiphora, &c. p. 284, London, 1818. — ^Wardrop's Morbid Anatomy of the Human Eye. Vol. ii. p. 65. London, 1818. 443 progress of the dropsical effusion, and the symptoms by which it is accompanied, are by no means ahke in all cases. When the ac- cumulation takes place ;^lowly, the loss of vision is gradual, and the attending pain and redness are not severe. In other cases, the water is collected quickly, and is accompanied with great pain in both the eye and head ; the choroid, pressing against the sclerotica, produces the extenuation of the latter, while the eyeball undergoes either a general or partial enlargement ; the pupil becomes dilated and sometimes displaced ; and when the disease is far advanced, there appears an opaque body behind the pupil, which is nothing else than the retina compressed into a cone, the apex of which is at the entrance of the optic nerve, while the basis surrounds the crys- talline lens. Mr. Wardrop mentions, that in one instance this ap- pearance was mistaken for cataract, and an attempt made to couch it ; a fruitless operation which gave great pain.* Treatment. In suspected cases of sub-choroid hydrophthalmia, there can be no doubt of the propriety of following the practice of Mr. Ware, and puncturing the eye at the usual place of passing the cataract needle through the sclerotica and choroid. Mr. "W. recommended a grooved needle for this purpose, so that the fluid contained between the sclerotica and choroid might more certainly- escape. Care must be taken in making the puncture, to direct the point of the instrument, so that it may not wound the poste- rior part of the crystalline capsule. The operation may be re- peated from time to time should the symptoms seem to demand it. The first case related by Mr. Ware, affords a good example both of the disease and of the relief afforded by paracentesis. The pa- tient, a lady of about 45 years of age, perceived first of all a dimness in her left eye, the cause ot which she was not able to assign. She supposed it to have been the consequence either of taking cold, or of the cessation of a discharge from one of her legs, to which she had been subject for a considerable time. The dimness was dis- covered accidentally, on her attempting to see an object with the left eye whilst the right was shut, and in a short time the sight af- forded by that eye rendered her no assistance ; objects when placed straight before her being invisible, and their appearance, when re- moved to the outer side of the axis of vision being obscure, and indistinct. The eye had not altered its apoeaiance in any respect, the pupil being neither cloudy nor dilated. In December 1804, about two years after the dimness was first perceived, she began to feel pain in the eye, and it became slightly inflamed. Although the inflammation never appeared to be considerable, the pain rapid- ly increased to a most violent height, affecting, in a few days, both the eye and the head, and proving particularly severe during the night. The pupil, now for the first time, became dilated, and had a misty appearance ; but the degree of opacity was very insufficient to account for the total loss of sight. * Morbid Anatomy of the Human Eye. Vol. ii. pp. 67, 274. London, 1818. 444 Leeches, blisters, fomentations \vith poppy heads, and a free use of opium internally, were repeatedly tried, but did not afford any relief The internal employment of the muriate of mercury was equally ineffectual. The progress of the disorder, and the state of the patient at this period, closely resembling those of another pa- tient, in whose eye, after death, Mr. Ware had found a sub-choroid collection of thin fluid, with coarctation of the retina, led him to think that the violent pain which this lady suffered might depend on a similar state of the eye. It also occurred to him that if the effused fluid could be discharged, it might be a means of affording relief The operation seemed neither impracticable nor difficult, and the patient readily acceded to submit to it, as indeed she would have done to any operation, whatever might have been its hazard, so extreme was the pain she at that time endured. Mr. Ware in- troduced a common spear-pointed couching needle through the scle- rotica, a littleforther back than where it is usually introduced for the purpose of depressing a cataract. As soon as the instrument entered the eye, a yellow fluid immediately escaped, sufficient in quantity to wet a common handkerchief quite through. The needle was kept in the eye about a minute, in order to afford the fluid a more ready exit : and as soon as it was withdrawn, the discharge ceased. The tension of the eye was considerably diminished by the ope- ration. A compress dipped in a saturnine lotion was bound upon it, and the patient put to bed. She continued in pain about ten minutes, but then fell into a sound sleep, which lasted upwards of two hours ; and on awaking, her eye was quite easy. The compress was again moistened with suturnine lotion, and she took some nour- ishment. She passed the next night very comfortably, without the assistance of laudanum, although previously it had been given her in large doses. The same application was continued to the eye, which afterwards remained perfectly easy, with scarcely any ap- pearance of inflammation. The pupil continued delated, but did not become opaque. About three weeks after the operation, the patient caught a cold, and complained that the eye felt more ten- der than usual. Mr. W. was alarmed lest a fluid might again be effused in the old place, and the pain return ; but this was happily prevented by the application of a blister on the side of the head. 4. Dropsy of the Vitreous Humour. Beer has described this disease as characterised by the following symptoms. 1. An increase of size, chiefly in the posterior part of the eyeball ; the eye assuming the form of a cone, the cornea being pushed forwards without undergoing any other change. 2. The aqueous humour diminished m quantity, and the iris • Remark on the Ophthalmy, &c. p. 233. London, 1814. See also Ware's Ob- servations on the Cataract, and Gutta Serena ; p. 443. London, 1812. 445 pushed forwards into contact with the cornea ; the iris not changed in colour, nor the pupil extremely dilated. 3. The sclerotica from distension assumes a deep blue colour. 4. At first, short-sightedness, soon followed by weakness of sight, and then by complete amaurosis, so that not even the least sensi- hility to hght remains. 5. The movements of the eye are much sooner impeded than in aqueous dropsy. The eye becomes extremely hard, and altogether motionless. 6. There is pain in the eye from the very commencement. It daily increases in violence, and spreads to the half of the head, to the teeth, and to the neck. At last the patient becomes almost mad with the pain, and calls upon the surgeon to evacuate the contents of the eye. Beer saw a man who did this for himself with his penknife. Even when the pain is comparatively mode- rate, the patient's sleep and appetite entirely fail. 7. Allowed to go on without interruption, the enlarged eyeball presses upon the walls of the orbit, and induces caries. Causes. These are equally obscure as those of the dropsy of the aqueous humour. The scrofulous or syphilitic cachexia is blamed, or a union of both is sometimes suspected. Treatment. General remedies may be directed against the particular cause which is supposed to give rise to the disease ; but most relief is derived from diminishing the quantity of the vitreous humour. This may be attempted by puncturing the sclerotica and choroid, as in cases of sub-choroid dropsy. Should this fail, the mode recommended by Beer will require to be adopted ; name- ly, to make a section of the cornea, as in the operation of extrac- tion, and evacuate the lens and part or the whole of the vitreous humour, after which the coats of the eye gradually shrink to a small size. 5. General Hydr ophthalmia. Both the aqueous and the vitreous humour may be increased in quantity at the same time, so that the whole eye is greatly en- larged, in which state the name hwphthalmos has been bestowed on it, from its resemblance to the eye of an ox. This disease presents a union of the symptoms of the first and fourth varieties of Hydrophthalmia, as far as they can co-exist. The pain is excessive. The motion of the eye is lost. The pa- tient is deprived of sleep, appetite for food, and at last even of reason. Caries of the orbit takes place, if the case is neglected ; and the patient dies, worn out by fever, before the eye gives way. Beer had met with this disease only in extremely cachectic, and especially scrofulous and scorbutic subjects. Evacuation of the contents of the eye must be had recourse to, as in the vitreous hydrophthalmia ; or, if the eye be disorganized by inflammation, as well as enlarged by dropsy, it may with pro- priety be extirpated. 446 SECTION III. SANGUINEOUS EFFUSION INTO THE EYE. , Effusion of blood into the aqueous chambers frequently follows a blow on the eye. iSmaller quantities of blood are sometimes seen to accompany hypopium, especially that which arises from the bursting of an abscess of the iris. Wounds of the iris are gen- erally attended by a discharge of red blood ; and the same is ob- served when the iris is torn from the choroid, either accidentally or for the purpose of forming an artificial pupil. Blood is also occa- sionally effused into the substance of the cornea, in consequence of inflammation. To such cases as these, I do not mean at present to direct the attention of the reader ; but to an internal haemorrhage of the ej'e, which appears neither to arise from injury, nor to depend altogether on inflammation, and which sometimes has been spoken of under the name of apoplexy of the eye. As the recorded instances of this disease are ver}^ few in num- ber, 1 shall quote two of the most interesting of them. They will serve to illustrate the symptoms of this remarkable affection much more completely than I could pretend to do by any general des- cription. The first case w^iich I shall quote is by Mr. John Bell, and affords an example of this disease occuning in an eye previously healthy. " Mr. A . though not yet twenty years of age, is more than six feet high ; and three j^ears ago^ when first he was struck with this singular kind of iDlindness, was growing so rapidly, that he actually believes he gained five inches in the year. He was then a stripling, and is now tall, slender, and delicate in his constitution, though remarkably well formed, and destined to become a strong and muscular man. Early in the month of September, 1803, on the day in which he wms first attacked with this blindness, he had his hair cut early in the morning, he ate very heartil)^ a hurried dinner, when, a companion having called while he was yet at table, and proposed a party in a house at some distance, he went with him, and, being mere lads, and in a playful humour, his friend ran, and he pursued at full speed, for the space of three or four liuudred yards ; he instantly was sensible of his sight being dim, in the left eye : he disregarded at first a feeling which he imagined to be temporary, but, having arrived at the house, and sat down, he was alarmed to find his vision still more obscure, and, turning round to those who were in company, he asked whether they perceived any thing wrong in his eye ; they said there was blood upon it ; upon looking into a mirror he saw the blood, found himself totally blind of the left eye, was assailed with dreadful pain : the bloody effusion took place, the blood be- came visible, and the vision was entirely obscured in the short space of fifteen minutes ; then the violent pain began, a conse- 447 quence plainly, and not a cause of the blindness, and for ten days he continued entirely blind of that eye. " His vision was gradually restored, by the blood which had filled the whole of the anterior chamber of the eye, subsiding below the level of the pupil : the blood was still visible in the lower part of the eye, and continued so for three weeks ; it gradually van- ished, and the eye recovered its wonted appearance, except that, in the very lowest part, under the level of the pupil, there remained a little white matter, viz. the gluten of the effused blood. Such was the first attack of the disorder, from which he continued free for the space of six months. "In the month of May, 1804, one evening while sitting at sup- per, not conscious of any previous excitement, from violent exercise or exposure to heat, but probably affected by the supper, wine, light, and heat, and animated conversation, he suddenly perceived the obscurity coming over his vision, the blood again appeared in the chamber of the eye, which was next morning affected with violent pain : yet this was in all respects a less severe paroxysm than the first. " Little more than a month had elapsed, when having, in the warm month of June, gone into the river to bathe, he was in the act of swimming, and just when coming out of the water, struck with this obscurity of vision. The blood instantly came over his eye, which, on the ensuing day was affected with most excruci- ating pain, extending to the temple ; but in three weeks or a moni h, his sight was completely restored, and the eye had recovered its natural splendour and cleanness. In the end of September, or beginning of October, he was again attacked, though he was con- scious of no excess, ^nd was quiet, regular, and discreet in his way of living ; he was seized while writing, and recollects no sen- sible cause to which the paroxysm could be ascribed, unless it were to the hanging of the head and straining of the eye. The sight was obscured, the blood appeared again in the chamber of the eye, the pain returned, the blood was absorbed again within the usual period, and the sight was in course restored. " It was on the first of November, in walking across the bridge at night, betwixt ten and eleven o'clock, that he sustained the fourth attack, but without such total loss of vision, or so much effusion of blood as heretofore, and certainly the blood was not so long of being absorbed, nor was he so long obliged to cover the eye from the light : in eight or ten days he was able to uncover the eye, the appearance of suffusion of blood was gone, but the lym- phatic coagulum, occupying the anterior chamber of the eye, was manifestly accumulating. On the 3d of February, 1805, he had a like paroxysm, arising from very obvious causes ; being a day of election of Member of Parliament for this city, his regiment was marched out of town to the distance of eighteen miles ; and both in matching out to the temporary quarters allotted for his regiment, 448 and in returning, he walked along with the men, was greatly heated by the exercise, and very naturally refers this attack to a cause so expressly resembling that which first gave rise to his malady, that it could not fail to attract his particidar notice. ' From this time.' says Mr. A , ' these paroxysms became pe- riodical, and seemingly spontaneous ; they returned once a month, the eye was kept in a state of constant irritability and frequent pain, so that I was forced to have it constantly covered from the light ; 5'et no circumspection in this respect, nor in my habits of living seemed to avail me. '• ' Of the few paroxysms which I am able to particularize, as aris- ing from any obvious excitement, one was on the morning after our review, in the month of August last, when, after being in the field, we sat down to a dinner of ceremony, and drank late ; I must have exceeded, but am not conscious of having been intemperate ; I went to bed, perhaps a little heated with wine, I rose earl}^ in the moi'n- ing to go upon guard, and, in the act of dressing, and especially in stooping to wash my face, 1 Avas sensible on the instant of the effu- sion of blood, and the return of the blindness.' The second memo- rable occasion was still more particular in the circumstances, the excitement more marked than any, and explaining all of th€ others: Mr. A had gone abroad to a supper party of young people, where a most unusual degree of hilarity prevailed, some very ludi- crous songs were sung, and he joined the general mirth, and laughed immoderately, and so long, that in the end he saw the candlea dim, and, in a moment, found his eye quite suffused with blood. " This gentleman's disease has now taken a most decided form ; it returns sometimes once a fortnight, sometimes once a month, seldom do two months elapse without a new effusion of blood ; and it returns with a degree of regularity almost periodical. The sen- sibility of the eye is such, that he is obliged to keep it always shad- ed ; and each new effusion of blood is now followed by a paroxysm of pulsatory pain in the temple of the side, with an intolerable throbbing, something betwixt general headach, and pain of the affected organ, a pain v/hich is in some degree relieved by steady and continued pressure. Sometimes, as you will learn from the narrative, the excitement is sensible, and the cause of it such as in strict prudence he should have avoided, but is often too slight to be observed ; now the effusion returns always, or almost always, with- out an express or sensible cause, from a predisposition so strong, that he is come to a conviction, that laughing, crying, singing, running, swimming; stooping, excess in wnne, or any of those causes which have at former times plainly produced this effusion, would cause it instantly to return. "It must seem very surprising, that an organ so delicate as the eye should be able thus to sustain repeated effusions of blood, with- out having its structure entirely ruined ; but the resistance of its strong coats, filled and tense with its own humours, plainly has its 449 effect in limiting' the bloody effusion, yet the additional tension is such, as occasions that violent pain which is excruciating even on the first, and at its acme, the second day after the effusion has taken place. That the extravasation is of pure blood, which keeps its properties unaffected by the dilution with the aqueous humour, is both sensible to sight, and proved by the solid white coagulum, which each successive effusion leaves behind.* ******* Its form is in no degree changed ; if there were the slightest reason to apprehend any alteration of bulk or form, it is from the eyelid being drawn down, and that somewhat obliquely over the eye, so as to cover much of the cornea, or coloured part, and exposing chiefly the inner side and lower part of the eye, where the coagulum lies. The blood of its proper purple colour obscures the whole ; the pupil is not to be seen, the coagulum which, in consequence of its bulk, is very thinly covered with the blood, is almost white, and occupies all the lower part of the anterior chamber of the aqueous humour, and the space betwixt the low^er half of the iris and the cornea, covers some part of the pupil, and has, I fear, irremedia- bly injured the vision, which yet is not extinct ; but strict regimen, profuse evacuations, a seton in the nape of the neck, and opiates to appease the sensibility of the eye ; an abstemious, quiet, and regu- lated course of life, will, I hope, prevent futui'e effusions ; and when his growth is ascertained, and these paroxysms of local arterial ac- tion are abated, I hope that much of this coagulum will be ab- sorbed."* The following case, communicated by Dr. Houttuyn of Amster- dam, to the Royal Academy of Sciences, affords an instance of hae- morrhage, which, although not expressly stated to have been into the cavities of the eye, I presume was so,t the haemorrhage being complicated with other diseases of the organ, and going to a much greater length than in Mr. Bell's case. A physician, of 58 years of age, originally possessed of good sight, but which had become somewhat impaired by frequent employment of the microscope, was surprised one morning, on getting out of bed, to find that he scarcely saw any thing with the left eye, although he felt no pain in it. The weakness of this eye continued to in- crease during the space of a year ; at last it ceased entirely to per- form its function, without any thing being extraordinary in its ap- pearance. The case was regarded as one of amaurosis. In about a year after this, the eye. appeared to be affected with a kind of cataract, which formed a white round spot in the pupil ; this spot, at the end of three months, changed colour, becoming yellowish, and then of a bluish green ; in a word, it assumed the characters of glaucoma, and remained in that state during two years and a half, without the patient suffering any pain. At the * Principles of Surgery, "Vol. iii. p. 270. London, 1808. t Dr. Voigtel and Mr. Wardrop have come to the same conclusion regarding this case. 57' 450 end of that period, and towards the termination of the month of June, while occupied in his garden, gathering hyacinth roots, with his back turned towards the sun, he was seized with inflammation in the diseased eye. From this he soon recovered ; but some days after, he felt the eye suddenly swell up, till it appeared to him of the size of a hen's egg. This sudden distension, the exact nature of which Dr. Houttuyn leaves undecided, was accompanied by acute pain. Some drops of fluid, which the patient found running from the nostril, led him to blow his nose, which occasioned a dreadful noise in the head, and rendered the pain of the eye still more severe. At the same moment there began to flow from the inner canlhus of the eye, a small stream of blood ; the pain then diminished, and soon ceased entirely ; but the haemorrhage con- tinued for two hours, and he lost from five to six ounces of blood. In six weeks he had recovered from the immediate effects of this accident, but the eye had shrunk to a very small size.* SECTION IV. FUNGOUS EXCRESCENCE OF THE IRIS. In the seventh, eighth, and ninth sections of Chapter IV. I have described certain excres'cences and tumours of the membrane hning the eyelids, and investing the anterior third of the eyeball, which, in general, will easily be distinguished from the diseases which originate in or within the proper tunics of the eye. Mr. Ijawrence mentioned in his Lectures,t that he had seen a young boy, who had an apparently simple, fleshy, and vascular growth proceeding from the iris. It had caused ulceration of the cornea, and thus protruded externally. As the patient hved in the country, Mr. L. did not witness the termination of the case, but he was informed that the tumour after a time subsided, and that the eye shrunk in the socket. Maitre-Jan relates an interesting case of a soldier, whose eye was completely covered by a fleshy excrescence, which he com- pares to a mushroom, and which projected even from between the eyelids. He destroyed it by the repeated application of one part of corrosive sublimate with four of dry crust of bread, after which he discovered that its root was narrow, forcing its way through an ulcer of the cornea, and arising from the iris. Under the continued use of escharotics, the front of the eye sloughed, and the lens and vitreous humour were evacuated, after which the pain ceased, and the ulcer cicatrized.t ♦ Histoire de 1' Academic Royale des Sciences, pour 1769, premiere partie, p. 86. Paris, 1777. + Lancet; Vol. x. p. 514. London, 1826. t Traite des Maladies de I'CEil ; p. 456. Troyes, 1711. 451 SECTION V. SCIRRHUS OP THE EYEBALL. The eyeball is subject to at least three malignant affections ; namely, scirrlius^ medullary fungus^ and melanosis. Leaving out of view, for the present, the last of these diseases, which is comparatively rare, and has only of late attracted particu- lar attention, I am led, from what I have seen of the malignant diseases of the eye, to say, that the first of the three is slow in its piogress, never ends in any tumour of a very large size, and, upon extirpation, so far from presenting any thing like a fungus, or like medullary substance, is found extremely firm, and of such a fibrous or striated texture, as to merit the name of scirrhus. This degen- eration of the eye I have never met with except in adults con- siderably advanced in life, and more frequently in women than in men. In the second of the three diseases above enumerated, the tu- mour, after bursting through the fore-part of the eye, advances with great rapidity, and often reaches an enormous size ; it presents a spongoid, or fungous texture, becomes attended at last by frightful haemorrhage, and is found on dissection, to consist of a brownish- white substance, almost entirely destitute of fibres, and which may be compared, in point of consistency and general appearance, to brain. This kind of tumour I have met with both in children and in adults, but much more frequently in the former. Extirpation of the eye is sometimes attended with complete suc- cess in the first set of cases, although even in these there is a dan- ger of scirrhus afterwards attacking the eyelids or the cellular sub- stance of the orbit. In the numerous cases of the second kind, which have come under my observation, the operation of extirpa- tion has never been attended by permanent success ; a fatal re- production of fungous excrescence from the optic nerve has invari- ably followed, and generally within the period of a few months. The patient with scirrhus of the eyeball has always a history to give us of Jong-continued inflammation in the eye, originating in many cases from cold, supervening in females about the time of life when menstruation ceases, attended by racking pain in the eye and head, and soon followed by dimness of sight, and at length by total blindness. To these symptoms we find that there has suc- ceeded a deformed and indurated state of the eye, the cornea having become opaque, misshapen, and shrunk, the sclerotica of a dirty yellow colour, and irregularly prominent, the external blood vessels varicose, and the conjunctiva sometimes thickened, or even tuber- culated. The eye is affected with sensations of itchiness, burning heat, and lancinating pain, is overflowed with tears on the least exposure, and is unable to bear the slightest touch. Severe hemi- crania, aggravated during the night, totally prevents sleep, deprives the patient of all desire for food, and renders him unfit for any continued employment of body or mind. One of the most remarls- 452 able characteristics of this disease is the length of time during which it may continue without affecting the neighbouring parts, or advancing to ulceration. At last, however, the eyelids and cel- lular membrane of the orbit are involved in the carcinomatous in- flammation, the lids become swoln, red, and indurated, the eyeball is no longer capable of motion, the lymphatic glands of the face and neck become enlarged and painful, the conjunctiva begins to ulcerate, and discharges a thin acrid matter, the ulcer spreads ,and grows deep, one part after another is destroyed as in cancer of the eyelid,* till the patient is gradually worn out by fever, pain, anxiety, and inanition. If the eye is extirpated before the disease is allowed to proceed to such a length, the sclerotica, especially near the optic nerve, is found greatly thickened, hard, almost cartilaginous, and, on being divided with the knife, presents the whitish bands, which are deemed diagnostic of scirrhus ; the muscles of the eye are similarly affected ; the eyeball itself is misshapen, in some cases shrunk, in others enlarged ; its natural contents are absorbed, or if any por- tion of them remain, they are with difficulty recognised ; while a whitish or yellowish substance, of less firm consistence than the sclerotica, but like it divided by membranous septa, occupies the place of the vitreous humour. Prognosis and Treatment. Neither any internal medicine, nor external application appears to have the slightest power to arrest the progress of this disease. Its nature is intractable ; but from the slowness of its course, many years may elapse before it proves fatal. In the early stage, that is to say, so long as the disease appears to be confined to the globe of the eye, and this remains movable in the orbit, extirpation ought to be had recourse to, and may be urged as a means highly likely to be successful. If the conjunc- tiva, eyelids, or orbital cellular membrane be in any degree affected, removal of the parts cannot be so confidently recommended, on account of the liability of the disease to return. Still, the opera- tion ought to be adopted, unless we have reason, from the com- pletely fixed state of the eyeball, strongly to suspect that its mus- cles, the whole cellular membrane of the orbit, and perhaps even the periosteum, are involved in the scirrhous degeneration. Should the patient refuse to submit to extirpation of the eye, or should it appear to the surgeon, either from the state of the gene- ral health, or the advanced stage of the local affection, that it would be improper to propose an operation, palliatives must be used to mitigate the pain, and lessen the constitutional disturbance. Much may be done in this way by careful attention to the state of the bowels, the observance of a mild and nourishing diet, and the avoidance of whatever over-fatigues the body, or irritates the mind. * See page 121, &c. 453 Narcotics are to be had recourse to, first of all externally, as in fo- mentations and the like ; and should such applications fail, opium may be administered in clyster, or by the mouth. In advanced cases of ulcerated cancer of the eye, large doses of the preparations of opium are absolutely necessary, to relieve the sufferings of the patient. SECTION VI,—- SPONGOID OR MEDULLARY TUMOUR OF THE EYEBALL. The disease described by Professor Burns, under the appellation of spotigoid inflammation* afterwards by Mr. Hey, under that of fungus hcematodes, t and which has been known also by the names of medullary sarcoma and soft cancer, X not unfre- quently attacks the eyeball. A case of this kind, in which the «ye was extirpated by Mr, Hunter, was described as early as 1767.§ Mr. Hey also expressed his opinion, that, if he did not mistake, this disease not unfrequently affected the globe of the eye, causing an enlargement of it, with destruction of its internal organization ; and that if the eye were not extirpated, the sclerotica burst, a bloody sanious matter was discharged, and th-e patient sunk under the complaint.il Mr. Wardrop, however, was the first to prove, by numerous cases and dissections, that in this opinion Mr. Hey was perfectly correct.*!! Sym^ptoms. This disease presents three distinct stages. In the first, or incipient stage, the exterior form of the eye is un- changed, and the disease is perceived through the cornea and pupil. In the second stage, the form of the eye is altered, the organ is enlarged, and its tunics are ready to give way. In the third, or fungous stage, the eye has burst, and the tumour pro- trudes. \st Stage. The pupil is observed to be dilated and immovable, and behind it, deeply seated in that part of the eye naturally oc- cupied by the vitreous humour, a yellowish-coloured appearance is observed, especially when the eye is looked at from one side, ■or the patient turns it in certain directions. The light, especially when not strong, is peculiarly reflected from the bottom, or from one side of the eye, where the retina is, or ought to be, so that there is some resemblance between the eye in this state, and that ■of a cat or a sheep, reflecting the light from the tapetum of their choroid. By and by, it is quite evident that this appearance, now * Dissertations on Inflammation. Vol. ii. p. 302. Glasgow, 1800. t Practical Observations in Surgery, p. 233. London, ]803. t Abernethy's Surgical Observations, containing a Classification of Tumours, &c. p. 51. London, 1804. § Case of a Diseased Eye; by Mr. Hayes. Read August 26th, 1765. Medical Observations and Inquiries. Vol. iii. p. 120. London, 1767. Jl Op. cit. p. 283. IT Observations on Fungus Haematodes, p. 6. Edinburgh, 1809. 454 become bright like the reflection from the surface of a brass plate, and so remarkable as to attract the notice of the most casual ob- server, arises from the presence of a solid body at the bottom of the eye. Slowly, in the course of months, or it may be of years, this body is observed to be advancing towards the pupil. Its surface is seen to be more or less irregular, and partially covered with red vessels, which are supposed to be the ramifications of the central artery of the retina. As it advances, this body presses the vitreous humour and crystaUine lens before it ; the latter becomes opaque ; both are absorbed ; and the tumour touches the iris. At this point of its progress, it has sometimes been mistaken for cataract, and attempts have even been made to couch it. Still advancing, it presses the iris into contact with the cornea. The iris loses its natural colour, and becomes of a greyish or yellowish brown. This spongoid, or medullary tumour, when once it begins to shoot forwards, generally proceeds with rapidity. I have known it lie dormant, at the bottom of the eye, for nearly three years ; but in a few weeks after commencing to advance, it not only occupied the whole cavity of the eye, but dilated it to more than thrice its natural size, the first stage hurrying thus into the second. This first stage of the disease is, in general, unattended by pain or external inflammation ; but, in some cases, inflammation of the eye is the very first symptom which attracts attention. 2d Stage. By the end of the first stage, the sclerotica, around the cornea, has probably assumed a leaden colour, and the eye, fixed in the orbit, appears larger than natural. These symptoms soon become more decided, and are attended, from time to time, by smart attacks of pain and external inflammation. The form of the eye is changed. It grows knobbed at one, or several places, the sclerotica becoming extenuated, and the tumour pressing out- wards. In some cases, the eye turns very much inwards or out- wards, so that the cornea is scarcely to be seen, while the tumour pushes its way through the sclerotica, either at the temporal or nasal edge of the cornea, according as the eye is turned inwards or outwards. In other cases, we see the tumour advancing into con- tact with the cornea, between the lamellae of which, matter is at last eff"used, ulceration follows, and the cornea bursts. 3f/ Stage. The tumour, protruding through the ruptured cor- nea or sclerotica, (in the latter case covered for a while by the con- junctiva, which it pushes before it), grows with great rapidity, and assumes the appearance of a dark-red fungus, irregular on its sur- face, soft, readily torn, and bleeding profusely on the slightest irri- tation. Portions of it die and slough off" from time to time, but the general bulk of the fungus is not at all reduced. On the contrary, it increases so as to distend the eyelids to an eno: mous degree, and even to dilate or destroy the orbit, while the portion which projects from that cavity, and overhangs the cheek, sometimes ex- ceeds the size of a man's £st. 455 The lymphatic glands of the cheek and neck become enlarged, sometimes to a very great degree. The patient becomes affected with great constitutional irritation, restlessness, thirst, want of sleep, and disturbance of all the func- tions of the body ; and at length expires, exhausted by loss of blood, and worn out by hectic fever. Appearances on dissection. I have now before me an eye, ex- tirpated by the late Dr. Monteath, during the first stage of this dis- ease. Immediately after the operation, I divided the cornea and sclerotica by a crucial incision, and laid back the four flaps. The iris and choroid were entire. I divided them in Hke manner, laid them back, and along with the choroid, I found that I reflected also the retina, which, though broken, and here and there deficient, is still sufficiently entire to give a white coating to the whole internal surface of the choroid, and has evidently nothing to do in this in- stance with the medullary tumour, which occupies the whole space of the vitreous humour and crystaUine lens, and springs from the optic nerve, as from a root. The tumour, enveloped in a mem- brane similar to the hyaloid, was of the consistence of brain, and of a yellowish-white colour. The optic nerve exterior to the scleroti- ca, did not appear diseased. The subject from w"hora this eye was removed, was a child of about three years of age. In a few months after the operation, the orbit was filled with a new tumour, and the child soon after died. I carefully examined the parts, and have them now before me. The orbit was occupied by a diseased mass, sprouting from the stump of the optic nerve, and similar in texture to that which had formerly existed within the eye. I opened the cranium, and found the optic nerves, from their origin in the brain to their union, ap- parently healthy ; but from their union to the optic foramen, the nerve of the diseased side was as thick as the middle finger. By passing through the optic foramen, it was strictured as if it had been surrounded by a ligature, but instantly on entering the orbit, it again expanded, so as to fill the space between the recti. The tumour, covered by these muscles, filled the orbit so completely, that it still retains the pyramidal form of that cavity. The appearances on dissection in this disease, are very far from being uniform. They may all, however, be referred to the eflfects of a medullary growth from the optic nerve. Although the retina was tolerably entire in the case which I have just related, in general it is so completely changed, that no part of it can be detected. In the case before me, the tumour had pressed forwards from the end of the optic nerve, within the retina, in such a manner as to produce the complete displacement and ab- sorption of the vitreous humour and crystalUne lens ; but in some cases, the tumour has been known to push itself between the scle- rotica and choroid, while in other instances, the fungus has arisen from the optic nerve, before its entrance into the eye, and proved 456 destnictive to this organ, by pressure exercised on it from without. It may even happen tiiat there shall be several fungous growths, arising in succession, but latterly going on together, one perhaps behind the sclerotica, another between the sclerotica and choroid,- and a third within the retina. The sclerotica appears to suffer less from this disease than any other part of the eye. The choroid is sometimes pushed to one side by the tumour, and on dissection, appears Uke an irregularly shaped bag, containing- vitreous humour. In some cases, shreds merely of the choroid can be discovered, dispersed through the morbid growth. In other cases, portions of the choroid are increased to five or six times the natural thickness. Occasionally, no trace of this membrane appears. The humours are alDsorbed in proportion to the pressure of the tumour, and in cases where it has burst through the sclerotica or cornea, they are generally altogether destroyed. I believe that, on minute examination, it will rarely be found that the optic nerve exterior to the eye, presents a healthy structure. It will, in general, be found thicker than natural, softer, of a yellowish colour, and presenting, instead of a bundle of nervous filaments, as it ought to do, a uniform pulpy substance. In other instances, the nerve is contracted, lying loose in its neurilema, firmer than natural, and of a reddish colour. In some cases, the nerve is found to be split into several pieces, tiie morbid growth filling up the interven- ing spaces, surrounding the several portions of the nerve, and form- ing one connected mass with the contents of the eyeball. The diseased state of the nerve will in general be found to extend to that portion of it which is contained within the cranium, and in many cases, the brain itself is affected, being changed into a soft pulpy mass, and presenting cavities, either in the substance of the part which has suffered the spongoid degeneration, or around it, filled with blood. The tumour varies in appearance in different cases, but has al- ways more or less resemblance to the medullary substance of the brain, being in general opaque, v.'hitish, homogeneous, and pulpy. Like brain, it becomes soft when exposed to the aii', mixes readily with cold water, and dissolves in it : while in alcohol or acids, it becomes firm, or even hard. When the softer parts are washed away in water, or when the mass is forcibly compressed, the more solid parts remain, and are found to consist of a filamentous sub- stance, resembling cellular membrane. The consistence of the tu- mour varies, to a certain extent, in different cases, and in different parts of the same tumour, being in some as fluid as cream, in others firmer than the most solid parts of a fresh brain. In some rare in- stances, gritty particles, probably bony, have been found interspersed through the morbid growth. The colour of the tumour, although commonly that of the medullary substance of the brain, or a very 457 little darker, is sometimes redder, or even of a dark brown colour, while, in the advanced stage, it often presents portions which nearly resemble clots of blood. When the absorbent gland lying over the parotid, or any of the absorbent glands of the neck, are enlarged in this disease, they are found to be converted into a substance resembling, in every respect, that which composed the tumour of the eyeball and brain. In some cases, the glands ulcerate before death, and form a very un- healthy sloughy ulcer, but most frequently the patient dies before the skin covering them is destroyed. Mr. Wardrop mentions, that after the skin covering such contaminated glands had given way, he never observed any fungus to arise from them. On examining the bodies of those who die of spongoid tumour of the eye, the same disease is sometimes discovered in the viscera of the abdomen or thorax ; especially in the liver, kidneys, uterus, or lungs. Subjects. This disease is much more frequent in children than in adults. Out of twenty -four cases which had come to Mr. Ward- rop's knowledge, twenty of them occurred in subjects under twelve years of age. The greatest number of cases has been observed in children from two to four years old. Sometimes the disease has been met with within a few months after birth. Instances have happened, on the other hand, in which it has attacked adults, or even persons far advanced in life. The children who fall victims to this disease, are generally of a well-marked strumous constitution. Exciting Causes. In many of the cases on record, a blow on the eye is mentioned as having preceded, and apparently excited this disease. It may be doubted, however, whether the blindness of the affected eye does not render children more liable to meet with blows on that side, after which, the eye being examined, may be found to present symptoms which had previously existed, but with- out attracting attention. Diagnosis. Mr. Lawrence stated, in his Lectures, that many cases occur of changes of structure producing all the visible appear- ances of fungus haematodes of the eye, but which do not turn out to be malignant. " We have seen children at this Infirmary,"" said he, " with the appearances of fungus haematodes in the first stage, namely, the altered colour of the pupil, the metallic reflection in the bottom of the eye, and so on. The uniformly unfavourable result of extirpation has deterred us from proposing the opera- tion. Yet in some instances, very contrary to our expectation, the case has remained for some time in that state, and afterwards, instead of destroying, the globe has shrunk, and become atrophic."t Mr. Travers, also, has lately published some important observations on the difficulties attending the diagnosis of this disease. He is of opin- * London Ophthalmic Infirmary, Moorfields. t Lectures in the Lancet, Vol. x. p. 518. London, 1826. 68 458 ion that the tapetum-lil-e appearance at the bottom of the eye, in the early stage, cannot be rehed on as diagnostic. He mentions that he had seen several cases, in which this appearance was stationary for a time, after which the eyeball dwindled, so that they might fairly be presumed not to have been instances of mahgnant disease. It so happened, however, that long-continued alterative courses of mercury or protracted salivations had been used in these cases, so that the fact of their disappearance was consequently open to anoth- er explanation, namely, that they were examples of mahgnant dis- ease, which had been arrested by this treatment. That the appear- rance in these cases was very analogous to that of medullary tumour, we may readily admit from the fact, that in one of them, the extir- pation of the eye w^as over-ruled only b}' one dissentient voice, at a consultation, including some eminent members of the profession : and although Mr. Travers had on two several occasions sat down to perform the operation. The patient, a lady, had recovered with the loss of sight, several years before Mr. T. published this statement of her case, and still continued in perfect health. It accords exactly with my own experience, that the adhesive inflammation of the choroid, terminating in a deposite of lymph, w^hich undergoes vascular organization between that membrane and the retina, presents an appearance exactly resembling incipient medullary tumour. Mr. Travers states that in a young lady's eye, the fawn-coloured resplendent surface, with red vessels branching over it, was so strongly marked, that he should certainly have con- sidered it to be the nascent malignant disease, but for the circum- stance of its having followed a wound with a pair of fine scissors, a fortnight before. The instrument had passed obliquely between the margin of the iris and the ciliary body. Deep-seated inflam- mation ensued, and bUndness, after three days, became complete. The lens remained transparent for months, so as to permit the ap- pearances described to be observed. At length, a cataract, with constricted pupil, ensued upon the chronic inflammation of the iris ; and the e3-eball, which had never enlarged, gradually shrunk. Chronic choroiditis also is occasionally productive of appear- ances, which are very similar to those of medullary tumour. Lymph appears to be effused, to become organized, and even to advance towards the cornea, producing an absorption of the vitreous humour. I have known cases of this sort, which continued for many months, without either manifesting hydrophthalmic enlarge- ment, or shrinking by interstitial absorption of the contents of the eyeball, two sure indications, as Mr. Travers remarks, that the disease is not mahgnant. Such are some of the difficulties attending the diagnosis in the early stage of medullary tumour. In the fungous stage, it is apt to be confounded with exophthalmia, arising from the pressure of encysted or other tumours in the orbit, or from severe inflammation of the orbital cellular membrane. A deep transverse section, from 459 the outer to the inner canthus of the enlarged eye, so as completely to evacuate its contents, is an efficient remedy in simple exophthal- mia, which is always attended with great disfigurement from pro- trusion, excessive vascularity of the conjunctiva, and agonizing sympathetic heniicrania on the same side with the diseased eye. In the medullary tumour, this proceeding is of no avail ; but, as Mr. Travers advises, if any doubt of the nature of the case exist, it should be practised. In the malignant disease, the globe remains firm, the section being followed only by a small discharge of blood ; but if a considerable discharge of discoloured fluid or matter takes place, and the globe collapses, the disease is not mahgnant, and the cure is complete.* Treatment. Medullary tumour, like cancer, has hitherto resisted the power of all external or internal medicines. Extirpation of the eye has frequently been performed on account of this disease, but it may fairly be doubted whether it has in any one instance eflfected a radical cure. In many cases, the disease has certainly been known to return after extirpation of the eye, the optic nerve having probably been diseased previously to the operation, or at all events, giving rise to a new medullary growth, sufficient to fill the orbit in the course of a few months, so that although the removal of the eye may have saved the patient from the suffering which always attends the rupture and destruction of that organ, yet it probably hastens rather than retards the fatal termination of the disease. The extirpation of the eye has always failed, when the disease was so far advanced that the posterior chamber was filled by the fungous mass ; whether it might be more successful, were it performed when the disease first appears at the bottom of the eye, it is impossible to say. At that early period, the friends of the patients could scarcely be expected to bring themselves to consent to extirpation of the eye, nor, after the state- ments of Mr. Lawrence and Mr. Travers, regarding the uncer- tainty of the diagnosis, could the surgeon fairly insist on this mea- sure, as being absolutely indicated. During the inflammatory attacks which attend the progress of medullary tumour within the eye, advantage will be derived from the application of leeches to the temple, a spare diet, laxatives, and evaporating lotions. In the advanced stages of the disease, opiates will be required internally; and their ex'ternal application also gives relief SECTION VII MELANOSIS OF THE EYEBALL. To this malignant tumour or disposition, Laennec gave the name of melanosis^ on account of its black colour.* Equivocal * Observations on the Local Diseases termed Malignant, by Benjamin Travers ; in the Medico-Chirurgical Transactions, Vol. xv. p. 235. London, 1829. M«wtf, black. 460 traces of it are to be found in the works of Morgagni, Bonetus, and Haller ; but the continental pathologists of our own times have been the first to treat of this affection as distinct and peculiar. In the beginning of the present century, Bayle and Laennec first pub- lished upon the subject ; but it would appear from a controversy which arose on that occasion, that M. Dupuytren had been ac- quainted with this disease several years before, and had annually mentioned it in his lectures.* Since this period, melanosis has at- tracted the attention of numerous pathologists, both on the conti- nent and in this country ; of whom we may mention particularly M. Breschet, who has inserted a paper on the subject in the first volume of Majendie's Journal, and Mr. Fawdington, who has given to the pubhc an interesting case of this disease, with gene- ral observations on its pathology, and eight admirable lithographic plates, illustrative of its appearances in various organs of the body. The most striking physical character of melanosis, in whatev- er region of the body, or under w^hatever form it occurs, is its black or dark colour, varying from the hue of Indian ink to a brownish yellow, but in general approaching near to the former. In consistence, the product of melanosis bears a considerable re- semblance to that which the contents of a decaying lycoperdon or common puff-ball would present, if rendered cohesive by the addi- tion of a small quantity of liquid. Melanosis displaces or destroys the different textures of the body in a variety of ways. It is most frequently met with in tubercles, or even in considerable masses : is sometimes encysted, and connected to the neighbouring parts by pedicles ; sometimes diffused through the parenchyma of the viscera ; in other cases, deposited upon their surface, or under their investing membrane. It appears that no tissue is free from the invasion of this disease, although it attacks some parts more readily than others. In its progress, however, it involves indiscrim- inately the adjacent textures, supplanting and destroying all that oppose a barrier to its ravages. Even the bones are not exempt from Its influence. Some of the lower animals, and especially the horse, are subject to this disease. M. Breschet has been at some pains to ascertain whether the sub- stance of melanosis is truly organized. With this view, he threw into the arteries and veins of the contiguous parts, some of the finest and most diffusible injections, without discovering any con- tinuity of vessel between the cyst and the substance it contained, or any organization in the latter. The composition of the tumours in melanosis has been ascer- tained, by chemical analysis, to approach very nearly to that of the coagulum of the blood. In fact, with the exception of the black, colouring matter, all the other elements are the same with those of • Journal de Medecine de Corvisart, Tomes ix et i. 461 the coagulum. Thenard and Barruel recognized a large quantity of carbon in melanosis, and to tliis some have attributed the black colour of this disease. From these results of the anatomical and chemical examination of melanosis, it has been, perhaps hastily, inferred, that the sub- stance which collects in this disease is the product simply of a se- creting action of the original exhalent system ; or, in other words, an exudation of one of the constituents of the blood, slightly modi- fied in its transmission through the capillaries. Mr. Fawdington justly remarks that this opinion is hardly tenable, when we consid- er how entirely absent the common signs of vascular congestion are in this disease, and how unlike its character is to that which would result from a simple secretion or effusion. Although ap- parently destitute of vessels, it is probable that melanosis is not beyond the pale of a vital influence, but possesses, like many other tumours, an inherent power of growth, controlled by laws as yet unknown, but different from those which regulate the increase of such diseases as present an unequivocal vascularity. Melanosis is undoubtedly of a fungous nature, and being not un- frequently found in conjunction with other kinds of fungous disease, especially the medullary, it has been regarded by Mr. Wardrop* and others, merely as a variety of fungus haematodes. This view has been countenanced by the fact, that tumours have been met with, possessing almost every possible degree of intermediate feature, as so to render it difficult to determine whether the character of melanosis or that of medullary fungus prevailed. If, however, we take the extreme state of each disease, we discover, (as Mr. Fawdington observes,) differences of a very marked and striking character. In the anatomical structure of melanosis, the paucity or entire want of vessels, constitutes a distinguishing peculiarity ; while me- dullary tumour, which invades the system as extensively, appears under similar forms, attacks the same textures, and eventually pro- duces a like influence on the general economy, is as remarkable for a contrary state, namely, a luxuriant vascularit}^, Laennec re- marked that fungus haematodes is in general supplied by a great many blood vessels, the trunks of which ramify on the exterior of the tumours, or between their lobes only, while the minuter branch- es penetrate into the substance of the morbid growth ; and that the coats of these vessels being very fine, they are readily ruptured, thus giving rise to clots of extravasated blood in the interior of the tumours, sometimes of considerable size. Nothing of this kmd is observable in melanosis, no extraordinary development of arterial branches leading to the tumours, none visibly ramifying on the cysts which surround them, none in the morbid substance. Mr. Fawdington has carefully compared the local phenomena * Observations on diseased Structures, prefixed to the second volume of Baillie'S Works, p. liii. London, 1825. 462 presented during life by these two diseases. In fungus hsematodes, if the tumour be at all advanced, there is pain, constant or occa- sional, sharp and lancinating, and often accompanied by signs of low vascular excitement. In a farther stage, the suffering is increased ; an ulcerated breach having been produced in the in- teguments, the fungus grows and sloughs by turns ; it discharges an offensive sanies, and considerable haemorrhages take place, which for a time reheve both the vascular and nervous irritation attendant on the progress of the disease. Lastly, the absorbent glands in the vicinity participate in the mischief, and the general powers become exhausted, from the combined influence of pain, irritation, and discharge. Now, in melanosis, unless the growth of the tumour be circumscribed by textures which yield with difficulty, such as the tunics of the eyeball, or the cavity of the orbit, there is neither pain, as a necessary concomitant, nor an excited state of vessels in the circumjacent structures. As to the phenomena of melanosis in the ulcerative stage, there seems to be a blank which must be left to future observers to fill up ; but reasoning from its low state of organization, it may be concluded that many of the pathological changes which attend the career of fungus haematodes, wnll not be found to exist in melanosis. The process upon which the softening of this tumour depends, is as inexplicable as the laws of its production and increase : but that it arises from a power in- herent in the morbid structure, and distinct from the common con- ditions of suppurative inflammation in other structures, is to be in- ferred from the absence of those agents which support the latter in the situation where the softening is first observed. Symptoms of Melanosis of the Eyeball. The cases on record are too few to enable us to say more under this head, than that the patient complains in the early stage of imperfect or destroyed vision, with a sense of fulness and pain in and round the eye, followed by enlargement of the eyeball, extenuation of the sclerotica, and a pe- culiar opaque appearance of the pupil. Neither in Mr. Allan Burns's case, nor in Mr. Fawdington's, did the eye give way, so that we are unable to state what may be the termination of this disease, when the eye is left to itself. Both patients died of melan- osis in the viscera, after the affected eye was extirpated. Like fungus hccmatodes, melanosis occasionally occurs exterior to the eyeball, in the cellular membrane of the orbit. In this case, the tumour pushes the eye before it, and at last the eye is destroyed by inflammation.* Cases. The following is an abridged account of the two cases above referred to. Case 1. In Mr. Wardrop's work on Fungus Haematodes, and again in Mr. Allan Burns's Observations on the Surgical Anatomy * See a cise of Melanosis by Dr. Chomel, quoted from the 3cl volume of the Nou- veau Journal de Medecine, in the Dictiongire des Sciences Aledicales, Tome xxiii. p. 187. Paris, 1819. 463 of the Head and Neck, a well-marked case of melanosis of the eye is related merely as a variety of meduDar}^ tumour. The patient, Mrs. Scott, about 41 years of age, had always been of a delicate habit of body, and sallow complexion. The progres- sive advancement of the disease of the eye appears to have occupied a period of two years and a half. It first manifested itself, by the patient being unable to see distinctly with her left eye ; and on looking at the organ, a milkiness was seen behind the pupil. This opacity, which Mr. Burns speaks of as seated in the lens, gradually increased during four months, when the patient became completely blind of that eye. About four months after losing the sijjht of the eye, it became very much inflamed, without any obvious cause. By bleeding with leeches, &c. the inflammation abated, but the redness and pam never entirely left the eye. From what Mr. B. had been able to learn, the opacity of the lens could not be so de- cidedly ascertained after this attack, owing to the turbid state of the contents of the anterior chamber. The further progress of the case was not traced till within six months of the time when Mr. B. thought it necessary to remove the contents of the orbit by operation. At the beginning of that period, a tumour began to protrude from the lower side of the scle- rotic coat; just behind the edge of the cornea. Two months after this, Mr. B. found the cornea rather more prominent than usual, but he could distinguish with accuracy neither the iris nor thecrys- talhne lens. The appearance impressed him with the idea, that a fungus was lodged behind the cornea, ready to protrude so soon as the cornea gave way. The tumour at the lower part of the sclerotica was now about the size of a musket-ball, and seemed to contain a dark-coloured fluid, the cyst being formed by that part of the conjunctiva which covers the sclerotica, while over the surface of the sac a number of red vessels ran in every direction. The pain was intense and lancinating ; sleep was interrupted, and be- sides being affected with hysteria and pain in the back, the patient was in some degree hectic. After four months more, matters were in a much worse state, and the patient's health completely broken ; she had confirmed hectic fever, and was often attacked with paroxysms of hysteria ; she was much reduced and exceedingly weak, and had not been out of bed for two months. The cyst, which formerly had not been larger than a musket-ball, had now attained the size of a pigeon's egg, and formed a solid fungous mass, which could with difficulty be raised, so as to uncover the under eyelid. The cornea was flat, and was hid beneath the upper eyelid. From the body of the large fungus, two small fungi protruded, and towards the temporal extremity of the lower eyelid, there was a hard tumour, situated under the integuments, and adhering firmly to the cheek- bone. The patient was anxious to have the parts removed by operation, 464 which was accordingly done by Mr. Burns, assisted by Mr. Ward- Top. As the tumour exterior to the eyelids was of considerable size, Mr. B. separated them by an incision at their temporal angle. He then grasped the tumour, and dissected back the lids from it» As he wished to take out all the diseased parts in connexion, he endeavoured to detach them from the lower margin of the orbit ; but, to his surprise and regret, he found that the bone on which they rested was softened and black in colour. He therefore gave up the attempt, and proceeded to detach the eyeball from its con- nexions, with a common scalpel. While separating it from the roof of the orbit, he was cautious, lest, the bone being there soft^ the point of the knife might pass into the brain. By the pressure employed in pulling forward the morbid parts, they burst, and a considerable quantity of inky fluid was poured from the opening, Mr. B. traced the optic nerve to its exit from the skull, and there divided it. Even there its medullary substance was as black as ink. He next chisseled away as much as he could of the diseased edge of the orljit. but with little hope that the issue of the operation would be favourable. The diseased state of the optic nerve, and the condition of the lx)ne, hardly allowed any reasonable expecta- tion that the patient would ultimately recover. The bleeding from the divided vessels was easily restrained b}" the pressure of a plug of lint. As soon as possible after the operation, a section was made of the morbid parts which had been removed. When dividing the eyebciU and optic nerve, a great quantity of a thick viscid dark- brown matter, coloured the knife. The eyeball and tumour seemed entirely composed of a similar dark-coloured matter. This singular-looking substance was of the consistence of thick oil-paint, thongh not so clammy nor oleaginous. It soiled the fingers of a dark brown or amber colour. It readily dissolved in water, and both Mr. Burns and Mr. W ardrop were struck with its resem- blance to the pigmentum nigrum. The cornea appeared sound, and the crystalline lens behind it was of an amber colour. The sclerotica, at that part which corresponded to the malar portion of the orbit, was ruptured by the tumour, and the torn edges v:ere separated about a quarter of an inch from one another. The sclerotica was at the same place split into two layers, a small quan- tity of the dark-coloured substance being interposed between them. No distinct remains could be traced of the iris, but the choroid ap- peared much more vascular than natural, and at one part a\ as five or six times its usual thickness. At the place where the sclerotica was ruptured; the choroid insensibly terminated in a white pulpy substance, composing part of the diseased mass. The contents of the eyeball were composed chietiy of a medullary-hke pulp}^- sub- stance, variously tinged in different places by the dark-brown col- ouring matter. The tumour projecting beyond the sclerotic coat, appeared to be composed of a similar structure, and upon macera- 465 tion, numerous white striae, and in some places spots, appeared throughout the substance of the diseased mass. Exterior to the eyeball, the tumour was covered with a thick mucous membrane, except at the two small prominent parts where it had been ulcer- ated, this covering being probably derived from the conjunctiva, which the tumour in its progress had pushed before it. The optic nerve was of its natural size, but by examining its section, it was found that the medullary part of it had a black ap- pearance, exactly resembling the tumour in the eyeball, while its neurilema was apparently healthy. No remains of the retina could be detected. One of the lymphatic glands lying by the side of the optic nerve was changed into a dark coloured substance. Although much reduced by hectic, and emaciated to a great degree at the time of the operation, the patient soon appeared to recover ; she gained flesh and strength, her appetite was restored, the pains in her back and loins left her, she slept well, and was able to walk about. The orbit discharged good pus in moderate quantity, and was at last filled up with a soft substance, which although dark in colour, skinned over. When she and her friends considered her recovery certain, the weather became cold and damp ; the pain about her back soon re- curred, she lost her appetite, and was unable to walk from exquisite pains in the loins. She could obtain no sleep, except from opium. The lower eyelid was protruded by an elastic fungus, which also began to project from between the lids. The disease in the orbit gave her no uneasiness, her whole complaint being seated in the back and loins. The pain there was so excruciating, and occa- sionally so much increased in intensity, that she screamed from agony. She could neither turn in bed, nor permit herself to be turned. In this deplorable condition, she lingered for two or three months ; the tumour below the orbit all the wliile increasing in size, and the pain in the loins in no degree remitting. When Mr. Burns saw her, three weeks before her death, she was emaciated to the last degree. The tumour below the orbit was as large as a pullet's egg ; its surface unequal, the most prominent parts of it covered with livid integuments, and the swelling conveying to the fingers the impression as if it contained a fluid. From between the eyelids, a very small fungus protruded, covered with a coat of bloody-looking matter. She had little or no pain in either the orbit or the head, and the vision of the other eye remained unim- paired. From this time to her death, she sunk gradually, the tu- mour going on to enlarge, and becoming more discoloured on its surface, and more irregular, but the fungus between the lids under- going no change. About twenty-four hours previous to her death, she became suddenly comatose. On dissection, the liver was found to contain some tumours of a similar texture and appearance with the contents of the eyeball, as ascertained after its extirpation. There was also a cyst in the 59 466 substance of the liver, filled with a great quantity of grumous- looking purulent matter. Above the kidneys there were similar tumours of pretty considerable size, and the uterus was cartilag- inous. The urinary bladder was enormously distended with a turbid, bloody-looking fluid ; but otherwise, in so far as this viscus was examined, its structure appeared healthy. By making a vertical section of the orbit and fungus it contained, the tumour was found to arise entirely from the antrum maxillare^ which had burst both above and in front. The fungus projected also beyond the lower spongy bone and investing membrane of the nose, into the nostril. The tumour proceeding from the an- trum was, on its outer surface, studded over with small knobs of a dark livid colour. Internally, this tumour was made up of a soft substance of an ink colour, intersected by membranous slips, in- termixed with a greyish substance, and with ragged fragments of bone. The anterior wall of the antrum was destroyed at its upper part, and the floor of the orbit was elevated, so as to have merely the periosteum and a thin layer of fat between it and the orbitary plate of the frontal bone. The fungus was exterior to the orbit, although from the destruction of the periosteum attached to the malar portion of the orbit, it had been allowed to protrude from be- tween the eyelids. This portion of the periosteum was partly de- stroyed by disease, and partly in conseijuence of the removal of a carious portion of the bone, when the eye was extirpated. With regard to the optic nerve, it was expected that its extremity would have been connected with the fungus. Between them, however, the periosteum of the floor of the orbit was interposed. The nerve itself was of its natural size, but of a black colour where it entered the foramen opticum. From this point to near where it had been divided in the extirpation o.f the eyeball, it was in a similar state ; the neurilema had only a slight connexion with the diseased substance of the nerve. At the bottom of the orbit there was considerable matting and induration of the origin of the mus- cles. At its termination the nerve formed a sharp point, its coats adhering to the thickened periosteum of the floor of the orbit, which was pressed in contact with it by the fungus from the antrum. The optic nerve within the cranium was as thick as the little finger, and as dark in colour as the part of it contained in the orbit. The junction of the nerves was so much enlarged, that it formed a tumour extending into the third ventricle. As, from the dark colour of the diseased parts, this was a fa- vourable opportunity for ascertaining whether the optic nerves decussate, or merely unite, the state of these parts was carefully examined. The dark colour w^as found to extend much beyond the point where the nerves join ; but this change of colour was confined to the left side, or to the nerve of the affected eye. On the right side, the nerve was of its natural size and colour, and was attached to the black diseased parts merely by cellular 467 shreds. This dissection, therefore, clearly proved, that the nerves did not, in this individual, cross each other. Case 2. In January, 1824, Thomas Peckett, aged 30, a robust healthy-looking rnan, consulted Mr. Wilson of Manchester, respect- ing a violent and incessant pain in his left eye. Six months pre- vious to his application, he had received a blow upon the organ, from the projection of a small piece of iron ; but the injury appeared to be of a very trifling nature, as he experienced but little pain, and the eye did not exhibit any external appearance to attract the notice of others. About a fortnight after this accident, he experi- enced a sensation of fulness in the globe, and upon shutting his right eye, discovered that his sight in the left was very imperfect. The pain and dimness gradually increased, the former to a most distressing degree, affecting chiefly the ball of the eye and margin of the orbit. The conjunctival vessels were now enlarged and tortuous, and the sclerotica generally inflamed and undergoing absorption, the dark choroid being just visible towards the internal canthus. The iris was immovable, and a slate-coloured opacity occupied the cen- tre of the dilated pupil. No symptoms of cerebral affection were manifested. The treatment had been limited to the occasional ap- plication of leeches to the temple. By drawing blood freely and repeatedly from the temple and nape of the neck, together with bHstering, active cathartics, and an abstemious diet, the pain was removed ; but no amendment in vision ensued. At this, however, he was not disappointed, as Mr. Wilson had given him no reason to hope that his sight would be restored. After remaining in Manchester nearly a month, he was permitted to return into Staffordshire. Towards the end of March, he again applied on account of a return of pain. He stated, that a few days after he returned home, he had experienced his former sensations, and the pain was now so violent and incessant, as to prevent him from sleeping. The disease had made considerable progress, and it was to be feared, that the pain was owing to a morbid growth within the eye. The sclerotica, at its upper part and towards the inner canthus, was extremely extenuated ; the choroid covering the protruding substance. The opaque appearance in the pupil had assumed a dirty red colour, resembling newly organized lymph, and this seemed to be the apex of a conical-shaped body, situated deep in the bottom of the eye. The former treatment, with moderate ptyalism, was ineffectually adopted, and on the 19th of April, Mr. Wilson removed the contents of the orbit. A section of the eyeball discovered, in the situation of the vit- reous humour, a black pultaceous tumour, occu|)ying more than one-half of the interior of the globe. There were two cavities or cells filled with a brownish-red fluid, one situated at the side of the 468 tumour, the other anterior to it, and behind the lens. No trace of the vitreous humour or cells could be discovered. The choroid was entire, and could easily be separated from the sclerotica, except at one point towards its superior and internal part, where it ceased to be distinguishable from the general mass of the tumour. The sclerotica was here reduced to an extreme degree of tenuity, and had a split appearance. The retina was quite detached from the choroid by the interposition of the disease, and lay folded across the globe, forming a kind of septum between the black mass and the larger of the two cavities, containing the brownish-red fluid. The lens was opaque and of a yellow hue, the capsule thickened, but partially transparent ; a fold of retina covered the posterior cap- sule. The ciliary ligament was distinct, and some ragged portions of membrane at the margin of the lens, and posterior to the iris, which was perfect, showed a remnant of the cihary processes. The optic nerve, where it had been divided at the time of the operation, appeared to be sound. He recovered from the operation, and returned home at the end of a month, apparently well. In August he again applied, on account of three or four tumours on the face, about the size of leaden shot, perfectly black, but unat- tended by uneasiness. He complained of difficulty of breathing and stitches in his side, with a short cough. He had evidently wasted in flesh, and his pulse was quick and remarkably sharp. A tumour similar to those on the face, was discovered on the skin of the back, between the scapulae. In a few days, one or more were found on the scalp. His strength rapidly decHning, he came under the care of Mr. Fawdington on the 2d of October. His general aspect indicated a deficient supply of nutriment, or an imperfect appropriation of it to the purposes of the system. The surface of his body was pale and exsanguineous, and there was a considerable degree of muscu- lar emaciation, with oedema of the legs. But the most striking feature of the case was an exceedingly protuberant abdomen, ap- parently from enlargement of one of its viscera, and this probably the liver. The face and scalp displayed several perfectly developed melanose tubercles, and one on the lower lid of the extirpated eye appeared on the verge of ulceration. The bottom of the orbit was free from any visible melanose deposition. In every other situa- tion, excepting two or three points on the trunk, the cutis had es- caped the direct invasion of the disease ; but the subcutaneous tissue, over the whole chest and abdomen, was evidently loaded with melanosis, giving rise, where the cysts encroached on the skin, to faint- blue elevations, more or less distinct, and of various sizes ; none, however, exceeding the fourth of an inch in diame- ter. The patient died on the 3d of November, worn out by hectic. On dissection, the subcutaneoue cellular texture on the front of 469 the trunk was found granulated with melanose tubercles. The liver, enlarged to four times its natural size, was disorganized by the same disease ; with which also the peritoneum, pancreas, spleen, kidneys, pleurae, lungs, and heart, were more or less affected. The brain was not examined.* Causes and Treatment. As to the remote and exciting causes of melanosis, we are quite in the dark ; nor can we say any thing with certainty on the methodus medendi. I SECTION VIIT. EXTIRPATION OF THE EYEBALL. 1. In this operation, it is preferable to lay the patient along on his back, with his head raised on a pillow, rather than keep him in the sitting position. If a child, he may be laid across the knees of one of the assistants, who is to hold him by the elbows and trunk ; while another assistant, with his knees, fixes the child's head. 2. When the eyeball is not enlarged, it in^y be removed without any previous separation of the lids from each other at their tempo- ral angle. But if, on the contrary, there is any considerable en- largement of the eyeball, it is absolutely necessary first to effect such a separation of the lids, by means of an incision carried out- wards from their external angle, towards the temple. Even when the eye is small, such separation of the lids enables the operator to accomplish the extirpation of the eye with much greater facility. Nor does it leave any additional deformity, for the edges of the in- cision are brought togejher immediately after the operation is fin- ished, and generally adhere by ihe first intention. Care must be taken in making this separation of the lids, not to Hmit the incision to the skin merely, but to go through the fibrous layer of the lids, and the conjunctiva, so that the eyeball may be easily and fully ex- posed. 3. The operator now passes a large curved needle, armed with a strong linen thread, double and waxed, through the eyeball, from its temporal to its nasal side, avoiding the cornea, and any part which appears to be so disorganized that it would give way un- der traction of the ligature. The needle is then cut away, and the ends of the thread knotted together. By means of the thread, the eye can be carried in any particular direction during the re- maining steps of the operation. Some prefer a large sharp hook for the same purpose. 4. The eye being carried upwards and outwards, the operator plunges a double-edged scalpel directly backwards into the orbit, between the eyeball and the internal canthus, and then sweeping the instrument round, he separates the eyeball from the lower eye- lid, by a division of the conjunctiva. Next, dragging the eye in- wards and downwards, while one of the assistants elevates the up- * Case of Melanosis, by Thomas Fawdington. London, 1^6. 470 per eyelid, the connexion of the upper part of the conjunctiva is disunited, the scalpel passing round the eyeball to the inner can- thus. The cellular connexions of the muscles of the eyeball with the walls of the orbit are next to be divided, and the inferior ob- lique muscle cut across, bearing carefully in mind the directions of the sides of the orbit, and the thinness of its roof. The optic nerve at last forms the only remaining connexion which prevents the complete extirpation of the eye. Dragging the eye forward by means of the ligature or the hook, the nerve, thus put on the stretch, is to be divided with the strong curved scissors recom- mended for this purpose by Louis, and commonly called Louis's scissors. 5. As soon as the bleeding from the trunk of the ophthalmic artery has ceased, which it commonly does either spontaneously, or after throwing a little cold water into the orbit by means of a gum- elastic bottle, the operator examines the orbit with his index-finger, in order to discover whether any of the diseased substance be left behind. If there is any such, it must be dissected away. The lachrymal gland also, even when not diseased, it to be laid hold of with a pair of forceps, and removed with the scissors. 6. It was formerly the common practice, after this operation, to stuff the orbit with hnt, rolled up into a ball, and surrounded by a thread, which was left hanging from between the eyelids. This is now laid aside. The lids are merely brought together, and cov- ered with a piece of spread lint, a light compress, and a roller. If the lids have been separated by an incision carried from their outer angle towards the temple, the edges of this wound are to be brought into contract, and kept so by a suture. 7. As for the haemorrhage which occurs during or after this ope- ration, the free exposure of the bleeding vessels to the air for a few seconds, or the injection of cold water into the orbit, is in general sufficient to produce their contraction. We are of course provided, however, with the tenaculum, and ought to tie any considerable vessel within reach, which may still continue to bleed. If bleeding goes on to any considerable extent from the deep part of the orbit, pressure must be had recourse to. Sometimes the mere pressure of the finger for a few minutes is sufficient, but in other cases, it is ne- cessary to introduce into the orbit, a roll of lint, against which the lids being compressed by a bandage going round the head, the bleed- ing is completely checked. The roll of lint may be left in the or- bit for five or six days. 9. It occasionally happens that the disease of the eyeball has propagated itself to the eyelids, and that they are either adhe- rent to the eyeball, present a number of irregular prominences and fungosities, or have become affected with ulceration. In such cir- cumstances, it ma}^ be judged necessary to remove the eyelids as well as the eyeball. In this case, we commence the operation by the removal of the lower lid, then extirpate the ball, and if it be i 471 necessary to take away the upper lid also, terminate with its removal. 9. The patient must be kept quiet, fed on spoon-diet, and his bowels carefully attended to. In general, no bad effects follow the operation. The clotted blood which fills the orbit dissolves, the periosteum discharges pus, granulation follows, and the cavity is partly filled by newly-forrned vascular substance. It sometimes happens, hovi^ever, especially if lint has been left within the orbit, that violent inflammation ensues, followed by suppuration, within that cavity, in the eyelids, or the integuments of the forehead, or even withia the cranium. Mr. Travers mentions that he lost a pa- tient, a middle-aged countryman, otherwise in health, within a fort- night after this operation, owning to a suppuration of the dura mater, on the same side of the head. The attack of inflammation was sudden and rapid, commencing about a week after the operation, and ushered in by a severe rigor, after imprudent exposure to cold.* CHAPTER XIV. CATARACT.f SECTION 1. DEFINITION AND DIAGNOSIS OF CATARACT ; METHOD OF EXAMINING CASES OF THIS DISEASE ; CAUSES AND PROGNOSIS. The name cataract is bestowed on any opacity situated between the vitreous humour and the pupil. Enumerating the parts so situated, we have first, the posterior hemisphere of the crystalline capsule ; secondly, the crystalline lens ; and thirdly, the anterior hemisphere of the crystalline cap- sule. Any of these parts may become opaque, and will constitute a capsular or a lenticular cataract, according as the opacity is seated in the capsule or the lens. Between the internal surface of the capsule, and external surface of the lens, there exists, in the natu- ral state, a considerable degree of adhesion, but in consequence of disease, an opaque fluid is sometimes effused within the capsule, so as to separate it from its natural cohesion with the lens, and form what is termed a Morgagnian cataract. Any opacity situated in or within the crystaUine capsule, is termed a true cataract^ and it is evident that all those above enumerated, fall under this de- nomination. ** Synopsis of the Diseases of the Eye, p. 309. London, 1820. t From KcfrcLggiLo-a-ie, to break, or disturb ; vision being broken, or disturbed by this disease. Txa.v^ai/mct of Hippocrates. TvoyvfAit of Galen. Suffusio of Celsus. Gutta opaca of the Arabians. Caligo Lentisoi Cullen. 472 Between the anterior crystalline capsule and the pupil lies the aqueous humour of the posterior chamber. This cannot become opaque without the whole of the aqueous humour being similarly af- fected ; but it may be displaced by an opaque substance ; as, co- agulated lymph. Such a cataract as this is termed spitrious, and has its seat loithout the capsule. When the term cataract is used without any appellative, lenticu- lar opacity is generally meant. For instance, when we say that cataract is a slow disease, occupying one, two, or more years in its progress, it is of lenticular cataract that we speak ; for all the oth- ers, and especially the spurious cataracts, may be the product of a few days, or hours. It sometimes happens, however, that even lenticular cataract is fully developed in a very short space of time. I had lately a patient attending at the Eye Infirmary, with glau- coma and amaurosis of one eye, but without any affection of the lens. She was present as usual, on a Monday or Wednesday, the eye exhibiting exactly the appearances which it had done for some months before. On the Friday, I was surprised to find the lens completely opaque, and stellated by radiating lines, running from its centre. Richter, however, relates a still more remarkable case, in which cataract was completely formed in the course of one night. A patient who had been labouring under gout, had his feet exposed to a great degree of cold during the night, in conse- quence of which, the gout suddenly retroceded, and he was entirely deprived of his sight. Richter saw him next morning, and found a complete pearly-coloured cataract.* Mr. Wathen was of opinion that blacksmiths, and all mechanics who work near large fires, were more subject to cataracts than other persons, and he men- tions that he had had two patients who were instantly seized with cataract, at the very time they were thus employed. t Diagnosis. It is of much importance that we should distin- guish incipient cataract from incipient amaurosis. In the fully de- veloped state, these two diseases can scarcely be confounded by any one in the least acquainted with the diseases of the eye ; but in the early stages, such a mistake n^say readily be fallen into, and may be productive of very serious bad effects. For example, if a pa- tient with incipient amaurosis present himself to a practitioner who mistakes the case, and supposes it to be one of incipient cataract, the advice which he will very probabh' give, will be to wait with patience till the disease be fully developed, and then to submit to an operation for its removal. Should the patient return after some months with a fully developed amaurosis, instead of a cataract, the practitioner would necessarily feel that he had allowed the only season for treating an amaurotic affection with success to pass un- employed ; and thus, by his ignorance or inattention, probably de- prived his patient of all hope of regaining sight. * Treatise on the Extraction of the Cataract; translated from the German; p. 3» London 1791. t Dissertation on the Theory and Cure of the Cataract ; p. 12. London 1785. 473 The symptoms of cataract and amaurosis, as indeed of all dis- eases whatever, are subjective or objective ; that is to say, they consist either in certain changes which the patient experiences, as impaired vision, headach, giddiness, &c., or in certain changes , which we discover in the form, colour, texture, consistency, vas- cularity, and mobility of the different parts of the organ of vision. : Both sets of symptoms will require to be very closely examined in suspected cases of incipient cataract or amaurosis. 1. As to the impaired state of vision which attends both these diseases in the incipient stage, the patient affected with either of them, finds a difficulty in discerning objects with distinctness. In cataract, this difficulty increases very slowly, and is compared to what might be produced by a diffused mist, thin cloud, or gauze, intervening between the object and the eye : whereas in amauro- sis, the dimness of sight is often sudden, and, being partial, is compared to a fly, or other small black spot or spots, covering cer- I tain parts of an object. It is a fact, however, and one which strikingly illustrates the uncertainty which attends the diagnosis of ' cataract and amaurosis, that muscse volitantes, as the appearance I of dark spots before the eye has been termed, are sometimes a pre- I cursor of cataract, while in other cases, this symptom continues for many years, without ending either in the one or other of these ! diseases ; and that on the other hand, amaurosis not unfrequently declares itself in the early stage by the sensation of a gauze or mist, which slowly increasing in density, at length totally deprives the patient of sight. So complete a degree of blindness never oc- curs in cataract. That, however, is of little consequence, so far as our present object is concerned, namely, the diagnosis in the incipient, not in the advanced stage. 2. As the diminution of vision accompanying incipient cataract depends on the lens becoming opaque, and as this opacity gener- ally commences in the centre of the lens, we almost always find that the sensation of a mist or cloud is perceived most when the patient looks straight forward, rendering indistinct those objects chiefly which are placed directly in front. He sees considerably better when he looks sideways. This circumstance might appear likely to afford ground for distinguishing incipient cataract from amaurosis, were it not well ascertained, that those also who begin to be affected with diminished sensibiUty of the retina, are in many instances able to see objects placed to one side, much better than those which stand directly before them ; and that some, in whom amaurosis is even far advanced, continue to see only when they look inwards or outwards, while in every other direction, ob- jects are seen very obscurely, or not at all. 3. The different degrees of light in which those affected with incipient cataract or amaurosis see best, is worthy of attention. In those cases in which vision begins to fail from diminished sensibil- ity of the retina, there is in general a constant desire for an increase 60 474 of light ; when the patient reads with candle-hght, he brings the book as close as he can to the candle ; and his period of most distinct vision is noon-day, when objects are most brilliantly illu- minated by the sun. This is the very time when the cataract pa- tient sees worst. So much hght causes the pupil to contract ; any of the rays of light which enter his eye, must pass through the opaque central portion of the lens ; this they do with diffi- culty, and hence vision is obscure ; but in the twilight, when the pupil is dilated, the light penetrating through the transparent edge of the lens, the patient with incipient cataract finds his vision greatly improved. To witness the effects of moderating the intensity of the light to which his eye is exposed, and thus al- lowing a greater quantity of it to penetrate to the retina, we re- quire only to make him look to and from the window. In the former position, he sees perhaps very little ; but turn his back to the light, and he instantly discerns, more or less distinctly, every object around him. Yet even this must not be absolutely de- pended on. We meet with amaurotic patients, to whom strong light is distressing, and w^ho see best under a moderate degree of illumination. 4. It is rarely the case that incipient amaurosis is not attended by a variety of other symptoms besides failure of sight ; especially by headach, vertigo, and derangement of the digestive organs. In- cipient lenticular cataract most frequently occurs without any such combination of complaints. 5. Having carefully considered the account which the patient gives us of w^iat he himself has experienced, we turn to the symp- toms which are more strictly objects for our observation, and ex- amine first of all whether there is any opacity visible through the pupil, and if there is, endeavour to ascertain its seat, or its nature. It is rarely the case even in incipient amaurosis, that the pupil presents the jet-black colour of health. The appearance, however, is not so much an actual opacity, as a paleness, or greenishness, discerned only when the eye is regarded in certain directions, and which we know to be the result of the light being reflected from a diseased choroid. This symptom is what we now term glaucoTnay which has by mistake been commonly attributed to opacity of the vitreous humour. Repeated dissections of the eye in the state of glaucoma have convinced me, that deficiency of the pigmentum nigrum is the cause of this symptom, which is often attended, no doubt, by dissolution of the hyaloid membrane, and sometimes by yellowness of the centre of the lens. To distinguish incipient amaurosis with glaucoma, from incip- ient cataract, proves to beginners one of the most difficult pieces of diagnosis, and sometimes not to beginners only, but to those who for a length of time have attended to the diseases of the eye. About ten years ago, a gentleman was sent to me by his brother, a medical practitioner in the country, desirous to know if I thought 475 the cataracts, which he said I would see in his eyes, were ready for operation. The disease was glaucoma, with a great degree of shortness of sight, but without any disease of the lens. With much difficulty could I convince the brother of the real nature of the case, so wedded was he to the opinion that the opacity which he saw through the pupil, was cataract. The eyes of this patient continue at this day very nearly in the same state. I could men- tion many similar cases. Attention to the following circumstances, will in general enable the careful observer to discriminate between glaucomatous amauro- sis and cataract. First, The opacity in glaucoma is always greenish, whereas, in incipient cataract, it is greyish. Secondly, In glaucoma, the opacity appears to be seated at a considerable distance behind the pupil, or even deep in the vitreous humour ; whereas, in lenticular cataract, it is evident that the opacity is close behind the pupil. In posterior capsular cataract, the opacity is deep in the eye, but is always streaked ; whereas, the glaucomatous reflection is always uniform, never spotted, nor radiated. Thirdly, When we examine narrowly the surface of a lenticu- lar opacity, especially while concentrating the light upon it by means of a double-convex lens, it is seen to be slightly rough, and somewhat dull, never smooth or polished, in these respects forming a striking contrast to the appearances presented by a glaucomatous opacity. Speaking of glaucoma, Maitre-Jan justly remarks, that "les cataractes luismites sont toujours tres suspectes."* Fourthly, The eyeball, in glaucomatous amaurosis, always feels firmer than natural ; while in cataract, it presents its usual degree of resistance to the pressure of the finger. Fifthly, Glaucoma proceeds very slowly in its course. Years pass over without much more opacity than what was at first ob- served, and with little or no farther loss of sight ; while in cataract, vision rapidly declines, keeping pace with the growing opacity. 6. The mobility of the iris affords a valuable ground for diagno- sis ; for in incipient cataract, the pupil contracts and expands as extensively and as vividly as in the healthy state of the eye, where- as in incipient amaurosis, if the pupil is not already dilated and fixed, its motions are always limited and slow. 7. There are few cases of amaurosis, even in the incipient stage, in which the natural movements of the eyeball and eyehds are perfectly retained. No impediment of this kind is present in cata- ract; the patient opens the eyes, and turns them towards objects, without the least difficulty. But in almost all cases of amaurosis, we may observe a want of direction in the eyes, or a shght degree of stralDismus, and not unfrequently an imperfect power over the motions of the upper lid. • Traite des Maladies de I'CEil, p. 225. Troyes, 1711. 476 Circumstances to he attended to in cases of cataract. To ascertain with accuracy the existence of cataract, and the nature of any cataract which may present itself, it is necessary to attend minutely to the following circumstances. 1. The opacity ; its colour, extent, form, and seat. Whiteness denotes either a dissolved lens, or a capsular cataract ; greyness, a lenticular cataract ; amber, or dark greyness, that the lens is hard ; light greyness, that it is soft. If the whole extent of the pupil is uniformly opaque, the cataract is probably lenticular ; if the opacity is streaked or speckled, it is probably capsular. If the opaque streaks radiate from a centre, the posterior hemisphere of the cap- sule is probably the seat of the disease. If the form of the opacity is convex, the anterior capsule or the lens is the part affected ; if concave, the posterior capsule. With the light concentrated on the pupil, by means of a double-convex glass, all these particulars are carefully to be investigated. 2. The iris is to be examined ; its colour, mobility, form, situa- tion, and the shadow it throws upon the cataract. Is it green, or otherwise discoloured, denoting previous inflammation, which may have left the eye in a state unfavourable for any operation ? Cov- ering the eye which we are not examining, that all sympathetic motion of the iris may be avoided, we next examine whether the pupil moves rapidly, and extensively, as in health ; or slowly, and to a very limited degree, so as to lead to the suspicion of the retina being imperfectly sensible. Is the pupil fixed, and irregular, as if bound to the capsule by adhesion, in consequence of effused lymph ; or does it tremble on every motion of the head, denoting a peculiar paralytic state of the iris, attended by an inordinate quantity of aqueous humour in the posterior chamber, and generally by amau- rosis ? Is the iris convex, and nearer to the cornea than natural, an unfavourable circumstance for the operation of extraction ? Is the shadow thrown by the iris on the opaque body distinct, or is there no shadow ? This depends on the distance of the opaque body from the iris ; or, in other words, the depth of the posterior chamber. If there is no shadow, the posterior chamber is probably obliterated by the pressure of a large and soft lenticular cataract. If the shadow is distinct, the lens is probably small and hard. 3. The eyeball in general deserves attention ; its colour, degree of firmness, size, and place in the orbit. A dirty yellow colour of the sclerotica marks general ill health, which, of course, is unfa- vourable for attempting a cure by operation. A boggy eye marks deficiency of vitreous humour, attended by amaurosis. A stony hardness of the eye denotes glaucoma, with a superabundance of dissolved vitreous humour. An eye considerably below the medi- um size never recovers any useful degree of sight. A very prom- inent, or a very sunk eye, is unfavourable for extraction. In the latter case, that operation can scarcely be performed. In the for- mer, the lower lid is extremely apt to intrude between the lips of the wound of the cornea, and keep it from healing. 477 4. The degree of vision must carefully be noted, both as denot- ing the sentient state of the retina, and serving to determine the propriety of an immediate operation. If the patient can distinguish objects, while regarding them with his back turned to the light, the operation ought to be deferred till the sight is more obscured. If he distinguishes merely the shadow of the fingers, while they are moved across between him and the light, the retina is sensible, and the operation may be performed with the prospect of restoring an additional share of vision. 5. The age affects materially the consistence of the lens, whether in health or disease. Fluid in childhood, gelatinous in youth, firm at middle life, hard in old age, the lens, affected with opacity, may readily be divided in the first two periods by the needle, and will dissolve in the aqueous humour, while in flie last two, these pro- cesses may be difficult or impracticable. 6. The young practitioner ought never to pronounce absolutely even on the existence of cataract, without dilating the pupil by belladonna ; and the most experienced may derive advantage from exposing in this way the whole field of the disease to his view. Proximate Causes. 1. The most frequent kind of cataract is that which occurs in old age, apparently from defective nutrition of the lens, and independently of inflammation or injury. We as- cribe this variety of cataract to a gradual decay or neci'osis of the lens. The process begins in the centre of that body, where its nu- trient vessels are smallest, and ends in its complete coagulation, death, and opacity. It also loses its natural adhesion to the inter- nal surface of the capsule, and in some cases, an effusion of fluid or humor Morgagni, takes place between the capsule and the lens. 2. Next in point of frequency is cataract from injuries, which, rupturing the capsule, admit the aqueous humour into contact with the lens. In four-and-twenty hours after the receipt of such an in- jury, we sometimes see the lens rendered opaque by the coagulating influence of the aqueous humour. Should the rupture of the cap- sule remain open, the whole lens may dissolve in the aqueous hu- mour, be absorbed as that fluid is absorbed, and thus the pupil clear, and vision be restored.* But if the wound of the capsule closes, the dissolution ceases, the cicatrice of the capsule assumes a chalk-white appearance, and thus a capsulo-lenticular cataract is formed. It has been conjectured that the capsule is occasionally ruptured in that tetanic state of the eyes which attends the convulsions of young children, so that the aqueous humour being admitted within the capsule, the lens be- comes opaque. In some cases, a blow on the eye, without any penetration of its tunics, ruptures the capsule ; in others, a blow * It is in this way that cataract, originating without any injury, is sometimes cured by a blow on the eye. 478 dislocates the capsule with the lens enclosed in it, from its fosstila on the anterior surface of the vitreous humour, an accident which is followed by coagulation and solution of the contained lens, and thickening- and opacity of the insulated capsule ; while in a third set of cases, cataract, generally attended by amaurosis, follows a blow, without any apparent rupture or dislocation. 3. Inflammation is in some cases the proximate cause of cataract. Indeed, anterior and posterior capsular cataracts may be compared to specks of the cornea ; while in some instances, the lens also, from long-continued inflammation, becomes opaque, dissolves into a milky- like fluid, or even suppurates. This subject, as illustrated by the observations of Professor Walther, I have considered in the twenty- fifth section of Chapter X. Ossification of the capsule and lens is another termination of 'inflammation in these parts, which has al- ready been spoken of at page 432. 4. The lens is gradually changed in colour, as well as consist- ence, as fife advances. Uniformly gelatinous, and perfectly colour- less and transparent at puberty, it assumes in middle life a yellow- ish hue in the centre, which part, at the same time, acquires a con- siderably greater degree of tenacity than the exterior laminae of which the lens consists. In old age, the lens becomes so hard throughout, that it can never easily, and often cannot at all, be divided by the needle introduced into the eye, while at the same time, it assumes a deep amber colour, sometimes approaching to brown, and, as we are told, even to black. This mere depth of colour, independent of any such coagulation as occurs in the common cataract of old peo- ple, is sometimes sufficient to impede vision. Remote and Predisposing Causes. Many of these have hitherto escaped detection ; but the following have been ascertained as more or less frequent in their operation. 1. Old age. 2. Hereditary tendency. Instances are not uncommon of this dis- ease attacking individuals, one of whose parents had been affected with it about the same period of life ; while in other instances, sev- eral brothers or sisters are either congenitally the subjects of cataract, or become cataractous in after-life, and about the same age. 3. Those who are much exposed to strong fires, as glass-blowers, forgemen, cooks, (fee. are not unfrequently the subjects of this disease. 4. The use of wine and spiritoas liquors, but especially of the former, appears to favour the production of cataract, which is a com- mon disease in all countries where wine is so cheap as to be the habitual beverage of the lower orders. 5. The inhabitants of volcanic countries, as Naples and Sicil)^, are said to be very subject to cataract. 6. The sudden application of cold to the extremities of the body, so as to check any natural or morbid effort or evacuation, such as menstruation, or a paroxysm of gout, is apt to be succeeded by cataract. 479 General Prognosis. The prognosis in cases of cataract must necessarily vary considerably according to the particular species which is present, the local complications of the disease, and the age and general health of the patient. In the incipient stage, we seldom hesitate in prognosticating, es- pecially if the lens is affected, the uninterrupted increase of opacity, and decrease of vision, till merely a perception of light and shadow be retained. Should the anterior capsule be the seat of partial opa- city, this may remain stationary for a number of years, or through the whole of life, without affecting the transparency of the lens ; but posterior capsular cataract rarely continues long without induc- ing lenticular opacity. With regard to the ultimate prognosis, practitioners are too much in the way of raising sanguine hopes in the minds of patients af- fected with cataract, that by surgical operations on the eyes, their sight may be almost perfectly restored ; not weighing with sufficient consideration, the frequency with which other morbid changes in the organ of vision come to be associated with this disease, especial- ly in advanced life ; such as dissolution of the vitreous humour, ab- sorption of the pigmentum nigrum, and imperfect sensibility of the retina. Many a patient, who, before the operation, discovers the hand passing before the eye, sees very little more after the opaque ,lens is removed, on account of the dulness of the retina, or the de- ficiency of the choroid secretion. The dangers, too, attending the operations for cataract, are much too hghtly estimated, in pronouncing an ultimate prognosis in this disease. Operators on the eye seem to think that they have done enough, when by the publigation of a few successful cases, they have persuaded the profession and the public of their expertness : but unless the circumstances of each case are minutely detailed, and a history given, not of select cases, but of every case occurring dur- ing a year, or longer period, and each history brought down, not to a few days or weeks merely, but at least to several months, no con- clusion can be drawn, regarding either the abilities of the operator, the merits of his particular mode of operating, or the general success of operations for the cure of the cataract. Such facts only as the following are capable of serving as data for an ultimate prognosis in cataract. 1. The Royal Academy of Surgery, solicitous to know the truth with respect to Daviel's success, applied to M. Caque, one of their correspondents, who resided at Rheims. This gentleman, by a letter dated 15th January, 1753, informed them, that Daviel had there operated on thirty-four cases ; seventeen of which were per- fectly restored to sight, eight saw indifferently, and nine received no benefit.* * Memoires de I'Academie Royale de Chirurgie, 12mo, Tom. v. p. 397. Paris. 1787. 480 2. In June. 1753, La Faye, Poyet, and Morand, operated the same day upon nineteen cataracts ; the two former by extraction, although each according to his own method ; Morand. by depres- sion. Of those operated on by La Faye, two saw well, two indif- ferently, and two received no benefit at all. Two of Poyet's cases saw well, two less, one could discover only day-light, and two noth- ing. Three of Morand's patients could see tolerably well, and three remained as dark as before.* 3. Mr. Sharp, in a paper read before the Royal Society, 22d November, 1753, gives an account of his having performed the operation of extraction on nineteen eyes, with about half of which, he had what he thought tolerable success ; though he grants that not a single one escaped a considerable degree of inflammation. t 4. Dr. Tartra has published the results of the operations for cat- aract, performed in the Hotel-Dieu, at Paris, from the commence- ment of 1806 to 1810, inclusively. The total number of cases was 113, 70 of which were extracted, and 43 displaced. Nineteen of the 70 extractions, and 24 of the 43 displacements, were successful ; 6 extractions, and 4 displacements, were followed by partial suc- cess ; 8 extractions, and 5 displacements, were total failures ; and the results of the rest were either unknown, or more or less unfa- vourable. Dr. T. observes, that by adding to the 43 successful cases, the other 10, where the operation was attended by partial success, it appears that nearly half the patients operated on, obtained a greater or less degree of sight. He adds that it is generally thought that two out of five patients operated on for cataract, re- cover their sight. t Such are some of the data, furnished to us from the practice of general surgeons, on which to found an ultimate prognosis with regard to cataract. I am by no means of opinion, that the prac- tice of mere oculists would aiford more favourable results ; for their ignorance of eye-diseases being in general fully as great as that of general practitioners, they are led to operate in many cases where there cannot exist the slightest rational hope of success. SECTION II. GENERA AND SPECIES OF CATARACT. The most important classification of cataracts is that which ar- ranges them into true and spurious ; the true having their seat in or vnthin the crystalline capsule, and the sjntrious without / while the distinction of the genera and species, admitted under each of these classes, is founded either upon the particular part af- fected, or particular substance forming the impediment to vision. True cataract frequently exists alone, spurious is always com- bined with other morbid changes in the eye. * Ibidem, Tom. vi. p. 332. t Philosophical Transactions for 1753. Vol. xlviii. Part I. p. 322. London^, 1754. t De rOperation de la Cataracte, p. 83. Paris, 1812. 481 CLASS I.— TRUE CATARACTS. GENUS I. LENTICULAR CATARACT. Opacity of the lens is the most frequent kind of cataract. Its colour and consistence vary according to the period of life at which it occurs. In old persons, in whom it is most common, the opaci- ty is generally pretty dark, of a yellowish or amber-grey colour ; in younger subjects, it is often of the hue of half-boiled white of egg ; in children, still hghter, and approaching more to the colour of milk diluted with water. The opacity commences in the cen- tre of the lens, and spreads to its surfaces and edge. It is generally uniform in colour, not speckled, but fading towards the edge of the lens. In some cases, it presents radii, stretching from its centre to- wards its circumference, the lens already tending to break into such divisions as we see it fall into, when left to putrify or undergo desiccation. The opaque surface of the lens appears plain, or slightly convex, and at a sufficient distance behind the pupil to permit a shadow to be cast on it by the iris. This cataract has in general no influence on the motions of the pupil, being scarcely ever so large as to press against the iris, and obhterate the posterior chamber. The eyeball is in general healthy, except in old people, in whom this disease is often accompanied by- dissolution of the vitreous humour, and deficiency of the pigmen- tum nigrum. The patient is seldom totally deprived of sight by this kind of cataract. In by far the greater number of cases, he continues to distinguish not only light and shadow, but even bright colours ; and in the twilight, when the pupil expands, he often discovers the forms of large objects, especially of those placed to one side. On entering a bright light, he sees none ; and in some rare cases, the opacity is so dense to the very circumference of the lens, that not even light and shadow are distinguished. Lenticular cataract is fluid in childhood ; gelatinous in young persons ; firm, but still divisible by the needle, till about the age of 45 ; after which, and especially in persons of 60 and upwards, it is so hard that it cannot be divided by the needle. This kind of cataract is the most favourable for operation, and a pure case of this sort, with a lively pupil, ought always to be selected by the young operator, for his first attempt. GENUS II. CAPSULAR CATARACT. Species 1. Anterior Capsular Cataract. The anterior hemisphere of the crystalline capsule is much thicker, and more consistent than the posterior, resembling almost exactly the lining membrane of the cornea, and like it, rolling it- self together when freed from its natural connexions. It is much more subject to opacity than the posterior capsule, and is often opaque when the posterior is transparent. 61 482 The opacity in anterior capsular cataract is nev^er uniformly diffused like lenticular opacity, but alvv^ays streaked or speckled, and is generally of a chalk or pearl white colour. The specks are very irregular in form and disposition ; some of them stretching from the edge of the capsule, others occupying the centre. The quickness of the motions of the iris is in general diminished in this disease, and the capsule is often close to the iris, so that no shadow is thrown upon the cataract. The loss of sight may be greater or less than in lenticular cata- ract, depending partly on the place and extent of the specks, partly on coincident changes in the eye. As we have reason to believe that this disease is in almost all instances the result of inflammation, we might expect to find it frequently, or always, conjoined with marks of iritis. Yet this is rarely the case. The blood-vessels which nourish the anterior cap- sule, are derived from the cihary processes, and not from the iris. Neither are they the chief source of the nutrition of the lens. Hence it is, that anterior capsular cataract is really seldom com- bined with morbid changes in the iris, and that it often continues for many years, or for hfe, without bringing on lenticular opacity. Species 2, Posterior Cajjsular Cataract Is much rarer than the anterior, and as the blood-vessels which nourisn the lens are chiefly derived from the posterior capsule, the present disease is much more apt to superinduce lenticular opacity, so that the ultimate changes of ihe posterior capsule, when affected with cataract, come to be hid from our view. The opacity is never uniformly diffused, but always exhibits, the form of radiating lines, proceeding from the centre of the affected membrane. The ground upon which these opaque lines are placed, is evidently concave, while the lines therpselves, being viewed through the crystalline lens, have a watery dulness of appearance, easily distinguishable from the sharp chalky whiteness of the specks in anterior capsular cataract. Occasionally both hemi- spheres of the capsule are the seat of partial opacity, the lens re- maining transparent. Posterior capsular cataract has no influence on the iris, unless it is, as I have once or twice observed it, combined with amaurosis. I have repeatedly witnessed this disease without any complication whatever. Vision is impaired by this cataract in very various degrees, the patient being able, in some cases, to read with the aid of a mag- nifying glass ; while in other instances, he is almost totally de- prived of sight. This disease is sometimes slow, and continues for years in the same state. In an instance which came under ray observation, it occurred suddenly in both eyes, in consequence of stoppage of the menses from cold, and was speedily followed by lenticular opacity. So long as the lens continues transparent, this cataract is not to be 483 I touched in the way of operation. Even after the lens does become lopaqiie, the case is but an unfavourable one, owing to the difficulty I of removing the posterior capsule. GENUS III. MORGAGNIAN CATARACT. The efifusion of an opaque fluid between the lens and its capsule^ Iforms one of the rarest kinds of cataract. It is generally followed, after a time, by disorganization and dissolution of the lens, and not unfrequently by capsular opacity. This cataract, so long as it consists "in a mere effusion between the capsule and lens, presents a cloudy appearance, as if formed of milk and water imperfectly mixed. If the eyeball is repeatedly [rubbed with the finger, through the medium of the eyelids, 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 distended in cases of Morgagnian cataract, and pressing against the iris, obliterates the posterior chamber, and im- pedes the motions of the pupil. Vision is sometimes but slightly impaired, so long as the disease is purely Morgagnian, small objects only escaping the observation of the patient, especially after the eye has been rubbed or moved ; but ! after the lens dissolves, the sight is limited to the perception of light iand shadow. Beer observes, that this disease is sudden in its accession. The I only cause he had known to operate apparently in its production, was exposure of the eyes to the evaporation of mineral acids, during I the oxidation of metals. It is not to be touched in the way of operation ; and ma}'' perhaps be curable by other means, if attended to sufficiently early. GENUS IV. CAPSULO-LENTICULAR CATARACT. This is a union of the first two, or even of the three ^Tcnera already described. The appearances, and even more eeseiitinl cir- cumstances in capsulo-lenticulav cataract, are so unlike in different cases, that it is necessary to distinguish several species of I his genus. The circumstances in question, influence the choice and manner of operation. iSpecies 1. Central Cajisido-lenticidar Cataract Presents in general a very limited white point in the centre of the lens and anterior capsule, occasionally remaining unchanged through life. It is not very unfrequent in children, vvboni it ren- ders short-sighted, so that they cannot read or write. In some instances, the lenticular opacity is considerably broader than the capsular, and not so opaque. This disease is probably congenital. In one case which fell under my observation, it was not observed till after scarlet fever, and was supposed to have originated in that complaint. When very small, it is not to be touched in the way of operation. 484 Species 2. Common Capsulo-lenticular Cataract Is by no means rare. It may originate in the capsule in the lens, or in a Morgagnian effusion. Injury of the capsule and lens may give rise to this kind of cataract, but its most frequent cause is probably an insidious inflammation of the capsule. The opacity is partly chalky or pearly, as in anterior capsular cataract; partly cloudy, as the Morgagnian. The specks of the cap- sule have innumerable forms, and on these were founded the old distinctions of cat ar acta marmoracea,fenestrata^ stellata., punc- tata, dimidiata, <^c. In some cases, the opacity of the lens and capsule is only partial, so that on dilating the pupil by belladonna, the patient's vision is considerably improved. The lens presents various degrees of con- sistence in capsulo4enticular cataract; being sometimes hard; in other cases, partially or completely dissolved into a thick milk-like fluid. In the latter state, it sometimes distends the capsule so much, that the posterior chamber is obliterated, and the iris prevented from moving with facility. Belladonna dilates the pupil slowly and still more slowly does it return to its former size. It is some- times the case, that even the anterior chamber is diminished by the pressure of the distended capsule, and the consequent advance- ment of the iris. Sensibility to light is occasionally very feeble in this state of the lens and capsule. In some cases, however, it is observed, that if the patient remains perfectly at rest, and in the sitting position, for a quarter of an hour, the whiter and thicker part of the dissolved lens falls to the bottom of the cavity of the capsule, and the anterior hemisphere of the capsule not being altogether opaque, but merely speckled, vision becomes clearer, from the light being belter trans- mitted through the upper half of the cataract ; but on motion of the eye, the contents of the capsule are again mingled together, and the vision becomes as obscure as before. A still more remarkable improvement in vision occasionally takes place in cases of capsulo-lenticular cataract, with dissolved lens, after the capsule is simply punctured with the cataract-needle, so as to allow the opaque fluid contained within the capsule to es- cape. This fluid is speedily absorbed, and the hght transmitted through the transparent portions of the cataracta. fenestrata which remains, is sometimes sufficient for a considerable share of vision. Congenital cataract is generally found to be capsulo-lenticular, the lens being milky, and the anterior capsule of a bluish-white colour. In a case of congenital cataract, upon which I lately ope- rated, I found the one cataract such as I have now described, but in the other eye, the lens was fluid, and of a white colour, without any opacity of the capsule. The patient was a boy of about five years of age. In a girl of eighteen, affected with congenital cata- I 485 ract, on whom I operated some time previously, I found merely a scale of chalky lens, enclosed in an opaque capsule, an approach to what is termed the siliquose cataract. Species 3. Cystic Capsiilo-lenticular Cataract Is always, or almost always, the result of a blow either on the eye or the edge of the orbit, more frequently on the latter, suffi- ciently violent to separate, by its concussion, the lens enclosed in its capsule, from the vitreous humour. In consequence of such an accident, the capsule and lens become opaque, and the lens dis- solves. ' The opacity is white, and nearly uniform ; the opaque body is very convex, and pushes itself against the circumference of the pu- pil. After a time, the aqueous humour of the posterior chamber appears to become unnaturally abundant, so that the cataract bobbs about in it on ev^ery motion of the head.* Like a lens bursting the capsule from a blow, and passing into the anterior chamber, the cystic cataract sometimes rolls forward through the pupil, and rest- ing between the cornea and iris, induces inflammation of the lat- ter. Cystic cataract is rarely, if ever, unattended by amaurosis, so that if extraction is had recourse to, it is not so much with any hope of restoring vision, as merely to free the patient from the pain which is certain of being excited, if the cataract comes forward into the anterior chamber, and the danger of sympathetic inflammation attacking the other eye. On extraction, the opaque capsule is sometimes found greatly thickened. Species 4. Siliquose Capsulo-lenticular Cataract lb occasionally met with in adults, but more frequently in chil- dren. Its origin in the former is ascertained ; in the latter it is a matter of conjecture. In both, the chief characteristics of the dis- ease are interrupted reproduction, and even diminution or entire absorption, of the lens, with a shrunk and wrinkled capsule. In the adult, a mere scale of lens is all that remains, surrounded by a shrivelled capsule, which is hence compared to a large withered husk surrounding a shrunk seed. In the young subject, the lens is not unfrequently com|)letely gone, and the two hemispheres of the capsule in contact, so as to form an opaque, and elastic double membrane. In adults, this disease is generally the result of a penetrating wound of the capsule, through which the aqueous humour having been admitted, the exterior and softer parts of the lens have been dissolved, and the nucleus left. Schmidt had observed this kind of cataract onl)^ in young per- sons, who, during childhood, had been affected with convulsions, * Cataracts, tremulans vel natatilis ; Cataracte branlante. 486 during which he supposed rupture of the capsule to have happened, and thus the aqueous humour to have been adrnitLed to the l(3ns. Beer, however, rnet with tliis disease in children scarcely two mouths old, in whom no convulsions had ever happened. Whether it is possible for the lens to be absorbed, without the agency of the aqueous hmnour, leaving the capsule shrunk, but entire, is a point yet undetermined. The opacity of a siliquose cataract in children, is generally of a light gray colour, rarely very white. The capsule is evidently cor- rugated ; the cataract of small volume, and at a considerable dis- tance behind the iris. In adults, again, this cataract is often very white, especially at any spot where the capsule has suffered from injury ; elsewhere, it is dusky, or yellowish. It does not advance in a convex form, but appears flat. Neither in children, nor in adults, is the iris affected in its mo- tions, unless it is adherent to the capsule from inflammation. Yision is sometimes completely lost, from the efl'ects of the origi- nal cause on the retina ; in other cases, distinct sensibiUty to light is retained, so that an operation may be had recourse to with a rea- sonable hope of success. Species 5. Bursal Capsulo-lenticidar Cataract. One of the rarest kinds of cataract consists in capsulo-lenticular opacity, combined with the presence, within the capsule, of a small cyst, filled with purulent matter. This cyst has geneially been found behind the lens, but occasionally before it. The opacity is orange ; the iris sluggish ; the posterior chamber obliterated by the pressure of the over-distended capsule ; the per- ception of light indistinct ; the whole habit weakly and cachectic. CLASS II.— SPURIOUS CATARACTS. GENUS 1. — FIBRINOUS CATARACT. An effusion of fibiin, or coagulable lymph, in consequence of in- flammation of the iris and capsule, constitutes by far the most frequent kind of spurious cataract. It is in almost all cases at- tended by opacity of the anterior hemisphere of the capsule, and occasionnlly by capsulo-lenticular cataract. The effused lymph is met with in different states, and hence the distinctions which fol- low. Species 1. Flocciilent FihriJious Cataract. In this, as in all the fibrinous cataracts, the patient furnishes the first step 10 a knowledge of the nature of the case, by at once an- nouncing to us, that his bhndness was preceded by a painful and tedious inflammation of the eye. The opacity w hich is visible behind or within the pupil, is in the form of a fine net-work, surrounded by a misshapen, contracted, and partially or completely adherent pupil. 487 Vision is much impaired, although not always in proportion to the queintity of effused lymph ; for sometimes when the pupil is small, and the spurious cataract considerable, a tolerable degree of sight is retained ; while in other cases, although the pupil is large, and the net-work of lymph thin, the patient is almost totally blind, the inflammation in which these morbid changes had originated having probably extended its influence to the retina. Species 2. Clotted Fibrinous Cataract. In this case, a clot of lymph, apparently unorganized, occupies the pupil, and sometimes even projects through it.* The opacity is white ; the pupil angular, and motionless ; sensibility to light indistinct, or wanting. In most cases, the lymph is adherent to the capsule, which is also opaque and thickened ; but occasionally, the lymph is unadherent, and the capsule tolerably clear. Species 3. Trabecular Fibrinous Cataract A The pupil, in this species also, is angular and narrowed, and behind it, lies a capsu'o-lenticular cataract, in front of v.'hich there is a stripe, or bar of lymph, running sometimes in one direction, sometimes in another. This substance is connected at each side with the edge of the pupil, but it does not cease there. Passing behind the iris, it attaches itself to that membrane, or to the ciliary processes. The bar varies in consistence, being sometimes car- tilaginous, or even osseous. The iris is motionless ; the perception of light extremely indis- tinct, or wanting ; and the eyeball not unfrequently atrophic. GENUS II. PURULENT CATARACT Is much less frequent than the fibrinous. In cases of neglected hypopium, the matter is after a time absorbed, and the pupil again brought into view. It is observed, however, to be occupied by a spurious cataract, of a yellowish colour, which is nothing more than particles of purulent matter, involved in the interstices of a web of fibrin. Vision, under such circumstances, is in general irretrieva- bly lost. GENUS III. SANGUINEOUS CATARACT, Like the last mentioned, has its basis in a fibrinous effusion, in the interstices of which, minute clots of red blood are observed (o lodge, some of the blood-vessels of the iris or choroid having been ruptured by some previous injury, or during severe inflammation. Tlie iris is not so much contracted in this as in some of the former cases of spurious cataract, unless hypopium also has been present. " Cataracta pyramidata. t Cataracta barree 488 GENrs IV. PIGMENTOUS CATARACT Consists in a quantity of pigmentum nigrum, derived from the posterior surface of the iris, and adhering to the capsule. In some cases, this spurious cataract is the result of iritis, during the course of which, belladonna having been applied, while other remedies were probably neglected, the proper substance of the iris was forced to contract, leaving the pigmentum nigrum, or uvea, bound to the capsule by effused lymph. In other cases, a blow on the eye has the effect of detaching a quantity of pigmentum nigrum from the iris. Falling upon the capsule, it there adheres, and the capsule afterwards beconjing opaque, probably from the same cause v.hich detached the pigmentum nigrum, this substance forms a striking contrast with the white ground upon which it is placed. In either of these sets of cases, the flakes of black pigment present somewhat of a leafy appearance, and hence the name cataracta arborescens, which Ricliter bestowed on this sort of spurious cataract. The degree of vision is generally very hmited, whether iritis or injury of the eye has been the cause. SECTIOX III. VARIOUS ADDITIONAL CLASSIFICATIONS AND DISTINCTIONS OF CATARACT. Cataracts are often classified, or at least distinguished, according to their consistence, size, colour, duration, and curabihty. Those who have carefully studied the classification of cataracts founded on the part or parts affected in each genus, can be at little loss in re- gard to these additional circumstances, which may therefore be dis- missed in a few words. 1. Consistence. 1. Hard. Only a lenticular cataract can be hard, but all lenticu- lar cataracts are not possessed of this property, not even when they occur in persons far advanced in life. Yery rarely do we meet with hard cataract in those under forty-five years of age. In an old person, the darker the gray or arnber colour, and the smaller a len- ticular cataract is, the harder it will be found. A hard lens is nev- er white, and never so large as to prevent a shadow from being thrown on it by the iris. 2. Tough. This is a property which resides either in the cap- sule, or in some substance effused into the posterior chamber. The cystic, siliquose, and trabecular cataracts are of this description. They are all more or less white. 3. S'oft. This is a property which resides in the lens. In sub- jects about twcnl3'-five, we find lenticular cataract soft and cohesi^'e, so that although the needle passes freely through its substance, the fragments do not readily separate, at least on a first operation. After the aqueous humour is admitted into contact with such a cat- 489 aract, it becomes more friable. The colour of a soft cataract, is a light-gray, or grayish-white. Not unfrequently, the soft lenticular cataract is stellated from the division of the lens into triangular por- tions. During extraction, such a cataract is extremely apt to fall into pieces. 4. Fluid. The capsule is generally opaque, when it contains a fluid, or dissolved lens. In some cases, the opacity and fluidity of the lens precede the opacity of the capsule ; while in other cases, the opacity of the capsule appears to operate as a cause of the disorganization of the lens. The latter appears to be the fact in ordinary cases of capsulo-lenticular cataract ; while in congenital cases, the opacity of the capsule is certainly preceded by that of the lens. Fluid cataract is always white. In some cases, the heavier part of the dissolved lens may be seen to gravitate, on rest of the patient's head, to the lower part of the capsule. Leaning the head forwards or backwards, also affects, in some instances, the position of a fluid cataract. 5. Mixed. The Morgagnian is an example of a mixed cata- ract ; the capsule being tough, the lens hard or soft, according to the age of the patient, and the Morgagnian effusion fluid. The bursal cataract, and capsulo-lenticular cataracts in general, are also mixed. These distinctions, founded on the consistence of cataracts, are important, chiefly in reference to the cure of this disease by the operations of division and extraction. II. Size. The hard lenticular cataract is small, as is also the siliquose cat- aract ; the soft, fluid, and mixed cataracts, are large. The size is estimated by the presence or absence of aqueous humour in the posterior chamber, as indicated by the breadth of shadow thrown on the cataract by the iris, or the absence of such shadow. III. Colour. The lens, when affected with cataract, forms a bluish-white, light-gray, amber, or brown opacity, according to the age of the patient, and the nature of the disease. Green cataract is a compli- cation of lenticular cataract with glaucoma. The bursal cataract is orange. Capsular cataract is always white or pearly. IV. Duration and development. In former times, the distinction of ripe and unripe cataracts was considered of great importance. It was supposed that cataract de- pended on the coagulation of a fluid ; and till this process was judged to be sufficiently advanced to permit of the cataract being displaced by the needle, the disease was deemed unripe.* If we * Expectandum igitur est donee jam non fluere, sed duritie quidam concrevisse videatur. Celsus de Re Medica, Lib. VII. Pars. II. Cap. I. Sect. ii. 62 490 are still to retain the terms ripe and unripe, we must employ them with a very different meaning. However small or soft a cataract may be, we may call it ripe, when it is completely developed, and susceptible of no farther progress ; whereas, we may call it unripe, when it is not yet fully formed, and when there is a suspicion that the opacity will make considerable farther progress, as is the case with the central cataract, and the posterior capsular. These may continue for years unripe for operation. The distinctions of sudden and slow cataracts, and of those which exist from birth, or supervene at various periods of life, are not undeserving of attention. It must be observed, however, that congenital cataract is not always of the same sort, but may be cap- sular, lenticular, or capsulo-lenticular ; and hence the impropriety of using the phrase congenital cataract^ as if it were significant of any thing more than the date of the disease. V. Curability. Pellier introduced a practical or empirical distinction of three principal varieties of cataract ; namely, the true, or curable ; the mixed, or doubtful ; and the false, or incurable. The true, or curable, was to be known by the pupil retaining its natural power of contracting and dilating in full perfection, while the patient was at the same time able to distinguish the light of a candle, or of any other luminous body, and even certain bright colours, such as red, green, &c. The mixed, or doubtful, was characterised by a feeble contraction and dilatation of the pupil, and the patient could scarcely distinguish light from darkness. Along with an opaque state of the lens, this variety was supposed to be attended with disease of the retina, or of some other part of the eye. In the false, or in- curable cases, along with an opaque state of the lens, there was either a dilated or a contracted state of the pupil, the iris remaining immovable, to whatever degree of light the eyes might be ex- posed, and the patient unable to distinguish between the most bril- liant light and perfect darkness.* SECTION IV. COMPLICATIONS OP CATARACT. Cataract frequently presents itself along with other diseases of the eye, either purely local, or of constitutional origin ; while in other cases, it is complicated with constitutional diseases, which may, or may not have been instrumental in producing the cataract itself. A perfectly uncomplicated case is very rarely met with. It must evidently be a question of the highest importance in every instance of this disease. Is the organ of vision in a condition to re- sume its office to any useful extent, were the cataract removed 1 * Cours d'Operations sur la Chirurgie des Yeux. Tome I. p. 172. Paris, 1789, 491 1. As for purely local complications, I may mention those with inflammation and its consequences, such as specks of the cornea, adhesion between the iris and the cornea, or between the iiis and the capsule. Such complications as these will readily be recog- nized, and will influence us in the choice of an operation, and in the mode of executing the particular operation which we may select. 2. Some other local complications cannot easily, if at all, be dis- covered, except at the moment of operation ; such as preternatural adhesion between the capsule and the lens, sometimes sufficient to prevent extraction from being- accomplished, and a dissolved state of the vitreous humour, a complication scarcely less perplexing. The latter is a frequent, if not a constant attendant on glaucoma, and if the patient is known to have been glaucomatous before be- coming the subject of cataract, we must be on our guard against a fluid vitreous humour ; but in many instances, nothing is known regarding the previous state of the eye, and there is no very mani- fest sign to lead us to a knowledge of the fact. 3. Such complications as the following are very unfavourable, yet not sufficiently so, as absolutely to prevent us from operating ^ myosis or contracted pupil, not arising from inflammation, tremu- lous iris, slight varicosity, slight bogginess, preternatural firmness of the eyeball. In all of these cases, we may suspect an imperfect sensibility of the retina, and that although the patient may recover a certain share of vision by the removal of the cataract, the im- provement will be but very limited and temporary. 4. If the pupil is much dilated and fixed, and the patient unable to distinguish day from night, there can be no doubt that such a degree of amaurosis is present as renders it quite needless to think of an operation. But we would not willingly operate, even in cases where a much less considerable degree of amaurosis was present, were we aware of the fact. The mere perception of the hand pass- ing between the light and the eye, is by no means a sufficient in- dex that the retina is free from amaurosis. The amaurosis, indeed, must be in the incompieie stage, if so much sensibility is retained ; but if from the history of the case, and the appearances of the eye, there is reason to dread that the retina retains meiely the power of distinguishing light and shadow, as it often does in incomplete am- aurosis, it would be much better to let the patient alone, than to be raising in his mind false hopes of restoration to sight, subjecting him to the anxieties attendant on an operation, and exposing him to the troubles, often severe and long continued, which are apt to follow. For instance, if a patient, far advanced in life, discerns merely light and shadow, and does not possess the natural degree of control over the muscles of the eyes, so that on being desired to look in any particular direction, he gazes in that direction with a movement of the whole head, but without any movement of the eyes, it is almost useless to operate. 5. I have sometimes operated for cataract on an eye affected 492 with strabismus ; but even when I have done this in children, in the expectation that the accession of vision consequent to the re- moval of the cataract would operate in curing the squint, I have been disappointed. 6. Fully developed glaucoma with cataract is readily recognized. The opacity is greenish, or even sea-green. The cataract is volu- minous, and seems still more so than it really is, from being pressed forwards by the diseased and superabundant vitreous humour. At last, the lens is pushed in some degixe even through the pupil. The iris is discoloured ; the pupil dilated, and completely motion- less. The pupil is generally dilated irregularly, the iris shrinking chiefly in one or two directions, so that the pupil becomes oblong or angular. The edge of the pupil appears to be rolled back into the posterior chamber. The eyeball feels as hard as a pebble. Its external blood-vessels, and often the internal ones also, are varicose. Internal flashes of light are frequently experienced by the patient, who is totally deprived of any power of perceiving light from with- out. Arthritic ophthalmia, with severe and long-continued head- ach, is generally the precursor of this hopeless condition of the eye. 7. As for general and remote complications of cataract, the va- riety is endless. Among the most frequent are rheumatism, scrof- ula, gout, and syphilis, as general, and inveterate ulcers on the lower extremities, as remote complications. It is highly in^portant to make ourselves acquainted with the existence of any such com- phcations, and with the complete history of the patient's health who consults us on account of cataract. For instance, if an indi- vidual labouring under this disease, be of an inflammatory tendency, great care will be required, both before and after an operation, to avoid the causes of plethora and arterial action. It will probably be only by repeated blood-letting and purging, with an abstemious diet, both before and after removing the cataract, that the eye will escape destructive inflammation. SECTION v. TREATMENT OF CATARACT WITHOUT OPERATION. Three different modes of treating cataract without operation, have occasionally been had recourse to ; viz. the antipldogistic, the stimulant, and the counter-irritant. It may fairly be questioned, whether such means have ever succeeded in any case of true cata- ract, in restoring the natural transparency of the parts. Most of the alleged cures have, in all probability, been either instances of mere fibrinous effusions on the surface of the capsule, or else cases of ruptured capsule, in which the removal of the opaque lens has been effected by the solvent power of the aqueous humour ; while on other occasions, it is scarcely to be doubted, that no affection of the lens or its capsule existed, but that glaucoma, with incipient amaurosis, was mistaken for cataract, and submitted to certain modes of treatment, which not unfrequently prove efficacious in re- storing, to a certain degree, the sensibiUty of the optic nerve. 493 1. Blood-letting, and the use of mercury, are certainly likely to be attended with good effects, when inflammation is the cause of the opacity of the lens and capsule. The efficacy of these reme- dies, in some incipient spurious cataracts, is fully ascertained, but in true cataract they are seldom or never tried. Yet in certain cases of this sort they might prove beneficial ; for instance, in the Morgagnian cataract, which, according to Beer, results chiefly from external irritation. 2. Mr. Ware, in one of his notes to Wenzel's Treatise on Cata- ract, acknowledges himself " wilhng to hope, that means may hereafter be discovered, by which an opaque crystalline may be rendered transparent, without the performance of an^^ operation whatsoever ; " adding, that " the remedies which have appeared to him more effectual than others in these cases, have been the ap- plication to the eye itself of one or two drops of aether, once or twice in the course of the day ; and occasional frictions of the eye, over the hd, with the point of the finger, first moistened with a weak volatile or mercurial liniment." M. Gondret, to whom I shall have occasion to refer as strongly recommending counter-irritation as a means of curing cataract, makes use also of stimulants to the eye, especially electricity or galvanism, and ammoniacal collyria. Majendie, who has published a paper, by M. Gondret, on this subject,* regards the observations of this practitioner as illustrative of his own highly ingenious ob- servations on the influence of the fifth pair of nerves on the nutri- tion of the eye. When that nerve is cut across, the nutrition of the eye is interrupted, the cornea becomes opaque, and the hu- mours are transformed into a substance reserabhng curd. As sim- ilar changes are found to arise when the nerve is unable from dis- ease, to execute its functions, it is by no means an unwarrantable conjecture, that cataract, which is generally admitted to be in most instances of its occurrence, an effect of impeded nutrition, may arise as often from an imperfect action in the nerve which controls the nutrition of the eye, as from any impediment directly affecting the nutrient vessels of the lens. If this be correct, then it is ex- tremely probable, that by stimulating, or otherwise modifying the action of the fifth pair, the nutrition of the lens may be affected ; so that if want of nervous influence leads to opacity, excitation may remove the tendency to cataract, or even restore, in some cases, the natural transparency. 3. M. Gondret's paper, on the Treatment of Cataract, just re- ferred to, contains a number of cases not undeserving of attention, although not one of them is a satisfactory instance of true cataract cured by the means which he recommends. Sincipital cauteriza- tion, by means either of the actual cautery, or of an ointment formed with a very highly concentrated solution of ammonia, is * Journal de Physiologic, Tome v. p. 41. Paris, 1825. 494 the remedy upon which he chiefly depends. I am not at all pre- pared to deny the efficacy of such powerful counter-irritation, in changing the diseased action upon which the production of true cataract depends, but in most of M. Gondret's cases, especially in those in which the opacity visible behind the pupil was preceded by inflammation, there is a suspicion that the disease was spurious. SECTION VI. PRELIMINARY Q.UESTIONS REGARDING THE RE- MOVAL OF CATARACT BY OPERATION. Before entering on a particular description of the different meth- ods of operating for cataract, there are some questions of a general nature which require to be considered. I. When only one eye is affected with this disease, ought we to proceed to operate, or wait till the other eye is also attacked l Some tell us that we ought not to operate under such circumstan- ces, on account of the difference in visual power which would still exist between the two eyes, even were the cataract successfully re- moved ; a difference which, to a certain degree, could no doubt be remedied by the use of a double-convex lens, placed before the eye which had been affected with cataract, but which, without this as- sistance, might render the patient's vision so confused, that to see well with either eye, the other would require to be shut. This, then, is the practice which is generally followed. But others re- commend an immediate operation, asserting, that by removing the cataract from the one eye, this disease may be prevented from at- tacking the other ; or that if already commencing in this eye, it may be removed by external and internal remedies, if once the' completely cataractous eye were restored to its office by an opera- tion. The sympath}^ whicli exists between the eyes is undoubtedly very strong, and we can easily conceive that it may operate in inducing similar affections of the crystalline lenses, in the saine way that it often appears to do in producing similar diseases of the retinae, and still less equivocally similar ophthalmias. Were it established that cataract might thus be produced sympathetically, there could be no doubt of the propriety of removing a single cataract, even when not the shghtest appearance of this disease could be detected in the opposite eye ; but the fact is not established. The cataract of old people generally attacks both eyes within the period af a few months ; but in middle hfe, we often meet with this disease, in one eye, the other having continued unaffected for many years. II. When both eyes are cataractous, and equally or nearly equally affected, ought both to be operated on at the same time? To this question, my experience leads me to answer in the affir- mative, if division of the cataract is the operation to be performed ; but if we mean to extract, I regard it as much more advantageous 495 to operate on one eye only, and wait the result before touching the other. Double extraction decidedly exposes the eyes to greater risk of inflamraation. If we operate only on one eye, and allow it to recover, we may possibly observe, in the course of the operation and recovery, some particulars which shall be essentially useful to us in conducting the second operation, or shall even lead us to select a different and more suitable mode of operation for the second eye. III. Does the patient require to undergo any particular course of preparation, before submitting to an operation for cataract ? The time was when a long and severe preparation was thought necessa- ry, consisting in venesection, cupping and scarifying, purging, and low diet. Now-a-days, we have perhaps fallen into an opposite error, and avail ourselves too little of the precautions which might operate against the supervention of inflammation after the operation. As it is of the highest importance that recovery should take place without the excitement of much inflammatory action, it may not be improper to bleed the patient once before operating, both to moderate the impetus of the circulation, and to discover, by the appearances of the blood, whether there may not be inflammation already present in the system. Should the blood prove sizy, it would be highly imprudent to proceed immediately to an opera- tion. If the bowels are disordered, with foul tongue, deficient appetite, and headach, a dose of calomel every second or third night, fol- lowed by salts and senna next morning, ought to be given for three or four times, or till the symptoms in question are removed. Even if the patient appears to be in perfect health, three or four saline purges ought to be administered at proper intervals, and a strict antiphlogistic plan of diet followed for at least eight or ten days. Immediately before the operation, the patient must take no full meal, and must carefully avoid all articles which are difficult of digestion. When once an operation is resolved upon, it ought not to be put off without some good cause ; for the patient's anxiety grows with every hour, and he is apt greatly to magnify the dangers to be ap- prehended from the operation. Should it necessarily be postponed, the patient must carefully guard against all influences likely to produce any rheumatic or catarrhal affection of the eyes. On no account must the eyes be touched in the way of operation, if they appear affected in the slightest degree with any sort of oph- thalmia. IV. Is there any particular season of the year more suited than another for operating 7 The spring was formerly selected in pref- erence to any other season. Yet from the prevalence of catarrhal, rheumatic, and inflammatory affections at that period of the year, it is perhaps the worst that could be chosen. Patients who are liable to suffer from such complaints, ought to be operated on in 496 dry summer weather only ; but a purely local cataract, occurring in an individual otherwise healthy, may be removed at any season. V. In cases of congenital cataract, ought the operation to be delayed till the patient has attained an age sufficient to enable hira to give his assent, or ought it to be practised during infancy ? The answer decidedly is to operate in infancy. About the age of from eighteen months to tv/o years, the parts have attained a degree of resistance, which enables the surgeon to operate with greater pre- cision than at an earlier period, yet the capsule is not so tough and coriaceous as it becomes at a later period, and especially after the lens (as often happens in congenital cases) is completely absorbed. If the operation is delayed, the eyes, having no distinct perception of external objects, acquire such an inveterate habit of rolling, that for a long time after the pupil has been cleared by an operation, no voluntary effort can control this irregular motion. The retina, too, by a law common to all the structures of an animal body, for want of being exercised, fades in power. Speaking of the results of Mr. Saunders's operations, Dr. Farre states, that the sensibility of the eye, " in man}^ of the cases cured at the ages of four years and under, could not be surpassed in children who had enjoyed vision from birth ; but at eight years, or even earlier, the sense was evidently less active ; at tw^elve it was still more dull ; and from the age of fifteen and upwards, it was generally very imperfect, and sometimes the mere perception of hght remained." * These observations place beyond all contro- versy the propriety of an early operation in cases of congenital cat- aract. SECTION VII. POSITION OF THE PATIENT DURING OPERATIONS FOR CATARACT, AND MODES OF FIXING THE EYE. In operations on the eye, much depends on the position of the patient, assistant, and operator, and on each understanding what he is to do. The ignorant forwardness of the assistant, or the want of composure on the part of the patient, may in an in- stant defeat the most perfect dexterity of the operator. The patient is generally seated on a low chair or stool, and leans back his head against the breast of the assistant, who stands behind him, A clear and steady hght is to be chosen, entering the apartment by the window opposite to which the patient is seated, and by no other. With his hands he may lay hold of the seat, and he must be cautioned that on no account is he to raise them towards his eyes. If he cannot be depended on for this, an assistant at each side must watch his hands. * Saunders's Treatise on some practical points relating to the Diseases of the Eye, p. 154. London, 1811. 497 To the assistant is committed the charge of preventing the head from bending suddenly backwards, and of supporting the upper hd. If it is the left eye which is to be operated on, with his right hand he lays hold of the patient by the chin, while with the ex- tremities of the index and middle fingers of his left hand applied upon the border of the upper lid, he raises it as completely as pos- sible, and thus exposes the upper part of the eyeball. He allows his fingers to project so far beyond the border of the lid, that should the patient endeavour to raise the eyeball, it would come into con- tact with the fingerS; and thus be (as it were) scared back into its proper position. In general, the assistant does not require to make pressure on the eye in any stage of the operation. The operator sits before the patient, on a seat of such height that the patient's head is opposite to the breast of the operator, who, by this means, is able to observe with ease whatever goes on in the eye, and is not obliged to elevate his arms too much during the operation. If it is the left eye which is to be operated on, the op- erator having tried the point of the needle or knife, by passing it through a bit of thin leather, takes the instrument in his right hand, while w^th the index-finger of his left, he draws down the lower lid, and places the point of that finger upon the border of the lid, so as just to touch the eyeball. The middle finger he places on the caruncula lachrymalis, so as to prevent the eye from turning, , as it is very apt to do, towards the nose, a position, which if as- sumed after the operation has commenced, may be productive of very serious mischief. B}^ the fingers of the assistant and the operator, placed as has been now explained, the fugitive eye is fixed, yet without pressme. To whatever side it turns, it meets with the point of a finger, except towards the temple, where the needle or the knife is about to enter. Various sorts of specula, spikes, and hooks, have been invented for fixing the eye ; but all of them, except the bent silver wire, commonly called Pellier's speculum, are now discarded. It is oc- casionally employed, especially in operations on children, for sup- porting the upper hd, being applied either to its outer surface, or introduced beneath its edge. If it is the right eye which is to be operated on, the operator takes the needle or knife in his left hand, unless he be conscious of such a want of dexterity as to prefer standing behind the pa- tient, so that he may use the right hand, the patient leaning his head on a pillow laid over the back of a low chair. Some opera- tors prefer in all cases, that the patient be laid along upon a table ; alleging as one reason for recommending this position, that it is found greatly more convenient, if the patient should grow faint during the operation. When the horizontal position is adopted, the operator generally sits behind the head of the patient when the right eye is to be operated on, and stands by his left side, if it is the left eye. 63 498 If with the eye Tv-hich is not to be operated on the patient retains any considerable deoree of vision, some tell us to tie that eye up, that both eyes may be more at rest during the operation. There is no better mode, however, of fixing the eyes, than l^y desiring the patient to look at the operator who seizes that moment for entering the instrument into the eye. which is the subject of the operation. Of this advantage we are not so certain, if the other eye is tied up. SECTION VIII. GENERAL ACCOUNT OF THE OPERATIONS FOR CATARACT. There are three kinds of operation for the cure of cataract. All three have undergone innumerable modifications; but each is fotmd- ed on a principle totally different from that of the others. In the f.rst place, there is the mere removal of the cataract out of the axis of vision,, leaving it still in the eye. This was formerly called Couching. We now term it Displacement. There are two varieties of it. viz. Depression and Reclination. In the second place, we have the complete Extraction of the cataract. And in the tliird place, there is the Division of the cataract into frasrments. which remain exposed to the dissolving influence of the aqueous humour. It is possible to perform each of these three kinds of operation, either through the cornea or through the sclerotica. 1. In Depression or Reclination. we assign a new situation to the cataract, at the expense of the vitreous humour, which we know to be by no means a mere gelatinous mass, but an organized part, supplied with blood-vessels, and these derived from the same artery wliich nourishes the retina. We conclude then, that exten- sively to lacerate the hyaloid niembrane; as must be done in forcing down into ihe vitreous humour such a body as the lens, is highly likely to produce very serious injury to the internal textures of the eye. The mere shock of the operation is likelv to excite inflam- mation, disorganize the vitreous humour, and induce insensibility of the retina. The displaced lens. also, is apt to come into contact with the cilic.ry processes, and to induce iritis, followed by closure of the pupil : or to press against the retina, which must necessarily cause amauro-'is. These effects may follow more or less quickly. If tht' displaced lens is firm and entire, or enclosed within the cap- sule, it will not dis-olve in the vitreous hurrjour. but remain as a permanent cause of irritation and chronic i:itiammation. hkely to end sooner or later in amaurosis. In Depression, the lens is pushed directly below the level of the pu()il. It will follow, of course, the curvature of the eye, sweeping over the corpus ciliaie towards tiie anterior edge of the retina, and resting in such a position, that its anterior surface shall still be di- 499 reeled forwards, and a little downwards. If the lens is hard, and the depression rudely performed, the retina, and even the choroid, may readily be lacerated in this operation, and the eye deprived ii> an instant of all chance of recovering ihe powei- of sight. If the lens is left resting upon the retina, it is reasonable to conclude, that this of itself will prevent vision. Should it become loosened from its new situation, and rise a little from the retina, the sensibility of this membrane may perhaps return ; but in other cases, even after the pressure is thus removed, the amaurosis may continue. After depression, the lens is very partially covered by vitreous humour, and is extremely apt to reascend into its original situation, forming anew an impediment to vision, and again requiring to be removed by operation. To this last objection, RecUnation is not so liable. In this operation, the lens is made to turn over into the middle, and towards the bottom of the vitreous humour, so that the surface of the lens, which formerly was directed forwards, now looks upwards, and what v.'as the upper edge is turned backwards. Over the lens, displaced in this manner, the vitreous humour will close much more completely than over the depressed lens, so that re-ascension will be less likely to happen. Another advantage possessed by reclination is, that the retina will not be so liable to be pressed on by the cataract, as after depres- sion, the displacement effected by the former operation, carrying the lens completely below the level of the pupil, leaving it there in the vitreous humour, but not pressing it into contact with the floor of the eyeball. On the other hand, reclination must necessaril);^ break through and destroy the hyaloid membrane much more extensively than depression : while, after the former, as after the latter operation, the cataract will certainly remain, like a foreign body, the cause of con- tinued irritation within the eye, and in general, of ultiinate insensi- bility to light. II. Extraction is the complete removal of the cataract out of the eye at once, and if easy of peiformance, and not ver}^ dangerous for the eye, we would without hesitation pronounce it the operation which ought to be preferred. But, to perform this operation, whether through the cornea or sclerotica, requires no small degree of dexterity, and is attended by very considerable danger to the eye. If the cornea is chosen as the part to be opened for the extraction of the cataract, the incision of the cornea, in order that it may after- wards unite without inflammation, and without any cicatrice which would prevent the entrance of hght, must be perfectly circular, smooth, and at a regular distance from the sclerotica, and at the same time, be of sufficient size to allow the easy exit of the cata- ract. Both in this first period of the operation, and in the subse- quent one of opening the capsule, the iris ought to be left entirely uninjured. One of the chief dangers attached to this operation is 500 that of the loss of the vitreous humour, which is apt to burst through the membrane which naturally supports it, especially if this mem- brane is not perfectly sound, and to be ejected from the eye, either before, along with, or after the cataract. There remains, after the most favourable extraction, an extensive wound of the cornea, which we are most anxious should close by the first intention, and without any protrusion of the iris. The latter event, one of the most unfortunate which can possibly happen, appears in some cases to be the consequence, and is always an additional cause of inflammation. Occasionally violent suppurative inflammation at- tacks the eye after extraction, so that the natural structure of the organ is totally changed. In less severe cases, the iris suffers in texture, the pupil closes, or the cornea is rendered opaque. The operation of extraction through the cornea, is too artificial a piece of surgery to be trusted to the hands of those who have not made themselves complete masters of the subject, and already shown a certain share of natural or acquired dexterity in operating on the eye. It is too nice and dangerous an operation to be under- taken without the utmost precaution, composure, and steadiness. Nor is it likely that extraction through the sclerotica is less diffi- cult, or less dangerous. Indeed, this method appears to be at pre- sent universally abandoned, as exposing the eye to the almost certain loss of vitreous humour, and consequent destruction of the organ. Whether this risk is so great as has been imagined, and such as should deter us from an operation which possesses th.3 ad- vantage of leaving the cornea untouched, I have not had sufficient opportunities for ascertaining. III. Division is founded on the fact that the aqueous humour, acting as a menstruum perpetually absorbed and re-secreted, has the power of completely dissolving and removing the crystalline lens. Reasoning from this fact, and from the anatomy of the parts con- cerned, we naturally conclude that it will be easy to introduce a needle either through the cornea, or through the sclerotica, open up the anterior hemisphere of the capsule, so as to admit the aque- ous humour, and thus procure the solution of the cataract. Ac- cordingly, this is regarded as the least dangerous mode of curing this disease by operation. It is not exempt, however, from disad- vantages, trifling ones, indeed, when compared to the dangers at- tendant on displacement or extraction. The torn capsule is apt to reunite, so that the aqueous humour is excluded from the cataract, and the solution ceases. In this case, the operation must be re- peated, the lens itself divided, and the fragments brought into the anterior chamber. Iritis is not an unfrequent consequence of the operation of division, and is extremely apt to be attended by opacity of the capsule from inflammation. This may take place even when the iritis is very shght; and as the capsule is totally insolu- ble, there is no way of removing its opaque shreds from behind the pupil, except by displacement or extraction. If the cataract is hard, 501 division is impracticable; but in subjects under the age of 40, and especially in young persons and children, this method is not merely sutiicient for the cure of the disease, but is plainly the operation to be preferred. The conclusions to be drawn from this general view of the ope- rations for cataract are evidently these ; that each possesses its own advantages and disadvantages, and is attended by its own pecuUar dangers, that one of these operations will be suitable for one case of cataract, and another for another, and that there can be no more incontestable proof of a man's ignorance of this subject than his asking which of these operations we practise, or of a man's being a charlatan than his pretending to cure all kinds of cataract by one of these operations alone, modified by some trifling change in the manipulations, or the instruments. Each of the operations for cataract will, in certain circumstances, recommend itself by its own peculiar advantages ; none is to be universally adopted, and prac- tised to the entire rejection of the others. SECTION IX. DEPRESSION AND RECLINATION. In depression, the cataract is pressed by the needle almost per- pendicularly under the pupil, somewhat into the vitreous humour, and to such a depth as no longer to form an obstacle to vision. This operation, although by no means the best, is certainly the simplest, as it is the most ancient, and therefore claims to be first described. If we examine the figure of the eye, and the proportions of its several parts, it will be evident, that there is not suflacient room for the lodgment of a large catai act directly below the pupil; that if merely depressed, without being reclined or turned over, the lens will not be sufficiently covered by the vitreous humour, and will be very apt to reascend into its original situation ; that if pressed too much down, it will be lodged upon the ciliary processes and retina, or will be thrust between the retina and the choroid, or even through these membranes,* causing excessive pain at the moment of the displacement, pain which has in some instances been known to last through life; inducing vomiting some hours after the ope- ration, scarcely to be calmed ; and bringing on inflammation, and ultimately amaurosis. These appear to be the unavoidable effects of incautiously depressing a large lens. They are carefully to be distinguished from other bad effects which are apt to attend this operation, but which with attention may be completely avoided ; namely, wounding of the ciliary processes, the retina, or the iridal artery, at the moment of entering the needle into the eye. * Speaking of the situation of the lens in those who had been operated on by de- pression, and whose eyes he dissected after death, Daviel says, " Enfin il m' est arrive de le rencontrer place entre la retine et la choroide, et ces deux membranes dechirees in plusieurs endroits." — Memoires de 1' Academic Royale de Chirurgie. 12mo. Tome V. p. 377. Paris, 1787. 502 The frequent complaints made against the operation of depres- sion led Willburg* to propose that modification of displacement known by the name of reclinatiou. In this operation, the needle being applied, not to the vertex, but to the anterior surface of the lens, or rather of the capsule, the cataract is pressed backwards and downwards into the lower part of the vitreous humour, oppo- site to the interval between the external and inferioi' straight mus- cles, and is left with its anterior surface directed upwards, its supe- rior edge backwards. This operation must necessarily be attended with much disturbance of the vitreous humour ; yet it is in a great measure free from the principal objections against depression. Even a large cataract which has been reclined nmy lie imbedded in the vitreous humour, without being in contact with any other part of the eye. and consequently without pressing directly against the re- tina or the corpus ciliare. It will also be so enclosed and covered by the vitreous humour that it will not be likely to reascend. I. Depression and Redinaiion through the Cornea. la depression and reclination, the needle is generally introduced through the sclerotica and choroid. Some, however, have preferred passing it through the cornea, but in this way neither operation can be satisfactorily performed. If reclination be attempted through the cornea, the needle being passed near its lower, external, or upper edge, even although the pupil is fully dilated by belladonna, it is al.most impossible to separate the lower edge of the capsule from its natural connexions, so that the cataract will not be put quite out of sight, and will be very apt to reascend. If the opera- tor, feeling discontented on observing the displacement but imper- fectly effected, makes farther attempts to recline the cataract more completely, he will probably bruise and perhaps lacerate the iris in such a way as to excite severe inflammation. When partial ad- hesions exist between the iris and capsule, requiring to be separated before proceeding to displacement of the cataract, the separation cannot be effected by the needle passed through the cornea. II. Depression and Reclination through the Sclerotica. On the evening previous to the operation, extract of belladonna, moistened to the consistence of cream, is to be smeared on the eye- brow and eyelids, and allowed to remain till about half an hour be- fore the operation, when it is to be washed off with a sponge and tepid water. If the pupil is not b}' this time fully dilated, a little filtered solution of extract of belladonna in water is to be dropped upon the conjunctiva, not rudely dashed in, with a hair-pencil. The instrument best adapted for depression and reclination is either a straight lance-shaped needle, such as Beer's, or a bent needle, such as Scarpa's. The straight needle is more easily in- * Betrachtung Uber die bisherigen gewohnlichen Operationen des Staares. NOm- berg, 1785. 503 troduced and withdrawn, the bent one takes a better hold of the cataract. The lance-shaped, or the bent part of the needle should measure not more than |th of an inch in length, nor more than l-20th of an inch in breadth at its broadest part. The neck should be perfectly round, so that after the instrument is once introduced into the eye, it may be turned in any direction without distorting or enlarging the aperture by which it has been passed through the sclerotica and choroid. The chisel-shaped instruments sold in the shops, are totally inadmissible, as they cannot be turned round on their axis without greatly injuring the tunics through which they have been passed, and cannot, without being turned round, exe- cute the necessary manipulations of depression or reclination. Each of these operations is divided into three periods, which must not only be distinctly understood by the surgeon, but carefully ob- served by him in practice. In the first period, the needle is intro- duced through the tunics, and into the vitreous humour. In the second, the instrument enters the posterior chamber, and is applied to the cataract. In the tidrd, the actual displacement is effected. It is only in the third period, that rechnation differs from depression. ist Period. The needle must enter the eye so as to wound no- thing but what cannot be avoided, else we may be prevented from satisfactorily executing the remaining parts of the operation, or may inflict serious and irreparable injury. The parts which must be wounded are the conjunctiva, sclerotica, choroid, and vitreous humour. The parts to be avoided are the ciliary processes, the retina, the iridal or long ciliary artery, the lens, and as much as possible the vessels of the pars non-plicata of the corpus ciliare. If the cihar}^ processes, the iridal artery, or several of the choroidal arteries be wounded, haemorrhage is apt to take place into the eye, filling in an instant the aqueous chambers with blood, preventing the operator from seeing the cataract and the nee- dle with sufficient distinctness, and thus obliging him, if he con- tinues the operation, to perform it as if in the dark. We are taught to believe that the retina is insensible to mechanical irritation, so that the wounding of it with the needle should not be productive of any pain ; but as we know not how far the violent vomiting which not unfrequently follows displacement, may sometimes be owing to touching the retina with the needle, or how far its sentient power may afterwards be affected from being wounded, we should always avoid a part of the eye, the integrity of vhich it is reasonable to conclude, must be of the highest importance. If the needle is di- rected towards the cataract in the first period, it is apt to enter the substance of the lens, so that on attempting to proceed with the ope- ration, the whole cataract moves towards the pupil ; an inconvenient and awkward occurrence, requiring the needle to be withdrawn a little and freed from the lens, beiore it can be introduced into the posterior chamber. All these errors may be avoided by attending to the following rules. 504 1. Taking- the lance-shaped needle in his right hand, if it is the left eye which is to be operated on, and vice versa, the operator holds it with the one flat surface looking upwards and the other downwards, in order that in passing through the pars non-plicata of the corpus ciliare, it may divide as few of the choroidal arteries as possible. 2. The lids being fixed by the fingers of the assistant and opera- tor, in the manner specified at page 497, the operator leans with his little finger on the cheek of the patient as on a point of support, in order to prevent the needle from sinking' suddenly and to too great a depth into the eye. 3. The point of the instrument is to be directed towards the cen- tre of the vitreous humour, thus completely avoiding the lens. 4. The needle is to be entered at the distance of one-eighth of an inch behind the temporal edge of the cornea. If this rule is not attended to, but the instrument is entered nearer to the cornea or farther from it, the cihary processes on the one hand, and on the other the retina, can scarcely escape being; injured. 5. In order to avoid the iridal artery, the needle is to be entered not in the equator of the eye, but one-tenth of an inch below that line. 6. As soon as the needle has penetrated to the depth of one-fifth of an inch, or in other words, as soon as the lance-shaped part of it is fairly within the choroid, the first period of the operation is com- pleted, and the instrument is on no account to be thrust deeper into the vitreous humour. 2d Period. The second period of the operation commences with a double motion of the nsedle, by which, in the first place, it is made to perform a quarter of a revolution on its axis, so that one of its flat surfaces comes to be turned forwards and the other back- wards, while at the same time its handle is carried back towards the temple, and the point of the instrument forwards. This brings the point of the needle between the fringed circular edge of the cihary processes and the circumference of the lens. The operator now slowly pushes on the needle between these parts into the posterior chamber. He sees its point advancing from behind the temporal edge of the pupil, and carries it on through the posterior chamber, across the pupil, till its point is hid behind the nasal portion of the iris. The posterior flat surface of the needle is thus applied to the anterior sur- face of the anterior hemisphere of the capsule. SfZ Period. The rest of the operation differs according as the cataract is to be depressed or reclined. If the operator chooses to depress, he elevates the point of the needle by lowering its handle, till the point reaches the superior edge of the lens, and then he gives the instrument a quarter-turn, so as to apply the flat side of it to the vertex of the cataract. The handle is now gradually elevated, the point depressed ; the cataract descends from behind the pupil ; its course is downwards, and a 505 little outwards and backwards ; it is to be depressed till it is no longer in sight, which will always be effected when the handle of the needle has been so far elevated, that the direction of the whole instrument has become horizontal. Beyond this, there must be no farther depression. There is no room to carry the cataract farther in the direction of depression. Raise the handle higher than the horizontal position, the cataract is pressed through the retina, and vision extinguished by the very attempt which is made to restore it. For the space of a minute or two, the needle is to be kept in contact with the depressed cataract.* Its point is then to be gently raised, the operator taking notice whether the cataract reascends, or remains depressed. If it reascends, the depression must be re- peated. In this operation, and also in reclination, it is desirable that the capsule should be displaced along with the opaque lens. It is probable, however, that in many instances, the capsule is merely torn by the needle, and its shreds left attached to the circle of the ciliary processes. These shreds, being highly elastic, will roll them- selves up, and prove no impediment to vision, unless inflammation comes on and renders them opaque, in which case they will form a secondary capsular cataract. After the displacement is accom- plished, and just before withdrawing the needle from the eye, it is proper to turn the point of the instrument towards the cornea, and to move it three or four times round within the pupil, so as to en- sure the division of the capsule, if it had been left ifi situ. The needle is then to be removed from the eye, in the same position as to its surfaces in which it was introduced. If the surgeon prefers reclination to depression, he commences the third period of the operation by raising the point of the needle not more than the tenth of an inch above the transverse diameter of the lens, and then immediately proceeds to recUne the cataract by moving the handle of the instrument upwards and forwards, while its point of course passes downwards and backwards. By this manipulation, the cataract is made to fall backwards into the vitreous humour, and at the same time downwards and a little out- wards. The position of the needle at the end of reclination, is very different from its position at the end of depression. In the latter, it is horizontal ; in the former, the handle is pointing up- wards, outwards, and forwards, nearly in a Une with the temple of the operator. Manner of using the Needle. L This instrument is to be held extremely lightly in the hand, so that it may be moved easily in all directions. If it be grasped firmly by the fingers, the operator * Guy de Chauliac, who composed his work on Surgery in 1363, gives the follow- ing direction to the operator, regarding the time during which he should keep the needle in contact with the depressed cataract. "II la tiendra logee avec 1' eguille pendant le temps qu' il faut mettre a dire trois fois le Pater, ou une fois le Miserere.''^ 64 506 , I has comparatively no power over it, and is unable to execute the ' delicate movements required in the operations of displacement. 2. When once the needle is introduced into the eye, no part of the depression or rechnation is to be executed by a motion of the whole instrument in one direction ; but the point is always to be moved in one direction, and the handle in another, so that the needle forms a lever of the first kind, the sclerotica being the ful- crum. Upon this fulcrum, the instrument ought to be moved with the least degree of pressure possible, and without any dragging of the eye. Modifications of depression atid reclination according to varieties of cataract. 1. When the cataractous lens is friable, and breaks into fragments under the pressure of the needle, or when it is soft, so that the needle passes through it without dis- placing it, displacement ought to be altogether, or in a great mea- sure, abandoned, and the operation of division immediately substi- tuted in its room. The anterior hemisphere of the capsule, is care- fully to be lacerated, and its central part, if possible, destroyed ; the fragments of the friable lens will often pass almost of themselves,^ through the lacerated opening, and through the pupil into the an- terior chamber, where they will speedily be dissolved. If the nu- cleus of the lens, however, appears to be hard, we have our choice either to displace it, or leave it in situ exposed to the action of the aqueous humour. The pieces into which a soft gelatinous lens may be divided, are not so easily scattered by the application of the needle ; and in such a case, it is better not to attempt too much, but rather confine ourselves to the destruction of the anterior hem- isphere of the capsule, reserving for a subsequent operation the division of the lens and dispersion of its fragments. 2. If displacement be attempted in cases of capsulo-lenticular cataract, it not uufrequently happens that the instant the capsule is opened with the needle, the lens being in the state of a fluid, is- poured into the aqueous humour. In a day or two after, the aque- ous humour will again be of its natural transparenc)^, the fluid lens having been absorbed ; but unless something more has been done at the time of the operation than merely puncturing the capsule, vision will still be interrupted by the capsular part of the cataract. When we observe, therefore, that the dissolved lens is escaping into the aqueous humour, we should endeavour as completely as this state of matters will allow, to lacerate and destroy the anterior hemis- phere of the capsule ; and should we find after the absorption of the dissolved lens is effected, that the central aperture in the capsule is insufficient, either another attempt must be made with the needle,^ to clear away as much of it as shall secure the transmission of the rays of light to the retina, or it must be extracted through a small incision of the cornea. 3. We sometimes have to do with cases of cataract, in which the edge of the pupil, in consequence of previous iritis, is partially 507 or completely adherent to the capsule. When the adhesion era- braces the whole circumference of the pupil, to separate the capsule is almost impossible,* so that as far as the capsule is concerned, the formation of a cenUal opening in it is all that we should attempt. The lens we displace or divide, according to the estimate we are led to form of its consistence. When the edge of the pupil, on the other hand, is bound to the capsule in one or two points only, as will be rendered evident on bringing the iris under the influence of belladonna, we endeavour first of all to cut across these adhesions with the edge of the needle, then open up the centre of the capsule, and lastly, displace the opaque lens. Before withdrawing the needle, the central aperture of the capsule may be enlarged or com- pleted, unless we judge that enough has already been done, and that any thing farthef should be left to another operation, after an interval of some weeks or months. The cutting across of the ad- hesions between the iris and the capsule, is generally attended with some discharge of blood. 4. Cases occur m which the cataract instantly reascends, whenever the needle is raised in order to withdraw it from the eye. Such an occurrence has been ascribed to a greater degree of adhe- sion than is natural between the crystalline capsule and the vitreous humour, and has been designated elastic cataract. In such a case, we allow the cataract to resume the situation whence it l;:.d been forced by the application of the needle ; we then carry the instrument over the upper edge of the lens, and down behind the posterior hemisphere of the capsule; we move it upwards and downwards, so as to destroy the adhesion of the capsule to the hyaloid membrane, bring up the needle from under the cataract into the posterior chamber, and then repeat the displacement as be- fore. After-treatment. 1. Experiments on the degree of vision re- covered by means of the operation which has just been performed, are not advisable, as in the endeavours which the patient makes to discover the objects presented to him, the muscles of the eye are necessarily called into action, and this is apt to be followed hy re-as- cension of the cataract. 2. The eyes are to be shaded by means of a light Unen com- press, fixed by a roller going round the head, or pinned to the night-cap, 3. Rest is to be enjoined, both of the eyes and of the head, for some days ; the patient lying in bed, or sitting in a chair. Tho room is to be kept moderately dark. The food is to be of any easily digested kind, not too nourishing, nor of such a sort as to re- quire chewing. 4. After three or four days, the eyes may be protected from the * Mr. Hey relates an interesting case, in which after twelve operations with the needle, he succeeded in detaching the capsule under such circumstances, and restored vision. — Practical Observations in Surgery, p. 82. London, 1803. 508 light by a green bonnet-shade, but ought not for eight or ten days longer to be employed in examining objects. After this period, they are gradually to be brought into use, the patient taking care to avoid whatever excites pain or redness of the eyes, or gives rise to epiphora. Accidents during or consequent to the operation of displace- ment. 1. One cf the least considerable of the accidents which are apt to follow these operations, is the formation of a small thrombus under the conjunctiva, in consequence of one of the visible vessels of the eye having been wounded by the needle, a thing which may easily be avoided. Should such a thrombus follow, it is to be left to itself ; tlie blood contained in it will speedily be absorbed. 2. A small fungous excrescence sometimes rises over the wound made by the entrance of the needle through the coats of the eye. It may be touched once-a-day with a solution of nitrate of silver, or if this proves ineffectual, with the same substance in the solid state. 3. Effusion of blood into the chambers of the eye is by no means a frequent occurrence in the operations of displacement. Even when the iridal artery is divided, or the ciliary processes touched, the bleeding generally tends more to escape by the wound than to flow into the interior of the eye. At the same time, it cannot be denied that haemorrhage into the aqueous humour, suddenly ob- scuring the field of operation, does occasionally occur. In the ma- jority of cases, the blood may safely be left to be removed by ab- sorption. Rarely indeed is it in such quantity as to produce a feel- ing of pain or distension, or render necessary an opening at the edge of the cornea, with the extraction-knife, for its evacuation. 4. If the operator has either entered the needle in an improper direction, or plunged it too deep at first into the eye, the point of the instrument is apt to be buried in the substance of the lens, so that on attempting to proceed with the operation, the whole cataract moves forward towards the cornea. When the operator observes that this is the case, he must turn the needle several times round on its axis, so as to free it from the lens, withdraw it a little, and then proceed to the second period of the operation, in the usual manner. 5. It sometimes happens, that on attempting to depress or recline the lens, it is suddenly tilted forward through the pupil. When this is the case, it may be possible, with some difficulty, to carry it back again to its former situation, and then to displace it as had been intended. I consider it to be better practice, however, imme- diately to extract the lens. For this purpose, the operator should keep it pressed against the cornea with the needle, make a section of one-third of the circumference of the cornea with the extraction- knife, and laying hold of the lens with a hook, remove it from the eye. 6. Violent bilious vomiting in the course of a few hours, or dur- ing the first night after the operation, is a frequent consequence of 509 depression and reclination. This symptom has been attributed to various causes, as injury of the cihary nerves, or of the retina, at the moment of entering the needle, and pressure on the retina, or laceration of this part, from displacement rudely and ignorantly performed. The ordinary means for /checking vomiting are to be adopted, especially small doses of opium, frequently repeated. Blood- letting ought also to be had recourse to, as inflammation scarcely ever fails to occur in those cases where violent vomiting is excited by the operation. 7. Inflammation of the retina and of the iris is to be apprehended after the operations of displacement, especially when the manipula- tions have been rudely executed, and the needle kept long in the eye. Severe pain in the eye and round the orbit, coming on dur- ing the night, is generally the first symptom indicative of internal inflammation, after any operation on the eye. The sclerotica and conjunctiva become red, the colour of the iris changes, the pupil contracts, lymph is effused, the remnants of the loose capsule be- come opaque and coalesce, vision becomes extremely indistinct, and unless proper means of cure are adopted, onyx, hypopium, and de- struction of the eye, may ensue. Free blood-letting, both general and local ; opium, internally and externally ; calomel, so as speed- ily to affect the mouth ; and belladonna, to dilate the pupil, are the remedies chiefly to be relied on. Chronic inflammation of the internal textures of the eye is a fre- quent consequence of depression or reclination. It is not attended by much pain, but prevents the eye from ever attaining a degree of healthiness sufficient to render it useful. Epiphora, varicose dilata- tion of the external blood-vessels of the eye, and in general a con- tracted, but sometimes a dilated pupil, attend this state of the organ, the true remedy for which would be the entire removal of the lens, which lying in the vitreous humour, operates exactly as a foreign substance would do in the same situation. 8. Amaurosis, with dissolution of the vitreous humour, irregu- larly dilated pupil, haziness of the cornea, and varicose dilatation of the external blood-vessels of the eye, is a common result of the operations of displacement. If the retina is pressed upon by a firm lens, which has been depressed or reclined, insensibility to light is the necessary consequence. It sometimes happens, however, that after some days or weeks, the lens rises a little in the vitreous humour, the retina is thereby relieved, and the power of vision returns. Yet this result does not always follow ; the lens may reascend, and the retina remain in- sensible. If the practitioner who has performed depression or reclination, out of a too favourable opinion perhaps of these opera- tions, sees reason to suspect that the very means which he had adopted for restoring vision, threatens to destroy it, he ought not to hesitate about withdrawing the displaced lens from the eye en- tirely. Introducing a bent needle through the sclerotica, the cata- 510 ract is to be raised into its former situation, pressed forward through the pupil, and kept in contact with the cornea till a section is made, a hook introduced, and the lens laid hold of, so that it may be extracted. 9. If the lens is displaced, with its capsule entire, it will suffer no solution in the vitreous humour ; even stript of the capsule, a hard lens will remain unchanged for a great length of time. Beer saw a lens, which had been depressed thirty years before by Hil- mer, reascend in consequence of a fall upon the head ; and in many instances, he had found cataracts on dissection, lying in the vitreous humour, firm, and only slightly contracted, the lenticular part bearing no marks of solution, and the capsular none of mace- ration.* Re-ascension of a depressed or reclined cataract, is so common an occurrence, that some have gone the length of speaking of the operations of displacement, as affording only a palliative cure.t Re-ascension may take place at any period after the operation, but is more apt to happen within the first fortnight than afterwards. The plan usually adopted by those who have practised displace- ment, has been to repeat the same operation after each re-ascension, till the lens has fairly settled in the situation which they assigned to it. Thus we find Mr. Hey couching some of his patients six or seven times over.t I shall not pretend to say, that in all cases of reascension, extraction through a section of about a third of the circumference of the cornea should be practised ; but of this, there can be no doubt, that it is proper in all such cases, if extraction is not immediately resolved upon, to wait for a few weeks and watch what may be the effects of the aqueous humour on the cataract. It is quite evident, that many of the cures attempted by displace- ment, and recorded as instances favourable to the plan of couching, in preference to extracting, were actually accomplished by the dis- solution of the lens after re-ascension. Thus, Mr. Hey tells us, that in one of his patients, " the cataract in the left eye appeared again ; but in a few weeks it became sensibly wasted." § Should there be no appearance of dissolution after some weeks, it will be- come a question whether a repetition of displacement should be adopted, or an attempt made to extract the cataract. The latter cannot be safely attempted in the ordinary way, that is, by a sec- tion of half the circumference of the cornea, else the vitreous hu- mour, in consequence of what it has suffered from the previous displacement, will almost certainly be evacuated ; but the needle must be employed to press the cataract through the pupil, and a third part only of the circumference of the cornea opened for its extraction with the hook. * Lehre von den Augenkrankheiten. Vol. ii. p. 363. Wien, 1817. t Ibid. t Practical Observations in Surgery, pp. 79 and 81. London, 1803. § Practical Observations in Surgery, p. 77. London, 1803. 511 SECTION X. EXTRACTION. I. Extraction through a semicircular incision of the Cornea. Extraction of the cataract, through an incision of the cornea, appears to have been first practised as a regular method of re- moving this disease, by Daviel, a French navy surgeon, who had settled at Marseilles, about the middle of last century. He con- fesses that he had taken the hint of this mode of operating from Petit,* who in 1708, had opened the cornea to extract an opaque lens which had come forward into the anterior chamber; and that he had felt himself urged to devise some new mode of operating for cataract, by the want of success which he found to attend the operation of couching, and the destruction of the internal textures of the eye, disclosed upon dissecting the eyes of those who had undergone this opera tion.f Daviel commenced his operation, by passing a broad needle or small lancet into the anterior chamber, close to the lower edge of the cornea. He then enlarged the incision, thus made, by another instrument somewhat similar to the former, but which being sharp on the edges only and blunt at the point, could with less danger to the iris be introduced into the anterior chamber. He completed the semicircular section with bent probe-pointed scissors. The in- conveniences arising from the employment of so many instruments were perceived, and speedily remedied by Palucci, La Faye, Sharp, and others, who substituted a single knife, which being entered at the temporal edge of the cornea, passed through the anterior cham- ber, made its exit at the nasal edge of the cornea, and either by its progressive motion or by being pressed downwards, completed a crescentic incision parallel to the lower edge of the cornea. The operation of extraction divides itself into three periods. In the first, the cornea is opened with the knife. In the second, the anterior hemisphere of the capsule is opened, or rather destroyed as much as possible. In the third, the exit of the cataract, or the extraction properly so called, is accomphshed. Some dexterous and experienced operators have attempted to run these different periods together ; but it is absolutely necessary to study them individually, and it is always safer to execute each of the three objects above stated, deliberately and by itself * Memoires de rAcademie Royale des Sciences, Annee 1708. p. 311. Amsterdam. 1750. t Memoires de 1' Academie Royale de Chirurgie. 12 mo. Tomev. p. 369. Paris, 1787. — In 1707, Mery had seen Saint- Yves's perform extraction in a case similar to that in which Petit operated in the following year, and to which Daviel refers. Mery was led from the success of Saint- Yves's operation, to recommend extraction through the cornea as a mode of removing cataract worthy of being generally adopted, remark- ing " qu 'on risque moins a tirer la cataracte en dehors qu' a I'abattre au dedans de I'ceuil." Memoires de 1' Academie Royale des Sciences, Annee 1707, p. 606. Am- sterdam, 1746. — Extraction is not a modern invention. Antyllus appears to have practised it about the end of the first century; as also Lathyrion at a later period. Haly- Abbas, in the tenth century, describes extraction as minutely as he does the operation of couching. Histoire de la Medecine par Sprengel, traduite paf Jourdan. Tome vii. pp. 40, 41. Paris, 1815. 512 1st Period. In opening the cornea, care must be taken that the section be made of sufficient size, of a proper form, and at a specified and regular distance from the sclerotica. It must be of sufficient size to allow the exit of the lens without hindrance, and without the use of much pressure on the eye ; and to admit of this, the incision will require to extend to at least a half of the circum- ference of the cornea. Mr. Ware supposes the whole circumference of the cornea to be divided into sixteen equal parts, and states that nine of these should be included in the incision. It must be of a proper form, not angular, nor indented, but regular, smooth, and parallel to the edge of the sclerotica, that it may heal, if possible, by the first intention, and leave no cicatrice to impede the en- trance of light into the eye. It ought not to be close to the sclero- tica, for then the iris is left unsupported and is apt to protrude ; neither ought it to be far from the sclerotica for then the incision will be too small, and the cicatrice which may follow, will impede the light in its passage towards the pupil. A rim of cornea of at least the twentieth of an inch in breadth, should be left between the sclerotica and the incision. The inferior half of the circumference of the cornea has gener- ally been chosen for the incision ; some, however, have preferred the upper half, while others, entering the knife on the temporal side, and above the equator of the cornea, have brought it out below the equator on the nasal side, and thus effected a section of the usual crescentic form, half on the temporal and half on the lower side of the cornea. The incision of the lower half of the cornea is the most easily executed ; and through such an incision, the opening of the capsule and the exit of the lens, are accomplished with the least difficulty. But if this incision does not heal by the first intention, if it be prevented from healing by a protruding iris, or by the edge of the lower eyelid intruding into the wound, then a broad unsightly cicatrice will remain, very much impeding vision when the patient looks downwards, or even altogether preventing it. From this last objection, the incision at the upper edge of the cornea is entirely exempt ; for even supposing that it heals only after suppuration, and that in consequence of protrusion of the iris through the incision, the pupil has been dragged very much up- wards, or is even entirely closed or hid behind the cicatrice, still the lower part or the cornea (the most valuable part) will be left perfect, and b}^ opening up an artificial pupil, vision may still be restored. Through the incision at the upper part of the cornea, however, it is much more difficult to effect division of the capsule, and to conduct with the necessary caution, the abstraction of the lens. The half- lateral half-inferior incision, when the degree of prominence of the external angular process of the frontal bone is such as will permit the application of the knife in the obhque direction, is perhaps the best ; exposing less the lips of the wound to be disturbed by pro- trusion of the iris, or by intrusion of the edge of the lower lid, than 513 the incision of the lower half of the cornea, and more readily per- mitting the division of the capsule and safe exit of the lens, than the incision at the upper edge. Various forms have been given to the cornea-knife, but on the whole, the best is that which is now generally known as Professor Beer's. The cutting edge of this instrument is placed at an angle of 17" with the back, wliich is continued in a straight line from the handle. The point is double-edged for the length of a Une, the strength and temper of the instrument such that it is unbending, and it gradually increases in thickness as it does in breadth. The fingers of the assistant and operator are to be applied, as has been directed at page 497, and especial care is to be taken, that the operator's middle finger is so placed on the caruncula lachrymalis, that the eye about to be cut shall be prevented from turning towards the nose, a position which, if, by inattention to the rule here laid down, the operator permits, he may find it impossible to complete the section which he has commenced. This is one of the most important cautions in the whole operation. I shall suppose that the operator is about to open the lower half of the cornea. In doing this, he will require to observe the follow- ing rules. 1. The point of the knife is to be entered on the temporal side of the cornea, at the distance of l-20th of an inch from the sclero- tica, and l-20th of an inch above the horizontal diameter of the cornea. 2. The instrument is to be directed at first perpendicularly to the lamellae of the cornea, as if it were intended to penetrate into the iris, in order that the lamellae may be fairly punctured, and the point of the knife arrive in the anterior chamber. If this rule is neglect- ed, and the instrument be introduced into the cornea in a direction parallel to the plane of the iris, it may easily slip between the lam- ellae, and not enter the anterior chamber at all. 3. As soon as the point of the knife has penetrated into the an- terior chamber, or, in other words, as soon as the 'punctuation of the cornea is performed, the handle of the instrument is to be car- ried back towards the temple, and the extremity of the blade di- rected towards the point of exit on the nasal side of the cornea. Fixing his eye on this point, which ought to be rather a little above than below the horizontal diameter of the cornea, and at the same distance from the sclerotica as the point of entrance, the operator carries the instrument cautiously and steadily towards it, neither too quickly nor too slowly, and turning the edge of the knife neither forwards nor backwards, but keeping it perfectly parallel to the iris. In traversing thus the anterior chamber, let the operator bend his eye on nothing but the point of counter-punctuation ; if he do so, the point of the knife will be sure to follow, whereas, if he allow himself to be diverted to any thing else, for instance, to what the edge of the knife is doing, he may miss his aim, and bring out the 65 514 instrument at a wrong place. Having reached the point of exit, he carries the knife still onwards till the counter-punctuation is effected. He has now the eye completely under his control. The middle fin- ger, which it was so important should rest till now upon the carun- cula lachrymalis, and prevent the eye from turning inwards, may be shifted to the lower lid ; and, if, by the operator's express desire, the assistant has been making pressure on the upper part of the eye, that pressure must be discontinued. 4. The counter-punctuation being effected, the section of the cor- nea is to be completed, simply by the progressive motion of the knife till it has cut itself out. In this part of the operation, no pressing downwards of the edge of the knife is allowable, much less any sawing motion. The handle of the instrument is to be kept well back, so that the extremity of the blade may avoid touch- ing the nose as it advances. When the incision is nearly complet- ed, the operator cannot proceed too cautiously. If the aqueous hu- mour has been entirely retained till now, the knife should be turn- ed a little on its axis, so as to allow the aqueous humour to escape. If this is neglected, the pressure of the knife upon that fluid, acting on the lens and vitreous humour, is apt to burst the hyaloid mem- brane, particularly if this membrane is weak, as it often is in old age, and thus give rise to ejection of the vitreous humour. The instant that the section is finished, the upper eyelid is allowed to fall, the light admitted into the room ought to be moderated, and the patient is to be recommended to compose himself, and to be as^ sured that the worst of the operation is over. These same rules are to be followed, if the incision is made up- wards or laterally, except in regard to the points of entrance and exit of the knife. 2d Period. Various instruments have been employed for open- ing or destroying the anterior hemisphere of the capsule, which is the object of the second period of this operation. Some employ a simple needle, like a common sewing needle, fixed in a handle, its point bent with a gentle sweep, or at a right angle ; and with this, they make a single scratch through the capsule, in general quite sufficient to allow the exit of the lens. Others employ a lance- shaped straight needle, the lance-shaped part being broader and shorter than that of the needle for depression. The edges of this instrument are sharp, and one of them being turned against the capsule, this membrane is divided by several obUque incisions run- ning frora right to left, and crossed by as many running from left to right, so that the capsule is reduced to a number of small lozenge- shaped portions, some of which probably come away with the lens, but which, if left in the eye, cannot again unite to form a capsular cataract. The latter is the more satisfactory, the former the easier mode of opening the capsule. The assistant begins the second period of the operation, by very cautiously raising the upper lid, but does not bring the points of 515 ' the fingers over its edge. The operator draws down the lower lid, and presses it gently against the eyeball. The degree of pressure ought to be such as shall cause the cataract to advance a little, and the pupil to expand, so as to allow of the more complete division of the capsule. If no pressure is exercised, the capsule may escape being opened at all. If too much is employed, the hyaloid mem- brane will burst, and the vitreous humour be ejected. The needle is now introduced under the loose flap of the cor- nea, as far as the pupil ; the point or cutting edge is turned to- wards the capsule ; the division of that membrane is effected, as has already been stated, by one or by several incisions ; the in- strument is cautiously withdrawn ; and the lids are again permit- ted to close. The patient ought here to be cautioned not to squeeze the lids together, but merely to keep them shut, as if he were asleep, 3rf Period. If the pressure exercised upon the lower part of the eyeball, during the second period of the operation, were con- tinued, the lens would be observed immediately to follow the with- drawal of the needle with which the capsule was divided. The experienced operator may run in this way the second and third periods together, but those who have not operated frequently, will find it advantageous to pause for a few minutes before proceeding to the third period. It is usual to have the curette, scoop, or as it is sometimes called Daviel's spoon, attached to the opposite extremity of the same han- dle in which is fixed the needle for opening the capsule. Holding, then, the curette in the hand which formerly held th€ knife and the needle, while the assistant raises the upper lid as before, the operator depresses the lower lid and renews the degree of pressure formerly exercised through the medium of the lid on the lower part of the eyeball. The pupil is seen to dilate, the inferior edge of the lens advances through the pupil, the whole lens passes into the anterior chamber, and makes its exit through the incision of the cornea, without any other interference, in general, or any other means of extraction being employed, than a continuance of mode- rate pressure on the lower part of the eyeball. The curette is used to assist the extraction only if the lens appears to be arrested be- tween the lips of the incision of the cornea, or if it appears to be falling in pieces. The patient should now be desired again to close his eyes as if he were asleep, while the operator, having received the lens on his finger nail, examines whether it is entire. When the patient has recovered a little from the confusion aris- ing from the admission of light into the eye, he may turn himself round on his chair, so that his back shall be towards the window. The eye which has not been operated on, may now be covered with a light compress and roller ; and the surgeon, holding up his hand at the distance of about 18 inches from the patient's face, 516 may desire him to look with the eye whence the cataract has been removed, and to say whether he sees any thing. It were better, in some respects, to dispense with all this ; but the patient who submits to extraction, knows that such experiments are made and expects them, and if put to bed without having ascertained what degree of vision he is likely to recover by the operation, is apt to get anxious, and to make trials of his own, which may be much more detrimental. The patient is now to turn round again towards the light. The operator with his thumb repeatedly and gently rubs the upper eye- lid over the surface of the eyeball, raises the lid, and rapidly ex- amines the appearance of the pupil and the state of the flap of the cornea. If the pupil is circular and clear, and the edges of the in- cision of the cornea accurately in contact, he desires the patient to look upwards, and then immediately to close his eyes, informing him at the same time, that he is not to make any farther attempt to open them for four and twenty hours, but to keep them closed, without squeezing the lids together, and in fact, exactly as if he were asleep. A strip of court-plaster, about an inch long and the fifth of an inch broad, is now to be applied from the middle of the upper lid to the middle of the lower, both over the eye v/hich has been operated on, and over the other. A hght roller with a fold of linen attached to it is put round the head, the fold hanging down over the eyes. Modifications of extraction according to varieties of cataract, and peculiar states of the eye. 1. If the eye to be operated on is more than ordinarily prominent, the incision ought not to be mad© at the lower edge of the cornea, lest the lower lid should in- trude into the wound, and prevent it from healing by the first in- tention. The incision should be either at the temporal or the up- per edge of the cornea. 2. It sometimes happens that the cornea is not only remarkably flat, but that the iris appears to project forward in the anterior chamber, forming a convex instead of a plane surface. In cases of this description, the anterior chamber is so small, that if an at- tempt be made to complete the division of the cornea by one semi- circular incision, it will be found extremely difficult, if not impossi- ble, to carry the point of the knife from the temporal to the nasal edge of the cornea, without wounding the iris. Under such cir- cumstances, therefore, it is ad\dsable to include only one-third of the cornea in the first incision, and afterwards to enlarge the aperture by means of DavieFs scissors. 3. In cases of floating cataract, such as the cystic, of capsular cataract, and of cataract combined with dissolved vitreous humour, it is not necessary, and often not safe, to extend the incision to a semicircle. It will be sufficient, under such circumstances, to divide one-third of the circumference of the cornea, and through this small incision to extract with the assistance of a hook, as I shall hereafter explain at greater length. 517 4. In cases of capsulo-lenticular cataract , it is proper to attempt the extraction of the capsule as well as of the lens. Some do this before, others after the lens is removed. The cornea being divided in the usual way, a needle may be introduced, a little bent towards the point, with which we may attempt to divide the capsule in a circular direction, as near the edge of the pupil as the instrument can be applied without injuring the iris. The part included with- in the circular division may sometimes be brought away on the point of the needle ; but if this cannot be done, it should be ex- tracted by means of a pair of small forceps, and then the lens is to be removed as in ordinary cases. This is the mode recommended by Mr. Ware. Beer, on the other hand, first extracted the lens, and then attempted to remove the shreds of the opaque capsule, by means of a delicate pair of forceps, the one blade terminating in a a tooth, and the other in a notch which receives that tooth. This instrument is to be introduced through the incision of the cornea and through the pupil, opened so as to receive one of the shreds, and shut so as to hold it without any possibility of its escaping. Then with a sudden twitch, the shred is to be extracted ; and this is to be repeated till the whole are removed. 5. We sometimes know from the history of the case, that the posterior hemisphere of the capsule is opaque ; or immediately after the lens is removed, we observe that there still remains an opacity impeding vision. If we are satisfied that this opacity consists neither in opaque shreds of the anterior half of the capsule, nor in some portion of the soft exterior substance of the lens retained (as it sometimes is) in the eye, then we may conclude that it is the pos- terior hemisphere of the capsule in the cataractous state. Perhaps the better plan in such a case, would be to allow the eye to recover from what has already been done, and by a subsequent operation with the needle, to endeavour to remove the opaque membrane out of the axis of vision. Some, however, have recommended that we should immediately proceed to destroy, and if possible, to remove the posterior half of the capsule. This they have attempted by means of a needle, of which one of the edges forms a hook or barb, so that it enters easily through the membrane in question, and being then turned one quarter round on its axis and suddenly withdrawn, brings along with it a portion of the diseased capsule. This manipulation is to be repeated, till at least a considerable aper- ture is formed for the transmission of light into the deeper parts of the eye, an object which will scarcely ever be effected without some loss of vitreous humour. Accidents during or after extraction. 1. The spirting out of the aqueous humour before the counter-punctuation of the cornea is effected, is one of the most common accidents during the first period of extraction. The iris, in consequence of losing its usual support, immediately falls forward, and getting under the edge of the knife, will be cut across, if the section is pursued without push- 518 ing back the iris into its place. This must be attempted by press- ing with the point of the foie-finger on the cornea. If in conse- quence of this pressure, the iris retires, the knife is to be carried quickly across the anterior chamber, and the counter-punctuation effected. This once accomphshed, there is no farther danger of the iris falling under the edge of the knife, and the section is to be completed in the ordinary way. But if the iris does not retire on pressure of the cornea, the knife must be withdrawn, and either the operation deferred till a future day, or a small probe-pointed knife introduced through the aperture which has been made, pushed gently through the anterior chamber to the nasal edge of the cor- nea, and over the end of it an opening made with another knife so as to allow it to come through, after which the incision is to be fin- ished exactly in the same way as if the sharp-pointed knife only had been employed. 2. When the point of the knife reaches the nasal edge of the cornea, the operator occasionally finds it difficult to bring it through, in which case he may derive advantage from pressing the cornea against the knife with his finger-nail. In other instances, the point of the knife is seen to bend to one side, so that it is impossi- ble to perform the counter-punctuation in the ordinary way. When this is the case, the knife may be withdrawn aad the opera- tion postponed, or what is preferable, the cornea may be opened on the nasal side with another knife, and then the knife, which is already across the anterior chamber may be carried through this opening, and the section completed. 3. Too small a section of the cornea is a very frequent occur- rence, in consequence of the operator bringing out the knife at too great a distance from the nasal edge, and perhaps considerably below the equator of the cornea. In this case, the incision must be enlarged to a semicircle, by the aid of Daviel's scissors, which are so bent that the one pair serves for dividing the temporal side of the right eye and nasal side of the left, and the other pair for the temporal side of the left and nasal side of the right. Rarely will the incision require to be enlarged at both extremities ; but upon no account is the operator to proceed to the second and third periods of extraction, if he is conscious that the section of the cornea is less than a semicircle. Loss of vitreous humour, severe pressure upon the iris, and destructive inflammation, are the consequences to be dreaded froni forcing a large cataract through a small incision. Resting the scissors on the back of the finger which depresses the lower eyelid, and opening them a little, the one blade is to be passed under the middle of the flap of the cornea into the anterior cham- ber, the other remaining external to the cornea ; the instrument is then to be carried close to the temporal or nasal edge of the cor- nea, according to circumstances, and with a single stroke, the in- cision is to be enlarged to the requisite dimensions. 4. When the operator, proceeding to the third period of extrac- 519 tion, makes pressure on the lower part of the eyeball, but observes that notwithstanding this, the cataract does not advance through the expanding pupil, he ought to desist, and ask himself whether the section of the cornea be of the proper size, and whether he has reason to think that he has in a sufficient manner opened the capsule. If the answer in the affirmative is well founded, then merely by waiting a few minutes, directing the patient to turn his eye upwards two or three times, rubbing the eye gently through the medium of the upper lid, moderating the light still more than has been done, and then repeating the pressure on the lower part of the eyeball, the lens will probably advance, and make its exit in the usual way. But if the smallness of the section be the cause of the cataract not coming forward, the section must be enlarged ; or if the capsule has been imperfectly divided, the second period of the operation must be carefully repeated. Pressure is then to be em- ployed on the lower part of the eyeball, when, in general, the cat- aract will advance. The pressure must be at once moderate and sufficient. If it is too forcible, the hyaloid membrane is very apt to burst, and the vitreous humour to be ejected before the lens. If insufficient, or if too soon relaxed from timidity on the part of the operator, the lens may not advance, and he will distress himself with imaginary difficulties. Yet it sometimes happens that the section of the cornea is sufficient, the capsule sufficiently opened, and due pressure made, without the lens advancing. This arises from an unnatural adhesion between the lens and the capsule, and is to be remedied in the following manner. The operator is to continue the pressure till the lower edge of the lens appears in view, he is then to introduce a thin sharp curette through the pu- pil, under and behind the lens, and by the motion of this instru- ment from right to left, to separate the capsule witli the lens en- closed, from the hyaloid membrane. A hook is then to be intro- duced, and the lens and capsule extracted. This will scarcely be effected without some discharge of vitreous humour, but certainly less risk attends this mode of procedure than that of forcing out the cataract, under such circumstances, by continued pressure. 5. It sometimes happens from the lens falling in pieces at the moment of extraction, that part of it remains behind the pupil. In this case, if the operator rubs the eye gently through the medi- um of the upper lid, and then opens the eye, he will generally find that the fragments have advanced into the anterior chamber. They will readily escape on lifting the flap of the cornea with the curette. Any small particles which may be left will dissolve in the aqueous humour. 6. An escape of vitreous humour may take place before, along with, or after the exit of the lens. This accident is sometimes at- tributable to immoderate pressure on the eye, or to spasm of the recti, or orbicularis palpebrarum, but much more frequently it is the result of weakness of the hyaloid membrane from age or from 520 disease. If the escape of vitreous humour commences before the lens has been removed, no farther pressure must be made on the eye, but a small hook is to l^e introduced so as to lay hold of the cataract, which is to be withdrawn as speedily as possible. The eye is then to be shut, and very gently rubbed through the medium of the upper lid, in order to replace the iris, which is very apt, when there has been any escape of vitreous humour, to protrude through the wound of the cornea. The cornea heals more slowly than usual after this accident, the cicatrice is broader, the pupil not unfrequently distorted, and vision less perfect. If only a fifth or even a fourth of the vitreous humour is lost, vision may not be very materially affected. If a third is lost, we cannot calculate on any very useful degree of vision. If more than a third is evacuated, the pupil generally closes, and the eyeball becomes permanently atrophic. I have already had occasion to mention, that when the eye is known to have been glaucomatous before becoming affected with cataract, we may expect to meet with a dissolved state of the hya- loid membrane. If we operate by extraction in such a case, and extend our incision to a semicircle, we may lay our account with an ejection of vitreous humour. If the capsule has been opened in a previous operation, with the view, for example, of softening a hard cataract previously to at- tempting to divide it, or if displacement has been ineffectually per- formed, and the operator proceeds to extraction, he will almost to a certainty encounter a dissolved hyaloid membrane, and of course an evacuation of vitreous humour. 7. Immediately after the lens has escaped from the e)'^e, ihe iris is apt to protrude through the wound of the cornea. This is in general very easily remedied, merely by rubbing the eye for a lit- tle through the mediuixi of the upper lid, and then suddenly ex- posing the eye to the hght. Should this not succeed, we may en- deavour to press the iris into its place with the curette ; and should this also fail, a small snip may be made in the protruding por- tion of iris, when it will often return almost of itself into the eye, in consequence of the aqueous humour which was lodged behind it draining away. It is very different \vith a protrusion of the iris which is apt to take place about the fourth day after the operation, and which, though commonly attributed to some accidental blow upon the eye, restlessness on the part of the patient, or improper attempts which he may have made to use the eye, is, I am convinced, to be as- cribed rather to the supervention of undue inflammation of the cor- nea, and of inflammation within the eye, than to any mere me- chanical cause. I do not deny, however, that this accident is favoured by making the incision too close to the sclerotica. This protrusion does not take place suddenly. We first of all observe the wound gaping a little, and its edges white, swollen, and everted. 521 Next the iris begins to show itself between the hps of the wound, and as the aqueous humour accumulates behind it, this staphyloma iridis increases. At the same time, the protruding portion of the iris inflames, and is united by effused lymph to the edges of the wound of the cornea. The conjunctiva and sclerotica redden, the discharge of tears is frequent and irritating, the patient feels as if some foreign substance of considerable bulk were lodged beneath the eyelids, the eye and supra-orbital region become painful, the skin dry and hot, and the pulse quick. No direct attempt need be made to reduce this protrusion. Snipping it wit.h the scissors, however, can do no harm. A vein of the arm ought to be opened once, and again, if necessary ; leeches are to be applied liberally round the eye, and a blister behind the ear. The bowels should be acted on by a brisk purgative, and calomel with opium admin- istered till the mouth is affected. These are the most likely means to abate the inflammatory action upon which the protrusion appears to depend. Belladonna is to be avoided, as rather tending to fa- vour the protrusion. Indeed the fear of this accident is one of the principal causes why we refrain from the use of belladonna in ex- traction. From day to day, the protruding iris may be touched with a sharpened pencil of lunar caustic. A broad cicatrice of the cornea, with a dragging of the pupil towards the cicatrice, is the necessary consequence of this accident, even when the most appropriate means of cure are had recourse to. If neglected, the pupil may be so much distorted as to be completely hid behind the cicatrice, with the upper half of the iris very much on the stretch, a state of matters which still affords a tolerable chance of vision being restored by the formation of an artificial pupil. In still more unfortunate cases, the inflammation is so se- vere and extensive, and is prolonged for such a length of time, be- fore the prolapsed portion of the iris shrinks and the cornea unites, that the vessels of the eye are left varicose and the retina insensible. 8. It sometimes happens, perhaps in consequence of carelessness in adjusting the flap of the cornea, that the edges of the wound unite in so imperfect a manner, as to be unable to withstand the pressure of the aqueous humour. The consequence is, that there is protruded from between the lips of the wound a thin semi-trans- parent membrane, having the form of a vesicle, distended by aque- ous humour, and giving rise to the sensation of a foreign body in the eye. If this membrane, which has genei'ally been regarded as the lining membrane of the cornea, be punctured, the tumour formed by it subsides ; but speedily reuniting, it is protruded as before, so that it is better to snip it off close to the original edges of the wound, and keeping the eye shut for several days, endeavour thus to pro- cure a more perfect union. The cicatrice in every such case will be very considerable. 9. Inflammation is the consequence most to be dreaded after the operation of extraction. It attacks one or several of the textures of 66 522 the eye, occurs with very various degress of severity, and comes on at different periods of time after the operation. The conjunctiva is frequently its seat, and then it presents the symptoms of puro-mu- coLis ophthahnia ; the eye feels as if tilled with sand ; there is con- siderable chemosis with puriform discharge, and adhesion of the lids. In other cases, the cornea inflames more than is consistent with the healing of the wound by the first intention ; the lips of the incision gape, the iris is apt to protrude, and a broad un- sightly cicatrice is the result. In many instances the sclerotica and iris inflame ; the patient is affected with severe pulsative pain in and round the eye, aggravated during the night, followed by effusion of lymph from the iris, opacity of the shreds of the capsule, and it may be by closure of the pupil. In other cases, and es- pecially where the flap of the cornea has been often lifted, and numerous instruments introduced into the interior of the eye, the inflammation, although internal, does not partake so much of the adhesive as of the suppurative character ; so that the organ is in still greater danger of being destroyed. That pecuhar inflammation, call by the Germans arthritic, and which, whatever be its nature, is undoubtedly a specific inflammation, is also extremely apt to be excited by the operation of extraction. It very rarely happens that this operation is not followed by such a degree of inflammation in one or other of the textures of the eye, as to require the abstraction of blood from the system. So well established is this observation, that some make it a general rule to bleed the patient at the arm, in the course of the first twenty-four hours after the operation, whether pain is complained of or not. The quantity of blood to be removed, and the frequency with which venesection is to be repeated, will of course be regulated by the age and constitution of the patient, and the nature and se- verity of the inflammation. Puro-mucous conjunctivitis will re- quire much less depletion than sclerotitis or iritis, and might perhaps yield to local remedies alone ; but when the internal textures of the eye are attacked, copious and repeated blood-letting from the sys- tem will be necessary, followed by leeches to the temples, the use of calomel with opium internally, and the application of blisters behind the ear or to the nape of the neck. Belladonna is a doubt- ful remedy. Where closure of the pupil is threatened, it is hkely to be serviceable ; but if there appears to be any tendency to pro- trusion of the iris through the wound, it ought to be avoided. After-treatment. The room in which the patient is to sleep after the operation, should be large and well aired, with a tempera- ture of from 50° to 55°, and free from cold draughts. The patient ought neither to be loaded with unnecessary bed-clothes, nor ex- posed to cold from tTneir deficiency. He may lie either upon his back, or on the side opposite to that of the eye which has been operated on. He should be put to bed with as little movement of the head and body as possible. The room is not to be made too dark, but 523 is to be kept perfectly quiet, in order to avoid all causes of sudden alarm or starting. All unnecessary talking between the patient and those about him is to be prevented. A careful assistant or ex- perienced nurse, sitting constantly by the bed-side for the first for- ty-eight hours and for several succeeding nights, ought attentively to watch the patient when he wakes, taking care, especially, that he does not turn suddenly round upon the eye which has been cut, or put up his hand to rub the eye. If there is any particular reason to dread the latter accident, it may be proper to mufHe the patient's hands, and pin them down by his sides. The length of time during which the patient is to be kept in bed, is a point upon which there has been a wide diversity of prac- tice. It would appear that Wenzel was at one time in the habit of confining his patients to their backs, without change of posture for a fortnight or three weeks, but that afterwards he shortened the period of confinement to eight or ten days. Mr. Phipps, on tlie other hand, examined the eyes on the morning after the operation, applied a shade, and allowed the patient to rise.* A middle course appears to be the most judicious. The incision may be looked at on the third day. On the fourth day, the patient may be allowed to sit up for a short time. On the fifth, the eye may be fairly ex- amined, but immediately afterwards covered with the shade. In eight or ten days, the patient may be allowed to look at large ob- jects, and to walk about his room. It is desirable that the patient's bowels should not be disturbed for the first twenty-four or even forty-eight hours after the opera- tion, as the movements of the body in getting out of bed, and while at stool, may prove injurious to the eye. After forty-eight hours, a laxative clyster may be administered, if necessary. A strict antiphlogistic plan of diet is to be observed for eight days or more, according to circumstances ; after which, soup may be al- lowed, and in about a fortnight after the operation, a little animal food. The aqueous humour generally continues to be discharged from the eye for about 40 hours ; in some cases, however, for a shorter period, and often for a much longer, even for weeks. Lest the ready discharge of the aqueous humour, as also of the tears, should be prevented, it is improper to cover up the eye closely, and still more improper to load it with unnecessary dressings and bandages. Indeed, if the edges of the incision appear to come accurately to- gether of themselves immediately after the operation, and if the patient can be depended on to keep his eyes shut, I am convinced that it is better to employ no plaster, dressing, nor covering what- ever, except a simple shade. If a strip of court-plaster is apphed, it is to be removed after twenty-four hours, and either the eyes left * On the Treatment of Patients after the Operation for the Cataract ; by Jonathan Wathen Phipps ; published as an Appendix to Wathen on Fistula Lachrymalis. London, 1792. 524 uncovered, or the strip of plaster replaced by a small piece of linen spread with simple cerate. Each time the dressings are changed, the lower lid should be drawn a little downwards, to allow any- fluid accumulated behind the lids to escape. Bathing the lids should not be attempted for three or four days, and even then must be done with great caution, and only by the surgeon. II. Extraction through a section of one-third of the circum- ference of the Cornea. I have already had occasion to mention, when treating of the accidents attendant on the operations of displacement, that the lens occasionally passes through the pupil, and lodges between the cornea and the iris. It would be incorrect to say that when in this situation it was in the anterior chamber, for as the axis of the aqueous humour is to that of the lens as 3 to 4, it is evident, that after it has passed through the pupil, the lens will occupy not only the anterior chamber, but the posterior also, and even part of the space which it filled while in its natural situation. The iris con- sequently will be pressed backwards by the dislocated lens, and it will be easy to lay open a third of the circumference of the cornea, without touching the iris. A hook being then introduced, the lens is to be laid hold hold of, and extracted. This mode, then, of removing a lens which has fallen in front of the iris, has led, in a variety of other cases, to the practice of opening only a third, or less than a third, of the circumference of the cornea. The wound in this way being less extensive, will in general heal more readily ; and even should it inflame and unite but slowly, will leave less deformity, and produce a much less de- gree of impediment to the passage of light into the eye, than the broad semilunar cicatrice, which is apt to follow the common ope- ration of extraction. The lips of the incision, when only a third of the circumference of the cornea is opened, will close much more completely immediately after the operation is finished, so that we need not be afraid of prolapsus of the iris, and may therefore dilate the pupil by belladonna before proceeding to the operation, which will both enable the lens to be more easily brought forward in front of the iris, and render injury of the iris less hable to occur. Through a small section, also, of the cornea, especially in cases of dissolved hyaloid membrane, the vitreous humour is less likely to be evac- uated to any considerable extent. Of the reality of some of these advantages I am able to speak decidedly, as I have employed this method of extraction in a va- riety of cases. I now prefer it, when it is my object to extract a capsular cataract, or when I have reason to believe that the vitreous humour is dissolved. 1. The following is the plan which I have successfully adopted in cases of capsular or siliquose cataract, the lens having either been absorbed in consequence of an accidental wound of the cap- 525 sule, or removed by a previous operation. I place the patient in the horizontal position, and pass a small curved needle through the sclerotica, with which I endeavour as much as possible to gather together the opaque capsule into a mass, which 1 then push through the pupil. The needle I now deliver to the assistant, who is to hold it steadily in the same position, while with the extrac- tion-knife^ or a broad iris-knife, I open one side of the cornea (gen- erally the temporal side) to a third, or nearly a third of its extent. I then introduce either a hook or a small pair of toothed forceps, lay hold of the capsule, and either immediately extract it, or if I find this opposed by any adhesion, turn the instrument round on its axis till the membrane is detached. In one case, in which I found the capsule so strongly adherent to the iris, that I was afraid I might sooner sever the latter from the choroid than extract the capsule, I contented myself with prolapsing the capsule through the wound of the cornea, clearing in this way the pupil, and re- storing a very useful degree of vision. Under such circumstances, the iris-scissors might be advantageously employed in dividing the half-detached capsule. 2. Mr. Gibson, of Manchester, appears to have been the first to extract soft cataracts through a small incision of the cornea. He was led to adopt this practice from the great length of time which soft cataracts sometimes take to disappear by solution in the aque- ous humour, added to the fact that not only is the patient apt to grow anxious and to lose his health, but the eye to become affected with chronic irritability and inflammation, under this prolonged mode of cure. Mr. Gibson first of all freely ruptured the anterior hemisphere of the capsule with the needle, and after two or three weeks, proceeded to extract the pulpy lens. For this purpose he punctured the cornea near its temporal edge with a broad extrac- tion-knife, and if he had any doubt of the capsule having been freely lacerated in the former operation, he directed the point of the knife obliquely through the pupil, so as to make a more free division of the capsule. On withdrawing the knife, part of the aqueous humour, and some portion of the cataract were evacuated. The curette was next introduced through the incision, and towards the pupil ; and by that instrument the whole of the cataract was commonly removed by degrees, and the pupil rendered perfectly clear. Its removal was generally much facilitated by gentle pres- sure towards the vitreous humour, with the convex surface of the curette, whilst the point was inserted through the pupil. Mr. Gibson observes that it occasionally happens that upon in- troducing the curette, a considerable part of the cataract appears too solid for removal, and only a small portion escapes in a pulpy state. The nucleus of the lens is sometimes much more soHd than the rest, and will not be easily extracted in this way ; yet, much oftener the difficulty arises wholly from the smallness of the aper- ture in the capsule, so that it allows only an inconsiderable part of 526 the cataract to pass out at a time, the capsule having perhaps been tougher than usual, and not easily lacerated in the preparatory operation with the needle. In such a case, the opening into the capsule may be extended either by means of the curette, or by the small hook commonly used for lacerating the capsule ; or if this membrane appears uncommonly firm, it may be divided with the iris-scissors. Mr. Gibson concludes that by this operation the repeated use of the needle may be safely superseded, and with less risk of inflam- mation or injury to the eye. He adds, that in many instances, no traces of inflammation, or of any operation, could be seen on the eye the next day ; nor had the iris ever been injured, or even ir- ritated in the slightest degree, by the use of the curette.* This method of removing soft cataract has been adopted by Mr. Travers, with the difference, that instead of opening the cap- sule with the needle passed through the sclerotica, and then wait- ing for two or three w^eeks, he begins his operation, having pre- viously dilated the pupil, by a quarter-section of the cornea, dipping the point of the knife into the pupil, and freely lacerating the capsule. The fluid cataract, he states, is instantly evacuated with the aqueous humour ; the flocculent cataract frequently passes out entire, taking an oblong shape ; and the caseous cataract piece- meal, through the hollow of the scoop, on gently depressing the margin of the pupil.t 3. Mr. Travers,^ Sir William Adams,? and others, have w^ith more or less success had recourse also to the extraction of firm cataracts through a small section of the cornea. The pupil being previously dilated by belladonna, the steps of the operation are, to slit open the capsule with a small bent needle, introduced through the sclerotica ; tilt the lens forward through the pupil ; keep it fixed by means of the needle, which may now be committed to the charge of the assistant ; open the circum- ference of the cornea to about one-third of its extent; withdraw the needle ; introduce a hook, lay hold of the lens, and extract it. The opening in the capsule will require to extend to its whole diameter, else the dislocation of the lens will not be easily accom- plished. The dislocation is usually effected by pressing with the needle near the lower or upper edge of the lens, so that the opposite edge from that which is pressed upon is tilted forwards through the pupil ; and it matters little whether, in doing so, the lens re- volves, so that its posterior surface comes to be applied against the cornea, or not. If the operator is satisfied that the capsule is suf- ficiently opened, and yet fails in bringing the lens forwards by * Practical Observations on the Formation of an artificial Pupil ; to which are an- nexed, Remarks on the Extraction of Soft Cataracts, &c. p. 103. London, 1811. t Further Observations on the Cataract; in the Medico-Chirurgical Transactions, vol. V. p. 406. London, 1814. t Ibid. § Practical Inquiry into the Causes of the Frequent Failure of the Operations of Depression and Extraction, pp. 138 and 283. London, 1817. 527 pressing back one or other of its edges, he may withdraw the needle from the posterior chamber by carrying it under, and hence behind the lens, which he must then attempt to push forwards through the pupil. Keeping the needle in contact with the lens till the section is finished, or even retaining it in the eye till the cataract is extracted, is of great use, as it secures us against the lens falhng back into its former situation. The incision of the cornea is to be executed exactly in the same manner as the semi- circular incision, only that it is less in size. The hook is to be introduced, flat, between the lens and the iris, as far as the centre of the pupil ; the curved point of the instrument is then to be turned forwards, and the cataract laid hold of. The extraction is accom- plished without any pressure on the eye, which constitutes the great recommendation of this mode of operating, in cases where we have reason to suspect that the hyaloid membrane is unsound. III. Extraction through the Sclerotica. Mr. B. Bell appears to have been the first* to suggest this mode of operating, as one which was not only practicable, but in which the cornea and iris would be exempt from all direct injury. His experiments on the lower animals led him to believe, that the in- flammation induced by an incision through the sclerotica was not more considerable, nor the cure in any respect more difficult, than when extraction was performed in the usual manner. He recom- mended the opening to be made in the upper part of the %ye, the knife being entered about the tenth of an inch behind the cornea, the incision to be of sufficient size for allowing the cataract to pass, and a sharp curved probe to be introduced, the point of which to penetrate the lens, whicli might by this means be removed without any pressure upon the eyeball.t For extraction through the sclerotica, Sir James Earle invented an instrument, consisting of a small lancet, moving backwards and forwards between the blades of a pair of forceps. This instrument being introduced through the sclerotica and choroid, the lancet is withdrawn by means of a spring contained within the handle, while the forceps is left behind. The blades are then opened, and the cataract seized and brought away. Sir James entered the in- strument just behind the iris. In the first three operations which he has related, he introduced it in such a manner that the incision ran parallel to the edge of the cornea, and of course divided a con- siderable number of the choroidal vessels ; but in his fourth opera- tion he appears to have introduced the instrument in such a man- ner, that the incision would form a line perpendicular to the edge * Dr. Lobenstien-Lobel has conjectured that extraction through the sclerotica was the method adopted by Kerkringius, Burrhus, Ta3dor, and Woolhouse, when they boasted of having restored a ycung and acute vision to aged people, by removing the corrupted and turbid humours of the eye, and replacing new ones in their stead ; but this is very unlikely. t System of Surgery, Vol. iv. p. 246. Edinburgh, 1796. 528 of the cornea, or, in other words, run parallel to the course of the choroidal arteries. Having retracted the lancet, he then turned the forceps round, so that they might embrace the cataract ; a mode of procedure by which he thinks a discharge of vitreous humour less likely to occur. He states, also, that the wound which is made perpendicularly to the edge of the cornea heals with the same fa- cility as the other.* The following are some of the advantages, mentioned by Sir James, as possessed by extraction through the sclerotica. The wound need not exceed a fourth of the size of the incision required in the ordinary operation of extraction through the cornea ; in the passage of the forceps through the vitreous humour and in the use of them afterwards, not nearly so much derangement of the interior of the eye is produced as attended the employment of the needle in the old operation of couching ; the part through which the incision is made is immovable, consequeutly the edges of it must remain in contact, and heal with comparative facility.t A remarkable case of wound of the eye, attended with evacua- tion of the lens, had led Dr. Lobenstein-Lobel to form a favoura- ble opinion of extraction through the sclerotica,! but he does not appear to have ever put this operation in practice. I lately extracted a crystalline lens from under the conjunctiva ; it having been propelled, by a smart blow on the eye, through a laceration of the choroid and sclerotica. The opening through these tunics was already healed, the pupil clear, and the retina perfectly sensible. Such facts as this would lead us to pause be- fore rejecting, so absolutely as some have done, the operation of extraction through the sclerotica. I cannot pretend to speak with much precision of an operation which I have nev^er attempted on the human eye. I should con- sider it proper, however, to divide the capsule with the needle be- fore opening the sclerotica and choroid with the knife ; to select the upper part of the eyeball for the incision ; to make it perpen- dicular, not parallel, to the edge of the cornea ; and to extract the lens with a hook. Of course, pressure on the eyeball is in this operation altogether out of the question. SECTION XI. DIVISION. I. Division through the Sclerotica.X Ever since the days of Celsus,§ division of the cataract with the * From some experiments which I have made on the lower animals, 1 am convinced that an incision through the sclerotica perpendicular to the edge of the cornea gapes less, and therefore heal sooner than one parallel to the edge of the cornea. t Account of a New Mode of Operation for the Removal of Cataract. London, 1801. X Edinburgh Medical and Surgical Journal. Vol. xiii. p. 56. Edin. 1817. § Die Pott' sche Operationsmethode of the Germans. II Si subinde redit, eadem acu magis concidenda, et in plures partes dissipanda est. Celsus de Re Medica, Lib. vii. Pars ii. Cap. i. Sect ii. 529 couching needle has been regarded as a proper supplementary step to displacement, when this could not be perfectly performed. Bar- bette, Read, and Maitre-jan, all availed themselves of their know- ledge of the fact, that a cataract which had been merely cut up and left in its ordinary situation, would after a certain length of time entirely disappear. Barbette states, that in such circumstan- ces, vision would be restored after seven or eight weeks ; * Read employs the words consumed and dispersed^ to express the dis- appearance of the pieces of the divided cataract ; t Maitre-jan ob- serves that this disappearance, which he styles a precipitation^ takes place as well in the anterior as in the posterior chamber, and notices its connexion with a laceration of the capsule.t Pott ap- pears to have been the first, not merely to make use of the term which we now employ, namely, dissolution, but to adopt a lacera- tion of the capsule as a distinct mode of operating, independent of depression. § It is evident, that in this mode of operating, the object is not im- mediately to remove the cataract, but merely to expose it to a nat- ural means of cure, namely, the solvent action of the aqueous hu- mour. This may be done in two ways ; viz. first, by destroying the front of the capsule, so that the aqueous humour gains admit- tance to the lens ; and, secondly, by dividing the lens into frag- ments, and pushing these into the aqueous humour. Both of these objects may be attempted at one operation ; but it is better to ope- rate twice than to do too much at once, and to confine ourselves in the first operation to the division of the capsule only. The caution. deUvered by Mr, Hey is peculiarly applicable to the operation of division. " One principal thing," says he, " to be kept in view by the operator, is to do no harm. If he secures this, he will almost certainly do some good, and often much more good than he ex- pects."|| Division through the sclerotica naturally divides itself into four periods. In the first, the needle is introduced through the tunics, and into the vitreous humour ; in the second, the instrument en- ters the posteiior chamber ; in the third, the anterior hemisphere of the capsule is divided ; in the fourth, the lens is cut into frag- ments, and these are pushed into the anterior chamber. * Etiamsi sufficienter depressa haud erit cataracta, visum tamen saspe post septima- nas septem vel octo rediisse, in variis observavi, modo in partes varias divisa fuerit. Pauli Barbette, Opera Chirurgico-Anatomica, p. 66. Lugd. Batav. 1672. t Short but Exact Account of all the Diseases incident to the Eyes. London, 1706. t Traite des Maladies de I'CEil, p. 186. Troyes, 1711. § I have sometimes, when I have found the cataract to be of the mixed kind, not attempted depression : but have contented myself with a free laceration of the capsula ; and having turned the needle round and round between my finger and thumb, within the body of the crystalline, have left all the parts in their natural situation : in which cases I have hardly ever known them fail of dissolving so entirely as not to leave the smallest vestige of a cataract. Chirurgical Works, vol. iii. p. 156. London, 1808. Mr. Pott first published his remarks on the Cataract in 1775. II Practical Observations in Surgery, p. 72. London, 1803. 67 530 The pupil is to be dilated, in the manner mentioned at page 502. Whether a straight or bent needle is chosen, the neck of the in- strument must be round, its edges perfectly sharp, and its size rath- er under than above the measurements stated at page 503. The first and second jieriods of the operation are exactly the same with those of depression and reclination, as already de- scriljed. 3o?. Period. The needle having reached the centre of the pos- terior chamber, the operator turns its cutting edge towards the capsule, and proceeds by numerous gentle touches of the instru- ment, to cut up that membrane into shreds, to an extent rather ex- ceeding than falling wi'.hin the natural size of the pupil. The ob- ject is entirely to annihilate this central portion of the capsule, and thus allow the aqueous humour free access to the lens. Merely to pierce the capsule, slit it up, or tear it from the front of the lens, would, in all probability, not answer the purpose, because the por- tions of the capsule thus treated would speedily reunite, and the absorption of the lens be interrupted. Neither is it desirable to open the capsule in the whole of its diameter, because this would most likely be followed by dislocation of the lens, which would conse- quently press against the iris, or pass entire through the pupil into the anterior chamber. If the lens be fluid, it will escape into the aqueous humour and render it turbid, as soon as the capsule is opened ; and if soft and friable, portions of it, towards the end of this period of the operation, will generally be observed to break off, and float forwards through the pupil. If this be the first operation which the cataract has undergone, the needle should be withdrawn as soon as the division of the cap- sule is completed. A:th Period. It sometimes happens that the division of the cap- sule, in the manner and to the extent above stated, is sufficient^ without any further operation, to procure the absorption of the lens, and the restoration of vision. Much oftener the operation of di- vision requires to be repeated after the interval of two or three months ; and at the second operation, particular attention requires to be paid to the breaking up of the lens and dispersion of its frag- ments. The needle being introduced as before, the operator begins the division exactly as he began the former operation, lest the shreds of the capsule may in the interval have more or less completely coalesced, and therefore require to be separated and broken down. Having assured himself of the existence of a sufficient central aperture in the capsule, the operator next proceeds by gentle move- ments of the needle from side to side, to break the lens in pieces, and pushes these from time to time, as he proceeds, through the pupil, into the anterior chamber. In dividing the lens, it is some- 531 times necessary to move the edge of the needle backwards, or towards the vitreous humour ; but this direction ought rather to be avoided, in order that the posterior capsule may, if possible, remain entire, for if it be much injured, it is apt to become opaque, an oc- currenee rendering necessary new operations, which endanger the organization of the vitreous humour. It is by no means essential, even for speedy solution, that the pieces of the divided lens be brought into the anterior chamber. Some have been led to think that solution is accomplished fully as quickly when the lens, stript of its capsule, is left in its natural sit- uation. No doubt, the greater quantity of the menstruum by which the solution is to be effected, lies in the anterior chamber 5 but, on the other hand, it is probable that this menstruum is se- creted chiefly (if not entirely) in the posterior chamber,* and it is possible that it may possess more of the solvent power when just flowing from the capillaries which secrete it, than after it has passed forward through the pupil, and is about to be absorbed. Others have been of opinion, that the removal of the opaque lens, after the capsule is opened up with the needle, is to be attributed perhaps as much to the action of the absoibents of the lens itself, stimulated by the presence of the aqueous humour, as to the opera- tion of this fluid in the way of menstruum.t The facility with which tLe fragments of the divided lens are scattered by the needle, does not depend so much on its consistence, as on the degree of coagulation w^hich it has undergone. In pa- tients about the age of 25. we not unfrequentiy find the lens so soft that the needle passes easily through it in every direction, but at the same time so glutinous and tenacious, that the fragments can be separated with diinculty ; whereas in patients of 35, the lens is generally more friable, and breaks easily under the needle into scales and flocculi. By exposure, however, to ti;e aqueous humour for a few weeks, the glutinous lens becomes more completely coagu- lated, and then its fragments prove less adherent. Even the hard lens of an old person, if exposed for some time to the influence of the aqueous humour, occasionally becomes brittle, so that at a second operation with the needle, (the first operation having been devoted to the destroying of the anterior capsule,) we find the lens to scatter into fragments. This is an occurrence, however, too rare, to vindicate us in adopting division as a general mode of ope- rating on the hard cataract of old persons. What length of time is generally required for the cure of cataract by absorption ? To this I am inclined to answer, that we have no evidence to prove that the capsule is ever absorbed, whether it be in the transparent or in the opaque state ; and that as for the lens, the rapidity with which it is dissolved, depends partly on its con- sistence, and partly on the completeness with which it is exposed * See p. 423. t De la Garde's Treatise on Cataract, p. 51. London, 1821. 532 to the aqueous humour. If in a person below 35 years of age, the central portion of the anterior capsule be thoroughly destroyed with the needle, and if no inflammation follows the operation, the lens may be completely dissolved and absorbed in six weeks. Of course, the fluid lens of the child will be absorbed in a few days, while the hard lens of 55 or 60 may remain almost unchanged for several months. We constantly observe that solution and absorption go on much more rapidly when the eye is free from inflamniation or irritation. Indeed during an attack of pain, with redness and epiphora, solution and absorption seem to cease, but are renewed whenever the irritation subsides, or the inflammation is overcome. We explain this, partly by the well known fact that over-distension of the blood-vessels is always found to be inconsistent with a free action of the absorbents, and partly by this, that even although there may be no evident effusion of lymph behind the pupil, there is always a tendency in internal ophthalmia to such an effusion, and, of course, a tendency to close up and repair the injured cap- sule, an effort of nature, which however admirable its design, we must in this instance endeavour to counteract, by as complete a division of the capsule, in the first instance, as is possible, and, secondly, by a strict antiphlogistic after-treatment. The opinion above stated, that the capsule, so far as we know, is insoluble, is, I am aware, in contradiction to what has usually been maintained upon this point. The capsule in the transparent state we never see ; its shreds are invisible from the very circum- stance of their transparency. This membrane too is highly elastic, and upon being divided, rolls itself up like a bit of goldbeater's leaf. But if inflammation occurs, the capsule becomes opaque, and, un- less the inflammation is speedily subdued, will continue perma- nently so. The opaque shreds in the inflamed state tend also to reunite, and thus give rise to a secondary capsular cataract. Sub- due the inflammation by blood-letting, mercury, and other appro- priate remedies, and the opacity of the capsule subsides or entirely disappears. Neglect it, and not merely does the opacity become permanent, but however much the capsule may afterwards be di- vided, its shreds never disappear, except by displacement. They may be pushed aside, a central aperture cleared, and vision re- stored ; but portions of opaque capsule will be visible for life behind the edge of the pupil, brought under the influence of belladonna, and the minute shreds which fell down into the anterior chamber, will lie there without undergoing the slightest change. It is proba- ble, that the return of transparency, after inflammation of the cap- sule is overcome, has given rise to the erroneous opinion that this membrane is susceptible of solution in the aqueous humour. Modifications of division through the sclerotica, according to varieties of cataract. 1. When the lens is fluid, it will of course flow through the wound of the capsule into the aqueous hiimour. This renders it difficult to execute the division of the 533 capsule with precision. It is desirable, however, that the centre of it should be freely lacerated. The turbid aqueous humour is generally absorbed in a few days. In some rare cases, the effusion of the opaque lens excites considerable inflammation. 2. The appearances of the opacity, added to the age of the pa- tient, should in genei'al be sufficiently indicative of hard cataract ; and in cases of this sort, division ought never to be tried. Should the operator, however, have deceived himself, and supposed the lens to be soft when by touching it with the needle he discovers it to be hard, the best plan which he can follow is to bring the lens through the pupil, open one-third of the circumference of the cornea, and extract. 3. When the edge of the pupil is adherent to the capsule, which in this case is always more or less opaque, we may endeavor with the point or edge of the needle cautiously to separate the points of adhesion, particularl)'^ if they are but few in number, and having effected this, proceed to the division of the capsule in the usual way. If the adhesion comprehends the whole edge of the pupil, separation is scarcely to be accomplished ; but if the pupil is of a medium size, it is not necessary for the restoration of sight that the iris should be freed from its attachment to the capsule. Enough of the capsule can in this case be divided to admit the aqueous humour freely to the lens, and we probably run less risk of renewed iritis when we confine ourselves to the clearing away of the centre of the capsule than were we to attempt the separation of the mor- bid adhesions of the iris. After-treatment. Except in continued dilatation of the pupil, this does not differ from the treatment already recommended as advisable after the operations of displacement. If the pupil is kept under the influence of belladonna, the fragments of the divided lens are in a great measure prevented from irritating the iris, and thus iritis is waided off. It is pioper, therefore, to smear the eye- brow and eyelids with the extract of belladonna every evening, till the cure is completed. Should this mode of application appear to fail in producing the desired effect, a httle of an aqueous solu- tion of the extract, made lukewarm, may be dropped into the inner corner of the eye, the patient opening the eye and allowing the solution to spread over the conjunctiva. The solution ought to be filtered immediately before using it. Accidents duri?ig and after division through the sclerotica. Many of these are exactly similar to those which are apt to attend the operations of displacement, and need not again be particularly insisted on. 1. The needle, instead of entering the posterior chamber, some- times slips between the lens and the capsule. As it is impossible with the needle, in this situation, to divide the capsule in a proper manner, the operator ought to withdraw the instrument a certain way, and then repeat the second period of the operation, taking care to bring the point of the needle in front of the capsule. 534 2. Should it happen, in consequence of an improper use of the needle, that the lens bursts from the capsule, and passes through the pupil into the anterior chamber, the cornea should immediately be opened in the manner described at page 526, and the lens ex- tracted 3. If the hyaloid membrane is in a dissolved state, the lens and capsule, hitherto kept in their place by the adhesion of the circura- fereuce of the capsule to the ciliary processes, are apt, on being touched with the needle, suddenly to sink to the bottom of the vitreous humour. In this case, the cataract ought immediately to be laid hold of with the needle, brought up into its former place, pushed through the pupil, and extracted through a small section of the cornea. 4. A certain degree of inflammation may always be expected to follow division through the sclerotica ; reparative inflammation of the capsule, spreading in some degree to the iris, and if not timely checked, producing opacity of the capsular shreds, closing up the central aperture which has been formed by the operation, interrupt- ing in various ways the process of dissolution of the lens, and per- haps going the length of coarctation of the pupil and adhesion of the iris. Belladonna, blood-letdng, and calomel with opium, are the means to be employed to avert these dangers. 5. Has the process of solution and absorption of the lens no ex- hausting effects upon the internal parts of the eye ? Are these parts left as sound, after this process has been accomplished, as after extraction, in neither case inflammation having occurred? To these questions, I must answer, that after the process of solu- tion and absorption is completed, we frecjuently observe undeniable signs of the internal textures of the eye having suffered, not from inflammation apparently, nor from irritation, but rather from exhaus- tion. The iris, particularly, becomus paler and more flaccid than natural, the pupil smaller, and its motions less vivid ; while, in some cases, the wasting of the eye extends more deeply, the vitreous humour shrinks, and the retina becomes more or less in- sensible. II. Division through the Cornea* It has been conjectured that this is a very ancient method of curing cataract. Galen mentions that there was a tradition, that for the operation for the cure of cataract man was indebted to what was observed to happen to the goat,' v^^hich after pricking his eye against a sharp reed, retained the power of sight ; t whence it has been thought that the first operation practised for the cure of cata- ract may have been a division or punctuation of the lens through the cornea. * Keratonyxis of the Germans ; from xsgstf, comu, whence cornea, and yuTrai, to puncture. T T/v* Si ix. Tri^iTTTaia-ias; ^u.ti Trmivona-QsLi. ai; to tt^fictKevrejv tovc vTromyv/mvcvc at tou TrtgnrtTw ttiya., «t/j Trigi^Qj^uva. ttnQKi^iv, o'^uj-^oivw ifA7rttyit "TT Wagner de Coremorphosi, p. 36. GoettingsB, 1818. ** Journal der Practischen Heilkunde von Hufeland und Harles, fUr Januar, 1815, p. 47. 569 Langenbeck* was the first to whom it occurred to drag out through the cornea the portion of iris which is separated from the choroid, and by allowing the protruded piece to unite to the hps of the wound, to prevent in this way the closure of the new pupil. In this operation he employed a single hook, which is apt, instead of separating the iris from the choroid, to tear it through, or to let it go after the separation is commenced. We are therefore highly indebted to Dr. Reisingert for the invention of an instrument, con- sisting of two delicate hooks laid side by side, which when shut are no bigger than a single hook. In this state they are introduced into the anterior chamber, but by their elasticity they separate from one another, and thus serve to lay hold of the iris at two different points, and, being again brought together, seize that membrane also as a pair of forceps. Various other instruments have been invented for the same purpose, but none appear so manageable and effective as that of Reisinger. The operation divides itself into four periods ; viz. the incision of the cornea, the introduction of the double hook and laying hold of the iris, the separation properly so called, and the strangulation of the separated piece of. iris between the Hps of the wound. 1st Period. The situation of the incision through the cornea will of course vary with circumstances ; but care must always be taken that it shall be neither too near nor too far from that edge of the cornea behind which the artificial pupil is to be formed. We shall suppose that this is to be done behind the nasal edge of a cornea, the transverse diameter of which measures 5-lOths of an inch. In this case, the incision should be made in a vertical direc- tion, at the distance of 3-lOths from the nasal edge, or at any rate not nearer to that edge than the centre of the cornea. Were the incision nearer than this to the nasal edge, behind which we have supposed that the artificial pupil is to be formed, the separation of the iris would be too limited to form a pupil of sufficient size, and should an opaque cicatrice result from the incision of the cornea, this would necessarily cover the new pupil, and frustrate the object of the operation. On the other hand, were the incision much farther from the nasal edge, the artificial pupil would be enor- mously large, in consequence of our continuing to detach the iris till a sufficient portion of it was drawn through the incision. But by making the incision at the distance of 3-lOths of an inch from that edge of the cornea behind which the separation is to be effected, the result will be a triangular pupil, of moderate size. The incision will, in some cases, require to be made though a lucid portion of the cornea, and in other cases through one which is opaque. This is a matter of indifference, except only that we see * Wenzel Uber den Zustand der Augenheilkunde in Frankreich und Deutsch- land, p. 107. NUrnberg, 1815. t Darstellung einer ieichten und sichern Methode kUnstliche Pupillen zu bilden, p. 29. Augsburg, 1816. 72 570 better how to continue the operation, when the part of the cornea which is opened is transparent. It is important that the length of the incision should be fully 2-lOths of an inch : for if smaller, it will be difficult, or even impossible, to effect through it the necessary protrusion of the iris, or even to open the double hook so as effect- ually to lay hold of the part to be separated. If, on the other hand, the incision is too extensive, the piece of iris which is protruded will not be strangulated with sufficient force by the lips of the incision, but will escape again into the anterior chamber, and return towards the choroid. A double-edged knife has been recommended for making the in- cision, being pushed obliquely through the cornea, and across the anterior chamber, till its point reaches that edge of the iris which is to be separated from the choroid. To make the incision of suffi- cient length in this way. the knife would require to be entered at the distance of at least 3-lOths of an inch from that edge of the cornea behind which the artificial pupil is to be formed. Its edges would also require to divaricate at an angle of 36". Pushing the point of the instrument then obhquely through the lamellee of the cornea, it is to be carried through the anterior chamber, till it reaches the angle between the cornea and iris, on that side of the eye where the artificial pupil is to be formed, and immediately withdrawn. The incision will of course be vertical in its direction, when the pupil is to be either at the nasal or temporal edge of the cornea ; horizontal, if it is to be at the upper or lower edge ; parallel always to the basis of the intended pupil. The incision must not be perpendicular to the lamellee of the cor- nea, but oblique ; else it will be difficult, if not impossible, to effect the protrusion of the separated piece of the iris. 2d Period. It is desirable that the sudden withdrawal of the knife, aided by the obliquity of the incision, should prevent the aque- ous humour from being discharged, till the hook is introduced. Pressing the two branches of the instrument together, so that it as- sumes the appearance, and does not surpass the bulk of a single hook, the operator slides it, flat, along the surface of the cornea, till it shps into the incision, and then carries it rather rapidlv through the anterior chamber, till it reaches that edge of the iris which is to be separated from the choroid. The double hook now rests, with its points directed downwards, in the angle between the cornea and iris. Turning it a quarter round on its axis, and pushing it to the very edge of the anterior chamber, the operator by slowly relaxing his grasp of the instrument, allows its two branches to expand, and immediatel}- lays hold of tire edge of the iris, with the two hooks, thus separated from each other. He next closes the instrument, so that the two hooks again approach each other, carrying the iris with them, and la3'ing hold of it as if with a pair of forceps. The in- strument is now turned again on its axis, till the points of the dou- ble hook are directed downwards as before, and thus the second pe- riod of the operation is completed. 571 3d Period. Very slowly the operator now withdraws the double hook through the anterior chamber towards the incision of the cor- nea, carrying with it the iris, between which, and the edge of the cornea, he perceives the artificial pupil gradually formed. During this period, the instrument must be kept as close to the cornea as possible, in order to avoid any injury of the crystalline capsule ; and as this is the most painful part of the operation, care must be taken to keep the patient's head steady, and to guard against his raising his hand to his eye. The pupil, as it is formed, fills with blood, so that it is often impossible to discern the state of the lens and capsule. Ath Period. The operator now lequires to press the branches of the instrument closely together, and at the same time to depress the handle, so that the convex edge of the hooks may slip easily out of the incision ; for if any difficulty occurs in bringing out the in- strument, the operator is apt, in attempting to obviate it, to lose hold of the piece of iris which he has separated. The portion to be pro- truded rarely requires to exceed the size of a pin head. This, how- ever, must vary in particular cases ; for it sometimes happens, from the great extensibility of the iris, that the pupil will not be of suffi- cient size, unless the separation is continued even after the double hook is brouofht out of the eve : while in cases where the iris is much • ••11 diseased in texture, and its extensibiUty thereby greatly dimuiished, it is sometimes found difficult to effect a protrusion at all. The operator must be cautious of allowing the branches of the hook to separate, or of letting go his hold of the iris, till he sees that he has fully accomplished this part of the operation, and that the protrusion appears to be retained by the hps of the incision, w^hich will be done more effectually by carrying the protruded portion of the iris from the middle of the incision towards either of its extremities. The hooks are then to be freed from the protruding part of the iris. In withdrawing the instrument from the anterior chamber, should it happen that the hooks catch in the substance of the cor- nea, they must be pushed back again, and care taken to follow more exactly the rules above set down for this part of the operation ; or the instrument may be turned round on its axis, the handle raised, and the convex edge of the hooks brought out from below. The eye should now instantly be shut, in order, by the pressure of the lids, to assist in strangulating the protruding portion of the iris. After a few minutes, the eye may again be opened, in order to ascertain the state of the prolapsus. Should this have disap- peared, by the iris having retracted, which is not likely to happen unless the incision of the cornea is too large, the instrument ought to be re-introduced, the separated part again brought out, and to ensure the object of the operation, the protruding portion snipt oflf with the scissors, thus combining excision with separation. Should the application of the double hook not effect a satisfacto- ry separation, but rather tear the iris, which is likely to happen 572 only when its texture is much changed from disease, the portion which is protruded will, in all probability, be too small to remain fixed in the wound of the cornea, and will be apt therefore to re- cede, the consequence of which will be that the pupil will be too little, and will in general soon be filled up by effused lymph. Rei- singer recommends, therefore, under such circumstances, the excision of the protruded part of the iris. When the fibres of the iris are in a state of unnatural tension previous to the operation, as may happen from there having been a former protrusion of that membrane through a wound of the cor- nea, or through a penetrating ulcer, the protruding of a portion of the separated iris may be dispensed with, as, in such a case, there is no danger of the iris returning towards the choroid. When cataract co-exists with such changes in the cornea or iris as may demand the formation of an artificial pupil, and when we attempt this by the operation of separation, it will in general be useless, or even improper, to attempt any thing for the removal of the cataract at the time of forming the artificial pupil. Extraction is plainly out of the question, and it would be better to defer di- vision or displacement till the eye has recovered from so severe an operation as the separation of the iris from the choroid. Indeed the flow of blood into the aqueous chambers, especially when the separation is in the equator of the eye, is in general so great as to make it impossible for us to discern the parts posterior to the iris with sufiicient distinctness, to attempt any operation on the lens or capsule, till that blood is absorbed. SECTION VIII. COMPOUND OPERATIONS FOR THE FORMATION OF AN ARTIFICIAL PUPIL. 1. The combination of separation with excision has already been noticed. It has been recommended both by Assalini and by Reisinger, when the separated portion of the iris is found to recede towards the choroid ; and in such a case, there can be no question of the propriety of again bringing out the separated portion of iris through the incision of the cornea, and removing it with the scis- sors. 2. Another compound operation was proposed by Donegana,* namely, separation with incision, but which scarcely deserves to be particularly noticed. The instrument employed by him was a falciform needle, with which, introduced through the sclerotica, he first separated a portion of the iris from the choroid, and then endeavoured to divide the iris from its circumference towards its centre. The latter part of this operation it must be diflicult to accomplish. Indeed, it is hardly possible by the pressure even of the sharpest instrument, to effect a division of the iris, after sep- aration has once commenced. * Delia Pupilla Artificiale. Milano, 1809. 573 3. It is sometimes found advantageous to add incision to ex- cision. Thus, in a case of extensive opacity of the cornea, with ad- herent iris, a segment at the lower edge of the cornea remaining transparent, 1 first formed an artificial pupil towards one extremity of the segment by excision, but regarding it as too small, instead of attempting an additional excision, I introduced Maunoir's scis- sors, and divided the iris transversely, so as to enlarge the artificial pupil to a medium size. SECTION IX. ACCIDENTS OCCASIONALLY ATTENDING THE FOR- MATION OF AN ARTIFICIAL PUPIL. AFTER-TREATMENT. Many of the accidents which are apt to attend the formation of an artificial pupil, are similar to those which accompany the opera- tions for cataract, and need not be particularly insisted on. A few, however, are peculiar. 1. By every mode in which an artificial pupil is formed, blood is apt to be effused; much more in separation, however, than in the other operations, and much more when the iris is altered from its natural texture in consequence of inflammation. In separation, the trunks of the blood-vessels which nourish the iris are torn across, especially when the new pupil is formed towards the tempo- ral or nasal angle of the eye ; while after long-continued inflam- mation, the iris is thickened and loaded with blood, ^he bleeding after separation, and sometimes after excision j is so considerable, that it goes on for a few minutes through the wound of the cor- nea. Filling the aqueous chambers, the blood prevents us from making any experiments regarding the degree of vision likely to be recovered by the operation. In 24 hours, in general, the pupil becomes clear. Indeed, it is remarkable with what celerity a lai'ge quantity of blood is absorbed from the aqueous chambers. 2. Little or no pain attends incision and excision ; but it is otherwise with separation, owing to the tearing across of the ciliary nerves, attendant on this method of forming an artificial pupil. The pain of separation is always considerable, and often severe, rendering necessary the use of opium after the patient is put to bed. During the operation, the assistant requires to be on his guard, lest the patient suddenly moves away his head, when he feels the pain, which might lead to the separation of a much greater portion of the iris than the operator intended, or could be consistent with useful vision. 3. Should the operator find that he has formed too small a pupil to be very useful, he ought immediately to enlarge it, either by repeating the operation which he has been performing, or by con- verting it into some of the compound operations described in the last section. It must be observed, however, that an artificial pupil will often appear small immediately after it is formed, and while the eye is drained of aqueous humour, which, after the eye becomes plump again, will be found of fully a medium size. 574 4. When too large an artificial pupil has been formed, so that the eye is dazzled even by moderate light, it is necessary that the patient should shade the eyes, or wear a piece of pasteboard or hght wood, concave within and convex without, blackened on both sides, and pierced in the centre with a round hole of the size of the natu- ral pupil. This will enable him to see at least all large objects, al- though he will probably be unable to distinguish small ones even with the aid of this contrivance. 5. The treatment of patients who have undergone an operation for artificial pupil, has reference chiefly to the danger of inflamma- tion coming on in the eye, and especially internal inflammation. The patient for some days must remain in bed, his eyes excluded from bright light, and his diet strictly antiphlogistic. Belladonna may be applied when the pupil has been formed by incision or ex- cision, but ought to be avoided (at least immediately) after separa- tion. Should pain in the eye, or round the orbit, supervene, vene- section ought freely to be used, and followed up by the application of leeches. Calomel with opium ought instantly to be begun, in such doses as are likely speedily to affect the mouth, and con- tinued till all danger of iritis appears past. The inflammation excited by an operation for artificial pupil often partakes of the strumous character, and not unfrequently is strumo-catarrhal. Depletion, in such cases, does not require to be carried to the same extent as when the inflammation is internal ; and much benefit will be derived from the administration of the sulphate of quina. 6. The degree of vision recovered by the formation of an arti- ficial pupil necessarily varies according to the condition of the eye which has been operated on, the kind of pupil which has been formed, _and the success which has attended the operation. If the lens has been removed either before the formation of the artificial pupil, at the same time, or afterwards, cataract-glasses will be re- quired. If the patient is short-sighted or long sighted, but the lens entire, he will still be obliged to employ concave or convex specta- cles. So far as any other sort of imperfect sight is* concerned, no glass will be of any use to him. It often happens, that they in whom an artificial pupil has been formed, present, in the first instance, but very dubious signs of sensibility of the retina ; so much so, that the operator may be led almost to despair of a restoration to sight. I have known a fort- night elapse after all signs of inflammation had subsided, before the patient could tell one finger from another, and yet very tolerable vision be recovered. 575 CHAPTER XVI. PRETERNATURAL STATES OF THE IRIS, INDEPENDENT OF INFLAMMATION. SECTION I. MYOSIS.* Contraction of the pupil, with immobilityj appears to be one of the man)? changes which the eye undergoes from old age. This state is also sometimes met with in middle hfe, and is known by the name of myosis. Syraftoms. The pupil is very considerably below the medium size, perfectly regular, extremely limited and slow in its motions, scarcely dilating at all when the patient passes into a dark place, and yielding little even to the influence of belladonna. The pa- tient's vision is obscure, especially in weak light, in some cases he sees only during certain hours of the day, and when the myosis is complete, he is almost totally blind. The complaint is attended by pains in the head, especially in the forehead ; and the subjects of this disease are, in general, debilitated or cachectic individuals. Proximate cause. This is in fact unknown ; but has been supposed to be, in some cases, of a spasmodic nature, and in others, paralytic. Thus Plenck admits a spasmodic myosis, accom- panying hysterical and other nervous diseases, and attributable to spasm of the orbicular fibres of the iris ; and a paralytic myosis, arising from palsy of the straight fibres, and attendant on paralytic diseases.! It is worthy of observation, that contraction is the natural state of the pupil during sleep.J Facts also are recorded, leading to the conclusion, that under the influence of a full dose of opium, and even of belladonna, the pupil becomes greatly contracted. § In apoplexy, too, the pupil has been found gradually to contract, till at last, when the patient has become perfectly insensible, all vol- untary power having left him, the heart acting almost alone, and respiration being performed slowly and imperfectly by the dia- phragm, the pupil has been observed to form an extremely small aperture. II The probabihty is, that myosis does not so much depend, in general, on any disease direcily affecting the substance of the iris, * Prom fjLvo), to shut. t De Morbis Oculorum, p. 120. Viennae, 1777. The same notion was promul- gated by Mauchart, in his dissertation De Pupillce Phthisi. t Fontana del Moti dell' Iride. Lucca, 1765. — Janin, Memoires et Observations sur I'CEil, p. 8. Lyon, 1772. — Cuvier, Le9ons d' Anatomic Comparee. Tome ii. p. 409. Paris, 1805. § On the Muscularity of the Iris ; by John Dalrymple ; in the Journal of Morbid Anatomy. Vol. i. p. 61. London, 1828. II Ibid. p. 64. 576 as on some morbid change of the nerves by which this membrane is animated and excited to motion ; and hence, in^certain cases, myosis comes to be conjoined with amaurosis. Exciting causes. Frequent and long-continued employment of the eyes in the examination of minute objects, especially of those which reflect the light strongly, induces a habitual contraction of the pupil ; and this ends in an inability of this aperture to expand, even when the eyes are exposed to feeble light. Those who read or write much by candle light, embroiderers, watchmakers, setters of jewels, and the like, are thus exposed more [thanjothers to myosis. Treatment. The few well-marked cases of this disease which have fallen under my observation, appeared to be scarcely at all benefited by any mode of treatment. Temporary dilatation of the pupil by belladonna only increased the weakness of sight by which the myosis was accompanied. Antispasmodic and antipar- alytic remedies are recommended in the treatment of this] disease ; but probably more good w^ill be effected by carefully guarding against the exciting causes of the disease, than by medicines of any kind. The eyes should be shaded ; reading, writing, and similar laborious occupations of the sight, should be avoided ; exercise in the country should be enjoined ; and the patient should retire to rest at an early hour. SECTION II. — MYDRIASIS.* A preternatural dilatation of the pupil is styled mydriasis ; the pupil, in general, no longer contracting, even although the eye be directed to a near object, or exposed to a bright light. Yery fre- quently, this is merely one of the symptoms of certain kinds of amaurosis : such as, the hydrocephalic. But, occasionally, it would appear that mydriasis occurs independently of any other affection, and when this is the case, the dilatation sometimes proceeds to such a degree, that only a narrow rim of iris remains in view. Of course, in this state of the pupil, the eye is so much dazzled by the uncontrolled influx of light, that the patient is unable/especially in broad day, to look steadily at any object, or to discern any thing with distinctness. He sees objects apparently confused, and sometimes they seem smaller than natural. He is more deficient in the perception of near than of remote objects. By looking through a hole in a card, however, the vision of the eye afiected with mydriasis is greatly improved ; in some cases, the improve- ment is such that the patient is even able to read!; and this fact constitutes one of the chief grounds of diagnosis between the sym- pathetic dilatation of the pupil which attends amaurosis, and idio- pathic mydriasis. Demours had never seen mydriasis in both eyes. * From a./j.uiS'^o;, obscure j or from juvJ'itai, to abound in moisture, because it was thought to depend on redundant moisture. 577 Causes. Different species of idiopathic mydriasis have been dis- tinguished by authors ; such as, the paralytic, arising from palsy of the supposed sphincter fibres of the iris, and the spasmodic, from spasm of the straight fibres. The mydriasis which follows the ap- plication of belladonna, and some similar narcotics, and of which so much advantage is taken in the treatment of inflammation of the iris, and in certain operations for cataract, is generally regarded as paralytic ; but it is evident that this is entirely a gratuitous as- sumption. A frequent cause of mydriasis is the passage of a large cataract through the pupil in the operation of extraction. Preter- natural distension is supposed in this instance to give rise to atony of the iris, which, generally after a few days, wears off, so that the pupil "contracts to its former diameter. Blows on the eye, and other injuries, sometimes induce mydriasis, without any affection of the optic nerve. Rarely is it the case, that any signs of cerebral disor- der are attendant on simple dilatation of the pupil. Mr. Ware ob- serves, that most of the persons with mydriasis whom he had seen, had been debilitated by fatigue or anxiety before the disease of the eye was discovered ; and that in some, it had been preceded by affections of the stomach and alimentary canal. To mydriasis, amaurosis is sometimes superadded. In other cases, amaurosis has been known to attack an eye which had been cured of mydriasis. We are as unable to explain the proximate cause of mydriasis as of myosis. Both probably depend on some peculiar change affect- ing the ophthalmic ganglion or the ciliary nerves. Cases. We are indebted to Dr. Wells and Mr. Ware for two in- teresting cases of mydriasis. Case 1. Dr. Wells was consulted by a gentleman, about 35 years of age, very tall, and inclining to be corpulent, who, about a month before, had been attacked with a catarrh, and as this was leaving him, was seized with a shght stupor, and a feehngof weight in his forehead. He began at the same time to see less distinctly than formerly with his right eye, and to lose the power of moving its upper lid. The pupil of the same eye was also observed to be much dilated. In a few days, the left eye became similarly affected with the right, but in a less degree. Previous to this ailment, this pa- tient's sight had always been so good, that he had never used glasses of any kind to improve it. On examining the eyes, Dr. Wells could not discover in them any other appearance of disease, than that their pupils, the right particularly, were much too large, and that their size was little affected by the quantity of light which passed through them. At first, he thought that their dilatation was occasioned by a defect of sensibihty in the retinae ; but he was quick- ly obliged to abandon this opinion, as the patient assured him, that *his sensation of light was as strong as it had ever been during any former period of his life. Dr. Wells next inquired, whether objects at different distances appeared to him equally distinct. He answer- 73 578 edj that he saw distant objects accurately, and in proof told what the hour was by a remote public clock : but be added, tbat the let- ters of a book seemed to him so confused, that it was witb difficulty he could make out the words. He was now desired to look at a page of a printed book, through spectacles with convex glasses. He did so. and found that he could read it with ease. " From these! circumstances.'* observes Dr. Wells. " it wms veiy plain, that thiaj gentleman, at the same time tbat his pupils had become dilated, and' hk upper eyelids paralytic, had acquired the sight of an old man, by lotsiDg suddenly the command of the muscles, by which the eye is enaJded to see near objects distinctly ; it being known to those, who are conversant with the facts relating to human vision, that the eye in its relaxed state is fitted for distant objects, and that the seeing of near objects accurately, is dependent upon muscular exertion.''* Case 2. Mr, Ware has recorded the case of a lady, between 30 and 40 yeais of age, the pnpil of whose right eye, when she was not engaged in reading, or in working with her needle, was always dilated very nearly to the lim of the cornea ; but whenever she looked at a small object, nine inches from the eye, it contracted within less than a minute, to a size nearly as small as the head of a pio- Her left pupil was not affected hke the right ; but in every degree of light and distance, was contracted rather more than is usual in other persons. The vision was not precisely ahke in the two eyes ; the right eye being in a small degree near-sighted, and receiving assistance from the first number of a concave glass, where- as the left eye derived no benefit from it. The remarkable dilata- tion of the pupil of the right eye had existed for twenty years. A fariety of remedies had been employed at different times to correct it, bat none of them had made any alteration. Mr. Ware mentions particularly, that in order to produce the con- traction of the dilated pupil, in this case, the object looked at required to be placed exacdy nine inches from the eye. If it were brought nearer, it had no more power to produce the contraction, than if it were placed at a remoter distance. It was also observed, that the ctmtinuance of the contraction of the pupil depended, in some de- gree, on the state of the lady's health ; since, although the contrac- tion never remained long after the attention was withdrawn from a near object, yet, whenever the patient was debihtated by aoy tem- porary ailment, the contraction was of much shorter duration than when her health was entire.! Frog-ttosis. DemourSjl who appears to write on mydriasis fully more from experience than most other authors, pronounces rather a favourable prognosis in this disease. He says, that when it has not been the effect of a contusion or serious wound of the eye, he has generally seen it yield, and diminish one half in the space of the * Pluloei^Iucal Transactions, toL ci. p. 378. London, ISll. + PhiloBaphical Transactions, vol. ciii. p. 36. London, 1S13. t Traite des Maladies des Yeas. Tome. i. p. 444. Paris, 1818. 679 fir?L six months, even in those who employed no means of cure. ^Vhat remains of the disease disappears mnch more slowly. He had witnessed complete restoration of the pupil to its natural size, even after a contusion of the eye ; although in such cases recovery is extremely rare. The result of his observations was, that seven cases out of nine proceed towards a cure, even without any treat- ment : and that httle more can be done than to accelerate the cure, chiefly by the use of external stimulants. Treatment. The remedies which have been found most useful in mydriasis are blood-letting and a spare diet, followed by such applications as are likely to excite contraction of the pupil. De- mours remarks, that, if any acrid liquid is dropped upon an eye affected with this disease, even although the dilatation of the pupil ! has been carried to the utmost degree, that aperture instantly con- tracts nearly one half, and the patient recovers for a minute or two the power of seeing such minute objects as previously he has been able to distinguish only by looking through a hole in a card, or similar small opening. The stimulating practice followed by De- mours consists in directing small electric sparks against the eye, then rubbing it gently for about half a minute with the end of. a silver probe bent into the form of a ring, and immediately after- wards dropping in upon it a cold infusion of tobacco. M. Serret, of Uzes, has ventured to treat mydriasis, (or, as he terms it, idiopathic paralysis of the iris, without affection of the retina and optic nerve.) by the apphcation of nitrate of silver to the cornea near its junction with the sclerotica, and has found this a more powerful and useful excitant than the means recommended by Demours. In a memoir presented to the Royal Academy of Medicine, he related four cases, in illustration of the success of his method, and the committee of the Academy to whom ihe subject was referred, found the apphcation of the caustic, in the manner directed by M. Serres, efficacious in three other instances. The caustic should be applied for one second. It is useful that some lacrymation should be excited by the application, and that it should be followed l^y a slight injection of the vessels of the conjunctiva. The slight cloud which appears on the cornea rarely continues above a few days. The committee of the Academy observed that this means of cure, totally useless in amaurosis, could be of service only in those idiopathic palsies of the iris arising from an affection of the ciliary nerves, or of the other branches of the 3d and 5th pairs.* SECTION III. TREMULOUS IRIS. The cases in which the iris is affected, on every movement of the eye, with a pecuhar tremulous or undulatory motion, are very various, and by no means unfrequent. The texture of the iris, in * Archives Generales de Medecine. Tome xTii. p. 307. Paris, 1828. CHAPTER XVII. GLAUCOMA AND CATS-EYE. SECTION I. GLAUCOMA. t 580 such cases, is apparently uninjured, and the pupil generally of its natural fonn ; but the membrane seldom appears to retain almost ■ any power of contracting or expanding. I have seen it, however, from sympathy with the pupil of the other eye, which was healthy, move briskly and extensively. This state of the iris is frequently, but not necessarily, connected with amaurosis. We meet with it combined with cataract, and especially with capsulo-lenticular cataract. It often results from a blow on the eye, and in this case is generally attended by partial or complete insensibility of the retina, and opacity of the lens. In those born amaurotic, or affected with congenital cataract, trem- ulousness of the iris is often met with ; and in such subjects, it is attended by oscillation* of the eyeball. When this disease of the iris is combined with cataract, the latter not unfrequently partakes of the tremulous motion.! After operations for cataract, and es- pecially after operations on eyes, the vitreous humour of which has been found dissolved, or from which a considerable quantity of the vitreous humour has been evacuated, the iris frequently presents this undulatory motion. In all cases of tremulous iris, there appears to be a larger quan- tity of aqueous fluid in the posterior chamber than natural, and, in many of them, the whole cavity behind the iris is filled with fluid, in consequence of dissolution of the hyaloid membrane. The fibres of the ii-is being probably paralytic, the membrane hangs loose, and is unable to resist those undulations of the aqueous hu- mour which take place whenever the eye is turned from one side to another by the action of the recti muscles. It is then only, in fact, that the tremulousness of the iris is perceptible. We do not observe it so long as the patient fixes his attention on the same object, nor does the attempt to accommodate the eye to objects placed at a variety of distances, but in the same right line, appear to produce the motion in question. This affection of the iris has hitherto been regarded as incurable, and certainly it affords an unfavourable index of the state of the vitreous humour and retina. It is evident that Hippocrates comprehended under this term every sort of opacity which appeared behind the pupil. Thus, in enu- * See page 222. t See page 476. t TKa.vKMfx^, the eye ; the (xvai^ or short-sighted person being in the habit of winking or half-shutting his lids, when he endeavours to see objects distinctly. 75 594 Avish to see clearly and distinctly, to the distance of two or three inches, or even as close as one inch from the eye, while other my- opic persons are able to enjo)'^ as good \asion although the object is at six or nine inches' distance. The eye which perceives noth- ing distinctly beyond ten inches may be considered myopic. This imperfection, then, cannot be concealed, if the individual affected with it attempts to read, or to examine any small object minutely. If we direct his attention to objects at any considerable distance, it is evident that tbey either make no impression on his retina, or one which is exceedingly indefinite and obscure. He cannot dis- tinguish the countenances of the performers on the stage, nor the subject of pictures when placed a few feet above his head ; he cannot read the inscriptions on doors and houses, nor recognise persons across the street ; if he go into a large room, in which there are many persons, he cannot readily distinguish those he knows. It is remarked of those who are short-sighted, that they do not look at the person with whom they converse, because they cannot see the motion of his eyes and features, and therefore they are at- tentive to his words only ; that in reading, they hold the book ob- liquely towards their eyes, this helping them to see it distinctly, either by allowing the light to illuminate it better, or by bringing its image upon the lateral part of the retina ; that they see more distinctly and somewhat farther off by a strong light than a weak one, on account of the contraction of the pupil which is thereby produced, and which serves to exclude all but the more direct rays of light, and consequently to lessen the apparent confusion ; that on the same principle, when they endeavour to see any distant ob- ject distinctly, they almost close their eyelids, and that through a pin-hole in a card, objects appear to them much clearer and better defined. Short-sighted persons write a small hand, and prefer to read a small type, because they can thus see more at a view. They can read a very small print, in a degree of light quite insufficient to allow an ordinary eye to make out even large letters. When they endeavour to write in a large hand, they find it difficult to do so, and are^apt to mis-shape the letters. The eyes of those who are short-sighted are frequently promi- nent ; the cornea is sometimes preternaturall}^ convex, the pupil generally large, the eyeball firm, the eyelids often tender. It is a question which naturally occurs to one who first turns his attention to the nature of myopia, whether this disease consists merely in over-refraction, or involves also a deficiency in the ac- commodating power of the eye to different distances. Dr. Smith, no mean authority on such a subject, is decidedly of opinion, that the power of varying the quantity of refraction is still retained by the myopic eye. "If short-sighted persons," says he, "can read a small print distinctly at two different distances, whereof the larger is but double the lesser, which I beUeve most of them can do ; it 595 follows that as great alterations of figures are made in their eyes as in perfect eyes, that can see distinctly at all intermediate dis- tances between infinity and the larger of these two. And this is the reason that a short-sighted person can see distinctly at all dis- tances with one single concave of a proper figure ; which other- wise must have been differently figured for different distances. It follows then that the cause of short-sightedness, is not a want of power to vary the figure of the eye, and the quantity of refraction ; but that this whole quantity is always too great for the distance of the retina from the cornea." * It is rarely the case that the two eyes even of the same person correspond in refractive power. The left, partaking perhaps in the tendency to debility and disease, which so frequently attaches itself to the left side of the body, is often found to be somewhat short- sighted. Few are aware of the disparity which often exists be- tween their eyes, until some accidental circumstance leads them to make a comparative trial of the two ; and it is by no means un- common to meet with individuals, who, on making the experiment,, have discovered that one eye was greatly defective, or even entirely bhnd. Mr. Wardrop remarks t that it will generally be found, that not only the right is more perfect than the left eye, but that when a person is apparently looking at an object with both eyes, generally only one of them, and that the right one, is actually directed to the object. But this will depend entirely on whether the right or the left is the better of the two. To ascertain the fact, let a spot, at the distance of a few yards from the observer, be covered with the point of one of his fingers, while he endeavours to look at it with both eyes. If the short-sighted eye, which we may suppose to be the left, be now closed, the point of the finger will continue to ap- pear to cover the spot, and to preserve the same relative situation to it as when both eyes were open ; but if the right eye be closed and the left opened, then the relative situation of the point of the finger and spot will appear altered, the spot being uncovered ; proving, that in directing the finger to cover the spot, the right eye had alone been employed. Mr. Wardrop has met with myopia more frequently in the left eye than the right; Mr. Ware, on the other hand, observes that most of the near-sighted persons with whom he has conversed, had the right more affected than the left, and he thinks it not improbable that the differences had arisen from the habit of using a single concave hand-glass,^ which, being com- monly applied to the right eye, contributes to render, it more short- sighted than the other.l Although near-sightedness is in general gradual in its progress, manifesting itself about the period of puberty, and increasing from * Complete System of Optics. Vol. ii. p. 2. Cambridge, 1738. t Morbid Anatomy of the Human Eye. Vol.ii. p. 229. London, 1818. t Philosophical Transactions. Vol. ciii. p. 34. London, 1813. 596 that period up to twenty or twenty -five years of age, yet in- stances occasionally occur of its existence even in children, or of its suddenly affecting the eye of a grown-up person, who had pre- viously seen distinctly at the ordinary distance. In the cases of children, we should examine the appearances presented through the pupil,»for very often a central cataract* will be found to exist under such circumstances ; w^iile the sudden accession of myopia in those who had previously seen well, should lead us to suspect either dropsy of the vitreous humour t or some affection of the brain. Efficient Causes. Myopia has been attributed to a variety of efficient causes, several of which may coexist. 1. Too great convexity of the Cornea. As it is before the rays of hght reach the crystalline lens that they undergo their gi'eatest degree of refraction, it is evident that a preternatijrally con- vex cornea will produce a convergence so rapid, that the foci will fall very considerably short of the retina. While it is undeniable, however, that in some of the very aggravated instances of myopia, the cornea, natural in diameter, may be observed to project consid- erably above its average altitude, it is also certain that this con- formation is by no means a common, nor even a frequent, attend- ant on this disease. When it does occur, it is generally accom- panied by a superabundant quantity of aqueous humour, and occa- sionally by a degree of pressure backwards on the iris, so that this membrane, instead of being plane or convex, becomes concave on its anterior surface. 2. Too great thickness of the cornea will undoubtedly tend to bring the rays of light to a focus sooner than they ought to be brought ; but it is not at all likely that the cornea is ever of such extraordinary thickness in the adult eye, as of itself to be the cause of myopia, unless at the same time it projects in a conical form.t At birth, indeed, the cornea is very thick in proportion to the size of the eye"; and to this Petit has ascribed (in part) the indistinctness of vision in very young children. § 3. Too great convexity of the crystalline lens wiU assuredly produce short-sightedness, whether the over-convexity be on one only, or on both sides of that body. Such conformation has been regarded as probably one of the most frequent causes of myopia ; and notwithstanding the testimony of Percy and Reveille-Parise,|| that on examining the lenses taken from the eyes of a number of persons who during life had been short-sighted, they were unable to detect any excessive convexity, we must still admit not merely the possibility of this cause, but the likelihood of its frequent ex- istence. 4. Preternatural density of any or all of the transparent media of the eye is also a cause, which will infallibly produce * See page 483; t See page 444. t See page 437. § Memoires de I'Academie Royale des Sciences, pour 1727; p. 346. Amsterdam, 1732. II Hygiene Oculaire, par J. H. Reveille-Parise ; p. 32. Paris, 1816. 1 597 myopia, and which is not unUkely to occur, I have generally observed that myopic eyes are considerably firmer tO' the touch than natural, even at an early period of life. 5. Preternatural elongation of the eyeball., so that the dis- tance between the cornea and retina is increased, will necessarily occasion myopia, and has even been regarded by some as the only admissible cause of this disease. Such conformation of the eye has been supposed to be sometimes congenital, and in other cases to be acquired from frequent exercise of the sight upon minute ob- jects. 6. The dilated state of the pupil., which almost always ac- companies myopia, has been generally set down amongst the causes of this disease, whereas it is much more probably an effect. When the sight is perfect, and still more when it is presbyopic, the pupil will have frequent occasion to contract, in aiding the person to see near objects more distinctly, and thus an habitual degree of myosis may be produced ; but in those who are short-sighted this will not happen, for to them near objects appear distinct, and therefore not having occasion to contract the pupil for seeing such objects more distinctly, this aperture probably maintains an habitual state of dilatation. Subjects of myopia. 1. Age. Young people seldom discover that they are remarkably near-sighted, until about the age of pu- berty, or when they begin to use their eyes in earnest. Many persons reach the age of thirty or forty years, who have no notion that they are near-sighted, until they happen accidentally to look through the concave glasses of some other individual, when they are surprised and delighted to find that they perceive remote objects with a clearness and sharpness of outline, to which they had for- merly been altogether strangers. They may have suspected that they did not see across the street or at the theatre, quite so plainly as other people, but as they could read a small print as well as any body, they had no idea that they were the subjects of any defect in their eyes, or that they could improve their vision by any kind of glass. It has been very generally asserted that near-sighted eyes are by age rendered fitter for perceiving distant objects than they were in youth. This opinion appears to have been built on the follow- ing false analogy ; viz. That if those who possess ordinary vision when young, become from the flatness of the cornea or other changes in the structure of the eye. far-sighted as they approach to old age, which is a well-established fact, then, the short-sighted must, from similar changes, become better fitted to see distant objects. Short-sightedness tends generally to increase rather than diminish, as age advances ; and should it be joined by glaucoma, the person is obliged to bring any object, which he wishes to see distinctly, within a very short distance of the eye. It not un- frequently happens, however, that as a near-sighted person advances 598 in years, he both becomes shorter-sighted so far as the vision of diis* tant objects is concerned, and longer-sighted in respect to near ob- jects. He finds that he can read with tiis naked eye, at nearly the ordinary distance, which he could not do before, or he is obliged even to use convex glasses in reading ; but at the same time he finds himself under the necessity of employing deeper concave glasses than ever for the perception of distant objects. 2. Rank and Occupation. Myopia is much more common in the higher than in the lower ranks of life, and among those who occupy themselves with the close examination of minute objects than in those who scarcely ever attempt to read, write, or apply themselves to an}' similar pursuit. Mr. Ware remarks, that among persons in the inferior stations of society, artificial means are rare- ly resorted to for correcting shght defects of this nature ; and that there is even reason to believe, that in such people, near-sightedness is not unfrequently overcome by the increased exertions that are made by the eye to distiiiguish distant objects. When persons in the higher ranks, on the other hand, discover that their discern- ment of distant objects is less quick or less correct than that of others, though the difference may be very slight, influenced perhaps by fashion more than by necessity, they immediately have recourse to a concave glass ; the natural consequence of which is, that their eyes in a short time become so confirmedl}^ myopic, that the recov- ery of distant vision is difficult, if not impossible. With regard to the proportion of near-sighted persons in the dif- ferent ranks of society, Mr. W'are endeavoured to obtain satisfac- tory information, by making inquiry in those places where a large number of individuals of nearly the same station are associated to- gether. He inquired for instance of the surgeons of the three regi- ments of foot-guards, consisting of nearly 10,000 men ; and he was informed that near-sightedness v.as almost unknown amongst them, not six individuals having been discharged, nor six recruits rejected, on account of this imperfection, in the space of nearly twenty years. At the Military School at Chelsea, where tliere were 1300 children, the complaint of near-sightedness had never been Uiade among them, until Mr, Ware mentioned it, and then only three were found who experienced the least inconvenience from it. He pursued his inquiries at several oi' the colleges in Oxford and Cambridge, and found near-sightedness very prevalent in these institutions. In one college in Oxford, where the society consisted of 127 members, thirt3'-two either wore spectacles or used hand-glasses. It is not im- probable, that some of these were induced to do so solely because the practice was fashionable : but Mr. W^are believes the number of such to have been inconsiderable, compared with that of those whose sight received some small assistance from glasses, although this as- sistance could have been dispensed with, without inconvenience, if the practice had not been introduced.* ** Philosophical Transactions, Vol. ciii. p- 31. London, 1813. I 599 Treatment. It is but rarely the case that the medical prac- titioner has an opportunity of advising those in whom myopia is not yet confirmed, to that course of treatment, which might remove the incipient symptoms of this very serious imperfection of sight. If it be correct, that this disease, in by far the greater number of instances, is induced by too much exercise of the eyes upon minute objects, as in reading, writing, sewing, miniature painting, en- graving, and the like, the cure would probably be found in ab- staining entirely for a time from such occupations, refraining also from the use of concave glasses, and employing the eyes chiefly upon large and distant objects. Haller recommends looking through a small aperture, as a remedy for myopia ; but probably this, as well as gradually removing the book from the eye, till it can be read at the ordinary distance ; reading through convex glasses ; and other attempts of a similar sort, will prove of little use, in com- parison of the good effects to be derived from frequent exercise out of doors, walking and riding into the country, and travelling through new and interesting scenes. If, instead of such a plan of treatment, recourse be had to the employment of concave glasses, and the frequent and long-con- tinued observation of near objects be persisted in, the disease be- comes not only confirmed, but sometimes greatly aggravated. " When I first learned to read, at the usual age of four or five years," says Sir Charles Blagden, " I could see most distinctly, across a wide church, the contents of a table on which the Lord's Prayer, and the Belief, were painted in suitably large letters. In a few years, that is, about the ninth or tenth of my age, being much addicted to books, I could no longer read what was painted on this table ; but the degree of near-sightedness was then so small, that I found a watch-glass, though as a meniscus* it made the rays diverge very little, sufficient to enable me to read the table as before. In a year or two more, the watch-glass would no longer serve my purpose ; but being dissuaded from the use of a common concave glass, as likely to injure my sight, I suffered the incon- venience of a small degree of myopy, till I was more than thirty years of age. That inconvenience, however, gradually though slowly increasing all the time, at length became so grievous, that at two or three and thirty, I determined to try a concave glass ; and then found, that the numbers two and three were to me in the relation so well described by Mr. Ware ; that is, I could see distant objects tolerably well with the former number, but still more accurately with the latter. After contenting myself a little time with No. 2, I laid it wholly aside for No. 3 ; and, in the course of a few more years, came to No. 5, at which point my eye has now been stationary between fifteen and twenty years. An earlier use * Sir C. Blagden here employs the word meniscus, from fumn, the moon, in a sense, ■which, though perhaps vindicated by occasional practice, it were better to avoid. A watch-glass is merely a segment of a hollow sphere, the surfaces of which are parallel. 600 of concave glasses would probably have made me more near- sighted, or would have brought on my present degree of rnyopy at an earlier period of hfe. If ray friends had persuaded me to read and wi'ite with the book or paper always as far from my eye as I could see ; or if I had occasionally intermitted stud}", and taken to field sports, or any employment which would have obliged me to look much at distant objects, it is very probable that I might not have been near-sighted at all."* When once a near-sighted person has experienced the pleasure of seeing remote objects, with that distinctness and comparative brilliancy, which the aid of concave glasses affords, it is not easy to persuade him to renounce their use. Their efTect, as is now universally known, is merely to diverge the rays of hght before these enter the eye, by this means counteracting the over-refractive power of the organ, and bringing the rays of light exactly into foci upon the retina. The assistance afforded by concave glasses to one set of defective eyes, and by convex to another, had been the subject of admiration and perplexity for several hundred years, till Kepler, in his Ad Vitellionem Pm^alipotneiia, published in 1604, cleared up the mystery, by explaining, for the first time, the true mechanism of the eye. It had been proposed as a question to Kepler, by his patron, Dietrickstein, in what manner spectacles assisted sight. The first answer he gave was, that convex glasses were of use, by making objects appear larger. But his patron ob- served, that if objects were by them rendered more distinct, because larger, no person would be benefitted by concave glasses, since these diminished objects. The striking resemblance between ex- periments with the camera obscura and the manner in which vision is performed in the eye, had been pointed out by Baptista Porta, who compared the pupil to the hole in the window-shutter, but fell into the mistake of supposing that it was the crystalline lens which corresponded to the wall which receives the images. Kepler, in the work above referred to, showed that this office is per- formed by the retina, and gave the first clear explanation of the effects of lenses, whether within or without the eye, in making the rays of a pencil of light converge or diverge. He now explained, that convex glasses assist the sight of presbyopic persons, by so altering the directions of rays diverging from a near object, that they should afterwards fall upon the eye, as if they had proceeded from a more remote one, and that concave glasses benefit the myopic, by producing a contrary effect upon rays which diverge from a distant object — a theory to which no addition has been made by any succeeding author. The glasses commonly employed for the assistance of myopic eyes are double concaves, of equal concavity on each side. Occa- sionally, however, the two sides are made of unequal depth. A plano-concave glass might answer ; and in the use of concavo-con- ♦ Philooopliical Transactions, Vol. ciii. p. 110. London, 1811. 601 vexes, (the exterior surface of the glass, or that which is turned from the eye, being convex, and having a less degree of curvature than tiie interior, or that which is turned towards the eye, which is concave), there is supposed to be a considerable advantage, in so far as they allow the eyes a greater degree of latitude in vision, without fatigue, whence the name periscopic glasses, under which they have been latterly recommended by Dr. Wollaston. Myopic persons are extremely apt to adopt the use of a single eye-glass, against which v/e ought to put them on their guard. Spectacles are always preferable, because by keeping both eyes in action, not only is vision rendered brighter and easier, but the la- bour of each eye is considerably lessened. Dr. Wells has pointed out another reason, why glasses should be employed rather in the form of spectacles, than singly, which, though it applies more strong- ly to the use of convex than of concave glasses, I shall here intro- duce in his own words. " In regard to such spectacles as I have tried upon myself, I have always found, that when I looked with them at objects, placed at moderate distances before me, my optic axes passed through the glasses, more inwardly than their centres. With respect, therefore, to spectacles for long-sighted people, as the inner halves of their glasses may be regarded as two prisms, whose lefracting angles face each other, to have allowed both my eyes to receive through them pencils of rays from the same point of an object, the intervals of my pupils must have been less than was necessary for that purpose in naked vision, — the consequence of which would be, an increase of the refractive power of my eyes. Again ; as the like parts of glasses in spectacles for short-sighted persons, may be esteemed to be two prisms, the refracting angles of which are turned from each other, the interval of the pupils must have been increased, and the refracting power of my eyes by this means diminished, when I look- ed at an object through them, which was directly before me. And effects similar to what I have mentioned, must have followed my viewing objects placed oblicjuely, through glasses of both kinds. Here then is one advantage, which persons who see with both eyes, either do or may enjoy from spectacles, but which they cannot de- rive from using single glasses. For if they are presbytic, they can see an object by the means of them with a higher refractive state of the eyes, than if the optic axes met there, as in naked vision ; and if myopic, with a less. It is also worthy of remark, that this advantage does not ultimately tend to increase the evil, which first gives occasion for spectacles. On the contrary, if what every writer upon vision asserts be true, that we are apt to become short or long- sighted, according as we are much accustomed to view near or dis- tant objects, it must serve to diminish that evil. In support of this opinion, I shall mention a fact, with which I have been made ac- quainted by Mr. George Adams, of this place, who is not only well skilled in the theory of vision, but, from his situation, as an artist, 76 has better opportunities, than most persons, of learning such mat- ters. The fact is this, that he does not know a short-sighted per- son, who has had occasion to increase the depth of his glasses, if he began to use them in the form of spectacles ; whereas he can re- collect several instances, where those have been obliged to change their concave glasses repeatedly, for others of higher powers, who had been accustomed to apply them to one eye only." * Double-concave glasses are numbered 1, 2, 3, &c. beginning with the longest focus, or shallowest concavity.t We must re- commend to the near-sighted person to be content with the shal- lowest glass, or lowest number, which answers his purpose. If No. 1 enables him to discern distinctly the names on the corners of the streets, and gives a decided outline to objects whose dis- tance does not exceed about 40 feet, he ought not to have recourse to No. 2. Objects should appear clear through the glass which is chosen ; but if it makes ihem less than natural, or gives them a dazzling or glaring appearance, or if the eye feels strained or fa- tigued after looking through it for a short time, it is too deep, and a lower number should be selected. When a near-sighted person wishes to be fitted with glasses, the simplest and surest plan is to try each eye with a series of them, at an optician's shop. It may happen, however, that an individual in the country is desirous of writing to town for concave glasses, and wishes to mention the focus which will be likely to suit his eye. This may be ascertained by means of the optometer, as im- proved by Dr. Young ; but as this instrument is not always at hand, the following rules may be followed. 1. If the near-sighted person is desirous of assistance in seeing remote objects, i. e. beyond 200 or 300 yards, the focal distance of the glasses which he will require for that purpose, should be the distance at which a small object appears distinct to his naked eye. * Experiments and Observations on several Subjects in Optics, p. 99. London. t The gradations of concavity, in the common glasses for near-sighted eyes, are not always worked to a certain standard, so that what one calls No. 1, another rates as No. 2, and so on. Neither are the two sides always ground on a tool of the same radius, so that the one side is sometimes deeper than the other. Mr. Ramsdem made the first number of his concave glasses equivalent to a convex of 24 inches focus, i. e. if a convex of that focal length were united to a concave No. 1, the combination would be equivalent to a plane, and objects would appear through the two glasses neither larger nor smaller than they really are. No 2, he made to correspond to a 21 inch convex ; No. 3 to an 18 ; and so on. The following are the foci in inches of the concave glasses usually kept in the shops. No. 1 . . 48 No. 5 . . 14 No. 9 . . 5 2 . . 36 6 . . 12 10 . . 4 3 . . 24 7 . . 9 11 . . 3 4 . . 18 8 . . 7 12 . . 2h The focus of a concave lens may be ascertained, by reflecting from its surface, upon an opaque body, the image of any very distant luminous object, such as the sun, ob- serving when the image becomes smallest, and measuring the distance between the surface of the lens and the body upon which the image is received. The distance will be the focus. 603 For example, if he reads this type at 12 inches' distance, 12 inches will be the focus of the concave glasses which he will require for seeing distant objects distinctly. 2. If the glasses wanted are intented for reading with or seeing near objects, let the near-sighted person multiply the distance at which he is able to read with ease with the naked eye, say 4 inches, by the distance at which he wishes to read, say 12 inches ; divide the product 48 by the difference between the two, which in this instance is 8 ; the quotient, 6, is the focal length of the glass in inches, which is required. It is a very common error with those persons who begin to use concave glasses, to tire of those which they first employ, and have recourse to deeper ones. To these the eyes do not fail (at least for a tinie) to accommodate themselves ; but, in the end, the patient who thus proceeds from one degree of concavity to a greater, will find it difficult to obtain glasses sufficiently deep to affiard him much assistance, or he may produce such weakness of the retina, or am- blyopia, as sliall render him unfit to engage in any ordinary pur- suit. Near-sightedness generally continues, as has been already stated, in nearly the same degree during the greater part of life. Therefore, the same glass will continue, for man}'^ years, to afford precisely the same assistance, and ought not to be heedlessly changed for one of deeper concavity. Dr. Kitchener tells us, that he was about fifteen years old, when he first discovered that he could not discern distant objects so dis- tinctly as people who have common eyes usually do. " Seeing," says he, " that I could not see what persons with common eyes fre- quently pointed out to me as well deserving rny» attention, 1 paid a visit to ati optician, and purchased a concave eye-glass No. 2. Af- ter using this some little time, I accidentally looked through a concave No. 3, and finding my sight much sharper with this, than with No. 2, had my spectacles glassed with No. 3, which appeared to affi)rd my eye as much assistance as it could receive. After using No. 3 for a few months, I chanced to look throueh No. 4, and again found the same increase of sharpness, &c. wliich I perceived before when I had been using No. 2 and first saw through No. 3, therefore concluded that I had not yet got glasses sufficiently con- cave, and accordingly procured No. 4 : — however, this soon became no more stimulus to the optic nerve than its predecessors Nos. 2 and 3 had been. I then began to think that the sight was sub- ject to the same laws which govern the other parts of our system, i. e. an increased stimulus by repetition soon loses iis power to pro- duce an increased eflfect. Therefore, i refused my eye any further assistance than it received from spectacles glassed with No. 2, which I have worn for upwards of thirty-one years, and it is very nearly, if not quite as sufficient help to me now, as it was when I first employed it." * * Economy of the Eyes, Part I. p. 111. London, 1826. 604 The same author recommends persons who are extremely short- sighted, in order to prevent their being obhged to stoop in writing, reading music, and the like, to wear spectacles with very shallow concaves, just enough to enable them to see the objects required in such cases, at the same distance with other persons ; but for dis- tant objects, to use a small opera-glass, which having an adjustable focus, if it magniiies only twice, will be infinitely better than any single concave, because it can be exactly adapted to the various dis- tances. It is advisable that near-sighted persons should not wear spec- tacles constantly, but only on occasions when they more particu- larly require such assistance. When they have been worn for a considerable time, the person does not at first see so vrell on leav- ing them ofif as he did before ; but this is only temporary. SECTION II. PRESBYOPIA,* OR FAR-SIGHTEDNESS. Although this state of defective vision, the general nature of which has been explained at the beginning of the last section, oc- casionally occurs, like myopia, suddenly, and at any period of hfe, yet, in by far the greater number of instances, it is merely part of the changes, which the human system undergoes at the approach of old age. The refractive powers of the eye growing too feeble, or its axis becoming shorter than natural, the raj's of hght are not converged sufficiently soon, to be brought into focal points upon the retina. The image, therefore, is diffused, and the per- ception indistinct ; ,to remedy which, the individual moves the ob- ject of examination to a greater distance from his eye than his previous point of distinct vision, by this means counteracting the tendency of the rays of light, proceeding from the object when at the usual distance, to collect into foci, not upon the retina, but behind it. Symptoms of Presbyopia. It is on an average, about the age of forty-five years, that we discover, that, especially by candle-light, w^e see near objects less perfectly, and that we are obliged at once to illuminate them more strongly, and remove them farther from the eye than formerly. The discovery, that the eye is thus be- ginning to be impaired by age, is gradually made, in consequence of the difficulty which the individual experiences in reading small print, nibbing his pen, threading her needle, and the hke. On at- tempting to examine any small object close at hand, its outline be- comes obscure, as if it were seen through a mist; very minute ob-' jects, such as the characters of a small-printed book, are either not discerned at all, or they seem to run into one another, or to appear double ; and if the attempt to see such objects is persevered in, the eyes soon feel fatigued, and the head begins to ache. Dis- * From TTcio^u;, old, and »>j,, the eye; this being a state of vision to which old age is almost invariably subject. 605 tant objects continue to be seen as before. The person can read a distant inscription, or tell the hour by a distant church clock, when he cannot read a common printed book held in his hand, or see the figures and hands of a watch. As age continues to advance, the presbyopic defect generally be- comes more and more decided, the eye appears to lose more and more the power of discerning near objects with distinctness, so that the individual, unless he has recourse to the aid of glasses, is forced to renounce all employments which require minute inspection ; or, if he has begun the use of glasses, he is obliged to change them from time to time, in proportion as the refractive power of his eyes decreases. There are, however, great differences in the progress of far-sightedness in different individuals. Some eyes at thirty years of age, require the aid of convex glasses as much as others do at fifty, while the sight of certain individuals continues almost as perfect at fifty as it was at thirty. Young men of twenty sometimes cannot see to read or write without convex glasses of six or eight inches focus, while persons of eighty years, and upwards, are occasionally met with, who are able to read even a small print without assist- ance. Some, after commencing the use of spectacles, are obliged every few years to change them for others of shorter focus ; others change them only once or twice in the course of a prolonged old age, or continue for perhaps forty years together to see satisfactori- ly with the aid of the same glasses. These and similar differ- ences depend upon the original formation of the eyes, how they have been used, and the general health and constitution of the in- dividual. The few, who, after the age of forty, can see quite as well by candle-light, as they could before that age, will generally find that there is a small degree of shortness in their sight, which is the cause of their possessing that advantage longer than persons in general do. If they try a very shallow concave glass, they will find it give a decided outhne to distant objects, which they never saw defined so sharply before. Instances occasionally occur of old persons, long accustomed to use convex glasses of considerable power, recovering their former sight at the advanced age of eighty or ninety years, so that they no longer required any artificial assistance even in reading. Dr. Porterfield was led to attribute this remarkable amendment to a decay of the adipose substance at the bottom of the orbit, in con- sequence of which, he supposes, that the eye, from a want of its usual support, will be brought by pressure of the muscles on its sides, into a kind of oval figure, in which state the retina will be removed to a due distance from the flattened cornea.* Mr. Ware objects to this explanation, that we never see a morbid accumulation of adipose substance in the orbit produce presbyopia, but that, on the * Treatise on the Eye. Vol. ii. p. 70. Edinburgh, 1769. 606 contrary, myopia is sometimes induced by that cause ; and thinks it more probable, that the remarkable revolution in question is^oc- casioned by an absorption of part of the vitreous humour, in con- sequence of which the sides of the sclerotica are pressed inward, and the axis of the eye proportionably lengthened.* Although the eye, after middle hfe, loses the power of distinguish- ing near objects with correctness, it generally retains the sight of those that are distant. Instances, however, are not wanting of per- sons of advanced age, requiring the aid of convex glasses to enable them to see distant, as well as near, objects. Thus, Dr. Wells informs us, that when twenty years younger, he was able, with his left eye, to bring to a focus on the retina, pencils of rays which flowed from every distance greater than seven inches from the cornea ; but by the time he reached the age of fifty-five, his eyes had altered considerably, with respect to their seeing near objects distinctly, and he had, in consequence, been obliged, not only to use convex glasses, but to change them several times for others of higher power. On carefully examining the state of his sight, previously to the repetition of some optical experiments, he found, to his great surprise, that the power of adapting his eyes to different distances was com- pletely gone, in other words, that he was obliged to regard all objects, whether near or remote, in the same refractive state of those organs. He found that he required not only a convex glass of six inches focus, to enable him to bring to a point on the retina rays proceed- ing from an object seven inches from the eye, but likewise a convex glass of thirty-six inches focus, to enable him to bring to a point parallel rays.t The objective symptoms, which generally attend presbyopia, are an apparent diminution in the size of the eyeball, which is also more sunk in the orbit ; flatness of the cornea, shortening of the axis of the anterior chamber, and smallness of the pupil. Causes. There can be no doubt that deficient refraction is the proximate cause of presbyopia, and that it is intimately connected with the decline of life. It is also said that it is more apt to occur in those who have used their eyes much upon remote objects. With regard to the efficient causes, flatness of the cornea from diminution in the quantity of the aqueous and vitreous humours is the one most frequently mentioned, this diminution being sup- posed to depend on the impeded manner in which the function of secretion is performed in advanced life. Diminished density of any of the refractive media of the eye, or diminished convexity, will prove a sufficient cause of presbyopia. So far as the crystalline lens is concerned, it is generally admitted that its density increases as age advances, which should tend to counteract any presbyopic tendency arising from flattening of ihe cor- nea or deficiency of the aqueous or vitreous humours. At the same * Philosophical Transactions, Vol. ciii. p. 42. London, 1813. t Philosophical Transactions, Vol. ci. p 380. London, 1811. 607 time, the increase of density of the lens may possibly be attended by a degree of shrinking, by which its form may be rendered less con- vex, and its refractive power diminished. It appears to be the general opinion, that along with diminished refraction, there attends upon presbyopia a loss of that power of ac- commodation to the perception of near objects, which is possessed by the healthy eye. Whether this power depends on a change of form or of place in the crystalline lens, or on both of these, or some change different from either, it is easily conceivable that a partial or total loss of this power would be quite analogous to the diminish- ed activity which takes place in all the functions of the body on the approach of old age. Treatment. Although it would be in vain to expect any plan of treatment to have the effect of removing, or perhaps even lessen- ing a degree of presbyopia already produced, it is but reasonable to suppose that by avoiding whatever over-fatigues the sight, and by- following whatever tends to delay the progress of decrepitude, this defect may in a considerable measure be warded off. It is only to such influences, added to an original soundness of constitution, that we can attribute the exemption from presbyopia, which is occasion- ally possessed by men far advanced in life. The assistance, which the presbyopic eye derives from a double convex-glass, ought neither to be too soon had recourse to, nor too long delayed. Many injure their sight, by adopting the use of magnifiers suddenly, and before they have any need of them ; while others, actuated perhaps by a desire of concealing their age, refrain from employing them long after the period, when they would not merely have afforded them a valuable assistance, but have proved a means of saving their sight. The presbyopic eye, if refused the aid of glasses, is necessarily strained by every attempt to perceive near objects, and suffers more in a few months by such forced exertion, that it would do in as many years, if assisted by such glasses as would render vision easy and agreeable. It would evidently be absurd to fix upon any period of life at which glasses should be first employed, or at which the presbyopic eye should be assisted by stronger magnifiers than those which the individual has made choice of in the first instance ; but it may be laid down as a general rule, that whenever a person of forty-five years of age, or upwards, finds, that in order to see small objects distinctl}^, he is obliged to carry them far from his eye ; that he moves, as it were instinctively, nearer to the light, when he wishes to read or work, or holds the book or other object close to the light, in order to see with facility ; that very small objects, after he has looked at them earnestly for some time, appear confused ; that his eyes, after slight exertion, become so much fatigued, that he is obliged to turn them to other objects, in order to give them some relaxation ; and that the sight, on awaking in the morning, is very weak, and does not recover its customary degree of force for 608 some hours ; then, he may, if he has not hitherto used convex glasses, begin to use them, or if he has ah"eady had recourse to those of a very long focus, he may change them for a pair of shorter focus, or, in other words, of greater refractive power. A double-convex glass improves the vision of a presbyopic eye, simply by lessening the divergence of the rays of light proceeding from near objects, and thus ensuring their being brought into foci upon the retina. To see distant objects with distinctness, glasses are in general not required by the presbyopic eye ; on the contrary, parallel rays being sufficiently converged by the refractive media of the eye itself, to be brought to their respective foci on the retina, the convex-glasses must be laid aside, when objects at a distance are to be examined. As a meniscus will produce the same effect as a double-convex glass, in enabling the presbyopic eye to perceive near objects with distinctness, while it will allow the eye greater latitude without fa- tigue, Dr. Wollaston has recommended the former as a pe7'iscopic glass for far-sighted persons. Similar directions must be followed in choosing convex glasses as in selecting concave ones ; viz. that each eye is to be tried sep- arately : that the lowest powei\ or longest focus, which answers the purpose, is to be chosen : and that as the concave glasses made use of b}^ the near-sighted should not make objects appear smaller, neither should the convex glasses employed by the far-sighted make them appear larger than natural.* Persons at a distance from an optician, may determine the focal length of the convex glasses, which they will require, by means of the following rules. 1 . If the}' have a distinct vision of objects tnoderately remote, let them multiply the distance at which they see minute objects most distinctly, say 20 inches, by the distance at which they wish to read by the aid of glasses, say 12 inches, and divide the product, 240, by the difference between the two, S ; the quotient, 30, will be the focal length of the glasses required. 2. If the distance at which the person sees most distinctly be very great, then the focal length of the glasses required will be equal to the distance at which be wishes to see objects most dis- tinctly. Convex glasses of about thirty-six inches focus are often used by *_ Convex glasses are kept in the shops of every focal length from thirty-six inches to six. It is evident, that no certain estimate can be formed from a person's age, of the focal length of the glass which he will require ; although perhaps the following may be received as a tolerable approximation to an average, upon this head. Tears of age •. 40 45 50 55 58 60 65 70 75 80 85 90 100 Focal lengths in inches, ... 36 30 24 20 18 16 14 12 10 9 8 7 6 The focus of a convex glass may be measured by holding it near the side of a room, facing a window, or what is still better, opposite to a candle, and moving it slowly backwards and forwards, until the image of the window-frame, or of the flame of the candle, upon the wall, becomes smallest and most distinct. The distance between the glass and the wall at that moment is the focal length. 609 ignorant people, under the name of preservers, before their sight has attained that degree of presbyopia, which renders the use of glasses necessary. They seem to think that preservers have the power of arresting the progress of that failure of the sight, which is the natural consequence of age. As it is chiefly by candle-light that the presbyopic patient com- plains of his deficient sight ; even after he has suppHed himself with proper glasses, it is advisable that he should refrain, as much as possible, from employing himself at night in occupations, which require intense use of the organs of vision. The moment that the eyes begin to feel hot and fatigued, while the individual is oc- cupied in reading, writing, or the like, especially by candle-hght, he should take the hint, and allow them a period of repose. When presbyopia occurs suddenly in subjects much under the age of forty years, it will lead us to suspect, either some derange- ment of the internal parts of the eye, some pressure behind the eyeball, or some disease of that portion of the optic apparatus which is contained within the cranium. Instances of this sort have oc- curred even in children, and have sometimes yielded to the use of evacuating remedies. Thus, Mr. Ware mentions the case of a boy of eight years old, who suddenly became presbyopic, and was repeatedly punished at school, on account of his incorrect and de- faced writing, the real cause being unknown to his master. After the presbyopia had continued a fortnight, and different local appli- cations had been used without producing any sensibly good effects, cure was accomplished by the application of leeches to the tem- ples, and the use of purgative medicines. Two sisters of this pa- tient were similarly affected. The elder, twenty years of age, had never been able to do fine work, and for three years had been greatly assisted by convex spectacles. The younger, a girl of fif- teen, had been presbyopic for about a year, being obliged to use glasses whenever she read, or worked with her needle. This pa- tient, in the course of six weeks, during which she totally abstained from the use of glasses, was completely relieved from the necessity of using them, by the apphcation of two leeches to each temple twice a week. The eldest sister, in the same space of time, expe- rienced much relief from similar treatment, but was still unable to do fine work without glasses, partly in consequence of the long continuance of the infirmity, and partly on account of her not having abstained from the use of her spectacles with equal steadi- ness.* SECTION III. INSENSIBILITY TO CERTAIN COLOURS. Numerous instances have now been recorded of persons, who were liable to strange mistakes regarding the colours of objects, or were * Philosophical Transactions, Vol. ciii. p. 48. London. 1813. 77 610 even totally unable to perceive certain colours. Some of the indi- viduals in question appear to have been myopic, but the eyes of most of those who presented this defect are described as appearing in no way diseased or unnatural, and to have fulfilled their func- tions perfectly, so far as the size, form, and distance of objects were concerned. Mr. Huddart mentions the case of one Harris, a shoe-maker at Maryport in Cumberland, who could distingush only black and white, and who had two brothers almost equally defective, one of whom always mistook orange for green. Harris observed this defect when he was four years old. Having by accident found in the street a child's stocking, he carried it to a neighbouring house to inquire for the owner : he observed the people called it a red stock- ing, though he did not understand why they gave it that demoni- nation, as he himself thought it completely described by being called a stocking. The circumstance, however, remained in his memo- ry, and together with subsequent observations, led him to the knowl- edge of his defects He observed, for instance, that other children could discern cherries on a tree by some pretended difference of colour, though he could distinguish them from the leaves by their difierence only of size and shape.* Another case, of a Mr. Scott, is recorded, to whom full reds and full greens appeared alike, while yellows and dark blues were vary easily distinguished. 3L'. Scott's father, his maternal uncle, one of his sisters, and her two sons, had all the same imperfec- tion. t Mr. Dalton, the celebrated chemist, cannot distinguish pink from blue, by daylight ; and in the solar spectrum, the red is scarcely visible to him, the rest of it appearing to consist of two coloLU's, yellow and blue. He appears to have remained long un- conscious of his defect ; and was led, rather to suppose that there existed some perplexity in the nomenclature of colours, than any incapabihty in his own power of distinguishing them.t Those W'ho feel inclined to examine the particulars of other in- stances of this sort, may consult the work referred to in the note. 5 They w^ill find, on doing so, that the chief peculiarities of these cases are, the confounding of red with green, and pink with blue; in other words, that red light, colours in which it forms an ingre- dient, and its accidental colour, are not distinguishable by those who labour under the defect in question. Red appears to them * Phil. Trans, vol. Ixvii. p. 260. Lond. 1777. t Ibid. vol. Ixviii. p. 611. Lond.1779. t Memoirs of the Literary and Philosophical Society of Manchester. 1st Series. Vol. V. p. 2.9. Manchester^ 1798. § Nicholl in McJico-Chirur^cal Transactions, Vol. vii . p. 477, and Vol. ix. p. 359 ;. and in Annals of Philosophy, Xew Series, Vol. iii. p. 1-23. — Butter in Transactions of the Phrenological Society, p. 209. — Combe, ibid. p. 222. — Harvey in Transactions of the Royal Society of Edinburgh, Vol. x. p. 253, and in Edinburgh Joiarnal of Science, Vol. v. p. 114. — Article Light, in Encyclopaedia Metropolitana, p. 434, § 507. — Brewster in Edinburgh Journal of Science, Vol. iv. p. 85. — Phrenological Journal, Vol. iii. p. 265. — Colquhoun in Glasgow Medical Journal, Vol. ii. p. 12. 611 merely a dark colour, and green a shade of drab. Yellow and blue they readily distinguish ; but tliey judge of orange, purple, and brown with great difficulty ; and even the shades of black, grey, and white, they are often unable to decide upon without hesi- tation. We should scarcely suppose, that a deficiency in the perception of colours could be attended with any advantage ; yet in one res- pect, this appears to be the case. " 1 see objects," says one of the subjects of this defect, " at a greater distance and more distinctly in the dark than any one I recollect to have met with ; this I dis- covered many years before I was aware of my defective errors in colours." * Another makes the following observations on the same point. " All objects whatever, when viewed at a distance, lose their local colouring, and assume more or less, of a pale, or azure blue tinge, which painters term the colour of the air, which is inter- posed between the spectator, and the distant object. No colour contrasts to me so forcibly with black as this azure blue, and as you know that the shadows of all objects are composed of black, the forms of objects which have acquired more or less of this blue hue, from being distant, become defined, and marked by the possession of shadows, which are invisible to me in the high-coloured objects in a fore-ground, and which are thus left comparatively confused, and shapeless masses of colour. So much is this the case with me, when viewing a distant object, as to overcome the effect of perspective, and the shading in the form and the garments of hu- man beings at some distance from my eye, is often so predomi- nant, and marks them so distinctly, as to overcome the effect of diminution of size ; and although I see the object most distinctly, I am unable to tell whether it be a child near me, or a grown-up person at a considerable distance." t Causes. The following are some of the notions which have been formed regarding the probable causes of insensibility co colours. i. Mr. Dalton thinks it probable that the red light is, in these cases, absorbed by the vitreous humour, which he supposes may have a blue colour ; a very unlikely conjecture, at the best, but which appears to be refuted by the simple experiment of looking through a pair of green or blue glasses. When we do so, we still recognise every primitive colour in bodies, with a shade merely of green or blue over them. Therefore, supposing the rays of hght to pass through a blue vitreous humour, it does not follow that ob- jects should appear blue, or that we should be prevented from dis- cerning red light, or any other colour. In old age, we view all objects through an amber-coloured crystalUne lens, and yet see every thing of its natural hue. 2. A writer in the Edinburgh Journal of Science,! going on the supposition that the choroid coat is essential to vision, gives it as * Medico-Chirurgical Transactions, Vol. ix. p. 361. London, 1818. 1- Glasgow Medical Journal, Vol. ii. p. 14. Glasgow, 1829; t Vol. iv. p. 86. 612 his conjecture, that the loss of red light in the subjects of this de- fect, arises from the retina itself having a blue tint, so that the light, falhng upon the choroid coat, being deprived of its red rays by the absorptive power of the blue retina, the impression con- veyed to the retina by the choroid, will not contain that of red light. 3. Dr. Young, adopting apparently the notion of Darwin, that the retina is active not passive in vision, regards it as the simplest explanation of this defect, to suppose that those fibres of the retina, which are calculated to perceive red, are absent or paralyzed. 4. Dr. Brewster conceives that the eye, in these cases, is insensi- ble to the colours at one end of the spectrum, just as the ear of cer- tain persons has been proved, by Dr. WoUaston, to be insensible to sounds at one extremity of the scale of musical notes, while it is perfectly sensible to all other sounds. 5. The phrenologists maintain, that the faculty of distinguish- ing colours does not depend on the eye, but on a particular part of the brain, to which they give the name of the organ of colour ; and that in those who are deficient in judging of colours, the defect lies in this organ, and not in the eyes, the mechanical construction and optical effects of which appear to be perfect in the individuals in question. SECTION IV. CHRUPSIAj* OR COLOURED VISION. It is evident, that in health we should suffer no imitations of vis- ual sensations, no flashes of light from internal changes in the eye, no false perceptions of muscse volitantes ; that we should see ob- jects of their natural colours, not tinged with hues entirely foreign to them, or of which they in general appear to be free ; and that we should have the consciousness of being impressed by the view of external objects, only when such objects are present and actually affecting our organs of vision. Yet such is the constitution of the optic apparatus, that by various derangements to which it is liable, we become the subjects of many sensations, which have actually no prototype. Even a mere defect of power in this apparatus to be affected in the natural way, frequently gives rise to false sensa- tions. Circulating through the immediate organ of visual sensation, the blood, during a state of perfect health, makes no visual impression on that organ ; but let the circulation through the retina, and neighbouring parts, be either accelerated or impeded, and certain morbid sensations are immediately produced. One of these is what is commonly called seeitig the circulation of the blood hi the eye. Thus Sauvages observed, that the pulsations of the ophthalmic artery might be perceived, by looking attentively on a white wall. From Xi'^'h colour, and o-^n, \ision. 613 well illuminated. A kind of network, darker tlian the other parts of the wall, appears and vanishes alternately with every pulsation. This change of colour of the wall he ascribes to the compression of the retina, by the diastole of the artery," Dr. R. W. Darwin, also, describes what he calls seeing the circulation of the blood in the eye. " The circulation may be seen," says he, " either in both eyes at a time, or only in one of them ; for as a certain quantity 'of light is necessary to produce this curious phenomenon, if one hand be brought nearer the closed eyelids than the other, the circu- lation in that eye will, for a time, disappear. For the easier view- ing the circulation, it is sometimes necessary to rub the eyes with a certain degree of force after they are closed, and to hold the breath longer than is agreeable, which, by accumulating more blood in the eye, facilitates the experiment ; but in general it may be seen distinctly after having examined other spectra with your back to the light, till the eyes become weary • then having covei-ed 3i'our closed eyelids for half a minute, till the spectrum is faded away, which you were examining, turn ymiir face to the light, and re- moving your hands from the eyelids, by and by again shade them a little, and the circulation becomes curiously distinct. The streams of blood are, however, generally seen to unite, which shews it to be the venous circulation, owing, I suppose, to the greater opacity of the blood in these vessels." t In this, and the next four sections, we shall notice some of the most remarkable false visual sensations. The first is what is called 'chrapsia, or coloured vision. Patients, who are partially amaurotic, complain not unfrequentlj 'of luminous objects, as, a Mghted candle, appearing as if surrounded by the colours of the rainbow- This symptom has been called chrupsia, and has been supposed to depend on some derangement of the lenses of the eye, by which the achromatic power of this or- gan becomes im.paired. In all such cases, it would be proper to guard against our being deceived, by those causes, which might induce a decomposition of the rays of light by inflection merely, such as contraction of the eyelids. Another variety of chrupsia, consists in seeing objects of a differ- ent colour from that which is natural to them. Some amaurotic patients see objects as if tinged of a yellow, green, or bluish colour, I have at present a patient under my care with prolapsus of the nasal portion of the iris through an accidental wound of the cor- nea, who sees all objects of a greenish hue. The alleged yellowness of objects in jaundice, which, if it ever occurs, is exceedingly rare, the red tinge which is seen by the pa- tient whose anterior chamber is filled with blood, and even the phenomena of ocular spectra or accidental colours have all been crowded together under the appellation chrupsia. * Nosologia Methodica, Vol. ii. p. 180. Amstelodami, 1768. + Philosophical Transactions, Vol. Ixxvi. p. 344. London, 1786. 614 SECTION V. PHOTOPSIA. That sensations of light may be excited independently of the ordinary impressions from external objects, is familiarly known. The flash, produced upon sneezing, or by a sudden blow on the eye, or by the passage of tlie Galvanic influence through different parts of the face, as in the simple experiment of applying a piece of zinc and a piece of silver to the tongue, and then bringing them into contact, is generally considered as sufficient proof, that the retina may be so impressed, as to produce the sensation of light, altogether independent!}^ of the actual presence of light. The ef- fect is produced whether the eyes be opened or closed, and whether the experiment be made in daylight or in the dark. In like manner, there are sensations of light, which are alto- gether the result of disease in the optic apparatus. Flashes of light, the appearance of shining stars, a gUttering as if from the points of innumerable needles, and a variety of other lucid spectra attend retinitis, and occur in the commencement of certain kinds of amaurosis. In some peculiar and distressing cases, the patient is annoyed by the sensation as if his eyes were directed towards globes of light swimming before him, or as if he were looking at a sea of melted goJd. The distress, which patients affected with such false sensations experience, varies greatly in degree ; but, on the whole, these lucid spectra are both less supportable by those who experience them, and ought to be regarded as of a more alarming nature, than the semi-transparent or dark muscm volitantes, which so frequently occur. Flashes of light are often the precursors of convulsive at- tacks, such as epilepsy ; subjects inchned to apoplexy, on raising their heads after stooping, see showers of shining spectra ; those who have suffered from internal ophthalmia are often troubled with such sensations as that of a luminous wheel, rapidly revohing before them; and phrenitis is attended by false impressions of the same sort, which often continue long after all the other symptoms have ceased. It is of great Importance, to ascertain the cause of photopsia, and to distinguish it accurately from photophobia.t The latter often stimulates the former, especially in strumous, hypochondriacal, and hysterical patients. The cause of photopsia being discovered, the line of treatment can scarcely be mistaken. Case. The following interesting case of photopsia has been recorded by Mr. Ware, in the words of the patient himself, a med- ical practitioner. " About ten years ago, when about forty-eight years of age, I experienced the first attack of the malady which I mean to describe ; and it has repeatedly returned at irregular periods, from that to the ^ From paj;, litrht, and £i4«, ■vision. Visus Lucidus. Mx^iU^guj^a of Hippocrates, t See pages 139, 320, and 388. 615 present time. The first notice that I have of the attack, is a pe- cuUar indescribable sensation at the bottom of the eye, which does not amount to pain, and is so shght that its reahty is not to be determined, unless I direct my attention very particularly to it. After a few seconds the objects, in a small point, nearly in the centre of the field of vision, become indistinct ; and, shortly after- wards, invisible. ***** In a few seconds more, that is, in about half a minute from the commencement of the attack, the point that was invisible becomes lucid, appearing to be a circular spot, about the eighth of an inch in diameter, in which a yellow flame seems to undulate from the centre to the circumference with almost coruscating quickness and splendour. This spot increases by the extension of the undulating flame until it acquires an apparent diameter of about three quarters of an inch, which takes place generally in about six or eight minutes. The fiery veil, which conceals objects, becomes then thinner in the centre, and objects are there seen through it. The vision increases, until at length a ring of light only remains, which continues to enlarge until it is lost by seeming to extend beyond the field of vision. " The returns of the attack have been very irregular. Some- times the)^ have occurred daily for a week or ten days together ; at other times more than a month has elapsed between their ap- pearance. During one forenoon they returned almost every half hour ; but of late the intervals are much lengthened ; and I have been now exempted from the malady more than three months. " At first no pain was felt ; but during the last twelve months, a slight uneasiness under the forehead, on the opposite side to that of the affected eye, has generally accompanied and succeeded the attack. " The disease is common to both eyes, though it has never yet occured in both at the same time. My sight is not injured, though the sensibility of the retina appears to be morbidly increased : a strongly illuminated object producing a more brilliant spectrum than it used to do. " About six weeks ago I first saw the unpleasing appearance of a small dark circular spot, which, varying its situation with every motion of the eye, showed how appropriately the term musca voli- tans had been applied to it. The possibility of its being a partial paralytic affection, resulting from the frequent morbidly increased action of the retina, naturally alarmed me ; but six weeks having elapsed without any return, I am become easy concerning it. In this instance the immediate cause of the affection appears to have been an irregularly increased action of the retina ; and the remote causes were an over eager exercise of the mind, joined with too long continued employment of the eyes, and a disordered state of the stomach and bowels. 616 "■ With regard to the means of curC; reprehensible as it may ap- pear. I for a long time employed none. About three years ago^ however, having been harassed repeatedly at short intervals, and sometimes two or three times in the day^. by the above-mentioned appearances, I called on you, and, by your advice, took a dose of five grains of calomel. After this the spectrum did not appear for sev- eral months ; and when I again saw it, it yielded to a repetition of the same remedy. In the following year, having travelled two days together, and taken food of an improper kind, and in an irreg- ular manner,- the attacks oa the third morning were so frequentl)^ repeated, that I \vas unable to see my way without difiiculty and danger. I tbeiefore stopped and took my dose of calomel ; after which the spectrum immediately disappeared, and it did not return for many months. That w^hfch was black as well as those which were lucid, were equally removed by the use of this medicine ; antJ 1 have not now perceived either of them for a considerable length of time." * SECTION VI. OCULAR SPECTRA, OR ACCIDENTAL COLOURS. A very short notice of this class of phenomena will not, I think, appear improper, if we consider that they are the result of fatigue of the eye, and that fatigue is not only in itself a disease, but is often the prelude to other diseases of more permanent char- acter. When one has long and attentively looked at a bright object, as at the setting sun, on closing his eyes, or remo\nng them, an image,, which resembles in form, the object he was attending to, continues for some time to be visible. This appearance is called the ocular spectrum of the object \ and as it is often of a colour diSerent from that of the object which has produced it, Buffon gave to the colours which arise in this way^ from the continued action of light upon the retina, the name of accidental colours, in order to distinguish them from those which are produced by the decomposition of white-, hght. Dr. R. W. Darwin, of Shrewsbury,! considers ocular spectra un- der four heads. To understand his views of this subject, it is ne- cessary to know that he regards the retina as a fibrous substance^ capable of a certain sort of activity, which produces vision, and ca- pable even of spasmodic or irregular action. I. The retina is not so easily excited into action by a less irri- tation, after having been lately subjected to a greater ; and hence a class of ocular spectra from defect of sensibility, as in the simple experiment just referred to. Certain of the muscoi voli- tantes, complained of by people of delicate constitutions, when their * Medico-Chirur^cal Transactions, Vol. v. p. 274. London, 1814. + Philosophical Transactions, Vol. Ixxvi. p. 313. London, 1786. 617 eyes are a little weakened by fatigue, are probably ocular spectra of this kind. II. The retina is more easily excited into action by a greater irrita- tion after having been lately subjected to a less : and hence a class of ocular spectra from excess of sensibility, as in the following experiment. Make with ink on white paper a very black spot, about half an inch in diameter, with a tail to it about an inch long, so as to represent a tadpole ; look steadily for a minute on this spot, and, on moving the eye a little, the figure of the tadpole will be seen on the white part of the paper, whiter or more luminous than the other parts of the paper. The part of the retina which was ex- posed to the black spot, is now more sensible to light than the other parts of it, which were exposed to the white paper. Dr. Darwin regards this as put beyond a doubt by the following experiment. On closing the eyes after viewing the black spot on the white pa- per, a red spot is seen of the form of the black spot : for that part of the retina, on which the black spot was dehneated, being now more sensible to light than the other parts of it, which were exposed to the white paper, is capable of perceiving the red rays which pen- etrate the eyelids. III. There is a set of ocular spectra, which resemble their ob- ject in its colour as well as form. These Dr. Darwin terms direct ocular spectra. If, in the night, we place the bright flame of a spermaceti can- dle before a black object, look steadily at it for a short time, till it is observed to become somewhat paler, and then close the eyes, and cover them carefully, but not so as to compress them, the image of the blazing candle will continue distinctly visible. In this case, according to Dr. Darwin, a quantity of stimulus some- what greater than natural excites the retina into spasmodic action, which ceases in a few seconds. If we place a spermaceti candle in the night about one foot from the eye, and look steadily on the centre of the flame, till the eye becomes much more fatigued than in the last experiment ; on clos- ing the eyes a reddish spectrum will be perceived, which will re- peatedly cease and return. In this case, a quantity of stimulus somewhat greater than the former excites the retina into spasmod- ic action, which ceases and recurs alternately. IV. There is a set of ocular spectra, of a colour contrary to that of their object. These may be called reverse ocular spectra. They are excited by a stimulus somewhat greater than what is sufficient to produce the direct spectra, and are supposed by Dr. Darwin to depend on the retina falUng into an opposite spasmodic action to that which had previously existed. If we place a piece of coloured silk, about an inch in diameter, on a sheet of white paper, and about half a yard from the eyes, look steadily upon it for a minute, then remove the eyes to another part of the paper, a spectrum will be seen of the form of the silk, 78 618 but of a colour opposite it. Red silk will produce a green spec- trum, green a red one, orange blue, blue orange, yellow violet, and violet yellow. These reverse spectra are similar to a colour, formed by the combination of all the primary colours, except that with which the eye has been fatigued in making the experiment. In contemplating any of these reverse spectra with the eye closed and covered, it disappears and re-appears several times suc- cessively, till at length it entirely vanishes, hke the direct spectra ; but with this additional circumstance, that when the spectrum be- comes faint or evanescent, it is instantly revived by removing the hand from before the eyelids, so as to admit more light. The ret- ina, being still sensible to all other rays of light, except that with which it was lately fatigued, is stimulated, by the admission of these rays, into those motions which form the reverse spectrum. If the retina is excited by a stimulus greater than the last men- tioned, it falls into various successive spasmodic actions. Thus De la Hire observed, that after looking at the bright sun, the im- pression in his eye first assumed a yellow appearance, then green, and then blue. Excited by a still greater stimulus, the retina may fall into a fixed spasmodic action, which may continue for some days. Thus Dr. Darwin found, that after having looked long at the meridian sun, till the disc faded into a pale blue, he frequently observed a bright blue spectrum of the sun on other objects all the next and succeeding day, which constantly occurred when he attended to it, and frequently when he did not previously attend to it. A quantity of stimulus greater than the preceding induces a temporary paralysis of the organ of vision. Place a circular piece of bright red silk, about half an inch in diameter, on the middle of a sheet of white paper ; lay them on the floor in a bright sun- shine, and fixing the eyes steadily on the centre of the red circle, for three or four minutes, at the distance of four or six feet from the object, the red silk will gradually become paler, and finally cease to appear red at all. The following miscellaneous facts regarding ocular spectra ap- pear worthy of notice. The full iEustration of them will be found chiefly in Dr. Darwin's paper ; and the reader may farther con- sult, on this subject, the works mentioned below.* 1. Though a certain quantity of Hght facilitates the formation of the reverse spectrum, a greater quantity prevents its formation, as the more powerful stimulus excites even the fatigued parts of the eye into action ; otherwise we should see the spectrum of the last viewed object as often as we turn our eyes. * De la Hire sur les differens Accidens de la Vue, 1694. — Jurin's Essay on Distinct and Indistinct Vision, at the end of Smith's Optics — Buffon sur les Couleurs Acci- dentelles, Memoires de I'Academie Royale des Sciences, 1743. — Porterfield on the Eye, Vol. i. p. 343. — ^pinus, Novi Comment. Petrop. Tom. x. — Memoires de I'Acad. de Berlin, 1771. — Hauy's Traite de Physique. — Rozier's Observations sur la Physique, Tom. xxvi. pp. 175, 273, 291. — Article, Accidental Colours, in the Edinburgh Ency- clopsdia. 619 2. When a direct spectrum is thrown on colours darker than itself, it mixes with them ; as the yellow spectrum of the setting sun, thrown on the green grass, becomes a greener yellow. But when a direct spectrum is thrown on colours brighter than itself, it becomes instantly changed into the reverse spectrum, which mixes with those brighter colours. So the yellow spectrum of the setting sun thrown on the luminous sky becomes blue, and changes with the colour or brightness of the clouds on which it appears. But the reverse spectrum mixes with every kind of colour on which it is thrown, whether brighter than itself or not : thus, the reverse spectrum, obtained by viewing a piec^ of yellow silk, when thrown on white paper, is a lucid blue green ; when thrown on black Tur- key leather, it becomes a deep violet. In these cases the retina is thrown into activity or sensation by the stimulus of external colours, at the same time that it continues the activity or sensation which forms the spectra. 3. All experiments upon ocular spectra are apt to be confounded, if they are made too soon after each other, as the remaining spec- trum will mix up with the new ones. This is a very troublesome circumstance to painters, who are obliged to look long upon the same colour ; and in particular to those whose eyes, from natural debihty, cannot long continue the same kind of exertion. 4. From some occasional phenomena observed in experimenting on the subject of ocular spectra, it would appear that an impression on the one retina can be conveyed to the other. Thus, Dr. Brews- ter taking advantage of a fine summer's day, when the sun was near the meridian, formed a very brilliant and distinct image of his disc, by means of the concave mirror of a reflecting telescope. His right eye being tied up, he viewed this luminous disc with the left through a tube, which prevented any extraneous light from falling upon the retina. When the retina was highly excited by the solar image, he turned his left eye to a while ground, and examined the series of ocular spectra which followed. After uncovering his right eye, a remarkable phenomenon appeared ; for on turning it on a white ground, he found that it also gave a coloured spectrum. He repeated the experiment twice, in order to be secure against de- ception, and always with the same result. The spectrum in the left eye was uniformly invigorated by closing the eyelids, because the images of external objects efface the impression upon the retina; and when he refreshed the spectrum in the left eye, that in the right was also strengthened. On repeating this experiment a third time, the spectrum appeared in both eyes, which seems to prove, that the impression of the solar image was conveyed by the optic nerve from the left to the right eye ; for the right eye being shut, could not be affected by the luminous image.* 5. Ocular spectra sometimes continue for days or weeks, and * Article, Accidental Colours, in the Edinburgh Encyclopedia. 620 are often followed in such cases by serious affections of the retina. Thus, Dr. Brewster found, after the experiments just quoted, that his eyes were reduced to such a state of extreme debility, that they were unfit for any farther trials. A spectrum of a darkish hue floated before his left eye for many hours, succeeded by the most excruciating pains, shooting through every part of the head. These pains, accompanied with a shght inflammation in both eyes, lasted for several days. Two years after, the debility of the eyes still continued, and several parts of the retina in both eyes had com- pletely lost their sensibihty.* Buffon tells us, that one of his friends having one day looked at an eclipse of the sun through a small hole, observed for more than three weeks a coloured image of that body upon all objects. When he fixed his eyes upon a brilliant yellow, as that of a gilt frame, he saw a purple spot ; when on blue, as that of a slated roof, a green spot.t Buffon himself brought on muscce, volitantes by his experiments on accidental colours. In the mouth of July, a lady of advanced age, went from Lon- don to the eastern coast of Kent, where she lodged in a house look- ing immediately upon the sea, and of course very much exposed to the glare of the morning sun. The curtains of the bed in which she slept, and also of the windows, were of white linen, which made her apartment very light. When she had been there about ten days, she observed, one evening, at the time of sunset, that first the fringes of the clouds appeared red, and soon after the same colour was diffused over all the objects around her. It was par- ticularly conspicuous when she regarded any thing white, as a sheet of paper, a pack of cards, or a lady's gown. This lasted the whole night. The next morning her sight was perfectly restored. But as the evening advanced, the same appearances came on again ; and they continued to do so regularly every evening, as long as she remained at that place, which was three weeks from the commencement of her complaint : the natural vision always returning in the morning. Six days after she had left the coast, Dr. Heberden saw her in London, still subject to the same affection. It persevered a fort- night longer, and then, of its own accord, ceased suddenly and entirely. While it was upon her, the sight seemed to be no other- wise impaired than by the degree of indistinctness necessarily pro- duced by this unnatural colour, which overspread all her view. There seems every reason to suppose that this lady's complaint was brought on by her being exposed to an unusual glare of light, and that it partook more of the nature of an ocular spectrum than of any thing else.t . * Article, Accidental Colours, in the Edinburgh Encyclopaedia. t Memoiies de I'Academie Royale des Sciences, Annee 1743, page 214. Amster- dam, 1748. See Larrey's Recueil de Memoires de Chirurgie, p. 227, for two cases of Amaurosis from viewing an eclipse of the sun. t Medical Transactions of the College of Physicians. Vol. iv. p. S&. London, 1813. 621 6, There must at all times, and from every object, be a ten- clency to the production of ocular spectra ; but partly from habitual want of attention to them, partly from their being effaced in the overwhelming effect of direct impressions, they are seldom mad'C the subject of complaint, except by those whose eyes are peculiarly sensible, or have become greatly weakened by over-fatigue and other causes. la such persons a mixture of photopsia, muscae volitantes, and ocular spectra, is not uncommon. There are few, however, who, after retiring from the toils of the day, have not, at one time or another, been sensible, on shutting their eyes where only a very moderate quantity of light was present, of an impres- sion as if from myriads of minute figures, of various colours, ap- pearing in constant motion, and assuming an endless succession of different arrangements, I presume that this sensation must iri general be referred to the class of ocular spectra, and be regarded as the effect of the infinite variety of impressions made upoti the retina through the course of the day. SECTION VH. MUSC^ VOLITANTES. Various false visual sensations have been described under the name of muscce volitantes. The name denotes that in general they bear a resemblance to flies moving through the air ; but the objects to which they are more particularly compared, by those who are the subjects of them, and the descriptions which are given of their figure, size, and degree of opacity, are widely different ; as are also the pictorial representations which are often made of them on paper. One set of muscse volitantes are semitransparent, and although when carelessly described, they are said to resemble mist, or a shower of minute drops, yet when attentively examined by the patient, he generally finds that they present an appearance of minute twisted tubes, partially filled with globules, which some- times appear in motion. Another set are more opaque or perfectly dark, and are therefore spoken of as black spots, which follow the motions of the eye, and partially cover every object to which the patient turns his attention, I have been led to suspect that these two sets of muscee volitantes are specifically distinct ; and that the latter are of a more dangerous character than the former. The black spot, or spots, whether com- pared to a flake of black wool, to the body of a spider, with perhaps three or four diverging legs^ or to whatever else, is not unfrequently the precursor of amaurosis : while the semitransparent spectra prove, in many instances, troublesome for ten, or even twenty years to- gether, and yet end in nothing seriously affecting vision. It is necessary, however, to mention that the dark muscae volitantes are not to be regarded as uniformly of a dangerous character ; for like 622 the semitransparent, they sometimes continue unchanged for many years, while in other instances, they are gradually dissipated, and at length totally removed. Muscfe volitantes seldom appear in the optic axis, but are gen- erally to one or other side of it, or above it, or below. Hence it is that the individual observes them only by the by; at first, he is led to suppose that some sooty filament, or particle of dust is chng- ing to his eyelids, which he endeavours to brush away with his hand ; for a day or two, perhaps, the sensation does not trouble him, and then it returns ; w^hen he endeavours to examine with more exactness the form and appearance of what seems flitting before him, he finds from its obliquity that it is difiicult to do so ; and when be turns his eye, as if to fix it in the axis of vision, it seems suddenly to fly from before him. If it happens, however, to be situated more in the direction of the centre of the retina, the patient finds that he can bring it directly before him for examina- tion, and that viewed upon a sheet of paper at the usual distance for distinct vision, it appears less in size, and more defined, than when he brings it upon a distant wall, or carries it to the sky. Patients are often persuaded that muscse volitantes move, and will not readily be convinced that this is a mere deception. They will sometimes tell us, for instance, that when they raise their eyes rather quickly, the muscee volitantes fly upwards, but if they fix their sight upon a cloud or other elevated object, that they descend slowly, as if towards the bottom of the eye ; that they do not see them when they continue to look steadily at the same object ; but that on the least motion of the eyes, the muscae leave the situation which from their gravity they had assumed, and come again into view. Now, all these motions are merely apparent. In those muscae, indeed, which present the appearance of globules contained within semitransparent tubes, there is sometimes perceived a motion which is real, and which is probably that of the blood passing through the vessels of the retina, or of the vitreous humour : but neither these semitransparent tubes themselves, nor any of the fila- mentous muscse, or black spots, which are so frequently complained of, possess any real motion, independent of the general motion of the eyeball. If the cause of the muscce volitantes. be it in the vit- reous humour, or in the retina, lies below the optic axis, it will pro- duce an impression as if it were placed above the level of the eye, inducing us to turn our eyes that way, expecting to bring it into the centre of the eye, that we may view it more distinctly ; and in this case the dark spots seem to fly upwards. Slowly as the eyes descend, the muscse again come into view. If the cause hes above the optic axis, we pursue it from the same motive, and it seems to move downwards. If the cause be placed much to one side of the optic axis, be it above or below, to the right or to the left, it is impossible to gain a deliberate view of the spectrum which it produces. It flies, as it were, before us, and as quickly returns 623 again to annoy the eye, equally tired of its presence and of the in- effectual attempis made to examine it more at leisure. But if the cause be within a few degrees of the optic axis, no difficulty is ex- perienced in obtaining a distinct view of the musca. The patient brings it at once on the paper, and with his pen delineates its form for the information of others. Proximate causes. Muscee volitantes are never seen, in the sense that objects out of the eye are seen. Opaque spots, in any part of the eye anterior to the retina, could never produce an im- age on that membrane, sufficiently defined to give rise to such im- pressions as the generality of muscse volitantes. Such spots might produce an obscurity in vision, by intercepting a certain number of the rays of light, exactly as specks on the cornea, depositions in the pupil, or incipient cataract does, or as any one may do by hold- ing an opaque body, such as a piece of wire or a common probe, across and close to his cornea ; but no object within the eye, (nor indeed without the eye, unless beyond a certain distance from the cornea,) can be brought to a focus on the retina, or produce any other impression than a greater or less degree of dimness. This, however, is evidently not at all the kind of impression produced in what we term muscee volitantes. Even when these appearances are remote from the axis of vision, so that they cannot be dwelt upon, but are only glanced at, as if in passing, they are still too much defined, to be of the nature of mere shadows, arising from intercepted light. I by no means deny that the branches of the arteria centralis retinae, which ramify through the hyaloid membrane, and end on the posterior hemisphere of the crystaUine capsule, are capable of becoming varicose; that opaque depositions may take place in the lens ; or opaque corpuscules float in the aqueous humour ; but as these cannot cause muscse vohtantes, this disease must be referred either to the retina itself, including of course the three laminae of which it is composed, or to the choroid coat. The probability is, that the semitransparent muscse of tubular form are owing to a dilatation of the branches of the arteria centrahs retinae, and that the dark muscae are the effects of certain portions of the retina hav- ing become altogether insensible to light, either from the pressure of some irregular projecting point or points of the choroid, or from some other cause. We can conceive the nervous layer of the retina to be in one or in many minute portions of its extent so altered by disease, or so pressed upon by the neighbouring parts in a mor- bid state, as to be no longer capable of being stimulated by light at the parts affected, each of which will necessarily give rise to the sensation of a musca volitans. Blood effused either by fhe vessels of the retina, or those of the choroid, is a likely cause of partial in- sensibility of the retina, and consequently of muscae volitantes. Remote Causes. A very proper distinction has been made be- tween those muscae volitantes which appear to depend on plethora 624 aiid sanguinous congestion, and those which are coonected with atony and general weakness. The former are apt to follow or tc be combined with photopsia, and may be caused by whatever pro- duces an increased supply of blood to the head and eyes, or im- pedes its return. The latter are among the most frequent effects- of disordered digestion, arising from want of exercise, and of a long continuance of any of the depressing passions. Prognosis. Few symptoms prove so alarming to persons of a nervous habit or constitution as muscse volitantes. They immedi- ately suppose that they are about to lose their sight, by cataract or amaurosis. We may safely assure them that there is no danger of either of these terminations, unless other symptoms be present.- These false perceptions do not render objects obscure, as incipient cataract doe& ^ nor is there any fixedness or even unnatural slow- ness of the iris, in simple cases of muscse volitantes. Trecetment. When this disease is evidently connected with sanguinous turgescence, there can be no doubt of the propriety of depletory treatment ; but in by far the greater number of instances^ an opposite plan requires to be followed, for in the weakly or ner- vous persons, who in nine cases out of ten form the subjects of muscse volitantes, debilitating remedies will not only afford no as- sistance, but even aggravate the symptoms. The mind must be relieved as much as possible from intense application of every kind^ and the patient assured, not only of the absence of all danger to the sight, if the muscse volitantes appear to be uncombined with other symptoms, but of the probability of these false perceptions be- coming less and less troublesome, in proportion as the strength and spirits are recruited. The state of the bowels must in every instance be attended to ; as these are often sluggish in their action, and the secretion of bile faulty OF defective. In such cases, purgatives will be found high- ly advantageous ; and ought to be followed by a course of tonics,- such as the precipitated carbonate of iron, the sulphate of quina and the like. Yalerian, and other anti-spasmodics are also useful. If the eyes have been weakened by the frequent discharge of tears, it will be useful to foment them v/ith a tepid infusion of chamomile flowers^ twice or thrice daily f and afterwards to rub^ the forehead^ temples, and outside of the eyelids with emi de Co- logne, or some sk»ilar apphcation. &ECTI©N VIII. SPECTRAL ILLUSIONS, The phenomena falling under this head may be- referred, in- one set of cases, merely to the insensibility of the eye to direct im- pressions of very faint light ; while another set must be regarded as symptoms of a disorder in that part of the brain, which assists in forming the optic apparatus. 625 I. Dr. Brewster observes, that when the eye is steadily directed to objects illuminated by a feeble gleam of light, it is thrown into a state nearly as painful as that which is produced by an excess of light: ^ A kind of remission takes place in the conveyance of the impres- sions ; the object actually disappears, and the eye is agitated by the recurrence of impressions which are too feeble for the perform- ance of its functions. These facts " may serve," says Dr. Brewster, " to explain some of those phenomena of the disappearance and reappearance of ob- jects, and of the change of shape of inanimate objects, which have been ascribed by the vulgar to supernatural causes, and by philoso- phers to the activity of the imagination. If in a dark night, for example, we unexpectedly obtain a glimpse of any object, either in motion or at rest, we are naturally anxious to ascertain what it is, and our curiosity calls foith all our powers of vision. This anxiety, however, serves only to baffle us in our attempts. Ex- cited by a feeble illumination, the retina is not capable of affording a permanent vision of the object, and while we are straining our eyes to discover its nature, it will entirely disappear, and afterwards reappear and vanish alternately."" II. An excellent account of spectral illusions, arising from dis- ease, has been published by Dr. Hibbert, under the title of Sketches of the Philosophy of Apparitions. He traces them to a great variety of causes ; as, highly-excited states of particular tempera- ments, hysteria, hypochondriasis, the neglect of accustomed periodi- cal blood-letting, febrile and inflammatory affections, inflammation of the brain, delirium tremens or mania a potu, &c. The spectral illusions, described by those troubled with this dis- ease, are infinitely various ; sometimes bearing the appearance of a single person or other object, and in the other cases, imitating the impression which might be produced by crowds of human beings moving before the spectator, or by scenes of endless diversity. Many patients affected with visions, are unable to distinguish them from real iinpressions, and call upon the spectators to look at the objects of their terror or surprise ; others, though they can scarcely persuade themselves that the impressions under which they labour do not arise from real objects, feel a degree of diffidence in announc- ing what they see to the bystanders, whose society they sometimes seek only in order to dissipate the intruders ; while a third set are perfectly conscious from first to last that they are labouring under a disease, which renders them the subjects of false perceptions. The fact, that spectral illusions, in some instances, have been attended by fatal effects, has been particularly mentioned by Hippocrates.f The beneficial influence of sleep, procured by the liberal adminis- tration of opiu in, in banishing the phantasmsof thoselabonring under mania a potu, is well known. Other sorts of remedies will be re- t * Edinburgh Journal of Science, Vol. iii. p. 209. Edinburgh, 182,5. t De Natura Muliebri. 79 626 quired in other ceises, and will sometimes operate in a manner almost equally striking. Witness the effects of depletion, in the celebrated case of Nicolai, the Berlin bookseller, who for nearly two months was constantly affected with spectral illusions. " Though at this time," says he, " 1 enjoyed rather a good state of health both in body and mind, and had become so very familliar with these phantasms, that at last they did not excite the least dis- agreeable emotion, but on the contrary afforded me frequent sub- jects for amusement and mirth ; yet as the disorder sensibly in- creased, and the figures appeared to me for whole days together, and even during the night, if I happened to wake, I had recourse to several medicines, and was at last again obliged to have recourse to the application of leeches to the anus. " This was performed on the 20th of April, at eleven o'clock in the forenoon. I w^as alone with the surgeon, but during the operation, the room swarmed with human forms of every descrip- tion, which crowded fast one on another ; this continued till half- past four o'clock, exactly the time when the digestion commences. I then observed that the figures began to move more slowly ; soon afterwards the colours became gradually paler ; every seven min- utes they lost more and more of their intensity, without any altera- tion in the distinct figure of the apparitions. At about half-past six oclock, all the figures were entirely white, and moved very lit- tle ; yet the forms appeared perfectly distinct ; by degrees they be- came visibly less plain, without decreasing in number, as had often formerly been the case. The figures did not move off, neither did they vanish, which also had usually happened on other occasions. In this instance they dissolved immediately into air; of some, even whole pieces remained for a length of time, which also by degrees were lost to the eye. At about eight o'clock, there did not remain a vestage of any of them, and I have never since experienced any appearance of the same kind. Twice or thrice since that time, I have felt a propensity, if I may be so allowed to express myself, or a sensation, as if I saw something, which in a moment again was gone." * Even a change in the position of the body, such as may possibly modify the state of the circulation through the brain, has sometimes been known to dissipate the phantasms produced by disordered sen- sation. " I know a gentleman." says an anonymous writer on this subject, " at present in the prime of life, who in my opinion is not exceeded by any one, in acquired knowledge, and originality of deep research ; and who, for nine months in succession, was al- ways visited by a figure of the same man, threatening to destroy him, at the time of going to rest. It appeared upon his lying down, and instantly disappeared when he resumed the erect pos- ture." t ** Nicolai's Memoir, in Nicholson's Journal, Vol. \i. p. IHl. London, 1803. t Nicholson's Journal, Vol. xv. p. 289< London, ISOti. 627 It must be Irighl}^ beneficial to those who lubouv under such disordered sensations, to be made acquainted with the fact, that they arc merely the subjects of a peculiar disease of the internal optic apparatus, the effect of which is to produce a repetition or imitation of former impressions. By this means the minds of those may be calmed, who otherwise might be led to ascribe their visions to su- pernatural powers, or who through fear or terror might be driven to insanity.* SECTION IX. NIGHT-BLINDNESS.t Case. As the servant to a corn-miller was employed, one evening near sunset, in mending some sacks, he felt himself sud- denly deprived of the use of his hmbs, and of his sight. At the time he was attacked by this uncommon disease, he was not only entirely free from any pain in his head, or limbs, but, on the con- trary, had a sensation of ease and pleasure ; he was, as he expressed liimself, as if in a pleasing dose, but perfectly sensible. He was immediately carried to bed, and watched till midnight ; at which time he desired those who attended him, to leave him, because he was neither sick, nor in pain. He continued the whole night totally blind, and without a wink of sleep. When the daylight of the next morning appeared, his sight returned to him gradually, as the light of the sun increased, till it became as perfect as ever. When he rose from his bed, he found his limbs restored to their usual strength and usefulness, and himself in perfect health. But on the evening of the same day, about sunset, he began to see but obscurely, his sight gradually departed from him, and he became as blind as on the preceding night ; though his limbs continued as well as in perfect health, nor had he from the first night any farther complaint from that quarter. Next day, with the rising sun, his sight returned ; and this was the almost constant course of the disease, for two months. The symptoms, which, from the second night, constantly pre- ceded the blindness, were a slight pain over the eyes, and a noise in his head. That he was totally bhnd every night, when these symptoms appeared, was evident, from his not being able to see the light of a candle, though held close to his eyes ; and that in the day his sight was perfect, was as manifest, from' his being capable of reading the smallest print, and threading the finest needle. * The reader who wishes to pursue the subject of Spectral Illusions, in addition to the worlis already referred to, may consult the following. — Cardanus de Vita Propria. — Ferrier's Theory of Apparitions. — Alderson, in Edinburgh Medical and Surgical Journal, Vol. vi. — Armstrong, in Ibid. Vol. ix. — Simpson, in Phrenological Journal, No. 6. — Edinburgh Journal of Science for April, 1830. t JVyctalopia of some, and hemeralopia of others, terms which it were better al- together to avoid. Nyctalopia more especially has been used to signify both seeing by night, and night blindness. Sometimes even the same author uses the word in both opposite D2eanings. It seems doubtful whether it is a compound of vufjand a^f, mere- ly, or of yu|, * primitive, and m^ j and a similar doubt hangs over hemeralopia. 628 The first day that Dr. Pye saw liis patient, he found his eyes perfectly natural, but some time after he observed the pupils, during one of the nocturnal paroxysms, to be enlarged about one-third in diameter. After nearly two months' continuance of the disease, it began to be less regular in its occurrence, the patient retaining his sight for a single night or for several nights together, and then the blindness recui'ring. Dr. Pye, who relates the case,* put him at last on the use of cinchona, and thought it successful in removing the complaint. It must be observed, however, that the patient, while taking the cinchona, laboured under a spontaneous diarrhoea, in consequence of which he became gradually weaker and weaker. His sight he retained from the first day after using the medicine, but ten days after, we find him delirious, and deprived of hearing, and, in five days more he died. I have quoted this case, as a good example of night-blindness, a disease which though rare in this country, is by no means un- frequent in warm chmates, and to which seamen appear to be par- ticularly exposed. Symptoms. The first attack of this disease generally excites great alarm. The patient is busy perhaps at his occupation, or enjoying himself in the midst of his family, when suddenly he finds his sight fail, and as evening advances, becomes almost completely blind. The medical attendant is immediately sent for, and is often as much amazed, and little less alarmed than the patient. He pro- bably finds the pupils dilated, but no other sign indicative of any serious affection of the head. He perhaps takes away blood, orders some purgative medicine, and pronounces a very unfavorable prog- nosis. To the joy of all concerned, the patient wakes in the morn- ing with his sight perfectly restored. But again on the approach of evening, symptoms are perceived of returning blindness. Objects appear as if covered by a bluish or greyish mist, and in the course of a few minutes, the patient is obliged to grope his way hke a blind man. Candles are brought. If he perceives that they are present, they appear as if glimmering through a fog, and scarcely ever enable him to see with distinctness. The effect, however, of artificial light is not uniformly the same in this disease. Night after night, the blindness returns, and becomes more and more complete. For a time, the restoration to vision through the day appears to be tolerably perfect, but at length the sight is evi- dently weak by day as well as by night. The patient is affected with photophobia, and becomes near-sighted ; his vision is more and more impaired ; and, if neglected or mistreated, the disease ends in incurable amaurosis. It sometimes happens, in incipient cases of night-bhndness, that the patient, though unable to distinguish even large objects after * Medical Observations and Inquiries, Vol. i. p. 111. London. 1763. 629 sunset or by moonlight, is restored to a tolerable degree of sight by the use of candle-light ; but in cases fully developed, even strong artificial illumination is unable to affect in any degree the sunken sensibihty of the retina. The appearances of the eyes are different in different cases. In many, there is scarcely any change from the appearances of per- fect health. Generally, however, the pupils are dilated during the attack, and do not contract on exposing the eyes to the light of a candle or of the moon. In some, the pupils continue dilated even during the day ; in others, they are contracted, and evince a pain- ful irritabihty on exposure to strong light. If the patient happens to look at the direct rays of the sun, especially of a tropical sun, or a strong glaring reflection of them, as from the sea, pain and temporary blindness are induced, from which he recovers by clos- ing his eyes for a time, and retiring into the shade. This disease does not appear to be necessarily accompanied by any constitutional symptoms. That such symptoms are occasion- ally present, is evident from the case already quoted, aad that a variety of them may attend, in different instances, will appear ex- tremely probable from a consideration of the remote causes of the disease. Prognosis. The duration of this disease, when left to itself, has been found to vary from one night to nine months. Its gene- ral period of continuance appears to be from two to three months, Mr. Bampfield states * that of more than a hundred cases of idiopathic, and two hundred of symptomatic night-bhndness, which had occurred in his practice, in different parts of the globe, but , chiefly in the East Indies, all perfectly recovered. Hence he in- fers that, under proper treatment, the prognosis may be always fa- vourable. . Europeans who have once been affected with night-blindness, in the East or West Indies, are particularly liable to a recurrence of the disease, so long as they remain in a tropical climate. Those who have suffered from this disease at some previous period, are also apt to be occasionally attacked with dimness of sight for some minutes, or for short periods of some nights, or to merely momenta- ry night-blindness. Proximate Cause. This periodic amaurosis probably depends on some pecuhar state of the choroid, rendering the eye insensible except to light of a certain degree of intensity ; but of the nature of that peculiar state it is impossible for us to form any rational supposition. In some cases, there is reason to suspect that the proximate cause does not affect the eye, but the brain. Remote Causes. 1. Scarpa is of opinion that this disease is most frequently sympathetic of disorder of the stomach. When this is the case, the tongue is foul, the breath foetid, and the appe- , tite deficient. * Medico-Chirurgical Transactions, Vol. v. p. 47. London, 1814. 630 2. Suppressed perspiration, owing to the coldness of the night- air, has been mentioned as a probable cause. 3. Exposure to an unusual glare of light has been known to in- duce night blindness, even in this country: and in w^arra climates, this cause frequently operates in the production of this disease. Insolation, and in particular sleeping with the face or head exposed to the rays of the sun. or to a very strong hght, have been particu- larly mentioned as causes. 4. A residence on lx)ard ship seems of itself to conduce to this disease. 5. Some authors have considered night-blindness as a symptom, or as a precursor of scurvy. Subsistence upon sea-diet perhaps fa- vours the one, as it certainly induces the other. 6. It is a popular notion in the East Indies, that the eating of hot rice brings on this disease. Subjects. Of twelve cases, taken by Mr. Bampfield, as they stood on the list, it was noted that seven had grey eyes, one dark- gre}", one black, three hazel, and one hazel-brown : their hair showed different shades of colour, from light-carroty to black ; their ages varied from twenty to thirty-eight. Treatment. 1. If there are signs of deranged digestion, an emetic is certainly indicated ; after which the bowels are to be cleared out by laxative clysters, and the use of purgatives. 2. A succession of blisters to the temples, of the size of a crown or half-crown piece, applied tolerabl}" close to the external canthus of the eye, has been strongly recommended by Mr. Bampfield. He states that under their application, the retina appears to regain its sensibibilit}', in the same gradual manner as it had been de- prived of it ; that the first blister commonly enables the patient to see dimly by candle-light, or to perceive objects without being able to discriminate what they are ; that in some shght cases, the first bhster effects a cure : that the second blister commonly enables the patient to see distinctly by candle-light, perhaps hy bright moon-light, or even half an hour after sunset, or that the disease intermits for short periods during the night ; and that a perfect recovery is often effected by the second blister. When this does not happen, a third, fourth, or fifth is to be applied ; and if the disease still continues in any considerable degree, a perpetual blis- ter is to be formed on each temple, and maintained till a cure is accomplished, which generally takes place within a fortnight. 3. If ihe night-blindness is attended with symptoms of scuivy, the use of blisters should be deferred, until the scorbutic disposition is corrected, by proper diet and medicines ; not only because well- founded apprehensions ought to be entertained of a scorbutic ulcer forming on the blistered parts, but because the night-blindness is often gradually got the better of, as the cure of the scurvy pro- ceeds. Mr. Bampfield reckons, that about a third of the cases of scorbutic night-blindness resist the antiscorbutic regimen and reme- dies, and require to be treated ultimately as idiopathic cases. 631 4. A shade should be worn over the eyes, both during the treatment and for some time after the cure, to defend them from the painful irritation occasioned by exposure to vivid lights. 5. The eyes ought to be bathed three or four times a-day with cold water. 6. Should the above plan of treatment not prove successful, and if there is no suspicion of the disease being attended with any tendency to sanguineous congestion in the head, cinchona may be tried. 7. Electricity, as a topical stimulus to the eye, has sometimes been employed with success. Also, exposing the eyes to the va- pour of ammonia, every three or four hours. ' 8. In apoplectic cases, general and local depletion will of course take precedence of all other remedies. 9. A residence on shore, and a return to Europe, are to be recommended in obstinate cases on board ship, or in the warm latitudes. These are also often the only means of preventing re- lapses, in those who have already repeatedly suffered from night- blindness. SECTION X. DAY-BLINDNESS. Although day-hlindness is enumerated by all systematic au- thors on the diseases of the eye, very little has been recorded on the subject from actual observation. A merely strumous intole- rance of light, the photophobia of the albino, or that of a person long shut up in the dark, and suddenly brought out into the glare of day, must not be confounded with a periodical amaurosis, the counterpart of that which we have last considered. Day-bhndness is mentioned as a symptom both of mydriasis and myosis. In the former disease, the pupil admits too much light to enable the pa- tient to see till after sunset. In the latter, the contraction of the pupil is supposed to relax in the obscurity of the night, and the vi- sion in this way to improve. On the same principle, the patient affected with incipient cataract sees little during the brightness of the day, but finds his sight in part restored by the dilatation of the pupil, which takes place in the evening. Among the few original observations tending to establish the fact of there being such a disease as a periodic amaurosis, which makes its attack through the day, and departs at night, may be quoted the following from Ramazzini. '•I have repeatedly observed," says he, "among our country peo- ple, and especially in boys, a thing sufficiently strange. In March, about the equinox, boys about ten years of age were affected with a great degree of weakness of sight, so that through the whole day * Hevieralopia of some ; nyctalopia of others. See note at beginning of last sec- tion. 632 diey saw little or nothing, and wandered about the fields like blind people ; but when night came, they saw again distinctly. This affection ceased without any remedy, and by the middle of April, the patients were completely restored to sight. 1 frequently observed the eyes of these boys, and found the pupils much en- larged." * This looks like an endemic or epidemic day-blindness ; but is evidently too vague to furnish grounds for any general conclusions. Baron Larrey has recorded a remarkable case of sporadic day-blind- ness, occuring in an old man. one of the galley-slaves at Brest, who had for thiity-three years been shut up in a subterraneous dungeon. His long residence in darkness had had such an effect on the organs of vision, that he could see only under the shade of night, and was completely blind during the day.t SECTION XI. HEMIOPIA.; This term has been used to signify a partial blindness, obscur- ing about a half of the field of vision. Very frequently it is the right half, or the left half of all objects, which appears dark, and that whether they are regarded with one eye only, or with both. In other cases, only one eye is affected. It is necessary also to ob- serve, that the upper or the lower half of the field of vision may appear dark, or that the patient, looking directly forwards, may see tolerably well within a certain angle, but nothing to either side. These latter varieties of hemiopia are less common than that in which the right or the left half of each retina appears to be insen- sible to light, but are not less worthy of attention. Dr. WoUaston, a few years before his death, was the means of directing considerable attention to this disease, by his paper On Serni-decussation of the Optic Nerves, published in the Philo- sophical Transactions. He had been repeatedly attacked by hemi- opia, had repeatedly met with the disease in others, and was led from the symptoms to adopt a peculiar notion regarding the course and distribution of the optic nerves. " It is now more than twenty years," says he, " since I vras first attacked with the peculiar state of vision, to which I allude, in con- sequence of violent exercise I had taken for two or three hours be- fore. I suddenly found that I could see but half the face of a man whom I met ; and it w^as the same with respect to every object I looked at. In attempting to read the name John.son, over a door, I saw oxAy son : the commencement of the name being wholly obliterated to my view. In this instance the loss of sight was toward my left, and was the same whether I looked with the right eye or the left. This bUndness was not so complete as + De Morbis Artificum, cap. xxxviii. Opera, p. 363. Londini, 1718. t Memoires de Chivurgie Militairc, Tome i. p. G. Paris, 1812. t Half -vision , from rifxio-u; half, and o-liq vision. Vu9us diviidiaiiis. 633 to amount to absolute blackness, but was a shaded darkness with- out definite outline. The complaint was of short duration, and in about a quarter of an hour might be said to be wholly gone, hav- ing receded with a gradual motion from the centre of vision ob- liquely upwards towards the left. " Since this defect arose from over-fatigue, a cause common to ^ many other nervous affections, I saw no reason to apprehend any return of it, and it passed away without any need of remedy, with- out any farther explanation, and without my drawing any useful inference from it. " It is now about fifteen months since a similar affection occurred again to myself, without my being able to assign any cause what- ever, or to connect it with any previous or subsequent indisposition. The blindness was first observed, as before, in looking at the face of a person I met, whose left eye was to my sight obliterated. My blindness was in this instance the reverse of the former, being to my right (instead of the left) of the spot to which my eyes were directed ; so that I have no reason to suppose it in any manner connected with the former affection. " The new punctum caecum was situated alike in both eyes, and at an angle of about three degrees from the centre ; for when any object was viewed at the distance of about five yards, the point not seen was about ten inches distant from the point actually looked at. " On this occasion the affection, after having lasted with little alteration for about twenty minutes, was removed suddenly and entirely by the excitement of agreeable news respecting the safe arrival of a friend from a very hazardous enterprise." * In consequence of reflecting on these attacks of hemiopia, Dr. WoUaston was led to the following hypothesis regarding the ar- rangement of the optic nerves. " Since the corresponding points of the two eyes," says he, " sympathise in disease, their sympathy is evidently from structure, not from mere habit of feehng together, as might be inferred, if reference were had to the reception of ordinary impressions alone. Any two corresponding points must be supplied with a pair of fila- ments from the same nerve, and the seat of a disease in which sim- ilar parts of both eyes are affected, must be considered as situated at a distance from the eyes at some place in the course of the nerves where these filaments are still united, and probably in one or the other thalamus nervorum opticorum. " It is plain that the cord, which comes finally to either eye un- der the name of optic nerve, must be regaided as consisting of two portions, one half from the right thalamus, and the other from the left thalamus nervorum opticorura.t * Philosophical Transactions for 1824. Part i. p. 224. 1- The origin of the optic nerve is now generally acknowledged to be, not in the parts called thalami nervorum opticorum, as Dr. WoUaston appears to have believed,, but in the anterior pair of the corpora quadrigemina, parts analogous to the optic tobes of birds and reptiles. SO 634 "According to this supposition, decussation ^vill take place only between the adjacent halves of the two nerves. That portion of nerve which proceeds from the right thalamus to the right side of the right eye, passes to its destination without interference ; and in a similar manner the left thalamus will supply the left side of the left eye with one part of its fibres, while i he remaining halves of both nerves in passing over to the eyes of the opposite sides must intersect each other, either with or without intermixture of their fibres. " Now, if we consider rightly the facts discovered by comparative anatomy in fishes, we shall find that the crossing of the entire nerves in them to the opposite eyes, is in perfect conformity to this view of the arrangement of the human optic nerves. The relative position of the eyes to each other in the sturgeon, is so exactly back to back, on opposite sides of the head, that they can hardly see the same object, they can have no points which generally receive the same impressions as in us ; there are no corresponding points of vision requiring to be supplied with fibres from the same nerve. The eye which sees to the left has its retina solely upon its right side ; and this is supplied with an optic nerve arising wholly from the right thalamus : while the left thalamus sends its fibres entirely to the left side of the right eye for the perception of objects situated on the right. In this animal an injury to the left thalamus might be expected to occasion entire blindness of the right eye alone, and want of perception of objects placed on that side. In ourselves, a similar iniury to the left thalamus would occasion blindness (as be- fore) to all objects situated to our right, owing to insensibility of the left half of the retina of both eyes." Having thus explained his hypothesis. Dr. Wollaston goes on to relate the following additional instance of hemiopia. "A disorder/' says he, "that has occurred within my own knowledge in the case of a friend, seems fully to confirm this rea- soning, as far as a single instance can be depended upon. After he had suffered severe pain in his head for some days, about the left teinple. and toward the back of the left eye, his vision became considerably impaired, attended with other symptoms indicating a shght compression on the brain. " It was noi till after the lapse of three or four weeks that I saw him, and found that, in addition to other affections which need not here be enumerated, he laboured under a defect of sight similar to those which had happened to myself, but more extensive, and it has unfortunately been far more permanent. In this case the bhndness was at that time, and still is, entire, with reference to all objects situated to the right of his centre of view. Fortunately, the field of his vision is sufficient for writing perfectly. He sees what he writes, and the pen with which he writes, but not the hand that moves the pen. This affection is, as far as can be ob- served, the same in both eyes, and consists in an insensibihty of 635 the retina on the left side of each eye. It seems most probable, that some effusion took place at the time of the original pain on that side of the head, and has left a permanent compression on the left thalamus. This partial bhndness has now lasted so long with- out sensible amendment, as to make it very doubtful when ray friend may recover the complete perception of objects of that side of him." Towajds the conclusion of his paper, Dr. Wollaston adds the following notice of another case of this disease. " One of my friends," sa3's he, " has been habitually subject to it for sixteen or seventeen years, whenever his stomach is in any considerable degree deranged. In him the blindness has been in- variably to his right of the centre of vision, and, from want of due consideration, had been considered as temporary insensibility of the right eye ; but he is now satisfied that this is not really the case, but that both eyes have been similarly affected with half-blindness. This symptom of his indigestion usually lasts about a quarter of an hour or twenty minutes, and then subsides, without leaving any permanent imperfection of sight." Dr. Wollaston died about four years after the publication of the paper, from which these extracts have been taken. Whether he had any third attack of hemiopia, I know not ; but in the account which has been published of the appearances observed on inspecting his body, we find it stated, that the optic thalamus of the right side was of an unusually large size, and that on making a section of it, with the exception of a layer of medullary substance on its upper part, httle or no vestige of its natural substance was perceptible. It had been converted into a tumour, as large as a middle-sized hen's egg, towards the circumference of a greyish colour, and harder than the brain itself, somewhat of a caseous consistence, but in the centre of a brown colour, soft, and in a half-dissolved state. This diseased structure was not confined to the thalamus, but extended to the neighbouring portion of the corpus striatum. The right optic nerve, where it passes on the outside of the thalamus, was of a brown colour, n)ore expanded, and softer than natural.* The reader will readily perceive, that between this state of the brain and the previous symptoms of hemiopia, there may or may not have been a connexion ; for there were two distinct attacks of the disease, at the interval of twenty years, each attack subsiding entirely after fifteen or twenty minutes, in the first attack objects to the left appearing dark, and in the second those to the right. We know that morbid alterations in the substance of the brain sometimes produce periodic diseases ; and that certain additional causes of excitement operating upon an unsound brain, will cause one or other of the functions of that organ to be for a time impeded, till the new cause ceases to operate, when the individual immediate ly returns to his former state of apparent health. * London Medical Gazette, Vol. iii. p. 293. London, 1829. 636 The following remarks have occurred to me, in reflecting on Dr. WoUaston's paper. 1. The notion of a semi-decussation of the optic nerves had not merely been entertained by several distinguished authors,* before Dr. WoUaston, but had in some measure been demonstrated by dissection.t The idea, however, that the two portions, of which each optic nerve may be regarded as consisting, remain distinct, even after they form the retina, is new, and probably without foun- dation. Dr. WoUaston appears to have overlooked the fact, that as the optic nerves pass through the sclerotica and choroid considerably nearer the middle line of the body than the centre of the globe of each eye, the two optic axes, which, if any two points deserve to be considered as such, are surely corresponding points, will not be formed by filaments from the same nerve, but from opposite nerves. It has always occurred to me as more probable, that the two portions, of which each optic nerve consists, mingle in the fibres, and then ex- pand into the retina, so that the membrane in each eye should be regarded as a plexus, every point of which contains fibres derived from each side of the brain. 2. It is not, however, by mere reasoning upon a subject Uke this, that we can arrive at any sound conclusion. By far the greater part of the mass of facts, in pathological and in what may be called ex- perimental anatomy, touching this question, go to prove, that inju- ries and diseases affecting one side of the brain, instead of hemiopia in both eyes, produce amaurosis only in the opposite eye.l The fact, also, which has been already mentioned in the beginning of this section, that we meet with a horizontal as well as a perpen- dicular hemiopia, appears scarcely reconcileable to the hypothesis of Dr. WoUaston. Not so, however, that other variety of the dis- ease, in which objects to each hand appear dark, and those only which are placed in front are seen distinctly : for were any tumour or excrescence to press on the optic nerves immediately anteriorly to their union, the effect would be, according to the hypothesis of i^emi-decussation, to paralyse the inner half only of each letina. Treatment. Hemiopia being merely a peculiar variety of amaurosis, must be treated on similar principles. The patient's constitution, whether plethoric or debilitated, the state of his diges- tive organs, the presence or absence of cerebral symptoms, as head- ach, vertigo, &.c. must be taken into account, and guide us in the choice of remedies. § * Vater, Ackermann, Vicq-d'Azyr, Caldani, Cuvier, &c. t Josephus et Carolus "Wenzel de Penitiori Structura Gerebri, pp. 109, 233. Tu- bingae, 1812, t Serres, Anatomic Comparee du Cerveau, Tome i. p. 331. Paris, 1827. § On the subject of hemiopia, the reader may consult — Arago, Annates de Chimie, Tome xxvii. p. 109.— Crawford, Medical and Physical Journal, Vol. liii. p. 48. — Pravaz, Archives Generales de Medecine, Tome viii. p. 59 ; Tome ix. p. 485. 637 SECTION XII. AMBLYOPIA,* OR WEAKNESS OF SIGHT. To some it may appear improper, to say any thing under tliis head, as it is well known that there is no specific disease to which the name amblyopia ought to be appropriated, and that v)eakness of sight is a complaint symptomatic of many and very different kinds of disease. The oculist will find, that many of those cases which come before him under the name of weakness of sight, have existed for a long period, and withstood a variety of remedies, be- cause they have never been carefully investigated, nor accurately discriminated. Lingering ophthalmia, perhaps catarrhal, perhaps strumous, chronic iritis or retinitis, photophobia, nebulous cornea, incipient cataract, ophtlialmia tarsi, epiphora from disordered sto- mach, slight blenorrhoea of the lachrymal passages, an inverted eyelash, myopia, presbyopia, photopsia, muscse voUtantes, incipient amaurosis, and many other affections of the organ of vision, from carelessness, or ignorance, are often set down as weaktiess of sight. Nay, treatises have been written on weakness of sight, and the proximate cause of what is merely a symptom of many and various diseases has been gravely investigated ; modes of treatment have been proposed for weakness of sight, and empirical cures, equally surprising to the patient and the practitioner, have sometimes been accomphshed. CHAPTER XIX. AMAUROSIS.t SECTION I. GENERAL ACCOUNT OF AMAUROSIS. I. Definitio7i. By amaurosis is meant an obscurity of vision, arising from a more or less insensible state of one or more of the nervous parts, which assist in forming the optic apparatus. If the retina be incapable of receiving with correctness, impressions of external objects through the medium of light, if the oplic nerve be unable to convey to the sensorium the impressions made upon the retina, or if the sensorium be incapable of receiving the impressions conveyed by the optic nerve, the individual must necessarily be affected with a greater or less obscurity in vision, or suffer a total deprivation of vision, according to the degree of inability in these several parts to execute their functions. Even when he goes no * From 'etf^^Kv; dull, and a>^ the eye. The term appears to be employed by Hip- pocrates, to signify impaired vision, unattended by any appearance of opacity in the eye. T From ctfAsugog, obscure. Gutta serena of the Arabians. Der schwarze Staar of the Germans. ' 638 farthei' thaa this, the pathologist must see the necessity of distia- guishing different cases of amaurosis, according as the retina, the optic nerve, or the brain, is the part first and principally affected. II. Seat. In order to prevent, if possible, our falling into false notions regarding the seat of amaurosis, it may be proper to recall to mind the following anatomical and physiological facts. 1. The optic nerves originate, a little behind the middle of the cer- ebral mass, from the anterior pair of the corpora quadrigemina ; and are, therefore, in communication with the posterior part of the medulla oblongata. The broad shp of medullary substance by which the nerve seems on each side to commence, turns round upon the outer edge of the mass commonly called the thalamus, crosses the crus cerebri, attaches itself to the middle and anterior lobes of the cerebrum, forms an intimate connexion with the tuber cinereum, and continues its course till it meets its fellow-nerve of the opposite side. 2. Numerous cases on record, in wliich atroph)^ of one of the optic nerves has been traced from a diseased eye to the opposite side of the brain, fully establish the fact of at least a partial de- cussation of the optic nerves. The outermost fibres of each nerve appear to continue their course toward the orbits without decussa- ting ; probably the innermost fibres pass from the one side to the other. 3. There is no proportion, and but slight connexion, between the optic thalami and the nerves of vision. In the horse, ox, sheep, &c. the optic nerves are as large as in man, but the thalami in man are much larger than in those animals. On examining the structure of tlie thalamus, it is found that a mere superficial layer of it is attached to the optic nerve, and that the whole of its interior fibres diverge backwards into the cerebral convolutions. When the optic nerve is affected with atrophy, the corresponding thalamus is diminished only in as far as the nerve itself has shrunk ; the interior of the thalamus suffers no change, but the atrophic state of the nerve may be traced back to the corpora quad- rigemina. Dr. Spurzheim tells us, that he once found in the brain of a woman who had died insane, the thalamus of the left side half converted into pus, the corpus striatum of the same side much shrunk, but the optic nerve healthy, and resembling in all respects its fellow of the opposite side, in the vicinity of which no organic change could be detected. The anterior pair of quadrige- minal bodies were also in their natural state.* 4. Each retina is probably a plexus, derived nearly equally from the two optic nerves. But besides these, there is reason to beUeve that the retina is in communication with other nerves ; that it influences them, and, on the other hand, is under their in- fluence. If we trace the great sympathetic nerv^e upwards from * Anatomy of the Brain, p. 80. London, 1826. 639 the first cervical ganglion, we find that its branches, the principal of which are two in number, surround the internal carotid artery, and pass with it into the carotid canal of the temporal bone. Within the cavernous sinus, the great sympathetic forms a gan- glion, whence are derived branches which communicate with the nerves of the sixth pair, third pair, and first division of the fifth pair. One or more branches of the cavernous ganglion communi- cate directly with the lenticular ganghon. The internal carotid artery, as it mounts into the cranium, is still surrounded by branches of the great sympathetic nerve, which cling to it, and may be traced along all its ramifications. The ophthalmic artery, with the rest, is invested with a plexus from this nerve, and in this way the arte- ries of the choroid, iris, and retina, are supplied with its influence. From the lenticular ganglion arise the nerves of the iris, and one anatomist* supposes that he has traced branches from the ciliary or iridal nerves, where they lie between the sclerotica and choroid, which penetrate the latter membrane, and run backwards into the retina. 5. If, in birds, we wound one of the optic lobes, parts analo- gous to the anterior corpora quadrigemina of n)ammiferous ani- mals, the vision of the opposite eye becomes weak or extinct ; and if, after a time, the same experiment is performed on the other side of the brain, the eye which formerly continued sound, becomes bhnd.t 6. If the optic nerve is divided in any animal, anteriorly to the decussation of the two nerves, the pupil of the eye on the same side becomes very large and motionless, and the power of vision of that eye is immediately abolished. Every trace of sensibility to light is lost, so that even on concentrating the light of the sun by means of a lens, and directing it into the pupil, not the least appearance of sensation is produced. 7. It is generally acknowledged, that the fifth pair of nerves communicate common sensibility to the parts to which they are distributed ; but over the eye, they certainly exercise a very remark- able, and at present, inexplicable influence. If the trunk of the fifth pair of nerves is divided in rabbits, guinea pigs, dogs, or cats, besides other effects, which show the great influence of the fifth pair over the nutrition of the eye, there are immediately produced fixed contracted pupil in the first two animals, fixed expanded pu- pil in the last two, and blindness, almost as complete as when the optic nerve is divided, in all. In the rabbit, it is believed, that the ciliary or iridal nerves are derived solely from the third pair, and that they do not form any lenticular ganglion ; in the cat, there is a lenticular ganghon, as in man, formed partly by the third, * Ribes, Memoires de la Societe Medicate d'EmuIation, Tome vii. p. 99. Paris 1811. t Magendie, Journal de Physiologie, Tome iii. p. 376. Paris, 1823. Series, Anatomie Comparee du Cerveau, Tome L p. 331. Paris, 1827. 640 and partly by the fifth pair. It scarcely admits of a doubt, that the integrity of the fifth pair is a necessary condition for the action of the retina as a sentient organ.* 8. If the trunk of the third pair be divided within the cranium of a pigeon, the pupil dilates, and cannot be made to contract by exposure to intense Mght. The section of the fifth pair in the same animal produces no change in the alternate motions of the iris. In birds, the third pair supplies the whole of the nerves of the iris. When the optic nerves are pinched within the cranium of a pigeon, the pupils contract. The same result follows a similar irritation of the third pair, but not that of the fifth. When the optic nerves have been divided within the cranium of a pigeon, if the portion of the nerves attached to the eyes be pinched, no contraction of the pupil ensues ; but if the portion adhering to the brain be pinched, a hke contraction of the pupil ensues as if the optic nerves had not been divided. If the third pair has been divided, no change in the pupil ensues on irritating the entire or divided optic nerves. From these facts, it may fairly be concluded, that in the habitual varia- tions of the pupil, an impression is conveyed along the optic nerve to the brain, which is followed by an affection of the third pair, causing the pupil to contract or dilate.t 9. If the great sympathetic be divided on one side of the neck of a dog, the pupil becomes fixed and contracted, and the nutrition of the eye is interrupted. If the experiment be performed on both sides, the pupils become fixed and dilated. Petit considers these different effects as analogous to w4iat takes place in amaurosis ; for if one eye only be amaurotic, the pupil of that eye does not, in general, become dilated : but if both eyes be blind, both pupils dilate.t From these anatomical and physiological facts, I do not mean, for the present, to draw any farther conclusions than these, that any strict inquiry into the seat of the different varieties of amaurosis, will necessarily embrace a field of considerable extent, and that we need not be surprised to meet, in the course of such inquiry, with many facts, which ma}^ appear not only inexplicable, but even con- tradictory. Our knowledge of the connexions and operations of the nervous system is only in its infancy; and we must beware, therefore, equally of the tendency of those, who would venture, upon the faith of a few defective data, to explain every thing in nervous diseases, and of those, who, shrinking themselves from the task of endeavouring to unravel a series of phenomena of multiplied diversity, and no little intricacy, would affect to despise the merito- rious, though imperfect labours of our predecessors. * Magendie, Journal de Physiologic, Tome iv. pp. 176, 302. Paris, 1824. Des- moulins, Anatomie des Systemes Nevveux, Tome ii. p. 712. Paris, 1825. t Mayo's Anatomical and Physiological Commentaries. No. ii. p. 4. London, 1823. F > t Memoires de I'Academie Royale des Sciences, 1727, p. 1. Amsterdam, 1732. 641 III. Causes. Very different efficient causes have been found to operate in the production of amaurosis. In some cases, the cause has been found to be of a local, direct^ and mechanical nature ; such as the pressure of a tumour on the optic nerve. In other cases, it has been of a local, but vital kind ; such as a ple- thoric or congested state of the blood-vessels of the brain or of the eye. In a third set of cases, the cause has been general or con- stitutional ; such as exhaustion, consequent to profuse or continued loss of some of the fluids of the body. The proximate cause of amaurosis is evidently, in by far the greater number of cases, pressure. The pressure oif an exostosis, or other tumour, or of gorged blood-vessels, upon the optic appara- tus, is an idea with which we are familiar, and regarding the reality of which, medical practitioners, in general, feel no hesita- tion ; but even when amaurosis is the result of inflammation, it can scarcely be doubted, that the brain suffers a certain kind of pressure, which renders it incapable of fulfilling its proper functions. One author, however, of high name, has promulgated a somewhat different view of the proximate cause of those diseases, which are generally attributed to compression of the brain. That we have no more right to believe that the substance of the brain admits of being compressed than that water is compressible, appears to be the opinion of Mr. C. Bell, who maintains, that what is called com- pression of the brain, operates not on the substance of the brain itself, but simply by preventing that due supply of arterial blood, which is necessary for the performance of the cerebral functions. I need scarcely mention, that amaurosis always results from an organic cause. The notion of such a thing as a functional am- aurosis appears to have arisen from the facts, that this disease is sometimes sympathetic, or arises in consequence of derangement of some remote organ, and that it is occasionally sudden in its at- tack, or, on the other hand, instantaneous in its departure. It cannot, however, admit of doubt for a moment, that even in cases of sympathetic amaurosis, the loss of sight must depend on some organic change in the optic apparatus. Take, for example, the amaurosis which arises from the presence of worms in the bowels. This result is only occasional ; the brain, of perhaps not more than one out of a hundred affected with worms, is so susceptible of dis- ease, that the irritation communicated to it, from the bowels, through the great sympathetic nerve, is sufficient to excite it to that morbid condition, which causes dilatation of the pupils and loss of vision ; but that the amaurosis, in these cases, is the consequence of any thing else than a certain morbid condition of the optic ap- paratus, is a proposition which scarcely deserves a serious refutation. Neither can it be admitted, when amaurosis occurs suddenly, as a disease of relation, that it is independent of organic derangement " in the optic apparatus, however indubitable it may be that the first link in the chain of causes has existed in some remote part of the 81 642 body. Dr. Abercrombie* mentions the case of a gentleman who after an apoplectic attack lost his sight, and continued in a state of perfect blindness for about seven years. After that time, while one day out in his carriage, he suddenly recovered sight. Such an occurrence as this is more favourable to the notion in question, than perhaps any other which could be adduced ; and yet the only ra- tional conclusion which can be drawn from it is evidently this, that cases of amaurosis, even of long standing, may sometimes depend on cerebral derangements, capable of being entirely and instantane- ously removed. Remote causes. Amaurosis springs from a great variety of pre- disposing and exciting causes. 1. We meet with instances of a hereditary predisposition to this disease ; so that several members of the same family, or of succes- sive families, lose their sight, about the same period of life. Beer knew several families who had a hereditary tendency to amaurosis. In one of them, all the females, even to the third generation, who had not born children, became blind, when they ceased to menstru- ate. The males of this family, who as well as the females, had dark-brown eyes, also shewed a decided tendency to this disease, although none of them lost their sight.t 2. Over-exertion of the sight, exposure of it to bright light, occu- pation of it upon minute objects, and employment of the eyes dur- ing the hours which ought to be devoted to sleep, form a set of causes which are extremely productive of amaurosis. In many in- stances, a single imprudent exposure of the eye to the operation of some such cause as those now mentioned, has been sufficient to extinguish the sensibility of the retina ; but, in general, it is from long-continued over-exciteraeut of the organs of vision, that they begin to fail, and at last become totally unable to continue their office. 3. A third set of predisposing and exciting causes are such, as promote a tendency to sanguineous congestion, or serous effusion, in the head ; such as insolation, rage, forced exertions of the body, occupations which require continued stooping, errors in diet, and especially the abuse of wine and spirits, retrocession of eruptive dis- eases, suppiessed discharges, interruption or entire cessation of the menses, and slowness of the bowels. 4. The operation of poisonous substances sometimes produces a sudden attack of amaurosis. Belladonna, stramonium, and some other narcotics, in any considerable dose, are almost immediately followed by this effect. Other poisonous substances, applied to the body, in small quantities every day, or several times every day, are probably productive of a sin)ilar effect, only (hat they operate more slowly. I am inclined particularly to signalize tobacco as a * Pathological and Practical Researches on Diseases of the Brain, p. 309. Ed- inburgh, 1829. t Lehre von den Augenkranheiten, Vol. ij. p. 443. Wien, 1817. 643 poison of this sort ; but many others have been accused of an insidious operation on the nervous system, terminating in blind- ness. 5. Gastric and intestinal irritation, acute or chronic, is in many instances the forerunner of amaurosis, and evidently operates as its exciting cause. 6. Exhaustion of the body, such as that which arises from chronic diarrhoea, excessive venery, long-continued grief, prolonged suckling, typhus fever, and the like, is a frequent cause of amauro- sis. 7. Blows on the head, injuries of the branches of the fifth pair of nerves, and even mere irritation of this nerve, have sometimes proved the remote causes of amaurosis. 8. Those who have suffered from strumous ophthalmia in childhood are very liable to become amaurotic, after they begin to use their eyes in earnest, and especially if they are exposed to one or more of the unfavourable influences just now enumerated. Complication of causes. If we investigate with care the his- tory of those cases of amaurosis which come before us, we shall find that this disease can rarely be attributed to the influence of any single remote cause; but that most frequently a number of circum- stances, favourable to the rise and progress of an amaurotic affec- tion, have for a length of time been acting on the individual. It is chiefly this combination of causes, which at once renders it so dif- ficult to discriminate with correctness between the different species of amaurosis, to classify them, and, in many cases, to decide on a proper line of treatment, and which but too often serves also to frus- trate the cure, even when tht; remedies aie judiciously selected, and carefully applied. IV. Symptoms. The symptoms of amaurosis naturally arrange themselves into two classes ; the objective and the subjective. The former class includes those which the observer discovers in the form, colour, texture, consistency, vascularity, and mobility of the different parts of the organ of vision, or in the general health of the patient ; the latter, those which the patient himself expe- riences, and which must be admitted very much upon his own testimony, as impaired and deranged vision, headach, giddiness, &,c. In general, it is advisable in examining any case of amauro- sis, first to attend to the objective, and then to the subjective symp- toms. Each eye ought also to be inspected separately, and with the other excluded from the light. Even in the history of his loss of vision, we ought to confine the patient to one eye at a time, unless both appear to have become affected at the same period, and from the same cause. /. Objective symptoms. I. The first symptom, which, in gen- eral, attracts the attention of an experienced observer, is the gait, and cast of eye, of the amaurotic patient. He advances towards us with an air of uncertainty in his movements, from which the 644 cataractous patient is in a great measure or altogether exempt, and instead of converging his eyes in the natural way towards an object, it is evident that there is something staring and unmeaning in his look. This latter symptom, which Richter * appears to confound with squinting, may exist, indeed, only in a very shght degree. It is, however, as that author well observes, the only ob- jective sign of amaurosis, which never fails to be present, a fact peculiarly valuable, in cases where we have reason to suspect sim- ulation on the part of the patient. In some cases of amaurosis, there is not merely the want of control, of which we are now speaking, and which is the evident consequence of want of sensa- tion, but there is actual strabismus, in many oscillation, and in some the eyes stand completely fixed in the head. The motions of the lids, also, as well as those of the eyes, are not unfrequently impeded ; in some, the levator of the upper lid being partially or completely palsied, and in others, the orbicularis palpebrarum, according as the motor ocuh, or the facial nerve is prevented from communicating their natural degree of influence to the muscles which they supply. 2. Besides the movements of the eyes, their prominence, colour, consistence, and form, deserve attention. We often observe them unnaturally prominent, or the one more prominent than the other ; their colour is seldom that of the healthy eye, the sclerotica being fi-euqently of a yellowish hue, sometimes blueish or ash-coloured, and often covered with varicose vessels; while there are few symptoms of amaurosis so certain as a change in the consistence of the eyeball, it being either considerably firmer to the touch, or greatly softer than natural. In some instances, we find the eye flattened on one or several of its sides. 3. Sluggish and limited motion of the pupil, or entire loss of motion, often attended with dilatation, sometimes with contraction of that aperture, forms one of the most remarkable symptoms of amaurosis. Widely dilated fixed pupil is generally regarded as a sign of pressure on the brain. For example, it almost always at- tends hydrocephalus, and fractured cranium with depression ; but that this state of the pupil is not always connected with pressure on the brain, nor even with any cerebral disease, is evident from the fact, that it is sometimes induced simply by a blow on the eye. The early and incomplete stages of amaurosis are rarely accom- panied by widely dilated pupil ; but after the perception of light is altogether extinct, this opening is generally found expanded, and quite motionless. There are two facts regarding the motions of the pupil in cer- tain amaurotic cases, which have attracted much attention. The first is, that the pupil of a completely amaurotic eye will often move briskly, according to the degee of light acting on the opposite • AnfangsgrUnde der Wundarzneykunst. Vol. iii. p. 423. Gottingen, 1804. 645 or sound eye, while, if we expose the amaurotic eye by itself, its pupil remains perfectly motionless, and much dilated. The second fact, and one accounted still more extraordinary, is that in some cases, where the patient is totally blind, both pupils, according to the intensity of light to which the eyes are exposed, vary in diam- eter exactly as in health.* The latter of these facts has hitherto received no probable ex- planation ; for the idea t of the iris acting in such cases, by a sym- pathy with the retina, independent of the brain, is altogether con- trary to the physiology of the iris, as founded on experiment. It appears to be absolutely necessary for the motions of that mem- brane, not only that the retina and the iridal nerves shall be sound, but that a certain degree of communication of both shall be kept up with the brain. It becomes, then, a question, whether the brain may not be so affected with disease, as to be incapable of acting as the organ of visual perception, and yet retain the power of communicating to the third pair the impulse necessary for the usual motions of the pupil. Now, if we suppose that the function of vision is accom- plished only where the optic nerves reach the corpora quadrigemina, and thus communicate with the posterior part of the medulla ob- longata, but that the association which undoubtedly exists between the optic nerves and the third pair, is accomplished farther forward on the basis of the brain, we shall be able to afford, at least, a plausi- ble explanation of the fact in question. The third pair makes its appearance immediately behind the tuber cinereum, a part of the brain with which the optic nerves have a manifest connexion. The third pair does not, indeed, appear to take its origin from the tuber cinereum, but from the central cineritious substance of the crura cerebri, bearing an analogy, along with the fourth, sixth, seventh, and ninth pairs, and the portion of the fifth pair which escapes the Gasserian ganglion, to the anterior roots of the spinal nerves ; but it is surely not an improbable supposition, that the optic nerve, either where it crosses the crus cerebri, or, more proba- bly, where it communicates with the tuber cinereum, forms that link of connexion with the third pair, which it is universally ac- knowledged to do in some part or other of its course. A disease, then, affecting the corpora quadrigemina, or, in other words, the origin of the optic nerves, on affecting any part between the corpora quadrigemina, and the communication between the optic nerves and the third pair, wherever that communication is affected, will, according to this view of the subject, produce blindness, but may leave unimpaired the influence of the optic nerves upon the third pair ; while, on the other hand, the cases of fixed and dilated pu- pils, in amaurosis, are probably owing, either to more extensive disease, or to disease so situated as to affect that part of the brain * Janin, Memoires et Observations sur I'CEil, p. 426. Lyon, 1772. t Travers's Synopsis of the Diseases of the Eye, p. 188. London, 1820. 646 where the optic nerves communicate their influence to the third pair. This conjecture receives no inconsiderable support from a case, shortly recorded by Mr. Travers, of circumscribed tumour compressing the left optic nerve, immediately behind the ganglion opticum, by which 1 suppose he means the thalamus. In that case the blindness was complete, but the iris was active.* If the above be the true explanation of that activity of the pupils, which sometimes exists in cases of total blindness, it will also serve to account for the motions of the iris of an amaurotic eye, when exposed along with the opposite sound eye, to various gradations of light. The right eye, we shall say, is healthy, but the left, on account of some morbid change in the retina, or in that portion of its nerve which extends from the retina to the point of union of the optic nerves, is blind. Still the right optic nerve, dividing at the point of decussation into two portions, one to the right and the other to the left side of the brain, is in communication with both nerves of the third pair, so that although the pupil of the diseased eye becomes expanded and fixed when the sound eye is kept shut, it instantly contracts when this eye is exposed to light, and so long as this is the case, performs exactly the same motions. This view of the matter appears to be confirmed by what 1 lately observed in a patient at the Eye Infirmary, in whom the retina, in consequence of an injury of the eye received some years before, was thickened, opaque, and separated from its natural adhesion to the choroid. The lens lay in the anterior chamber, and was removed by extrac- tion, but the eye remained perfectly insensible to light. When the diseased eye was separately exposed to light, its pupil stood fixed and dilated ; but when both were exposed, the pupil of the am- aurotic eye moved briskly. We had no reason to believe that, in this case, there was any other part diseased but the retina. Besides the motions of the iris, which of course must be exam- ined, as has been already mentioned, in each eye separately, and with the opposite eye excluded from light, there are various other particulars respecting the iris, wdiich deserve attention ; especially, the form and situation of the pupil, and the inclination of the iris, for sometimes the pupil is very irregularly dilated, at other times it has evidently shifted from its natural place towards one or other part of the circumference of the iris, while this membrane itself is in some cases observed to be bulging towards the cornea, and in others to have sunk back, so as to present anteriorly a concave or funnel-like form. 4. A point of great importance in every case of amaurosis is the appearance of the humours. In some instances, when, for exam- ple, the disease is hydrocephalic, and occurs in a young subject, the pupil presents its natural black hue, but in elderly subjects, it is rarely the case that some degree of glaucoma does not accora- * Travers's Synopsis of the Diseases of the Eye, p. 188. Lond. 1820. 647 pany amaurosis. Such a complication must, of course, render the prognosis more vmfavourable ; although, at the same time, it must be confessed, that some of the most hopeless cases of amaurosis are attended with a perfectly healthy state of the humours. 5. It is proper to observe, whether there be any cicatrices about the face or head of amaurotic patients, marking the previous occur- rence of such injuries as may either have affected the branches of the fifth pair distributed externally, and through them the optic apparatus within the cranium, or more directly have induced cere- bral effusions, or morbid formations.* 6. The general aspect and bodily constitution must be regarded with attention. We find all sorts of persons amongst the amau- rotic ; from him whose vessels seem on the point of bursting with plethora, and who has long revelled in the solid luxuries of the table, down to the emaciated victim of famine and habitual intoxi- cation ; all ages, all ranks, and professions; and not unfrequently it happens, that by directing our attention to the history of the in- dividual's previous mode of life, his pursuits, and his habits, we are enabled to detect the circumstances which have been the ex- citing causes of his complaint, and by the careful avoidance of which, for the future, the cure may be greatly promoted. //. Subjective symptoms. 1. The most important of these is impaired vision. The progress of this symptom, and the degree it attains, vary in different cases ; for in some instances the patient becomes suddenly and permanently bhnd, while, in others, the sight fails gradually during months or years, without ever termi- nating in total loss of sight. Hence the distinctions of sudden and slow, complete and incomplete amaurosis. In the commencement of this disease, it often happens that the failure of sight is observed only occasionally, occurring, perhaps, but seldom, and only for a short time,t assuming the form of night- blindness or of day-blindness, or coming on regularly after any continued exertion of the eyes in the perception of minute or lu- minous objects. Many an amaurotic patient can read with ease a few lines of a printed book, after which the letters appear so con- fused, and the effort to see them is so painful, that he is obliged to desist. Sudden and temporary attacks of blindness are often connected with gastric derangement, and are entirely removed by correcting the state of the digestive organs ; but it must also be confessed, that such transient attacks are sometimes the effect of incipient diseases in the brain, of the most formidable kind. The failure of sight, in some cases, extends to the whole field of view, and in others is only partial. On attempting to read, for example, more or less of the page appears indistinct. Perhaps the patient loses sight of a word only here and there,* or he sees only one-half of the page, while the other half is as if hid from his * See pages 3 and 103. t Amaurosis vaga. t Visus interruptus. 64S view.* It not unfrequently happens that an amaurotic eye will still discern certain objects, if they are placed in one particular di- rection ; t but if by the slightest movement of the eye or head, the person once loses sight of the object, he finds that he cannot easily recover the same point of vision. Some amaurotic patients see all objects disfigured, crooked, mutilated, lengthened or shortened, and, it is said, even inverted.^ The flame of a candle sometimes appears very long to such patients, and as if separated into several portions ; a symptom, which Beer considered indicative of disease within the cranium. The failure of sight in amaurosis occasionally assumes some- what of a myopic or a presbyopic form. I have known a con- firmed amaurotic patient see large objects with considerable dis- tinctness, through a double concave glass of 12 inches focus ; and another, who totally bhnd in the right eye, and with the left fast hastening to the same state, could still with the latter read an or- dinary type, by the aid of a double convex glass of 7 inches focus. 2. Intimately connected with the failure of sight in amaurosis, are the various false impressions of which the patients complain ; for although some maintain, that they have no sensation of any thing intervening between them and objects, and are not distressed by any sort of spectra, yet, in general, amaurosis is more or less attended by the disorders described in the preceding chapter under the heads of photopsia, onusccB volitantes, chriipsia, and acci- dental colours. Photopsia, in particular, is apt to occur at the commencement of this disease in plethoric individuals, and muscse volitantes in dyspeptic subjects. Double vision is a very common symptom. As the disease advances, the field of vision seems to become obscured by a universal cloud, § or net work, II the latter generally appearing grey or black, especially in a good light, or over any white substance, but sometimes becoming luminous in the dark, and assuming a blueish white cdour, like silver, or red- dish yellow, like gold. 3. The feehngs of the patient with regard to hght deserve at- tention ; for sometimes the early stages of amaurosis are accompa- nied by an unwonted sensibility to light, and even pain on expo- sure to its influence, while, in other cases, there are from the very beginning, a diminished sensibility of the retina, and a constant desire on the part of the patient for a more copious illumination of all objects — a thirst for light, as it has been sometimes called. 4. An unwonted dryness of the eyes and nostrils is by no means an uncommon symptom in amaurosis ; and it is observed, that, in general, great benefit is obtained, in such cases, if a restoration is once obtained of the secretions of the lachrymal gland, conjunctiva, and Schneiderian membrane. * Hemiopia. t Visus obliquus. t Visus defiguratus. § Visus nebulosus. II Visus reticulatus. 649 5. Pain in the eyes, and still more frequently in the head and face, forms one of the most important symptoms in cases of amau- rosis. The seat, extent, and natm^e of the pain are to be carefully investigated. It is necessary to inquire, whether it is general over the head, or confined to one particular spot, whether it is attended by throbbing, relieved or aggravated by the horizontal position, increased during the night, affected much by temperature, exercise, or diet, and whether it is constant, intermittent, or periodic. It is also important to ascertain whether the pain is accompanied by vertigo, tinnitus aurium, nausea, a tendency to coma, sleepless- ness, inability to exert certain of the mental faculties, and the like. 6. The general health, and the previous diseases of the individu- al, are worthy of serious consideration. Is the constitution stru- mous? Has the person suffered from venereal complaints, or long- continued courses of medicine for the cure of syphilis ? Had he ever typhus-fever 'l Has he had any apoplectic, epileptic, or para- lytic affection ? Has he been subject to hypochondriasis, or if the patient be a female, to hysteria ') Has he had gout or rheuma- tism ? What has been the condition of the digestive organs ? If the patient be a female, what has been the state of the uterine sys- tem ? Tliese, and many other points, which will naturally suggest themselves to the mind of the attentive observer, ought to be made the subjects of deliberate inquiry. V. Stages and degrees. It is proper to distinguish incipient from confirmed amaurosis ; and incomplete from complete. In the incipient stage, the disease is only developing itself, the patient, in general, is not completely deprived of sight, remedies will almost always be useful in checking the progress of the com- plaint, and in many cases a perfect cure will be accomplished. It sometimes happens, however, that even from the very first, the blindness is complete, and the case incurable. In the co?ifirmed, or inveterate stage, remedies may perhaps relieve some of the at- tending symptoms, but will very seldom effect a cure. The patient, however, is not always totally deprived of sight, even in confirmed cases of long standing ; but often retains a perception of light and shadow, or a certain degree of capability to discern different grada- tions of light, certain colours, and even objects well illuminated or strongly contrasted. In complete amaurosis, the patient is unable to distinguish any object or colour whatever, and is often insensible even to the presence of light. Any degree less than this is incomplete. VI. Diagnosis. It is chiefly with incipient cataract that amau- rosis is apt to be confounded. On this subject, I must refer to what has been said at page 472. Glaucoma is often mistaken for amaurosis, from the circumstance of being always attended by some of the subjective symptoms of 'this disease ; but the objective symptoms of glaucoma, such as the apparent greenness of the humours, and the hardness of the eye- 82 650 ball, are sufficiently remarkable, to enable us, in general, to distin- guish it from simple amaurosis. The complication, however, of amaurosis with glaucoma is extremely common. Amaurosis also occurs in combination with cataract ; and in this case, glaucoma is generally superadded. VII. Prog7iosis. There is scarcely any disease in which the prognosis is on the whole so unfavourable as in amaurosis. When the complaint, indeed, is recent, its cause evident, and the subject under middle life, a complete cure is not unfrequently obtained. This is sometimes the case even when the loss of sight is total. Much more frequently a partial amelioration only is effected ; the disease being checked, and a certain share of vision preserved. In confirmed cases, it rarely happens that much improvement takes place, even under the best directed treatment. A sudden amaurosis is generally less unfavourable than one which has developed itself slowly. When the pupil is only slightly dilated, still movable, and of its natural form, the consistence of the eyeball neither firmer nor softer than in health, and no glau- coma present, we may pronounce a more favourable prognosis than when the pupil is fixed in the state either of expansion or contrac- tion, the eyeball either boggy or of preternatural hardness, or the bottom of the ey& presenting a greenish opacity. If the attack has been sudden, a want of power in the muscles of the eyeball or eye- lids, along with the proper amaurotic symptoms, may be regarded as a sign, that the cause of the disease is some general pressure within the cranium, which energetic measures will probably re- move ; whereas the slow succession of one amaurotic and paralytic symptom after another is more likely to arise from the growth of some incurable tumour or exostosis. VIII. Treatment. It is evident, that in the treatment of any amaurotic affection, it should be our first object, to discover the cause or causes upon which it depends, and then to attack these by appropriate remedies. As the causes are very various, and even opposite, so must also be the means of cure. We may arrange them in two classes, general and local. I. General Means. 1. Depletion. When we find that an am- aurotic attack is attended by signs of a determination of blood to the head, such as headach, vertigo, flushed countenance, and arte- rial throbbing of the temples ; that the pulse is full, and the subject young or plethoric, we will of course employ general and topical blood-letting, purge the patient, and put him on low diet. If the case is purely one of pressure on the brain, from vascular disten- tion, these means, conjoined with rest, will probably effect a cure. If along with vascular pressure, there is effusion, or even some morbid formation within the cranium, still depletion will afford to a plethoric subject the most effectual palliative relief, and act as the best preparative for other remedies, especially for the use of mer- cury. It is impossible to lay down any general rule regarding the 651 point to which the bleeding and purging plan is to be carried in the treatment of amaurosis with plethora. We must equally be- ware of stopping short before our purpose is obtained, and the balance of the circulation restored, and of pushing the depletion so far that it becomes merely a means of weakening the patient, with- out promoting the cure. 2. Mercury has long and justly maintained a high character as a remedy in amaurosis.* It is probable that it aids in the cure of this disease chiefly as a sorbefacient, promoting, in particular, the removal of effusions within the cranium, and sometimes even of morbid formations. It cannot be doubted, that many of the disordered states of the internal optic apparatus, which end in am- aurosis, are originally of an inflammatory nature ; chronic inflam- mation of the optic nerve, and of the retina may sometimes be the cause of this disease, and in all such cases, there is reason to be- lieve, from what we know of the beneficial effects of mercury in other inflammatory affections of the organ of vision, that this medi- cine will prove more serviceable than almost any other remedy. There are, of course, cases of amaurosis, in which from the sunken state of the patient's constitution, it might prove injurious to employ mercury ; neither will it always be necessary or proper, in those cases in which we judge it right to try this remedy, to salivate the patient, although in some, salivation only will effect a cure. Mr. Travers, speaking of mercury in amaurosis, says, "I have been witness to its power in suddenly arresting the disease in too many instances, not to entertain a far higher opinion of it than of any other article of the materia medica."t Mr. Lawrence's testimony is not less explicit. " We must have recourse," says he, " to mer- cury, which appears to be as decidedly beneficial in these cases as in iritis, or general internal inflammation." " When the antiphlo- gistic treatment," he adds, " and a fair trial of mercury have failed, I do not know that it is possible to effect any further essential good by other means,"! 3. Emetics and Nauseants. That emetics must be useful in cases of amaurosis depending on gastric derangement, and that nauseants may sometimes prove serviceable, appears highly proba- ble. Accordingly we find, that in recent incomplete amaurosis, arising from irritation in the digestive organs, Schmucker, § Rich- ter, II and Scarpa 1 derived the best effects from the emetic plan of cure ; and although Beer, and several later observers, have been less successful in its employment, it still deserves attention. That it is not calculated, more than any other means of cure, for gen- eral adoption, and that, in some cases, it might even prove decidedly * Heister de Cataracta, Glaucomate, et Amaurosi, p. 331. Altorfi, 1713. t Synopsis of the Diseases of the Eye, p. 305. London, 1820. t Lectures in the Lancet, Vol. x. p. 578. London, 1826. § Vermischte Chirurgische Schriften, Vol. ii. p. 3. Berlin, 1786. 11 AnfangsgrUndet der Wundarzneykuns, Vol. iii. p. 443. Gottingen, 1804. •S Trattato delle Malattie degli Occhi, Vol. ii. pp. 227, 230. Pavia, 1816, 652 hurtful, can form no objection to its use, where the tongue is foul, the mouth bitter, the hypochondria distended, the stomach loaded with indigested food, and the patient complaining of continual nausea, without being either greatly debilitated, or, on the other hand, plethoric, and incUned to cerebral congestion. The following is the emetic plan, as laid down by Scarpa. For an adult, dissolve three grains of tartarised antimony in four ounces of water, of which give two table-spoonfuls every half hour, till it produces nausea and copious vomiting. Next day the patient is to begin the use of a resolvent powder, composed of one ounce of cream of tartar, with one grain of tartarised antimony, divided into six equal parts, of which one is to be taken in the morning, another four hours after, and a third in the evening ; and this to be repeat- ed during eight or ten successive days. The effects will be slight nausea, purging, and perhaps vomiting. If, during the use of the resolvent powder, the patient is troubled with ineffectual efforts to vomit, want of appetite, (fee. without any amendment in vision, the emetic is to be repeated ; and even a third and fourth time, if it seems necessary. The stomach being by these means cleared, the patient is to begin the use of the resolvent pills of Schmucker,* or of Richter.t Scarpa states the following to be the consequences usually ob- served to result from this treatment. The patient, after having vomited copiously, feels more easy and comfortable. Sometimes on the same day on which he has taken the emetic, he begins to distinguish surrounding objects ; in other cases, this advantage is not obtained till the fifth, seventh, or tenth day ; and in others, not till some weeks after the uninterrupted use of the resolvent pow- ders or pills. The cure is seldom effected in less than a month, and is aided by such local remedies as are calculated to excite the languid action of the nerves of the eye. 4. Evacuants, of different sorts, besides those already mentioned, are required in the treatment of certain varieties of amaurosis ; such as emmenagogues, when the disease appears to be connected with impeded menstruation ; anthelmintics, when it arises from worms ; diaphoretics, when suppressed perspiration is the cause. 5. Tonics, such as cinchona, and the preparations of iron, form a class of medicines of great importance in the treatment of amau- rosis. That this disease, in many instances, takes its origin in vascular exhaustion and nervous debility, and is corrected, or en- tirely removed, by the use of a nourishing diet, the cold bath, tonic * R Gummi-resinaB Sagapeni, Gummi-resinEe Bubonis Galbani, Saponis Veneti, aa 5i- Rhei optimi S^ss. Tartratis Antimonii, gr. xvi. Sued Liquiritise Si- Fiat massa, in pilulas formanda, singulas granum i pendentes. Fifteen to be taken morning and evening, for a month or six weeks. t ft Gummi-resinEe Ammoniaci, Gummi-resinsB Asssefoetidae, Saponis Veneti, Radicis Valerianae subtillissime pulverisats, Summitatum Arnicse, aa 5ii- Tartratis Antimonii gr. xviij. Fiat massa, in pilulas formanda, singulas grana ii pendentes. Fifteen to be taken thrice a-day, for some weeks. 653 medicines, and influences of a similar sort, must be well known to all who have had any considerable experience in the treatment of eye-diseases, and whose opinions are not warped by some particu- lar hypothesis, which leads them perhaps to regard amaurosis as always depending on one kind of cause, and therefore to be cured only by one plan of treatment. It cannot be denied, that tonics would, in many cases, do harm, just as bleeding, purging, vomit- ing, or the use of mercury would do, if misapplied ; but this is no reason why they should be indiscriminately rejected. 6. Stimulants. Many and various internal stimulants have been employed in the treatment of amaurosis ; most of them quite empirically, or on some vague idea of their possessing a power of rousing the sunken sensibihty of the nerves ; others, again, on the ground of their evidently exciting violent convulsions, which, of course, they are enabled to do only through the instrumentality of the nervous system. Camphor and nux vomica may be mentioned, as examples of this class of remedies for amaurosis. It is well known to toxicologists, that those substances, given in considerable doses, excite violent tetanic paroxysms, not only in the parts an- imated by the spinal nerves, but also in the muscles of the face, eyes, and eyelids. In the hope, perhaps, that they might also pro- duce a stimulating effect on the nerves of sense, these substances, and especially strychnia, the alkaloid contained in nux vomica, and one of the most energetic of poisons, have been applied in va- rious modes for the cure of amaurosis. Arnica montana, hellebo- rus niger, naphtha, phosphorus, and a host of other drugs, of simi- lar properties, have been employed on the same principle ; but it is extremely doubtful if they have been productive of the least good effect. 7. Antispasmodics^ as opium, musk, valerian, and the like, have occasionally been used in the treatment of amaurosis, especially when this disease has been connected with epilepsy. 8. Sedatives^ as belladonna, hyosciamus, and aconitum, have been tried ; and I have known ihe first mentioned of these useful, in cases where the amaurotic symptonjs were attended with ner- vous pain, affecting the branches of the fifth pair. 11. Local Means. 1. Coimier-irnVa^iow, excited by rubefacient liniments, tartar-emetic ointment, blisters, and issues, proves high- ly useful in almost every variety of amaurosis. A succession of blisters over the head is perhaps the most efficient mode of employ- ing counter-irritation ; but much advantage is also derived from stimulating friction of the forehead and temples, blisters behind the ears, or to the nape of the neck, caustic issues in the same place, or behind the angle of the jaw, a tartar emetic eruption be- tween the shoulders, and sometimes even by still more remote applications of the same sort, as the immersion of the feet in warm water, holding in suspension a quantity of powdered mustard. 2. Sternutatories have been used with some advantage, espe- 654 cially in cases where the mucous secretion from the conjunctiva, and Schneiderian membrane appeared to be partially suppressed. Mr. Ware has published * a considerable number of cases, in which the chief means of cure was a mercurial snuff. He recommends one grain of turpeth mineral to be mixed with twenty grains of powder of liquorice, and about a fourth of this to be snuffed up the nose two or three times a-day. In cases where the nostrils are particularly dry, the patient may promote the efficacy of the ster- nutatory, by previously inhaling the steam of warm w-ater through the nostrils. 5. Stimulating vapours, directed against the eyes, liave been recommended, especially in cases where there are evident signs of great local debility, without any appearances of congestion or ple- thora. A little sulphuric ether, or aqua ammoniae, may be poured into the palm of the hand, and held under the eyes till the fluid has evaporated ; and this may be repeated several times daily. 4. Electricity formerly enjoyed a considerable reputation as a remedy in amaurosis, but of late years has been almost entirely neglected. As it is not likely to be trusted to, nor even tried, where the disease is recent, it is not to be wondered at that it should, hke every other kind of remedy, prove totally inert in a great ma- jority of the confirmed or inveterate cases, which, as to a last re- source, may be submitted to its influence. The cases related by Mr. Hey t and Mr. Ware,+ afford sufficient ground for believing that electricity may occasionally prove highly serviceable in the treatment of this disease. Mr. Ware considers it more useful in amaurosis arising from the effect of lightning on the eyes, than in any other variety of the complaint. The mode of application is chiefly by directing the electric aura against the eyes, diawing it from them during the insulation of the patient, and sometimes by taking small sparks from the eyelids and integuments round the orbits. The general review which we have thus taken of the seat, causes, symptoms, and treatment of amaurosis, is sufficient to show that this subject is surrounded with difficulties, and that there is a necessity for exercising the most minute and careful observation, if we hope to make any advancement in the knowledge of this class of diseases. Each individual case of amaurosis, to do it jus- tice, would require to be considered at leisure, and in all its bear- ings — to be made, in fact, a subject for study. It is but too evi- dent, that many who have written upon amaurosis, labouring probably under a distaste for what they had found to be an irksome task, namely, the investigation of complicated phenomena, have * Observations on the Cataract and Gutta Serena, pp. 407, 410, 417, &c. Lon- don, 1812. t Medical Observations and Inquiries, Vol. v. p. 1. London, 1776. t Observations on the Cataract and Gutta Serena, pp. 379, 381, &c. London, 1813. 655 endeavoured to cut the matter short, and introduce, into a subject which does not admit of it, some easy simple arrangement of their own. FeeUng themselves, as well they might, unable to embrace the infinite diversities of this class of diseases, they have endea- voured to reduce the phenomena of amaurosis to their own con- tracted notions, and satisfying themselves with a few artificial dis- tinctions, have actually discouraged the attempt to follow nature with that perseverance, without which, in a subject like this, no real progress can be made. SECTION II. CLASSIFICATIONS OF THE AMAUROSES. Some will have no classification ; but insist that amaurosis is always one and the same. Others have adopted the division, al- ready noticed, into functional and organic, whereas every case of amaurosis is both. Beer has classified the different species accord- ing to their symptoms ; and it may not be improper to examine his classification somewhat more particularly. The principle is evidently good ; determining the seat and natu)e of the disease, by the particular symptoms present. Beer admits four classes : the^rs^ including amaurosis, character- ized only by subjective symptoms, or, in other words, by impaired vision, without any diseased appearances about the eye ; the second, amaurosis characterized not only by impaired vision, but by changes in the texture of some part of the optic apparatus ; the third, amaurosis characterized by impaired vision, with changes in the form and activity of some part of the optic apparatus ; and the fourth^ amaurosis in which the characteristics of the first three classes are combined. It does not admit of denial, that we occasionally meet in nature with cases of amaurosis, presenting such differences in the symp- toms, as Beer has chosen for the ground-work of his classification. For instance, it sometimes happens that in the amaurosis from ex- haustion, there is scarcely an objective symptom to be discovered about the eye, and we are obliged to admit the existence of the dis- ease almost solely on the testimony of the patient, the case evident- ly falling within Beer's first class. We may admit, also, the only instance which Beer has introduced into his second class, to be a correct example of amaurosis, characterized by loss of vision, with change in texture ; namely, that variety of the disease, which re- sults from absorption of the choroid pigment. In like manner hy- drocephaUc amaurosis very frequently presents no other symptoms than loss of pight, and fixed dilated pupil, so that it is referrable to Beer's third class. Amaurosis, again, from an injury of the eye, is often attended, in addition to loss of sight, by irregular immovable pupil, laceration of the tunics, and enlargement, or, on the contrary. 656 atrophy of the eyeball. Such a case will undoubtedly belong to the fourth class. I trust, however, that I shall not be accussed of rashness, nor of disrespect for the labours of Professor Beer, when I state my belief, that the cases arranged under his four classes, are not uniformly attended by the symptoms which he has assigned to them ; but that those species of amaurosis, which he has set down as characterized by subjective symptoms only, are sometimes attended by objective signs also, while, on the other hand, those changes in the texture and form of certain parts of the optic appa- ratus, which be has considered as characteristic of other species, are sometimes merely coincident, and not essential. The amauro- sis, for example, which originates from over-excitement of the eye, or from plethora, which Beer places in his first class, is often at- tended by fixed dilated pupil, a circumstance which should assign it a place in the third class. The amaurosis from rage, is merely a variety of the plethoric or apoplectic, and may or may not present the glaucomatous appearance of the humours, on account of which he has placed it in his fourth class. Glaucoma, one of the changes upon which Beer has founded his classification, is by no means an essential part of any amaurosis. Neither is fixed dilated pupil any thing more than a frequent coin- cidence. In the hydrocephalic amaurosis, for instance, the pupil,, though generally expanded and motionless, is not always so ; and it nmst evidently form an insuperable objection to any classification founded on symptoms, that sometimes they are,^ and at other times they are not present. Beer admits as species, an epileptic, and a paralytic amaurosis ^ whereas the epilepsy and anmurosis in the one case^ and the palsy and amaurosis in the other, ought to be regarded not as standing in the relation of cause and effect, but merely as coincident effects^ arising from one and the same cause, namely, some morbid change or formation within the cranium. While Beer's classes refer to the appearances presented in difier- ent cases, his distinctions of species are founded, in general, oi> the causes, efficient or remote, of the disease ; and on the same basis, I believe, we ought to form our general arrangement of the amauroses. In other words, we ought to group together those species, the causes of which bear a resemblance to each other. The following is a list of some of the principal varieties of amau- rosis, arranged according to their causes. It would,, no doubt, be desirable to have a classification,, founded on the efficient causes only, without being obliged to refer, in any instance, to the mere remote or exciting causes. But this does not appear practicable, on account of our ignorance of the mode in wliich certain remote causes act. I. Amaurosis prom Causes directly affecting the. Retina, 657 1. Pressure on the concave surface of the retina ; as by de- pressed lens,* vitreous dropsy ^\ (fee. 2. Pressure on the convex surface of the retina ; as. by sub-scle- rotic dropsy, % suh-choroid dropsy, h (fee. 3. Injuries of the retina; as, in blows on the eye,\ penetrating wounds of the eye, IF &c. 4. Inflammation affecting the choroid.** the retina,tt or both. 5. Ossification of the choroid, H or of the retina.§§ 6. Absorption of the pigmentum nigrum. II II II. Amaurosis from Disease of the Optic Nerve with- in THE Orbit, or from Pressure on that portion of the Optic Nerve ; as from inflammation^^li encysted arid other tumours,*** aneurisms, '\tt exostosis, XXX (fee. III. Amaurosis from Fractured Cranium with De- pression. IV. Amaurosis from Vascular Pressure. 1. Cerebral Plethora and Congestion. 2. Apoplexy. 3. Aneurismal Dilatation of the Cerebral Arteries. V. Amaurosis from Inflammation, or the immediate consequences of Inflammation of the Brain or its Mem- branes, AND especially OF THE PARTS FORMING THE OpTIC Apparatus. Amaurosis may be the consequence either of the first, or of the second stage of inflammation ; and in the latter case, one or other of the following secondary effects of inflammation may operate as the immediate cause of the amaurotic affection ; viz. 1. Effusion of Serum; 2. Effusion of coagulable lymph, with thickening of the membranes, or formation of false membranes; 3. Suppura- tion; 4. Ramollissement ; 5. Ulceration. The following are some of the exciting causes of inflammation of the internal optic apparatus. 1. Intense light. 2. Over-exercise of the sight. 3. Concussion, and other injuries of the head. 4. Irritation from teething, disordered bowels, (fee. ; as, in the itiflammation of the brain in children, commonly called acute hydrocephalus. 5. Febrile diseases ; as, continued fever, scarlatina^ measles, &.C. 6. Passions of the mind. 7. Habitual use of alcoholic fluids. 8. Insolation. > * See pp. 499 and 509. t See p. 444. § Ibid. 11 See p. 257. ** See p. 380. t+ See p. 386. §§ Ibid. III! See pp. 581 and 591. «*" See p. 220. ttt See pp. 240 and 247. 83 t See p. 442. ir Ibid. « Seep. 431. TTir See p. 213 m See p. 37. 658 9. Suppressed evacuations ; as, of the menses^ hcBmorrhoids, milk, matter of ulcer s^ mucus in catarrh, 689 ter sudden cooling of the head, followed by rheumatism, which though slight in its commencement, had fixed itself in the fibrous covering of the skull. The prognosis in this kind of amaurosis is, I need scarcely say, extremely unfavourable. The gradual development of complete blindness, and not only death, but a very mournful death, is to be dreaded. Nor does the heahng art possess any means which can be effectually employed in diminishing, much less removing, the organic changes upon which the disease depends, except perhaps in one or two cases. These cases are when the symptoms evident- ly originate in some constitutional disorder, and especially in syph- ilis. Case 1. The following case is one of those related by Sir Ever- ard Home. A. B., aged 21, in the year 1792, had some venereal symptoms, for which he underwent a course of mercury. The symptoms were removed, but he was ever afterwards subject to attacks of gid- diness, attended w^ith much general bodily uneasiness, and a re- markable degree of dejection of spirits. These attacks occurred at longer or shorter intervals, and appeared to depend very much on the state of his bowels. He was naturally of a very costive habit, in consequence of which he took frequent doses of calomel. By persevering in this practice, the above-mentioned symptoms became less, though they were never entirely removed. In November, 1806, he had a chancre on the glans penis, for which he took hy- drargyrus calcinatus, and confined himself to the house. His mouth became sore, and the chancre healed ; but he was soon after attacked with a severe pain in the right side of his head, at- tended with a tumefaction of the scalp in that part. The pain was so severe as to prevent his sleeping, and at times his sight and hearing were considerably impaired. At the end of six weeks he left off the mercury ; but the symptoms did not abate. On the 29th of December he caught cold, and the symptoms be- came much aggravated. On the 2d of January, an abscess burst in his right ear, the discharge from which continued for two or three days. The pain and swelling were now diminished, but it was found that his mouth was drawn to the left side. In consequence of this paralytic affection, he was kept low, and in three weeks it went off. In a week after the bursting of this abcess, the pain became as severe as before, and he now referred it to the left side of the head, over the parietal bone. The pericranium of that side was much tumefied. About the 14th of March, these symptoms were much aggravated ; and on the 17th, he became deaf. The pain was so severe, that he could hardly sit up. Sir E. Home made an inci- sion down to the parietal bone. The pericranium was found ex- tremely thickened and tender, so that the operation caused unusual pain. He experienced immediate relief, and slept well at night, 87 690 which he had not done during the whole progress of his complaint. On the 22d of March, an abscess burst in his right ear, and dis- charged for two or three days. In the course of a week after the operation, the pain and tumefaction subsided ; but he continued deaf, and complained of a noise and singing in his head. The wound was dressed at first with dry lint, afterwards with lint moist- ened with diluted nitrous acid. In two months, a portion of bone, of the size of a sixpence, exfoliated. In six weeks more, a similar exfoHation took place ; and after this the wound was allowed to heal. The patient's general health improved, so as to become better in every respect than it had been for several years before ; but he con- tinued deaf, and troubled with an incessant noise in his head. There was no return of his headachs.* Case 2. The following case, related by the late Mr. Wilson, of London, shows what may sometimes be done, even in circumstances which might appear almost desperate. In November, 1806, Mr. Wilson was requested by a surgeon of his acquaintance to visit a gentleman, who had been affected with a long and severe illness. Mr. W. received the following account of the case. In the spring of 1803, when influenza was very prevalent, Mr. C, a muscular man, about 28 years of age, and of rather a sanguine- ous temperament, was attacked with a very severe deep-seated pain in the orbit of the left eye. A physician of eminence was consulted, by whom a rigidly antiphlogistic plan was recommended. This was persevered in for a considerable time without benefit. The case was then deemed nervous, and medicines adapted for the rehef of nervous diseases were employed in large quantities. The pa- tient was ordered to remove to Hampstead for the benefit of the air. This plan not succeeding, other medical opinions were taken, and various remedies tried ; but the patient gradually became worse. The sense of hearing in the left ear was now totally lost. The leva- tor of the left upper eyelid became paralyzed, and a great degree of strabismus was produced by the rectus externus having also lost its power. The pupil of the left eye became much and constantly dilated, and the sight of that eye was lost. The right angle of the mouth was permanently drawn to the right side. An extreme hoarseness took place, and his articulation became so indistinct that he could not be understood even by his friends. He lost the power of swallowing solids, and swallowed fluids with very great diflficulty, as the attempt brought on a distressing sense of suffocation. A vessel was constantly placed at his side to receive the saliva, which he could neither swallow nor eject from his mouth, and which he therefore endeavoured to push out with his tongue. His bowels were most obstinately constipated, requiring the frequent use of dras- tic purges. * Transactions of a Society for the Improvement of Medical and Chirurgical Knowl- edge, Vol. iii. p. 146. London, 181 2. 691 j Upon visiting- the patient, Mr. Wilson found his right hand and .'drm folded up, and, with the leg of the same side, in a state of com- plete paralysis. Very violent pain in the orbit of the left eye still continued, and there was also considerable pain in the vertebrae of the neck, and at the' top of the shoulder. When in bed, he could not raise his head from the pillow ; he could scarcely sleep at all, and had no respite from excruciating pain ; in short, his dissolution was hourly expected. Mr. W. learned also, that before the commencement of the disease, he had had at two or three different times, chancres and incipient buboes, and that for these he had used mercury, until the symptoms disappeared, and the surgeon who attended him pronounced his cure to be complete. In the summer preceding his illness, he had strained his back in leaping ; a short time after which, a bubo formed in the right groin. This was particularly attended to, under the supposition that it might prove venereal. It suppurated, and healed without mercury having been used. Observing something particular in the figure of one of his legs, Mr. W. requested leave to examine it : and when the stocking was removed, perceived a cicatrice of considerable extent, and that the tibia was much enlarged. The patient did not, however, feel any pain in this bone. He expressed in writing with his left hand, that several years before, he had received a severe blow on this leg, and that a large piece of bone had come away ; he could not recol- lect whether he took any mercury at that time, and he did not think that his surgeon considered the disease in the bone as vene- real. He did not remember having had, at any time, spots on his skin or a sore throat. His present ailment, he said, had never been considered, by any of the medical persons whom he had con- sulted, as venereal, nor had the use of mercury ever been proposed for its cure. On examining his neck, Mr, W. found several of the vertebrae much enlarged. He discovered also a large swelling in the acro- mion of the right scapula, and a considerable enlargement of the whole of the spine, and greater part of the superior costa, of that bone. As the muscles were wasted, a swelling was readily per- ceived in the os brachii, a little above the attachment of the deltoid muscle. The right clavicle possessed at least three times its usual thickness. From the possibility of these swellings being venereal, Mr. W. felt justified in proposing the immediate use of mercury. The patient's relations were apprehensive that his extreme weakness, and the apparently rapid approach of death, would render the ex- periment useless ; but willingly consented to the attempt being made, as without something being done, and done quickly, death seemed inevitable. Accordingly, one drachm of the strong mercurial ointment, with five grains of camphor, was rubbed upon his skin every night, and a seton was inserted in the back of his neck. In four days, his 692 mouth became affected from the mercury ; in ten days, he swal- lowed with less difficulty, he slept well, and his pains were nearly gone in a fortnight, the enlargement of the clavicle was evidently lessened, and his muscles were much fuller and firmer. He had also recovered his speech, so far as to make himself understood. The quantity of the ointment was now increased to a drachm night and morning, and the use of it was continued for eleven weeks ; towards the latter part of v/hich time, when he could swal- low with ease, he took about eight ounces of the compound decoc- tion of sarsaparilla daily, and now and then some preparation of Peruvian bark. During this course, although the patient's mouth was affected with a considerable degree of soreness, he gathered health and strength daily, and before it was discontinued had grown fat. His muscles had acquired very nearly their original plumpness and strength, and the limbs their former capability of motion. The pains were wholly removed, and the thickening of the bones very much reduced. His power of swallowing and of moving the right extremities, seemed at first to increase, in the same propor- tion as the sweUings of the cervical vertebrae decreased. But though these swellings afterwards became stationary, the powers of the muscles were completely restored. His cure, with the following exceptions, was perfect, and had remained so for more than two years. The pupil of the left eye continued more dilated than that of the right, and the eyelid could not be raised quite so high as formerly ; but he could distinguish objects and colours in some measure with the left eye, and even small objects when he used plain green spectacles, and employed that eye only. When he used both eyes his vision was confused, as he then saw objects double. He still spoke with a very hoarse voice, but his articula- tion was sufficiently distinct.* XIV. Amaurosis from Morbid Changes affecting the Fifth Pair of Nerves. When disease W'ithin the cranium affects principally the fifth pair of nerves, a train of symptoms is produced similar to the changes which have been observed to follow the division of the trunk of the nerve, in experiments on the lower animals. Besides amaurosis, more or less complete, there is inflammation of the eye ending in ulceration and opacity of the cornea, insensibility of the conjunctiva and the other parts supplied with common sensation by the fifth pair, and loss of taste in the corresponding side of the tongue. Severe neuralgia generally accompanies this amaurosis ; and from the third pair being often involved in the morbid state of the brain or its coverings, the muscles of the eyeball and the levator of the upper eyelid, are apt to be at the same time affected with par- * Transactions of a Society for,the Improvement of Medical and Chirurgical Know- ledge, Vol. iii. p. 115. London, 1812. 693 alysis. These various symptoms follow each other, sometimes in one order, sometimes in another. In some cases the amaurosis, in others neuralgia, is the complaint which' attracts the most attention ; sometimes the disease is looked upon as merely an obstinate oph- thalmia, and in other instances it is considered as a paralysis. Case. A young man, an epileptic in the hospital La Pitie, died on the 12th of August, 1824, after having been under the care of M. Serres, for ten or eleven months. When he was admitted into the hospital, he complained, in addition to his epileptic seiz- ures, of slight inflammation of the right eye. The inflammation increased, the cornea became opaque, and sight, at first disordered, was ultimately lost by this cause. The organs of sense, on the right side, became successively deprived of their natural powers. This took place in June, 1824. The right eye, eyelids, nostril, and half of the tongue, were deprived of sensation, while the same parts on the left side possessed it perfectly. Shortly after, the dis- ease was aggravated by a scorbutic affection, which first manifested itself on the right side of both maxillae, on this side laying the teeth bare by an affection of the gums. At the advanced stage of the disease, complete deafness took place on the right side. On dissection, the ganglion of the fifth pair on the right side was found to be swoln, of a yellow colour, and less vascular than usual ; and the nerve, where it seems inserted into the pons Va- rolii, was changed into a yellow gelatinous substance, like the ganglion, which substance transmitted small processes into the pons, in the direction of the fasciculi of the insertion of the nerve. The muscular branches of the affected nerve were unaltered, and the action of mastication had never been disturbed.* XV. Amaurosis from Poisons. Almost all substances included under the classes of narcotic and narcotico-acrid poisons, produce, along with other effects on the ner- vous system, dimness of sight and dilated pupils. Dilatation and fixedness of the pupils follow the application of some of these sub- stances even to the skin merely, and of this we take advantage in the treatment of several of the diseases of the eye ; but it does not generally happen, that belladonna, or hyosciamus, the substances usually employed in this way. appear to cause any other affection of the retina, than a degree of obscurity and dazzling, such as the mere influx of light through a much dilated pupil might induce. Taken internally, however, these poisons, as well as many of their congeners, evidently induce insensibility, more or less complete, of the retina, along with mydriasis in most instances, but sometimes with myosis. They also cause delirium, coma, convulsions, and, if not speedily counteracted, death. The effects of large doses of belladonna have been frequently * SerreSj Anatomic Comparee du Cerveau, Tome ii. p. 67. Paris, 1827. 694 witnessed, in consequence of children and adults being tempted to eat the berries by their fine colour and bright lustre. Dryness of the throat is an almost uniform symptom in such cases, and, along" with difficulty in swallowing, is much complained of by the pa- tient. The delirium is generally extravagant, and accompanied with immoderate and uncontrollable laughter, sometimes with con- stant talking, but occasionally with complete loss of voice. The eyeballs are red and prominent. Vision is more or less affected ; sometimes so much so, that even the brightest light cannot be dis- tinguished. The torpor or lethargy which follows the delirium, occurs more or less quickly, but in general not for several hours after the poison is taken. Convulsions rarely appear to be produced by belladonna. The effects of this poison are by no means so quickly dissipated as those of opium. The blindness especially, is often a very obstinate symptom, sometimes remaining long after the affection of the mind has disappeared. For days, and even weeks, the pupils may continue dilated, and vision disordered. Similar effects are produced by large doses of hyosciamus, or stramonium. Blindness with dilated pupils, also attend poisoning by white hellebore, tobacco, and several other substances. Opium and alcohol also induce insensibility of the retina, sometimes ac- companied with dilatation, but more frequently with contraction of the pupils. It becomes a question of great importance. How do the narcotic and narcotico-acrid poisons act in the production of amaurosis? Do they operate, through the medium of the nervous system, on that part of the brain which forms the immediate organ of visual perception, the optic nerve, the third pair which animates the iris, and the other nerves connected with the external organs of this sense ? Or do they merely induce congestion of the vessels of the brain, and sometimes extravasation of blood within the liead ? They probably act in both these ways. Congestion of the cere- bral vessels is commonly, though perhaps not invariably, found on dissection, after death from a narcotic or narcotico-acrid poison ; and must undoubtedly tend to produce insensibility in cases of poi- soning, as it does in cases of apoplexy or cerebral plethora. But that the amaurotic effects of the poisonous substances in question are to be ascribed wholly to congestion does not appear probable, v/hen we take into account the dilatation of the pupils, which, often in the course of not many minutes, follows the application of belladonna to the skin of the eyelids, and which, whether it is to be regarded as produced by nervous communication or by absorp- tion, can scarcely with any degree of plausibihty be supposed to arise from cerebral oppression. I have already had occasion repeatedly to hint my suspicion, that one of the narcotico-acrids, which custom has foolishly introduced into common use, namely tobacco, is a frequent cause of amaurosis. A great majority of the amaurotic patients, by whom I have been 695 consulted during the last twelve years, have been in the habit of chewing, and still oftener of smoking, tobacco, in large quantities. It is difficult, of course, to prove that blindness is owing to any one particular cause, when perhaps several causes, favourable to its pro- duction, have for a length of time been acting on the individual ; and it is especially difficult, to trace the operation of a poison, daily applied to the body, for years, in such quantities as to produce, at a time, only a very small amount of deleterious influence, the accumu- lative effect being at last merely the insensibiUty of a certain set of nervous organs. At the same time, we are familiar with the conse- quences of minute portions of other poisons, which are permitted to operate for a length of time on the constitution, such as alcohol, opium, lead, arsenic, mercury, &.c., and we can scarcely doubt, that a poison so deleterious as tobacco, must also produce its own pecu- liar injurious effects. It would appear that there are two principles of activity in tobac- co, an essential oil, and a peculiar proximate principle called nico- tin, both of which are capable of producing death, but by very dif- ferent physiological actions, the former by its effects on the brain, the latter by its influence on the heart. The essential oil is so vir- ulent a poison, that small animals are almost instantly killed, when wounded by a needle dipped in it, or when a few drops of'it are let fall upon their tongue. Dr. Paris* records the case of a child, whose death was occasioned by her having swallowed a portion of half- smoked tobacco, which was taken from the pipe of her father, and in which there no doubt existed a quantity of essential oil, which had been separated by the act of smoking ; for in the process of smoking, the oil is separated, and being rendered empyreumatic by heat, is thus applied to the fauces in its most active state. Now, that the regular application, in this way, of a poison of such power, perhaps five or six times daily for months or years together, should at length be productive of serious effects on the nervous system, and especially on the brain, cannot surely be matter of wonder. Indeed it would be surprising, if it were otherwise. The Germans accuse a variety of bittet substances, employed either for food or medicine, as productive of amaurosis ; but with what degree of justice, I cannot pretend to say. Beer enumerates bitter almonds, the root of succory, quassia, and centaurium, amongst this class. Treatment. 1. If amaurosis be the consequence of a large dose of a narcotic, which still remains in the stomach, we ought in gen- eral to begin by giving a dose of tartar emetic, or sulphate of zinc, in as small a quantity of water as possible; for, as long as the nar- cotic remains in the stomach, the addition of any fluid which would not immediately be rendered by vomiting, would only dissolve the narcotic, if it has been swallowed in the solid state, and add to its * Pharmacologia, Vol. ii. p. 451. London, 1825. 696 activity. Vinegar, especially, which has been found so useful io removing the disease which arises from opium, only adds to its ac- tivity, if it be given before the poison has been rendered from the sto- mach. When no danger, however, of this kind is to be apprehend- ed, as is the case in alcoholic poisoning, injections into the stomach by means of the stomach pnmp, and the immediate withdrawal of the fluid injected, along with the poisonous substance, are to be prefer- red. As^soon after the contents of the stomach have been evacuated as is proper, a strong purgative ought to be administered, especially if we suspect that the narcotic has began to traverse the intestines. 2. Bloodletting, both general and local, is of great use in cases of amaurosis from narcotic poisons. This remedy probably proves serviceable, chiefly by relieving the tendency to cerebral congestion^ which uniformly accompanies this amaurosis. 3. The disease produced by the narcotic, and of which the am- aurosis is a part, ought next to be combated hy strong doses of coffee, camphor, vinegar, and the vegetable acids. 4. Cold applications to the head and eyes have been found use- ful. 5. In inveterate cases, after premising blood-letting and purg- ing, a course of mercury may be tried, with counter-irritation of different sorts, sternutatories, and electricity. The prognosis, in this stage, is very unfavourable, especially if the pupils are fixed, the retinae insensible, and the external vessels of the e3^e varicose. Case. On May 24, 1815, Mr. J. H., aged 19, unaccustomed, except for a day or two before, to the effects of tobacco, smoked one, and part of a second pipe, without employing the usual cau- tion of spitting out the saliva ; and partook, at the same lime, of a little porter. He became affected by syncope, with violent retch- ing and vomiting. He returned home, complained of pain in the head, undressed himself, and went to bed. Soon afterwards he was taken with stupor and laborious breathing. He was found in this state by the medical attendant. The countenance was suff'used with a deep livid colour ; the eyes had lost their brilliancy ; the conjunctivae were injected ; the right pupil was exceedingly contracted ; the left was much larger than usual, and had lost its circular form ; both were unaffected on the approach of light. The hands were joined, and in a state of rigid contrac- tion ; the arms bound over the chest ; and the whole body affected with spasmodic contraction. The breathing was stertorous ; pulse about 80 or 82, and nearly natuial in other respects. No more vomiting ; no stool or urine passed ; no palsy. Fourteen ounces of blood were immediately taken from the temporal artery, and vinegar was administered. He revived evi- dently ; the countenance became less livid ; the spasmodic affection of the hands ceased ; respiration became less stertorous. An ipe- cacaunha emetic was given, and operated once, and afterwards some purgative medicine was administered. 697 He dozed through the night. Next morning he was affected with syncope, during the efforts made to get out of bed to go to stool. He complained very much of pain of the head and eyes ; the eyes and eyelids appeared red and suffused. Tongue loaded and brownish. One stool. Pulse 80 and natural. Continued to doze. The feet were cold in the morning. Sixteen ounces of blood were taken from the arm. On the third day, he still dozed, and complained of pain in the head, nausea, and a tendency to faint. Countenance more natu- ral ; pupils natural, and contract on exposure to light. Pulse 72. A loose stool passed insensibly in bed. In the evening, he again became affected with a degree of stupor, spasms of the hands, and stertor in breathing. Six ounces of blood were drawn from the temporal artery, vinegar was given, a bUster applied to the forehead, and mustard cataplasms to the feet, with much relief to the symptoms. On the fourth day, he appeared much as on the preceding morning. There was some pain of head, but no sickness or vom- iting. After this he gradually recovered.* XVI. Amaurosis from Tnanition or Debility. This species of amaurosis declares itself from its commencement by the sensation of a network before the eyes, seldom, if ever, at- tended, however, by that glittering or dazzhng which accom- panies the same symptom in some other varieties of the disease. During its progress the power of vision manifests remarkable differences in degree, according to the physical and moral influences which affect the individual. After a hearty meal, or a few glasses of wine, or during the influence of some unexpected elation of mind, the patient sees for a short time much better than he did before ; while an opposite effect is produced by the depressing pas- sions, want of food, conthmed watching, and the like. Not un- frequently, this amaurosis first declares itself by the sensation of a mist before the eyes in the evenings, the common artificial light being too weak to affect sufficiently the diminished sensibility of the nervous apparatus of vision. In general there is no complaint of pain, neither in the head nor in the eyes, nor any feeling of ful- ness or weight. There are rarely any objective symptoms, except perhaps dilated pupils, attended by evident general debility, pale- ness, emaciation, and a weak, small, and frequent pulse. Causes. Among the most frequent causes of this amaurosis may be mentioned any considerable and continued loss of the fluids of the body, as in haemorrhage, chronic diarrhoea, ptyalism, immoderate venery, onanism, protracted suckling, the abuse of re- ducing remedies, and the like. This amaurosis is occasionally a sequela of typhus fever, especially when this disease has been * Case of the Effects of Tobacco, by Marshall Hall, M. D. in the Edin. Medical and Surgical Journal, Vol, xii. p. 11. Edin. 1816. 698 attended by profuse epistaxis, or treated with remedies producing hyper-catharsis. It has ah-eady been mentioned, that plethoric persons are in gen- eral able to produce a degree of congestive amaurosis at will, by stooping, tying their neckcloth tight, and the like. We also fre- quently witness a temporary amaurosis from exhaustion. For in- stance, if the nervous system is the seat of no particular excitement at the time, we ob-serve that by the sudden abstraction of blood, the organs of vision, and indeed all the organs of sense, are strikingly enfeebled. In some individuals the debility continues for several days, and if any one of the organs of sense has been previously weaker than the rest, the feebleness of that organ is in general in- creased by bloodletting. When syncope is produced Ijy loss of blood, sight appears to be the sense which fails first, and which re- covers last. Hearing is next ; while smell, taste, and touch, are less affected, and more easily reanimated by excitation. They re- turn in a very short time to their natural state ; but it is not so with sight. It is a popular opinion, that blood-letting weakens thesight^ and to a certain length the opinion is founded on fact. Treatment. The object of the treatment is by diet and tonic remedies, to strengthen the digestive organs, remove the general debiUty of the patient, and excite the sensibility of the nervous parts of the optic apparatus. Debilitating discharges are to be restrained,, bad practices on the part of the patient avoided ; country air, mod- erate exercise, the cold bath, and every other general influence likely to restore vigour, are to be employed. Local stimulants, such as etherial vapours directed against the eyes, have been found of use in such cases. Success in treating this disease will depend much on the practi- tionei-'s discovering the particular debilitating cause from which it has originated ; and when the disease is recent, the mere avoidance of the cause will frequently be sufficient to arrest its progress. Case 1. Arrachart relates the case of a young man, who had all his life been accustomed to drink wine as his ordinary beverage, but who, from change of place, was obliged to drink -a'ater only. DiarrhcEa was the consequence. This continued for nine months, when the patient was seized with fever of intermittent character. For this he was bled twice at the arm, and from that moment his sight began to fail. A third bleeding, from the foot, sensibly in- creased the weakness of sight, and immediately after a fourth bleed- ing, also from the foot, the patient became altogether bUnd. Large blisters were apphed, and tartar emetic given, first of all as a vomit, and then as an alterativ^e, during more than a month, without any success. The exhaustion of the patient rapidly increased, and still the tartar emetic was repeatedly employed. When Arrachart was called in, he prescribed mild, nourishing, and easily digested food, and put a seton into the neck. The patient's strength began to im- prove, but his vision remaining as before, he still continued to take 699 six grain doses of tartar emetic, without Arrachart's knowledge. These produced convulsions, without any evacuation. Arrachart having discovered this, prescribed some anodyne and antispasmodic remedies, and recommenced the nourishing plan of diet. In two months, the patient began to see a Utile with the left eye, and dur- ing the course of the next three months the vision of that eye sensi- bly improved, but the right eye remained blind.* Case 2. Mrs. S. when in her 30th year, was brought to bed ; and being a woman of a healthy constitution, chose to suckle her child herself. This she did for some time, without feeling any in- convenience from it; but, having continued it six weeks, her strength began to fail, and continued to decline daily, till she became incapa- ble even of moving about the house, without experiencing a very painful languor. About the same time her sight also was affected ; at first only in a small degree, but afterwards so considerably, that the full glare of the mid-day sun appeared to her no stronger than the light of the moon. At this period of her disorder, no black specks were perceived with either eye, nor did objects at any time appear covered with a mist or cloud. She was affected with vio- lent pain in the neck, running upwards to the side of the head ; and, on this account, the person who attended her, thought proper to take four ounces of blood, by cupping, from the part first affected. After this, her sight was worse than before, and it was not long be- fore she entirely lost the use of both eyes. She had been three days in this state of blindness, when Mr. Wathen was first desired to see her. He found both pupils very much dilated, and remaining un- altered in the brightest light. His first advice was, that the child should be weaned without loss of time. He ordered, at the same time, bark draughts to be taken by the mother three times in the day, prescribing also an opening medicine to be taken occasionally, on account of a costive habit of body, to which she had been almost constantly subject ever since the time of her deUvery. To the use of these remedies was added the frequent apphcation of the vapour of ether to the eyes and forehead. On the fourth day after this mode of treatment was adopted, Mr. Ware visited the patient, with Mr. Wathen, From the account she gave of herself, her strength and spirits seemed to be in some degree on the return ; and she could now perceive faint glimmerings of fight, though the pupils of both eyes were in the same dilated and fixed state as before. The bark and ether were continued, and next day a strong stream of the electric fluid was poured on the eyes, whilst several small electric sparks were variously pointed about the forehead and temples. The day after this, to increase the effect of the electricity, the patient was placed on a glass-footed stool, and the same experiments repeated as before. This appeared to have a considerable influence in promoting the cure. The first * Arrachart, Memoires de Chirurgie^ p. 209- Taris, 1805. 700 trial was almost immediately followed by such a degree of amend- ment, that the patient, to whose sight every object had before been confused, could now clearly distinguish how many windows there were in the room where she sat, though she was still unable to make out the frames of any of them. On the third day, soon after she had been thus electrified, the menstrual discharge came on for the first time since she had been brought to bed, and continued three days, during which it was thought proper to suspend the use both of the bark and the electricity. Immediately after this they were resumed ; and the effect was that the sight mended daily. At the end of a week, she could perceive all large objects ; and in a short time she could read even the smallest print. Her strength, indeed, did not return so quickly ; on which account she was advised to remove into the country, where the change of air, with the help of a mild nutritious diet, soon restored her to perfect health.* Case 3, A country lad, of robust constitution, became the alter- nately favoured paramour of two females, his fellow-servants, under the same roof. He was the subject of gutta serena in less than a twelve-month.f Case 4. Another, at an early period of puberty, suddenly fell into despondency, and shunned society. He never left his chamber but when the shade of night concealed him from observation, and then selected an unfrequented path. It was not discovered till too late, that in addition to other signs of nervous exhaustion, a palsy of the retina was the consequence of habitual masturbation. + XVII. Amaurosis from Irritation of the Branches of the Fifth Pair of Nerves. This appears to be by no means an unfrequent cause of sympa- thetic amaurosis ; numerous instances being on record, in which the removal of tumours in contact with branches of the fifth pair, and of carious teeth, has been the means of suddenly restoring sight. Case 1. The daughter of a person belonging to the establish- ment of the Marquis of Buckingham, at Stow, about 12 years of age, was brought to Mr. Ware, on account of total bUndness of the left eye, which had continued for six months without any visible cause to produce it. Upon the removal of a small encysted wart, which was situated on the edge of the lower eyelid, very near the punctum lachrymale, the child surprised Mr. "W. by immediately saying that she had re- covered her sight, and by telling him the name of everything that was held up before her.§ Case 2. A. healthy middle-aged man, a ship-painter by trade, * Ware's Observations on the Cataract and Gutta Serena, p- 385. London, 1812. t Travers' Synopsis of the Diseases of the Eye, p. 145. London. 1820. X Travers' Synopsis of the Diseases oftheEye, p. 145. London, 1820. ' Observations on the Cataract and Gutta Serena, p. 424. Lond. 1812. 701 desired Mr. Howship's advice in 1808, on account of a small tumour situated on tlie crown of the head. It was at least ten years since he had first perceived it. He supposed it might have been the consequence of some blow on the part, as those in his line of business were very subject to such accidents. It had never been painful, but yet he thought his general health was giving way, as for some years he had been subject to headach, a complaint he never was afflicted with in his life before. The frequency of the headach was increasing, and his sight had become so weak, that for more than two years he had been totally unable to read even the largest and clearest print. On pressure, no pain, or even sense of feehng, was excited in the tumour on the scalp. Having frequently removed such tumo^n's, Mr. Howship advised extirpation, which was done accordingly, by carrying two elliptical incisions through the teguments beyond the basis of the tumour, the portion of included scalp, with the tumour itself, being subse- quently dissected away from the pericranium, with which it was in contact. Two small vessels w^ere tied, and the integuments brought nearly together, with adhesive plaster. In three weeks the hgatures were off, and the wound perfectly healed. On examination, the tumour proved to be a strong cartilaginous cyst, seated in the cellular membrane beneath the scalp. The cavity of the cyst was filled with a yellow ])urulont fluid ; the thick parts of which had formed a curdy deposit upon the sides of the cavity. The patient had not lost above an ounce of blood in the opera- tion, but he rather unexpectedly felt his head better the following evening, than for many months before. He found his uneasiness and pain in the head continue to diminish from day to day, and stated, with some degree of surprise, that he also found his sight becoming much stronger, and clearer than before. By the time the wound was healed, he had quite lost all remains of pain in his head, and his sight was so greatly improved, that he was now again able to read the same small-printed book that he had been in the habit of using ten years before ; nor did the pains in the head, or the affection of the sight, afterwards return.* Case 3. F. Przesmycki, aged 30, who had always enjoyed good health, with the exception of occasional rheumatic pains in the head and joints, was suddenly seized in the autumn of 1825, with violent pain shooting from the left temple to the eye and side of the face. This pain was attributed to cold ; it lasted several days, then subsided, but returned periodically without being so se- vere as to lead him to consult a medical man. But in two months it recurred with such intensity, especially in the eye, that that or- gan appeared to the patient about to start from its socket, and at the same time he became sensible of having lost the power of * Howship's Practical Observations in Surgery and Morbid Anatomy, p. 1. London, 1816. 702 vision on that side. This discovery induced him to have recourse to professional assistance, and for six months various plans of treatment were adopted, without any other advantage than that the pain became periodical instead of continual. At the expiration of this period, the pain acquired new force, the cheek became swollen, and during the night, several spoonfuls of bloody pus were discharged from between the conjunctiva and the left lower eyelid ; after which the sweUing subsided, and the pain diminished, but the blindness remained as complete as before. In three weeks a similar discharge took place, and during the next six months it was occasionally repeated. In the winter of 1826, the disease was so severe, that at the commencement of 1827, the patient proceeded to Wilna, with the intention of having the eye removed, if he should find no other means of relief. M. Galenzowski; who was now consulted, found the vision of the left eye lost, the pupil remaining dilated. He conceived that pus had formed in the maxillary sinus, and made its way along the orbital part of the superior maxillary bone : but knowing also that suppurations of the upper jaw frequently depend upon carious teeth, a careful examination was made, and a rotten tooth found corresponding to the antrum. This tooth was extracted, to give a new outlet to the purulent matter, and, to the astonishment of M. Galenzowski and his patient, there was found attached to its root a spUnter of wood, about three lines long, and as thick as the head of a pin. The splinter is supposed to have been originally detached from a tooth-pick of wood, as no other probable explanation could be given. The removal of a probe, introduced into the antrum, was followed by a few drops of sero-purulent fluid, and in nine days afterwards the patient completely regained his sight.* XYIII. Amauj'osis from Worms i?i the Intestines. Among the symptoms generally enumerated as indicative of the presence of worms in the bowels, are dilatation of the pupil, want of lustre in the eye, blueness round the lower eyelid, epipho- ra, paleness of the countenance, headach, throbbing in the ears, and disturbed sleep ; while, in certain cases, we are told that am- aurosis, deafness, and apopletic or epileptic fits, arise from the same cause. The presence, however, even of the majorit}^ of these signs cannot be regarded as conclusive evidence of the existence of worms, nor indeed any other signs whatever, except their actual detection in the alvine excretions, or in the matter vomited by the patient. It must also alwa3'S admit of doubt, whether the amauro- tic symptoms present in those who are troubled with worms, do not spring from some other cause, as hydrocephalus or some mor- bid formation within the cranium. One of my medical friends in- forms me, that he some time ago treated a child, who was amau- * Archives Generales de Medecine, Tome xxiii. p. 261. Paris, 1830. 703 lotic, and who at the same time passed numerous lumbiici, to which he was led to attribute the affection of the eyes. The am- aurosis, however, did not yield to anthelmintic remedies, the child died, and on dissection, the pituitar}^ gland was found dilated into a cyst, which pressed upon the optic nerves, and had caused the absorption of their medullary substance. XIX. Atnaur sis f 7^0171 Acute or Chronic Disorders of the Di- gestive Orgatis. Every person, liable to occasional fits of dyspepsia, makes men- tion of certain symptoms affecting the organs of vision, as distension and stiff"ness of the eyeballs, dazzling and mistiness before the eyes, muscse volitantes, and the hke. These symptoms are generally at- tended by headach, and sometimes by vertigo, and gradually sub- side as the stomach recovers its wonted activity. In some cases, however, the sympathetic effects of indigestion are more alarming, consisting in dilatation of the pupils, sluggishness in the n^otions of the iris, and a great degree of dimness of sight. The patient com- plains, at the same time, of constant acid or foul eructations, with painful heartburn, a feeling of pressure at the scrobiculus cordis, distention of the abdomen, a great degree of flatulence, thirst, nau- sea, general uneasiness and restlessness ; the mouth is bitter, the tongue foul, and the pulse accelerated. All these symptoms, including, among the rest, the amaurotic, speedily subside in general, after the use of some absorbent and laxative medicine, as magnesia usta, or the carbonate of magnesia, a mixture of these with rhubarb and ginger, or the like. Frequently repeated and neglected attacks, however, of this kind, especially in sedentary persons, careless perhaps of their diet, and inattentive to the means of preserving health, lead at last to more serious consequences. The bowels grow habitually inactive, the biliary organs aie impeded in the discharge of their office, the ap- petite is impaired, digestion weakened, the mind becomes habitually fretful, and the spirits depressed. Undor such circumstances, allow- ed to continue uninterruptedly for years, there is not unfrequently produced a slowly increasing weakness of sight, terminating at last in confirmed amaurosis. In Milton, whose case I apprehend to have been one of this sort, the affection of vision went on for ten years before it ended in blindness ; and it sometimes happens, that even a longer period elapses, before the disease is fully developed. The patient, during all this time, complains of a constantly increas- ing imperfection of sight, without being rendered unable, perhaps, to continue his usual employments. Though generally slow in its progress, yet there sometimes occur cases, in which this species of amaurosis is rapid, or even metastatic. The pupil is dilated, the motions of the iris very sluggish and limited, the sclerotica tinged of a yellowish or dusky hue, the vessels of the conjunctiva often turgescent. Every object seems to the pa- 704 tient enveloped in a thick cloud, and not unfrequently he sees only parts of the objects at which he is looking. Dull, stupifying head- ach generally accompanies the failure of sight, extending over the whole head, and depriving the patient, even when a considerable share of vision remains, of all pleasure in those employments which require the exercise at once of sight and thought. Treatment. A relinquishment of whatever appears to have laid the foundation of the affection of the digestive organs is the most important particular in the treatment of this amaurosis ; whether the cause has been severe and protracted study, irregularities in diet, the use of alcoholic and other poisons, want of exercise, impure air, or the like. The patient's food should be plain and easily digested,- he must pay particular attention to keep his bowels regular, he ought to take daily exercise in the country on foot or on horseback, and court the society of the cheerful and well-informed. Alterative doses of mercury will often be useful, and much advantage will be reaped from the use of tonic medicines, judiciously selected and combirred. Beer strongly dissuades from the use of emetics and nauseating medicines in the treatment of amaurosis depending on chronic dis- order of the digestive organs ; also, from all external stimulants, and from electricity or galvanism. Case 1. Scarpa relates the case of a girl, aged sixteen years, of delicate constitution, and who had not menstruated, who towards the end of May, became affected with such a degree of morbid ap- petite, that she could scarcely satisfy it by swallowing every sort of gross food in large quantity, especially bread made of Indian corn. Fatigued also by the hard labour of the country, to which she was not yet accustomed, her sight began to grow dim. Her immoderate appetite suddenly ceased, she felt a bitter taste in her mouth, and began to experience a sense of weight in the region of the stomach, accompanied by nausea and continual headach. She then lost the sight of the right eye entirely, and hn a great measure that of the left. The pupils were considerably dilated, and almost immov- able to the strongest light. She seemed also, as if she had an inci- pient strabismus. On the 4th of June, she took in tablespoonfuk, a solution of four grains of tartar emetic in five ounces of water, which produced a great and continued degree of nausea, but no vomiting, except of a little viscid whitish matter. On the fifth, the same emetic was repeated in the same manner. It produced a more copious vomiting than on the preceding day ; but always of mucous whitish matter. The headach, however, was considerably relieved, as well as the sense of weight in the region of the stomach. The nausea, how- ever, and furred tongue, continued as at first. The pupil appeared a little moveable to a bright light, and with the right eye the patient could distinguish whether it was light or dark. She began to ex- pose the eyes to the vapour of ammonia every two or three hours. 705 On the 6th, she had httle pain in the head, and the mouth was less bitter. Tlie pupil had acquired some degree of motion. She was ordered to take three resolvent powders* daily, and to continue the ammoniacal vapour. On the seventh she had a very little head- ach. The powders had produced nausea for some hours, then two copious stools. The pupil contracted a httle, and the patient could discern the outlines of large objects. By the 8th, the headach was entirely gone, as well as the bitter taste and furred state of the tongue. The pupil also was more sensible. The patient con- tinued to take the resolvent powders on the 9th, 10th, 11th, and 12th, and to use the ammonia. On the 13th, she complained again of headach, and bitterness of the mouth, with foul tongue. Instead of the powders, Scarpa prescribed an emetic of half a drachm of ipecacuanha with a grain of tartar emetic, in consequence of which the patient vomited much yellowish-green matter. The headach ceased immediately, and the girl could then distinguish sufficiently well the objects that were presented to her. On the 18th, she felt herself very well. The pupil of the right eye, which had been the most amaurotic, was even more contracted than that of the left. On the 15th, the patient resumed the use of the resolv- ent powders, and continued the external application of the ammon- ical vapour. On the 16th. she could distinguish with the right eye a small needle. During the 17th, 18th, 19th, and 20th, the pow- ders produced two copious stools daily, without at all weakening the patient. She had a good appetite, and digested well. On the 21st, a decoction of cinchona, with infusion of valerian root, was substi- tuted for the resolvent powders. She was able in a few days to see the most minute objects, as well with the one eye as the other. She had acquired a good complexion, and the strabismus had almost entirely disappeared. She was dismissed perfectly cured, but ad- vised to continue the use of the vapour for a week longer, to take morning and evening a powder, composed of one drachm of cin- chona, and half a drachm of valerian, to observe a regular diet, and to avoid the scorching rays of the sun.t Case 2. Ehzabeth Healey, a slender delicate young woman, about 25, of a sedentary occupation, an emaciated figure, and feeble melancholic temperament, applied to Mr. Lessey on the 9th of June, 1820, for relief of an affection of the bowels, to which she had been liable for several years, requiring, even in a state of comparative convalesence, the constant use of purgatives. Indeed, the derange- ment of the abdominal viscera was so great and permanent, as to induce a belief that it was of an organic nature. In addition, she was liable to frequent and severe cephalalgia, and occasionally to attacks of dyspnoea, with spasms of the chest and throat, which, on her attempting to swallow, produced alarming symptoms of suffocation. These attacks were sudden and violent, were attended by great * See page 652. t Trattato delle principali Mallattie degli Occhi. Vol. ii, p. 281. Pa\ia, 1816. 89 706 feebleness of the voice, and succeeded by exhaustion. Her bowels: had been frequently relieved by mercurial and saline cathartics, the attacks of cephalalgia by venesection, and the application of leeches and blisters to the head and neck, and the affection of the lungs by a variety of remedies. She had an attack of disordered bowels in January, 1821, which appeared to be yielding to remedies, when she was suddenly seized, on the 23d, with violent dyspnoea. Every attempt to swallow, or even to speak, was followed by a convulsive spasm of the throat and chest, attended with frequent sobbing.* A few doses of ether and opium, with a blister on the sternum, relieved the immediate urgency of the symptoms ; but still the breathing continued labori- ous, and the voice, which had long been feeble, was reduced to a scarcely audible whisper. The derangement of her abdominal viscera returned ; her stools were green and slimy ; her pulse was feeble and her general debility so great, that Mr, Lessey despaired of her recovery. She remained in this state, with little variation, till the 15th of February, when the difficulty of breathing suddenly left her, and her voice became distinct, strong, and clear ; but a sudden and violent pain seized her head, and, to the astonishment of the people around her, she screamed out loudlj^ for help. Hastening to her assistance, the}^ found her in an agony of pain, and quite blind. Mr. Lessey immediately ordered her head to be shaved, and a bhster applied to it, with a dozen of leeches to the temples, which abated the violence of the pain, but produced no alteration in her sight. The eyes were fixed, and nearly motionless ; the pupil steady at a medium point, between contraction and dilatation, and totally insensible to hght. On presenting a candle suddenly to her eyes, she exhibited no con- sciousness of its presence, unless it was sufficiently near for her to feel the the warmth of its rays. Blisters were applied to her temples, dressed with cantharides ointment, and frequently repeated, so as to keep up a discharge for weeks. The bowels continued torpid, and required the constant use of purgatives. Blue pill was next tried, and her gums were slightly affected, but without any effect on her sight. Her voice continued strong, her breathing easy, and,, in fact, the affection of the chest appeared to have left her entirely. The pain in the head was considerably abated, but the vision remained so entirely lost, that all hopes of its recovery were aban- doned, and she was sent to the Manchester workhouse, as an incur- able amaurotic. Three months after her admission, she had a severe attack, both in her chest and bowels, obstinate constipation, dyspnoea, with violent * Such paroxysms, as are here described by Mr. Lessey, are generally regarded as- hysterical. In a female subject, who had long been subject to such fits, I found, on dissection, the heart of a remarkably small size. She had been bled exceedingly often in the course of the five or six years preceding her death, and perhaps to this circumstance the smallness of the heart might be owing. 707 spasm, and great difficulty of swallowing. This attack lasted three weeks, and subsided slowly. At the latter end of 1822, she had a slight attack of pleurisy, which yielded to bleeding, blistering, and the usual treatment ; after which she remained tolerably free from all her complaints, excepting slight headachs. Although she entertained little or no hope of again recovering her sight, yet she occasionally tried her eyes with a candle. On the evening of the 29th of October, she perceived no ghmmering whatever ; but, to her great surprise, on the following evening, as a person was conducting her through the streets, she saw a confused appearance of fire, and exclaimed, What is the matter with wiy eyes 7 In the course of a few minutes, she discovered that it pro- ceeded from the gas lamps, which she saw indistinctly. Her sight gradually improved during the course of the evening. Next day Mr. Lessey found that there was considerable mistiness and obscurity in her vision, with muscse volitantes, of a fiery hue ; but that she could distinguish the featiu'es of her acquaintances, and could even read the large capitals of a hand-bill, the smaller print seeming con- fused, and blended together. All distant objects were mixed up with coloured mists, and consequently indistinct and confused. On the 20th of November, her sight remained much the same. It had got better, however, during the interval, but was injured again by injudicious exposure to a highly heated room. The col- oured mists still troubled her occasionally ; the muscse volitantes were sometimes very numerous, and appeared mixed, she said, with white flakes like snow. She could not read better ; but, with the help of a double concave glass, she could distinguish print, which, to her naked eye, was a confused mass. Her bowels and lungs had been free from disease for twelve months, and she exulted in the prospect of ultimate recovery.* Case 3. Mr. Samuel Smith, aged 52, a patient of Mr. Gooke, had enjoyed a remarkably good state of health, with the exception of an occasional attack of lumbago, and, during two years, intima- tions of dyspepsia. The remedies employed for these were of the mildest character, usually affording temporary relief Early in 1826, he became the subject of more severe indisposition, the leading features of which were derangements in the digestive organs, particularly the liver, with some tenderness in the region of that viscus. This state, accompanied with pains, affecting the head, jihoulders, loins, and chest, was ascribed to exposure to cold, after the loss of a considerable quantity of blood from the socket of a loose tooth removed by a dentist. After an attack of lumbago, the right temple became exceedingly painful ; the left temple and the shoul- ders were successively affected, and ultimately the pectoral muscle of the right side, and the flexor muscles of the arms. The patient described the pains as gnawing, with exacerbation towards night ; ** Edin. Medical and Surgical Journal. Vol. xxv. p. 319. Edin. 1826. 708 the pain of the head being seated in the external parts, and not attended by internal throbbing or giddiness. Conjointly with attention to the state of the hepatic secretion, the application of leeches to the right hypochondrium, and a moderate abstraction of blood from the arm. the acetum colchici was adminis- tered, and fomentations, as well as solution of opium, were applied, during the more distressing paroxysms of pain, to the head. In little more than a fortnight the pain ceased, and in a few days more he ventured into business. Still the progress of recovery was very slow ; his appetite remained capricious, his bowels irregular, his sleep was interrupted, he had tenderness in the epigastrium, and his muscular powers v/ere feeble. At this period, he observed that his sight was not quite so clear as formerly ; for, though after looking towards an object for a short time he could see it distinctly, yet the eyes were longer in adapting themselves to changes of hght than is usually the case ; and he was constantly annoyed by muscse volitantes in both eyes. These illusions were regarded as a nervous derangement, and the patient was led to hope that they would disappear as he gained strength. A change of air was recommended, and he went to Hastings on the 23d of May. During his stay on the coast, a period of from five to six weeks, his general health was a little improved ; but after the first fortnight, he began to experience a violent pulsation on the left side of his head. He returned to Camberwell the 2ist or 22d of June, much the same in general health, and with no improvement in his eyes. Some days afterwards he found the right eye becoming more dim and on the night of June 29th, it became nearly dark. On Satur- day the 30th, Mr, Cooke was requested to see him. There was no appearance of inflammation, but a very slight opacity of the pupil. He complained of pain and pulsation along the left side of the head, but there had been no aggravation of this affection to explain the increased dimness in the opposite eye. The abstraction of twelve ounces of blood, by cupping, was immediately ordered ; a blister was afterwards applied to the nape of the neck, and grain doses of calomel, with some tartarized antimony, were directed to be taken every six hours. On Monday, Mr. Travers saw him. On the morning of that day, the eye had become inflamed for the first time, was greatly discoloured, and tender on pressure. With the right eye he could only distinguish hght from darkness ; the vision of the left was rather obscure. Mr. Travers concurred in the use of calomel and antimony, till ptyalism should be produced, ordered him to be again cupped, and recommended an opiate at night. In about four days he was sali- vated, without any amendment of sight. It was kept up mildly till another interview with Mr. T., when some improvement of diet was agreed upon. On Thursday evening, the left eye became dark to such a degree that he was unable to recognise his friends. 709 A consultation was now proposed with Dr. Farre. At this period the right eye was still much deeper coloured than natural, but no appearance of inflammation remained. The left eye looked heal- thy, but the movement of the iris was very indistinct. Dr. F, regarded it as an example of asthenic amaurosis, and prescribed tonics. At this time the patient was fully mercurialised. Within a few days after the adoption of the tonic plan, the morbid colour of the right eye disappeared, and a very shght motion was per- ceptible in the iris ; while the iris of the left eye became decidedly more sensible and mobile. The patient's general health improved ; the mercurial action decUned ; and all appeared going on well. At this time, however, Mr. Cooke was desired to see a swelling on the back, and found an indolent carbuncle, the size of a walnut, be- tween the shoulder and neck. This was freely incised without pain, and one or two red pimples were observed on other parts of the back. In two days one of these pimples had extended very greatly. It was seated near the right scapula, in the fleshy substance of the back, with extensive inflammation of the adjacent parts, and a dark vesicle on its surface. A deep incision relieved both the pain and tension. At this period, the 21st of July, he was using inter- nally a decoction and tincture of bark with sulphuric acid. In a few days, it was evident that the sensibility of both eyes had de- creased, especially that of the left. The iris could scarcely be observed to move, and the membranes had become discoloured as those of the right were a week before. From this period, till the termination of the case, the treatment directed against the carbuncular action, which became strongly manifested, was persevered in, and was occasionally attended with temporary improvement of the general health. In addition to tonics and nutritious diet, he had also at one time small doses of blue pill, and the bowels were kept regular by mild laxatives. On the 27th of July, profuse haemorrhage occurred from the removal of two very loose teeth ; and on the 8th of August, diarrhoea with tenesmus, supervened, which was removed, in a few days, by pro- per remedies. During this month, also, the abdomen was observed to be enlarged, and on careful examination by Mr. C, at the com- mencement of September, the liver and spleen were foimd of great size, the latter extending below the umbilicus. In October, he became progressively worse, and died on the eighth of the month following, frequent bloody and purulent discharges by stool having occurred for several days previous to dissolution. On examination after death, the eyes did not present an unnatural appearance, except that perhaps there was a little more cloudiness in the pupils than usual. The scalp and dura mater adhered (o the cranium with unnatural firmness, some fluid was effused between the membranes of the brain, and the pia mater presented a highly vascular appearance. The optic nerves anterior to their union ap- peared of full size, and healthy in texture ; but posteriorly towards 710 the thalami they were excessively softened. The cerebral substance exhibited rather more numerous points of blood than we find in the healthy brain ; this was more particularly manifest over the thai- ami nervorum opticorum. and in a greater degree on the right than on the left. The right thalamus was greatly softened in texture, and on its anterior surface the hning membrane appeared thickened and opaque, as if from a deposition of lymph. The left thalamus was in a similar state, though not to an equal extent. The left corpus straitum was unusually prominent. On opening the abdomen, the spleen first presented itself to view. It weighed four pounds and a half, and its surface was uniform, though it contained a few tubercles. The liver was double the usual size, and indurated, without apparent alteration of structure. The mucous coat of the intestines was much eroded by ulceration, and where that process had not gone on, was of a deep red colour. The cavity of the abdomen contained about iwo pints of serous fluid.* * Journal of Morbid Anatomy, Vol. i. p. 24. London, 1828. INDEX. Abscess of anterior chamber, 405 of cornea, 401 of orbit, 214 Abscission of iris, 555 Absorption of orbit from pressure, 49 cure of cataract by, 529 Accidental colours, 616 Albino wants choroid pigment, 587 Albugo, 411 Amaurosis, causes of, 641 classifications of, 655 consequent to scarlatina, 670 consequent to suppressed men- ses, 671 consequent to suppressed per- spiration, 673 consequent to suppressed pur- ulent discharge, 673 definition of, 637 diagnosis of, 649 from absorption of pigmentum nigrum, 591 from acute or chronic disor- ders of digestive organs, 703 from aneurism of central arte- ry of retina, 666 from aneurism of cerebral ar- teries, 664 from apoplexy, 664 from belladonna, 693 from blows on eye, 258, 260 from cerebral plethora and congestion, 660 from chronic diarrhcea, 698 from concussion or other inju- ry of head, 668 from depressed lens, 499, 509 from disease in antrum, 701 from disease of frontal sinus, 56 from disease of lacrymal or- gans, 181 from dropsy of the eye, 440, 442, 444 from excessive venery, 700 from exostosis of the orbit, 38 from fractured cranium with depression, 658 from inanition or debility, 697 from inflammation of choroid, 383 from inflammation of eye, 429 from inflammation of orbital cellular membrane, 214 from inflammation of retina, 389 from inflammation of internal optic apparatus, 666, 670, 671, 673 Amaurosis from injuries of branches of fifth pair, 103 from intense light, 666 from intoxication, 661 from irritation of branches of fifth pair, 700 from lightning, 655 from masturbation, 700 from morbid changes affecting fifth pair, 692 from morbid changes in optic nerves, 678 from morbid changes in mem- branes or bones of cranium, 627 from morbid formations in brain, 681 from orbital aneurisms, 249 from orbital exostosis, 38 from orbital tumours, 222 from ossification of choroid or retina, 431 from over exercise of the sight, 666 from poisons, 833 from pressure on eye, 257 from sanguineous extravasation in the head, 658 from tobacco, 694, 695 from tumour on crown of head and eyelid, 701 from worms, 702 i from wounds of eye, 257 from wounds of eyebrow or eye- lids, 102 general account of, 637 illustrations of the species of, 658 its diagnosis from cataract, 472 actantium, 699 neuralgia, 673 prognosis in, 650 rheumatica, 673 seat of, 638 stages and degrees of, 649 symptoms of, 643 treatment of, 650 with iritis after typhus, 362 Amblyopia, 637 Anchylo-blepharon, 416 Anel's probe, uses of, 193, 194 syringe, injections with, 170 Aneurism by anastomosis in orbit, 240 by anastomosis of eyelids, 127 of cerebral arteries, a cause of amaurosis, 664 of central artery of retina, in- duces amaurosis, 666 of ophthalmic artery, 247 712 Anterior dvamber, abscess of, 405 osseous deposit in, 430 Antrum, disease of, 62 disease of, causing amaurosis, 701 Apoplexy, amaurosis from, 664 state of pupil in, 576 Aqueous chambers, abolition of, 426 humour, evacuation of, 372 humour, loss of, 252 Aquo-capsulitis, 391 Arthritic iritis, 374 Artificial eye, adaptation of, 433 pupil, 548 pupil, accidents attending forma- tion of, 573 pupil, by excision, 549 pupil, by incision, 548, 564 pupil, by separation, 549 pupil, compound operations for, 572 pupil, general rules regarding, 555 pupil, states of eye requiring, 551 Assalini's operation for artificial pupil, 568 Atresia iridis, 354, 421 Atrophy of eye, 422 Balls passing through orbit, 18 Beer's artificial pupil by incision, 563 cataract knife, 514 classification of amauroses, 656 Bell's operation for cataract, 527 Belladonna, amaurosis from, 693 uses of, 358, 502, 552 Blenorrhcea of the excreting lacrymal or- gans, 177 Blepharospasmos, 139 Blood effused into eye, 446 Blows on eye, 257 Bonzel's operation for artificial pupil, 568 Brain, morbid formations in, producing amaurosis, 681 partial loss of, in wounds of orbit, 23 Buchhorn's improvement of the operation for cataract, 537 Burns of cornea, 255 of eyelids, 98 Buzzi's operation for artificial pupil, 568 Calculus, lacrymal, 95, 200 Callosity of eyelids, 120 Cancer of eyelids, 121 of eyeball, 451 soft, of eyeball, 453 Carbuncle of eyelids, 109 Caruncula lacrymalis, fungus of, 170 lacrymalis, inflammation of, 169 lacrymalis, scirrhus of, 170 Capsule, aqueous, inflammation of, 391 crystalline, inflamed, 394 Caries of exostosis of orbit, 41 of fossa lacrymalis, 34 of orbit, 26, 152 of OS unguis, 188 Cataracta arborescens, 480 cystica, 250, 485 fenestrata, 485 lymphatica, 355, 486 pyramidata, 487 tremulans vel natatiUs, 4S5 traumatica, 256 Cataract, 471 anterior capsular, 481 bursal, 486 capsular, 481 capsulo-lenticular, 483 causes of, 476 central, 483 classifications of, 480, 488 complications of, 490 congenital, 485, 489, 495 couching of, 498 cure of, by absorption or disso- lution, 529 definition and diagnosis of, 471 depression of, 498, 544 displacement of, 498, 544 division of, 528, 540 examination of cases of, 475 extraction of, 499, 541 fibrinous, 486 fluid, 489 genera and species of, 480 green, 489, 491 glasses, 546 hard, 488 _ history of pathology of, 580 lenticular,- 481 mixed, 489 Morgagnian, 483 pigmentous, 353, 488 operations for, 498 posterior capsular, 482 prognosis in, 478 purulent, 487 reclination of, 498, 544 sanguineous, 487 secondary, 544 siliquose, 485 soft, 488 tough, 488 trabecular, 487 treatment of, without operation, 492 questions regarding removal of, by operation, 494 Cataracts from inflammation, 421 spurious, 486 true, 481 Catarrhal ophthalmia, 273 Catarrho-rheumatic ophthalmia, 342 Cats-eye, 591 Cellular membrane of orbit, infiltration of,, 217 of orbit, inflammation of, 313 of orbit, scirrhus of^ 219 Celsus acquainted with the operation of division, 528 713 Cerebral plethora and congestion causing amaurosis, 660 Chemosis, 271, 281 Cheselden's operation for artificial pupil, 548 Choroid, ossified, 431 wounds of, ge7 Choroiditis, 380 ^^' Chrupsia, 612 Coarctation of retina, 383 Coloboma, 101 Coloured vision, 612 Colours, accidental, 616 insensibility to, 609 Compound ophthalmise, 399 Compressibility of brain doubted, 641 Concussion of brain, a cause of amaurosis, 668 Conical cornea, 437 Conjunctiva arida, 165 foreign substances in folds of, 158 fungus of, 165 fungus of, from foreign bo- dies, 159 granular, 287, 415 injuries of, 158 inflammations of, 270 tumours of, 167 warts of, 167 Conjunctivitis, in general, 270 catarrhalis, 273 erysipelato sa, 332 gonorrhoica, 302 leucorrhoica, 298 morbillosa, 336 phlyctenulosa, 317 puro-mucous, 272 puro-mucosa atmospherica, 273 puro-mucosa contagiosa, vel Egyptiaca, 278 pustulosa, 318 scarlatinosa, 336 scrofulosa, 316 variolosa, 332 Corectomia, 566 Conradi's operation for cataract, 536 Contusion of cornea, 248 Contusions on edge of orbit, 2 of eyebrow and eyelids, 97 Convulsions after wounded brain through orbit, 8 of eyeball, 213 Cornea, abscess of, 401 bums of, 255 conical, 437 contusion of. 248 fistula of, 40'8 foreign substances adhering to, 248 foreign substances imbedded in, 349 hernia of, 408 injuries of, 248 90 Cornea, inflammation of, 347 its mode of growth, 412 lining membrane of, inflamed, 391 penetrating wounds of, 252 punctured wounds of, 251 rupture of, 295 specks or opacities of, 411 ulcers of, 407 and iris, staphyloma of, 423 Corneitis scrofulosa, 347 Corodialysis, 568 Corotomia, 561 Couching, 498 Counter-fractures of orbit, 5 Crampton's operation for entropium, 156 Cranium, fractures of, 4 membranes or bones of, diseased, producing amaurosis, 687 pressure on orbit from cavity of, 69 Crystalline lens and capsule, injuries bf, 256 Dacryocystitis acuta, 171 chronica, 177 Daviel's operation for cataract, 512 Day-blindness, 631 Debility, amaurosis from, 697 Deformation of orbit, 49 Depression of cataract, 498, 499, 501, 544, through cornea, 502 through sclerotica, 502 Diarrhoea, chronic, a cause of amaurosis, 698 Digestive organs, amaurosis from disor- ders of, 703 Dilatation of orbit, 49 Dimple of cornea, 408 Diplopia, 200 Dislocation of eye, 14, 260 lens, 256 Displacement of cataract, 499, 544 pupil, 383 Dissolution of vitreous humour, 422 Distichiasis, 153 Distortion of eyeball, 211 Division of cataract, 500, 540 through cornea, 534 through sclerotica, 528 Donegana's operation for artificial pupil, 572 Double vision from want of correspon- dence in muscles of eyeball, 204 Dropsy of aqueous humour, 440 eye, 440, 445 vitreous humour, 444 subchoroid, 442 subsclerotic, 442 Dryness of eye, 74 Ducts, lacrymal, injuries of, 74 nasal, exostosis of, 201 nasal, injuries of, 171 nasal, obliteration of, 201 nasal, obstruction of, 193 714 Dura mater and pericranium, disease of, inducing amaurosis, 688 Earl's instrument, for extracting cataract, EcchjTDosis of eyelids, 97 under conjunctiva, 161 Ecthyma cachecticvun aifecting iris, 370 Ectropium, 145 Etfusion of blood into eye, 446 Effusions into eyeball, 437 Emphysema of eyelids, 110 subconjunctival, 161 Encanthis benigna, 170 maligna, 170 Encysted tumours in orbit, 220 of frontal sinus, 57 eyehds and eyebrows, 118 Enlargement of lacrymal gland, 78 Enlargements of eyeball, 437 Entropium, 154 Epiphora, 75 Erysipelas of eyelids, 105 Erj'sipelatous ophthalmia, 332 Evacuation of aqueous humour, 393 Eversion of eyelids, 145 Evulsion of eyeball, 261 Excision, artificial pupil by, 549, 557, 566 Excrescence of iris, fungous, 450 Excoriation of lower eyehd, 147 Exophthalmia, 88, 382 fungosa, 165 Exophthalmos, 38, 42, 71,72, 87, 88, 214, 215, 219, -240, 247, 384 Exostosis, cartilaginous, of orbit, 44 from maxillary sinus, 45 of orbit, 35, 37 of orbit, carious, 41 of nasal duct, 201 varieties of, 37 Extirpation of eyeball, 42, 167, 225, 469 of lacrymal gland, 80 of maxillary fungus, 65 of orbital tumours, 221 Extraction of cataract, 499, 541 of cataract, through semicir- cular incision of cornea, 511 of cataract, through section of one-third of cornea, 524 of cataract, through sclerotica, 527 Eye, adaptation of artificial, 433 apoplexy of, 445 blows on, 257 gunshot wounds of, 260 modes of fixing, during operations, 496 pressure on, 257 saniTuineous effusion into, 446 Eyeball, atrophy of, 422 convulsions of, 213 dislocated, 14, 260 enlargements of, 437 evalsioa of, 261 Eyeball, extirpation of, 42, 167, 225, 46^ immovable distortion of, 211 inflammatory diseases of, 261 ' '•■ injuries of, 248 ^ i melanosis of, 459 scirrhus of, 451 spongoid, or medullary tumour of, 453 oscillation of, 211 tumours within its coats, 437 Eyebrow, injuries of, 97 wounds of, 100 Eyelashes, false, 153 inversion of, 153 Eyelid, upper, falling down of, 141 upper, palsy of, 143 tumour on, producing amaurosis, 700 _ Eyelids, aneurism by anastomosis of, 127 bums and scalds of, 98 callosity of, 120 cancer of, 121 carbuncle of, 109 contusion and ecchymosis of, 97 emphysema of, 110 encysted tumours of^ 118 erj'sipelatous inflammation of, 105 eversion of, 145 extirpation of, 121, 126 inflammation of edges of, 111 injuries of, 97 inversion of, 154 naevus maternus of, 127 oedema of, 109 phlegmonous inflammation of, 105 retraction of, 144 spasm of, 139 syphilitic ulceration of, 126 twitching or quivering of, 138 warts of, 118 wounds of, 100 Far-sightedness, 604 Fifth pair, injuries of branches of, 103 irritation of, inducing amauro- sis, 700 morbid changes of, inducing amaurosis, 692 neuralgia of, 142 Fistula of cornea, 407 of lacrymal sac, 185 of lachrymal sac, spurious, 106j 107 true lacrymal, 94 Foreign body in orbit, 12, 14 substances adhering to cornea, 248 substances imbedded in cornea, 249 substances in folds of conjunctiva, 158 Fractured cranium with depression, a cause of amaurosis, 658 715 Fractures of cranium, 4, 658 of edge of orbit, 4 of walls of orbit, 4 Frontal sinus, diseases of, induce amauro- sis, 56 sinus, encysted tumours of, 57 sinus, polypus of, 60 sinus, pressure on orbit from, 55 sinus, trepanned, 57 Fungus hsematodes of brain producing amaurosis, 687 hffimatodes of eyeball, 453 of antrum, 65 of caruncula lacrymalis, 170 of conjunctiva, 165 of conjunctiva, from foreign bo- dies, 160 Gibson's mode of extracting soft cataracts, 525 Gland, lacrymal, enlargement or scirrhus of, 78 lacrymal, extirpation of, 80 lacrymal, inflammation and sup- puration of, 76 lacrymal, injuries of, 73 lacrymal, scrofulous enlargement of, 77 lacrymal, lacrymal tumour in, 86 Glands of cilia, inflammation of, 111 Glasses for cataract-patients, 546 for long-sightedness^ 607 for short-sightedness, 600 periscopic, 600, 608 Glaucoma, 580 dissections of eyes in the state of, 584 its diagnosis from cataract, 587 often mistaken for amaurosis, 689 Gonorrhoeal ophthalmia, 302 Grando, 117 Granular conjunctiva, 287, 415 Gutta opaca, 471 serena, 637 Hemeralopia, 627, 631 Hemiopia, 632 Hernia of cornea, 407 of iris, 407 of lacrymal sac, 189 Himly's operations for artificial pupil, 547, 568 Hordeolum, 117 Hyaloid membrane dissolved, 422, 586 membrane ossified, 432 Hydatid in brain producing amaurosis, 684 of frontal sinus, 56 of lacrymal gland, 87 Hydrocephalus, amaurosis from, 657, 670 Hydrops of lacrymal sac, 191 Hyperostosis of orbit, 35 Hypochyma, 581 V Hypopium, 405 Illusions, spectral, 624 Inanition, amaurosis from, 697 Incision, artificial pupil by, 548, 557, 561 through cornea, artificial pupil by, 563 through sclerotica, artificial pupil by, 562 Infiltration of orbital cellular membrane, 217 Inflammation of aqueous capsule, 391 bones of orbit, 26 caruncula lacrymalis, 169 choroid, 380 conjunctiva, 270 cornea, 347 crystalline lens and cap- sule, 394 •eyelids, erysipelatous, 105 eyelids, phlegmonous 105 edges of eyelids. 111 excreting lacrymal organs, acute, 171 excreting lacrymal organs, chronic, 177 frontal sinuses, 55 hyaloid membrane, 347 internal optic apparatus, a cause of amaurosis, 666, 670,671,673 iris, 350 lacrymal gland , 76 Meibomian follicles, 11 1 orbital cellular membrane, 28, 213 periosteum of orbit, 26 retina, 386 semilunar membrane, 169 Inflammations of eye from injuries, 397 Injections of lacrymal passages, 181 Injuries of branches of fifth pair, 103 conjunctiva, 158 cornea, 248 crystallme lens and capsule, 256 eyeball, 248 eyebrow and eyelids, 97 head, amaurosis from, 668 iris, 255 lacrymal canals, 171 lacrymal gland and ducts, 73 lacrymal sac, 171 muscles of eyeball, 202 nasal duct, 172 orbit, 1 Insensibility to certain colours, 609 Intermittent ophthalmia, 400 Intoxication inducing amaurosis, 661 Inversion of eyelashes, 153 eyelids, 154 Iris, fungous excrescence of, 450 hernia of, 408 inflammation of, 350 injuries of, 255 its motions eflfected through third pair, 640 paralysis of, 580 716 Iris, preternatural states of, 575 prolapsus of, 252 staphyloma of, 422 tremulous, 579 Iritis, 350 arthritica, 374 from ecthyma cachecticum, 370 pseudo-syphilitica, 370 rheumatica, 359 scrofulosa, 372 syphilitica, 364 with amaurosis after typhus, 361 Irritation of branches of fifth pair, amauro- sis from, 700 Jaeger's (C.) operation forentropivun, 155 (F.) operation for entropium, 155 Janin's operatiou for artificial pupil, 564 Kepler explains eflFects of glasses, 599 Laceration of retina, 259 Lacrymal calculus, 95, 200 canals, injuries of, 171 canals, obstruction of, 193 fistula, true, 94 gland and ducts, injuries of, 73 gland, enlargement or scirrhus of, 78 gland, extirpation of, 80 gland, inflammation and sup- puration of, 76 gland, lacrymal tumour in, 86 gland, scrofulous enlargement of, 77 organs, acute inflammation of excreting, 172 organs, chronic inflammation of excreting, 177 organs, diseases of excreting, 171 organs, diseases of secreting, 73 organs, diseases of induce amau- rosis, 181 sac, fistula of, 185 sac, injuries of, 172 sac, hernia of, 189 sac, hydrops of, 191 sac, mucocele of, 191 sac, relaxation of, 189 sac, spurious fistula of, 106, 107 sac, varix of, 192 tumour in lacrymal gland, 86 tumour in subconjunctival cellu- lar membrane, 92 Lagophthalmos, 33, 144 Langenbeck improves operation for artifi- cial pupil, 561, 569 Lapis divinus, 198 Lens and capsule, injuries of, 256 dislocation of, 256 opacity of, 480 ossified, 432 Lentitis, 394 Leucoma, 412 Leucorrhoeal ophthalmia, 298 Light, amaurosis from intense, 666 Lippitudo, 116 Luscitas, 211 Madarosis, 157 Marmaryge, 605 Masturbation, a cause of amaurosis, 700 Maunoir's operation for artificial pupil, 564 Maxillary sinus, exostosis from, 44 sinus, fungus or polypus of, 65 sinus, pressure on orbit from, 62 sinus, pus in, 62 Measles, ophthalmia from, 336 Meibomian apertures, obliteration of, 113 Melanosis of eyeball, 459 Menses, suppressed, a cause of amaurosis, 671 Mercury in iritis, 357 MUium, 118 Morbillous ophthalmia, 336 Mucocele of lacrymal sac, 191 Muscae voUtantes, 621 Muscles of eyeball, double vision from want of correspondence in, 204 of eyeball, injuries of, 202 of eyeball, palsy of, 203 Mydriasis, 576 Myocephalon, 318 Myopia, 593 Myosis, 575 Naevus maternus of eyelids, 127, 240 Nasal duct, exostosis of, 209 duct, injuries of, 172 duct, obstruction of, 195 Near-sightedness, 593 Nebula, 411 Necrosis of orbit, 26 Neuralgia, circumorbital, 86 Neuralgic amaurosis, 673 Nictitation, morbid, 139 Night-blindness, 627 Nostril, pressure from, on orbit, 51 Nyctalopia, 627, 631 Nystagmus, 213 Obliteration of pupil, 421 Obstruction of lacrjmial canals, 193 nasal duct, 195 puncta lacrymalia, 193 Oscillation of eyeball, 211 Ocular spectra, 616 CEdema of eyelid, 109 Onyx, 401 Opacities of cornea, 411 Opacity of crystalline capsule, 489 lens, 481 Operation for anchylo-blepharon, 419 cataract, questions regarding, 494 choice of, 539 eversion of eyelids, 145 147 w 1 w Operation for inversion of eyelids, 156 sym-blepharon, 420 Operations for artificial pupil, 557 compound, 572 cataract, general account of, 498 cataract, position of patient dur- ing, 496 cataract, indications and con- traindications for, 539 'Ophthalmia arthritica, 374, 590 catarrhal, 273 catarrho-rheumatica, 342 contagious, 278 Egyptian, 276, 278 epidemic, 275 erysipelatosa, 332 gonorrhoica, 302 irritable, attendant on gonor- rhoea, 314 Jeucorrhoica, 298 morbillosa, 336 neonatorum, 298 of new-born children, 298 phlyctenulosa, 317 porriginosa, 333 pseudo-syphilitica, 370 puerperal, 309 purulent, 278 purulent of infants, 290 pustulosa, 318 rheumatica, 337 scarlatinosa, 336 scrofulous, 316 syphilitica, 364 tarsi. 111 traumatica, 398 variolosa, 333 Ophthalmiae, 261 classification of, 264 compound, 399 diseases consequent to, 401 intermittent, 400 remedies for, 265 Ophthalmic artery, aneurism of, 247 Ophthalmo-blenorrhoea, 278 Optic nerve, tumour encircling, 225 nerves, destruction of, 680 nerves, morbid changes in producing amaurosis, 678 nerves, semi-decussation of, 632 nerves, their origin and connexions, 637 Orbicularis palpebrarum, palsy of, 140 Orbit, abscess of, 214 absorption of, 49 caries of, 26, 152 counter-fractures of, 5 deformation of, 49 dilatation of, 49 diseases of, 1 exostosis of, 35 fractures of, 4 gunshot wounds of, 17 hyperostosis of, 35 incised wounds of, 16 Orbit, injuries of, 1 necrosis of, 26 osteo-sarcoma of, 35 ostitis of, 26 penetrating wounds of, 5 periostitis of, 26 periostosis of, 35 pressure on, from cavity of cranium, 69 on, from frontal sinus, 55 on, from maxillary sinus, 62 on, from nostril, 51 on, from sphenoid sinus, 69 on, from within orbit, 51 tumours in, 219 Orbital aneurisms, 240 cellular membrane, infiltration of, 217 cellular membrane, inflammation of, 213 cellular membrane, scirrhus of, 219 Osseous deposit in anterior chamber, 430 Ossification in difl:erent parts of eye, 429 of choroid, 431 of cornea, 430 of crystalline capsule, 432 of hyaloid membrane, 432 of lens, 432 of retina, 431 Os unguis, caries of, 188 Osteo-sarcoma of orbit, 35, 47 Palpebra ficosa, 415 Palsy from penetrating wound of orbit, 10 of levator palpebrse superioris, 142 of muscles of eyeball, 202 of orbicularis palpebrarum, 140 of upper eyelid, 142 of upper eyelid, from wounds, 102 Paralysis of iris, 580 Periostitis of orbit, 26 Periostosis of orbit, 35 Periscopic glasses, 600, 608 Perspiration, suppressed, causes amauro- sis, 673 Phlegmon, subconjunctival, 162 Phlegmonous inflammation of eyelids, 100 Phlyctenula of eyehds, 118 Phlyctenular ophthalmia, 317 Photophobia, 139 Photopsia, 614 infantum scrofulosa, 140 Phtheiriasis, 157 Phthisis oculi, 422 Figmentum nigrum, amaurosis from de- ficiency of, 591 nigrum, congenitally deficient in albino, 587 nigrum deficient in glaucoma, _584 nigrum removed by absorp- tion 591 Pinguecula, 164 Pituitary gland converted into cyst pro- ducing amaurosis, 680 718 Pladarotes, 414 Poisons, amaurosis from, 693 Polypus in nose pressing on orbit, 51 of frontal sinus, 60 of maxillary sinus, 64 Porriginous ophthalmia, 324 Pott's operation for cataract, 528 Presbyopia, 604 Pressure on eye, amaurosis from, 257 on orbit, effects of, 49 on orbit from frontal sinus, 55 on orbit from cavity of cranium, 69 on orbit from cavity of nostril, 51 on orbit from sphenoid sinus, 69 on orbit from within orbit, 51 on orbit from maxillary sinus, 62 Prolapsus of iris, 252 operation of, 469 Psorophthalmia, 111 Pterygium, 162 crassum, 162 fleshy, 165 pingue, 164 tenue, 162 Ptosis, 140 Puerperal ophthalmia, 309 Puncta lacrymalia, obstruction of, 193 Pupil, artificial, 548 contraction of, 575 dilatation of, 576 displacement of, 383 obliteration of, 421, 553, 554 Pupils, affections of, in compression of the brain, 659 contract during sleep, 575 their occasional mobility in amau- rosis explained, 644 Pustular ophthalmia, 318 CLuivering of eyelids, 138 Read's treatment of granular conjunctiva, 416 Reclination of cataract, 498, 501, 544 of cataract through cornea, 502 of cataract through sclerotica. 502 Reisinger's instrument for artificial pupil, 569 Relaxation of lacrymal sac, 189 Retina, aneurism of its central artery, in- duces amaurosis, 666 coarctation of, 383 its probable structure, 633 laceration of, 259 ossified, 432 pressure on, by depressed lens, 501, 509 Retinitis, 386 Retraction of eyelids, 144 Rheumatic amaurosis, 673 iritis, 359 ophthalmia, 337 Rupture of cornea, 284 Sarcosis bulbi, 165 Scarlatina, amaurosis attending, 670 Scarlatinous ophthalmia, 336 Scarpa's operation for artificial pupil, 549 Schmidt's operations for artificial pupil, 568 Scirrhus of caruncula lacrymaUa, 170 of eyeball, 451 of lacrymal gland, 78 of orbital cellular membrane, 219 Sclerotica, wounds of, 257 Sclerotitis rheumatica vel atmospherica, 337 Scrofula affecting bones of orbit, 32, 39 affecting conjunctiva, 316 affecting excreting lacrymal or- gans, 179 affecting eyehds, 113 affecting lacrymal gland, 77 affecting os unguis, 189 Scrofulous corneitis, 347 iritis, 372 ophthalmia, 316 Secondary cataract, 544 Semilunar membrane, inflammation of, 169 Separation, artificial pupil by, 549, 557, 568 Short-sightedness, 593 Sight, over-exercise of, a cause of amau- rosis, 666 weakness of, 637 Small pox, ophthalmia from, 333 Spasm of eyelids, 139 Speck, vascular, 318, 411 Specks of cornea, 411 of crystalline capsule and lens, 421 Spectra, ocular, 616 Spectral illusions, 624 Sphenoid sinus, pressure on orbit from, 75 Spongoid tumour of eyeball, 453 Squinting, 205 Staphyloma, 422 choroid, 382, 429 conical, 426 iridis, 422 morbid anatomy of, 426 of cornea and iris, 423 operation for, 427 partial, 424 pellucida, 437 racemosum, 422 sclerotic, 381, 429 spherical, 425 total, 425 Steatomatous tumours in orbit, 219 Stiliicidium lacrymarum, 184 Strabismus, 205 convergehs, 205 divergens, 205 Style, use of lacrymal, 188 Suckling, amaurosis from, 699 Suppressed menses, amaurosis from, 671 perspiration, amaurosis from, 673 purulent discharge, amaurosis from, 613 719 Sycosis palpebrse, 415 Sym-blepharon, 416 Synchesis, 422 Synechia anterior, 421 posterior, 421 Synizesis, 421 i Syphilis affecting bones of orbit, 29, 31, 39 affecting os unguis, 188 Syphilitic iritis, 364 ulceration of eyehds, 126 Tarsal ophthalmia. 111 Tears, morbid, 94 Tetanus oculi, 213 Tic douloureux, 135 Tobacco a prolific cause of amaurosis, 694 Trachoma, 415 Traumatic ophthalmise, 398 Tremulous iris, 579 Trichiasis, 152 Tumour, lacrymal, in lacrymal gland, 86 lacrymal, in subconjunctival cel- lular membrane, 92 on crown of head producing am- aurosis, 701 on eyelid, producing amaurosis, 700 spongoid or medullary, of eye- ball, 453 Tumours, encysted, of eyelids and eye- brows, 118 encysted, of frontal sinus, 57 in brain, producing amauro- sis, 681 in orbit, 219 of conjunctiva, 167 within eyeball, 437 Turpentine, its use in iritis, 368 Tylosis, 116 Ulcers of cornea, 407 Ulcers of eyelids, cancerous, 121 of eyelids, scrofulous, 112 of eyelids, syphilitic, 126 of legs, discharge from, suppressed, brings on amaurosis, 673 Vaccination, cure of nsevus maternus by, 129 Varicositas oculi, 429 Variolous ophthalmia, 333 Venery, excessive, a cause of amaurosis, 700 Vision, coloured, 612 defective, various states of, 593 Visus defiguratus, 648 dimidiatus, 632 interruptus, 647 lucidus, 614 nebulosus, 648 obliquus, 648 reticulatus, 648 Vitreous humour, dissolution of, 423, 585 Warts on eyelids, 118 of conjunctiva, 167 Weakness of sight, 637 Wenzel's operation for artificial pupil, 549 Willburg's operation for cataract, 501 Wollaston on semidecussation of optic nerve, 632 Worms, amaurosis from, 702 Wounds, gunshot, of orbit, 17 incised, of orbit, 16 of choroid, 257 cornea, penetrating, 252 cornea, punctured, 251 eye, gunshot, 260 eyebrows and eyelids, 100 sclerotica, 257 penetrating orbit, 5 Xeroma, 74 '\ COLUMBIA UNIVERSITY LIBRARIES This book is due on the .date indicated beiowor^^ with the Librarian in charge. 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