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Les cartas, planches, tableaux, etc.. peuvent *tre film«s A des taux de reduction diffirents. Lorsque le document est trop grand pour dtre reproduit en un seul clichi. il est film* d partir de i'angle supArieur gauche, de gauche d droits, et de haut en bas, en prenant le nombre d'images nAcessaire. Les diagrammes suivants illustrent la mAthode. 32 X 1 2 3 4 5 6 /oo THE ANATOMY, PHYSIOLOGY AND PATHOLOGY or tax EYE. BY Hi^NRY HOWARD, M. R. C. S. L SURO.O» TO THB MONTKKA. KVK AND KAE INSTITUTIOK. '' ARMOUR & RAMSAY, Eonlron ; JOHN CHURCHILL. 1850. r«rNTEn Br iovkl,, ^sn """*°''' ^'"^^^^^^r^:;;^ y PREFACE. The organization of the Eye, and its beautiful adap- tation to the wants and necessities " of every living thing," has always been a subject sufficiently attrac- tive to secure attention and respect from the most thoughtless and indifferent; from those even, who in other respects, are disposed to forget the wonder- ful nature of their creation, the fearful construction of every organ and sense with which they are en- dowed. On an inquiry which possesses so many attrac- tions to the general Student, some feelings of diffi- dence might be fairly expressed by a writer, when committing his thoughts to the criticism of the public ; but the fears of the author rise into anxiety, when he invites the attention of the Faculty to a work, which not only treats generally, of the Organ of Vision, but professes to inquire critically, into its Anatomy, Physiology, and Pathology. The Author may, however, be allowed to say, that while he has not been insensible to the magni- ^"^BWWi^Rpnp*-' • IV PBEPACE. t"de of the undertaking in wl>ich ho ha, engaged . -«.l with unconcern, the difflcultiefwith which Its prosecution would be attended, he has been encouraged to perseverance, not only by the -nembrance, that a great part of his earl/studie w^directefc the guidance of one' of the most learned and successful of European Practi- t™> of Me .cul ,nd Surgical Science, but that he 7 «"■ the last four years, as the Surgeon to " The Montreal Eye and Ear Institution," devoted his ^ur. exclusively to the treatment of diseases in- cident to these organs. The Author has been desirous, by simplicity of armngement to facilitate the means of reference, and thus make his work acceptable to the Profession generally; nor is he without hope that, in the das- sificafon which has been adopted in reference to particular diseases, it will be found a useful com- pendmm to those who may wish to consult it in the course of their practice. He has availed himself of the pubUshed opinions of he numerous distinguished writers who have explored the field of Science in which he has labour- ed; and he wishes in this place to state, not only h.s great obligations to_t hemJbrJheJn^^ * Dr. Jacob, of Dublin. t I. "^S^Sj., t PREFACE. which he has been enabled to derive f™™ ,hej -nt,„g, but also to express to those learned and :;rf '"T ""^ ""^ -"'^'^"''^ -ny vain able notes and suggestions, his sense of the Lrvice hey have rendered to his inquiry; a serviee C only er,r,eh h,s work, but to confirm his own exponence of the propriety of the ...atn^ent wh^ he has successfully pursued; a treatment, which he ^uggested m any published treatise on the Patho .0.^ of the Ev. which has come under ht:^':: In conclusion he begs to state, that, in deference to the V.CWS of seve,.l friends, he has so far dev-ated from the plan indicated in his Pros' Fctus, as to dispense with the proposed Appendix to h,s work, and to include the matter of which u was to have been composed, in the body , <• the 6, St. Fbansois Xavier Street, Montreal, May, 1850. * ) t I y^:^ 'I 4 TABLE OF CONTENTS. CHAPTER I. . Page Anatomy OK THE ottDiT j Bonos forming the Orbit,.. ...... i Foramina in tlio Base of tlio Orbit " Foramina within the Orbit, ' 3 Contents of Uio Orbit ][ 3 Lachrymal Gland, ." .' " 3 Levator Palpebro) Supcriori's'.! '. 4 Hccti Muscles 4 Superior Oblique Muscle,. . . . . ." . 5 Lifcrior Oblique Muscle ' (j Anatomy or the PALrKDii.«,.. . ] , Orbicularis Pulpebnirum Muscle, 6 1 endo Oculi Muscle, 7 Tensor Tarsi Musclo ...." 7 Corrugator Supercilii, ." ." " g Tarsal Cartilogca \\\\ g Meibomian Glands . . CiUaj, '...\'.\'.'.'.'.'[ 8 Membrana Conjunctiva, !!!!!!!! 8 Caruucula Lachrymalis, . . . .'.'."' y PunctaLachrymalia,. ..',.."."" 9 Lachrymal Ducts 9 Lachrymal Sac, Nasal Duct 9 Nmi Canai,'.'.".'. v.".*. ." ." ." ." ." .' ." .' ." .' Jq CHAPl'ER II. The Anatomy of the Vessels and Nerves ok the Obbit, anp the Anatomy of the Globe c ' ; - Eye Arteries of the Orbit i{ Ophthalmic Artery " n Arteria Centralis Retinas,! ...." n Lachrymal Arteries,. ..'....,," n Superior Orbital Artery,. , , 10 Posterior Ciliary Arteries,..' ." ' " 10 Long Ciliary Arteries, " i» Supra and InfraMuscularArterieV 1 '' ^tlunoidal Artery ' " Superior and Inferior P^pebrai Arteries Nasal Artery, |q Frontal Artery,,.. ,0 Optic Nerve....... Jg 12 13 Orbital Plexus of Nerves,.... 14 Third Pair of Nerves, "14 Tnxihloator or Fourth Nerve,'. .' .' .' 15 1 rigomini or Fifth Nerve is Ino Ophthalmic Nerva,. . . m Lachrymal Branch of the Fifth,'.' 15 frontal Nerve, j^ Supra TroclJeator Nerve" '. .' .' .' ." ' u Supra Orbital Nerve 1 ,j Nasal Nerve, ," 17 Infra Trochleator Nerve, . .' .' '.'..'. 17 Nawal Nerve Proper, ...."!] 17 Sixth or Abducens Nerve,.!!" 17 Infra Orbital Nerve * ig Lenticular Ganglion, 13 Ciliary Nerves u, Anatomy of the Globe of 't'h'e 'Eyk i umca Sclerotica on Cornea X. Choroid Coat .!!!!!!!!!"" 22 Ciliary Ligament ! ! ! 03 Ciliary Muscle, Ciliary Processes ! ! ! ! ! Iris, " ■ ■ ■ Retina, !!!!!!" Aqueous Humour, . . ....... ! ! ! ! 27 Cry italline Humour •••••• ^^ Vitreous Humour !!!!!! 2i> CHAPTER III. PinSIOLOOY OF THE OkBIT AND ITS Contents, with the Exception ok THE Globe of the Eye Orbit, 3 Periosteum q„ Fat of the Orbit, !.!!!!!" 31 Tunica Vaginalis Oculi,.. 31 Vessels of the Eye,.. . 31 Conditions of the Eye, si Recti Muscles........... 33 Superior and Liferior"6bl'ique Muscle, ^ 3^ Levator Palpebroj Miis'cle,*.! ! " ' 40 Orbicularis Palpebrarum, . . "40 Tensor Tarsi,... ...!!!! 41 28 24 25 26 t i Till TAULC or CONTENTS. Paob NiEVKR or THi Eve, PALrBBR*, AND Orbit 42 Sympathetic Ncrvo 43 Optic Nerve . , 44 Motores Oculonim, or ThirJ Pair, 44 Trochleator or Fourth Ntrvo 48 Fifth Pair of Nerves 46 Iris, CO Sixth or Abduccni. NurvD, Bl Lachrymal Organs, 62 Conjunctiva 62 Meibomian GIondH, 62 Oilias 62 Eye-browp 62 CHAPTER IV. Optics, and PnysiOLOov of the Eyk Light 63 Dioptrics 67 Double Convex Lens, 00, 61 Double Concave Lens 62 Sunlight, 62 Chromatics, > 63 Optics Relating to the Eye 64 Cornea, a Transparent Medium,. 65 A(][ueous Humour 65 Iris 65 Myopia, 66 PresDyopin 69 Ciliary Muscle 71 Tunica Sclerotica, 74 Choroid Coat, 74 Ciliary Pi'ocesses, 74 Retina, 75 Cornea, 76 Afjueous Humour and its Tunic, . 76 Iris 77 Capsule of the Ijcns, 78 Lens, 78 Vitreous Humour, 78 Hyaloid Membrane 78 PART II. PATHOLOaY. CHAPTER V. Contusions of the Edge of the Orbit 79 Fractures of the Edge of the Orbit. 80 Componnd PVactures of the Edge of the Orbit, 81 Paoe InriHCtI and Punctured Wiiundu of the Edge of the Orbit 81 Oim-shot Wounds of ihu E-. 498 Mydriasis 493 Tremulous Iris ! ! ' 49^ Malformation of the Iris, . .". ! ! ! ! eoa Entozoa in the Organ of Vision, . 501 Irregular Refraction, 602 Insensibility of the Eye to cer- tain Colors 502 Crupsia or Colored Vision, 602 Photopsia or Shining Spectra,. . 502 Musca) Volitantes, 603 Nyctalopia or Night-blindness, ! ! 603 Hemeralopia or Day-blindness,. 604 Henuopia 504 Amblyopia, 606 Scotoma, gofr ... 483 ... 485 the ... Mft ERRATA, Page 150, line 13 froir top of page, for Liquor Amon, read Liavcr Ammon. Page 139, in prescripiion, for axungia, read axungia. Page 187, line 28 from top of page, for arthirtic, read arthritic. Page 232, line 29 from top of page, for Funguos, read Fungus. Page 252, in prescription, for aqua pur, read aqmpur, and for //. lotion, lead ft. lotto. Page 340, in prescription, for quinine, read quina. Page 355, line 3 from top of page, for hundreds, read numbers. Page 379, in prescription, for quinine, read quinad Liquor thritic. igus. ad for ft. bers. it gr. 1. ANATOMY OP THE ORBIT. The orbif^s are situated in the upper part of the face, one at either s.de of the nose. They are cavities, of a py ami d.ca shape, the bases of which look forwards ^nd outwTrd and their apices backwards and inwards. Thera r are obhquehnes which if continued backwards, would decu sate a the sella turcica of the sphenoid bonej v^Ie ant - norly these lines would diverge allvMt'r' ""™'''' '^' ''^''' *« «'^"«ted more later- ally than they are ,n man; consequently the former have a w. er range of vision than the latter, a power which of he greatest importance to animals of a timid nature as It the better enables them to see approaching danget ' BONES FORMING THE ORBIT. Seven bones enter into the formation of the orbit • viz • the frontal, sphenoid, a^thmoid, lachrymal, maxillln^" pala^ and malar bones. The base is formed ^^S,' by the frontal bone, e.terna% by the external orbital ange of the frontal, and by the ascending ramus of the orwSi process of the malar, ^nfer^orl, by th'e transverse /amus f th n ..T'" ''*'; "^'"- ^«"«' ^"^ *he anterior edge of the orbital process of the superior maxillary bone. Th W part of the base is formed by the extemal side o bones "■''''' "^ "'' ^''""''^ ^"-^ '^"P^'-'^^ ™--»ary There are /c«r foramina in the base of the orbit viz- m u * ANATOMY The roof of the orbit is formed anteriorhj by the orbital process of the frontal and posteriorli, by the lesser wing of the sphenoid bone. The roof is concave, and in Its posterior part (which is the axis of the orbit) is situated the optic foramen. ^ In the antmor, and external angle of the roof, there Is a depression for the lachrymal gland. Anteriorly and internally there is another for the trochleator muscle. The floor of the orbit is nearly a plane, and is formed by the malar, maxillary, and palatine bones. The Infra orbital ■canal extends along the floor. The external wall of the orbit is formed by the orbital process of the malar bone, and orbital surface of the great wing of the sphenoid bone. Its surface looks forwards and inwards towards the 'median line. The internal wall is formed by the lachrymal bone and os planum of the a;thraoid ' In this wall are the two internal orbital holes, which are situated close to the suture that unites the os planum to the OS frontis. There are five foramina within the orbit, viz • the yttc, which Is in the upper, Inner, and posterior part,' ihe Joramen lacerum superius, which is situated between the greater and lesser wings of the sphenoid bones : the third mA fourth are the two internal orbital foramina near the suture on the inner wall ; and the//?A the foramen lacerum inferms, which leads from the back of the orbit fomards and outwards along the floor; this last foramen Is a slit like opening of a triangular shape, its base being external and anterior ; It is bounded by the malar, maxlllaty, sphenoid and palatine bones. ' Through the foramen optlcum passes the optic nerve with Its neurilemma, and the central artery of the retina. The foramen lacerum supcrlus transmits the third, fourth, and sixth cerebral nerves with the first branch of the fifth The two internal orbital holes give passage to the anterior, ^nd posterior ^thmoidel arteries; the nasal nerve also passes the orbital ser wing of ts posterior 1 the optic there is a i internally formed by ifra orbital the orbital ' the great wards and al wall is : ajthmoid. * which are um to the )rbit, viz : Jrior part, tween the the third near the 1 lacerum forwards, is a slit external sphenoid, rve with la. The irth, and th. anterior, 10 passes OP THE EYE. 3 through the anterior hole. Through the supra-orbital hole passes the supra-orbital nerve and artery ; this artery is a branch of the ophthalmic; and the nerve a branch of the ophthalmic branch of the fifth nerve. Through the infra-orbital foramen passes the infra-orbital artery, and nerve; this artery is a branch of the internal maxillary; the nerve is the terminating branch of the su- perior maxillary nerve. Through the spheno-maxillary fissure, or foramen lacerum infenus, passes the infra-orbital artery, and the infra-orbital branch of the superior maxillary nerve, previously to that nerve entering the canal. The malar duct sometimes transmits small vessels and nerves into the orbit. The nasal canal contains the nasal duct, and branches of the fifth nerve, that terminate in the mucous membrane of that duct. CONTENTS OP THE ORBIT. There is contained within the orbit, the eye, with its six proper motor muscles, and an additional muscle called the levator palpebral superioris. It includes also vessels, nerves, cellular tissue, and fat, together with the UclryrmlaUnd and lenticular ganglion. ^ y «« The best way to get at these parts, as nearly as possible in situ, 18 by removing the roof of orbit. Lachrymal Gland.-The lachrymal gland is situated in the fossa which carries its name; it lies superior to the gh)be of the eye, and behind the conjunctiva ; its size is about that of a small bean, colour pale, and shape oval. It IS separable into two lobes, which can be again separated into numerous granules united by a loose capsule Prom these granules proceed five or six small ducts which open behind the upper eye-lid, along the line of re- flection of the conjunctiva from the palpebra superior to the tunica sclerotica. ANATOMV .apeb™ superioria, a long „,„scle running do„/,,c™. leum around He onlic foniiipn ih V° '"" P"'»=- »» additional aHacCenlT .h ? "'"""' "™"« '"""S tlie four muscle pa "forward "T '~'"°' ="!«""«. tat separated rombvTh;!-,- '"""'''"« ""^ "l"'" ""« by a quantity of fa rttlr"^ ,™''* »"" "«"«, and beyond' tl,e nHddle t !„ e™ VJT "'™'"' " «* (Tunic, vagi„ali.U,;;tt;™ ;,^; f^"""ap,„,e, «"*.be.a,er,offat.bitu:tr!.c.:i:::;x OP THE EYE. 5 is concave and open in front, and terminates In the eyc- Jids; and that it is inserted into the anterior extremity of he optic nerve, surrounding, without actual contact, the two posterior thirds of the eye. He says that the recti an ceHulo.hga.entous tissue, larger than the inferior Idl T"'' P^'P^*""* ^^e the globe of Ih ; ;he„ r?-^^ tbree-fourths of them are concave posterio Iv f ' ^ '''^''^- ^^th of of the eye. ^ir 1" i^J^ closely fitting to the surface with the eye-lash s IdC ^'^' ^"™"^«^ ^^^"oriy follicles. Th oppi^;^^^^^^^^ ^'f '^''^-ous mucous towams the eye, soThat thef ^^^^^^^^ '^^ ^^"'l"^'^ triangular canal is form d the bt / T ?'''''' " «°^* «f of the eye. When The iltl / ""^''^ ^' ^''^ «"rf«<=e cellular tiLerrTmoved from Z' vf «»»H."taneous muscle is exposed to vTw ^"''^'' ^''^ ^'''''^''''^is thin, and of an oval shaop r . ""'''' '^ ^'"o^ orbit, and occupiera S ' r -'"T".^' *^^ ^""^ «f *he by several fleshy fiLff^h^^^^ '""^ ''''' '* -'^es -----is^nd^rth^u;"^^^^^^ penor and e entrance rior rectus ed at the tendinous ne, above achrymal [Is, below s expan- sis of the floor of r tlie eye Qs cellu- tissue, brffi are irths of Both of surface leriorly mucous liquely sort of lurface ineous iularis )road, if the irises ocess eodo OK THE KYE. 7 oculi; the fibres proceed in curves, upwards, and outwards, along the upper edge of the orbit, eyelid, and tarsal cartilage, as far as the temple, and external commissure of the eye-lids ; there the fibres curve in a similar manner along the lower eye-lid, and inferior edge of the orbit, till they arrive at the internal canthus, where they are in- serted into the nasal process of the superior maxillary bone, and the inferior edge of the tendo oculi. The exter- nal or orbital fibres of this muscle are strong and red, and run circularly around the base of the orbit ; the middle or palpebral fibres are pale, thin, and scattered; the internal or ciliary fibres adhere more closely to the skin, and pre- sent an elliptical appearance, because the fibres from the upper and lower lids intersect each other at the outer canthus, and adhere to the ligament of the external com- missure. Tendo Oculi Miucle.— The tendo oculi, or tendo palpe- brarum, is a small muscle of about a quarter of an inch in length, inserted internally into the upper end of the nasal process of the superior maxillary bone; it crosses the lachrymal sac a little above its centre. From the edges of this muscle a strong aponeurosis is given off, which covers the whole of the anterior surface of the lachrymal sac, adhering to the margins of its bony gutter, where it becomes continuous with the periosteum. This tendon can be seen or felt during life through the iatcguraents, parti- cularly when the muscle is in action, or when the eye-lids are drawn towards the temple; it passes outwards and backwards to the internal commissure of the eye-lids, where it divides into two slips which enclose the caruncula lachrymalis, each sUp being inserted into the tarsal car- tilages and lachrymal ducts. Tetuor Tarsi Muacle.~This little muscle (which is called Horner's muscle) arises tendinous from the posterior edge of the OS unguis, passes forwards between the conjunctiva 8 ANATOMY frontis, then passes un7ar T'^?' ^'''''' '^ '^' "» •nsorted into th ll^dTe cf/ 1 T''''' «"^ ''^^"^e^ ""•xed with the flbrs of th or •'".■•"' "''"' " '^^^''^^^ talis muscles. ''' "''"'"'''"« «"^' occipito fron- P'aHl?S:7l';V"'« -^"•'«^- - thin, elastic inferior eye-lid Th. ^ '"P'"°'"' "'« «ther in the '-ger th;n^re^•n^l^rh t tr?'*-'""«^ «^"P^' -^ straight. The ciliary marlirnf k ,^' """"'"' '^"^ "ea'-'y «dges are thin, andconnofted IT "Z '^''^'^ '^' ^^b"«' hmcuts, wl, ch are r. r ' "'^" ^^ ^^e palpebral feirstronWstptrt L; ::r^^^^^ ^ P-'^'-- ;^^eussate, and unite the^c rZt at il7' 7''''' ^"^^ n"«8urej the tendo oculi BxZTj- *""■ '^*'''"«' <:o"- - they are J^^eul:^^^^^^^^ ^^ »es, surface of the tarsal cartre Z T '" '^' P«^^«"o - beneath .het„7 ^^trf "" "" '«''' "«' """■"oas than these of thTlol?! kT' ''"■"" ""= '»»"' towards each other. ' '""' ""« """d convei ""«<" at their margm „i,h ilT„,„ '"''"'''"'• »"'' b »n«. he anterior part of the eye^J rbT"""'„'' " * "™" '"■e palpeh™. Nearthe iZer c Lh "S'f *" ™ " *»» kwe is ,hr„„„ i„,„ , f„|f ™"™' »f 'lie eye, this mera- " ^^ "■» '""nml" lachrymalis, — -S., OP THE EYE. which fold is called the aem{4unar fold. This mcmbrano next lines the lachrymal ducts and sac, and nasal duct ; and finally becomes continuous with the raucous membrane of the nose. This membrane is loosely connected with the sclerotic, and becomes delicately fine as it approaches the cornea, to which It becomes so adherent as to render it impossible to remove it, except it bo macerated previously, or changed by disease. It is more vascular on the palpcbrae and carun- cula, than it is on the surface of the eye. Caruncuh Lnchrymalis.—ThG caruncula lachrymalis is a small fleshy looking tubercle, somewhat of a conical figure It 18 situated at the internal canthus, and is composed of a few mucous follicles and the bulbs of some hairs which pro- ject from its surface. ANATOMY OP THE EXCRETING LACHRYMAL ORGANS. I\mcta Lachrt/maha.—The puncta lachrymalia are two small holes situated in the edges of both lids, in little cartila- ginous projections, about two lines from the inner canthus ; each of these puncta is an orifice of the lachrymal ducts. When the lids are closed, both puncta meet. Lachri/mal Ductji.—ThQse ducts are very small, and lead from the puncta to the lachrymal sac, Into which they open at Its superior and external part, sometimes by one! and sometimes by two distinct orifices, behind the tendo oculi, a process of which surrounds each duct. Lachrt/malSac-The lachrymal sac is a small oval pouch of mucous membrane, situated In the fossa formed in the an- terior surface of the os unguis at Its junction with the nasal process of the superior maxillary bone. This sac is closed supmorly, with the exception of the openings of the lachry- mal ducts. It terminates t«/mWy in the nasal duct and 13 covered by Integument, tendo ocull, and fibres of the or- bicularis muscle. to ANATOMY membrane. Wkile Zin! .^' ,"?"'"■■ ''''''' °' """:»«< •tubbed .0 Ibe Sr "" "■" """'' " ■•' '■'»"')' ."«.oof.b?L:;:S-;;,t»^-;'«.liMbei„.er:? ■>"«; Us course i. i,n«Z, LT^' ""■'"""'"'"•■ -sal process „f .he sunerrL. T"^, ''^ "" '«" '" «-« II. ioferior part is bo„S ",",7 '"'"'' «"'' »» »"«"«. "f'heioferiSrsp ,g^° f;„T:f^'f '"» «'«"«l^<"e ™.rpl..e of .he superior ^M^Xt' ' '"" '""""'"■ '-, oppo.,.0 .be supci:;:ro5.r It;..;" "" ■"^■■"» CHAPTER II. THE ANATOMY OF THE VESSELS AND NERVES OF THE OBBIT, AND THE ANATOMY OP THE OLOBK OF THE EYE. Arteries of the Orbit.— X\\ the arterios of the orbif are branches of the ophthalmic, except tlic infra-orbital, w oich is the eighth branch of the intr nal maxillary. llie Infra-orbital artery enters the canal of the same nan o, and after traversing it, escapes through the infra-orbii U foramen, where it is distributed to the muscles of the face, and anastomosis with other arteries in that region. Ophthalmic Artery. — The ophthalmic artery is one of thi terminating branches of the internal carotid. It is given off close to the anterior clinoid process of the sphenoid bone ; it immediately enters the optic foramen, below and external to the optic nerve. When it enters the orbit, it rises above the optic nerve, and then bends down to the inner side of the orbit, along which it passes to the inner canthus, where it terminates. — In its course, it gives of ten branches, viz :— lat. The Arteria Gentralia Itetincc, which is the first branch of the ophthalmic. It is exceedingly slender, perfo- rating in an oblique manner the neurilemma, until it reaches the centre of the optic nerve, which position it keeps till it enters into the eye, where it divides into delicate ramifica- tions, spreading along the internal layer of the retina, one or two branches piercing the vitreous humour, and extending to the capsule of the lens. 2nd. Lachrymal Artery. — The lachrymal artery is the second branch of the ophthalmic. Its course is along the external rectus muscle. It supplies the lachrymal gland, and external part of the palpebra. 12 ANATOMY 3rd. Supra- Orbital Arterfj Tho the third branch of the onhnfoT- • '"P''«-«'"bital artery is orbital foramen, at '.Sh ^P^^. ^^^«"^-'^ the s„pra- nteguments of'the e'b o' 1^'' '' '''' ""^^'^« '"-^ head, it divides into several br^nr "T^'"^ '"^ ''^^ ^ore- ^«/he scalp, and fina^^^^tV'"'' ^^^ '^"^'^''^^^d «nd occipital arteries. '"'""""'^^tes with the temporal 4tA. Postertar Ciliary Arteries Th. "es are ten or twelve in numhpr""^ '' "^""-^ «"«" ^rte- «PhthaImic, they sur "„nd ' '"^ '^^ ^'^*^" «ff by the fe back part of LSScoauTlh^ ^"^ P^-« between it and the chorod arc .?w ?'^'' *''«» P^^^-nff tunic, some branches contTn„- 'l''*"'^»ted to the Jatt-r and the iris. '""^'"""^^ '"^^ f^-- ^^ the ciliary process ""•nberj although cflled le fiVTi; , \'''*'"'^ «••« ^^^ in ;°e is situated on either sde o/l, ''''' 'P'^'^^'"'^' ;--te the posterior part of he Cernr " "'^'^ ' ^''^^P«»«- t^en it and the choroid, 1 11 thev 1 ' '"'*' ^''^'^ ?««« ^e- ^vhere they form, by the r .n 7 "'^' «^ the ciliary circle ^reat circn^fereiroft^.^-'^^^^^^^^^^^^^ .^^ -^^^ on t' artenal circle, other smaller bran!r ' '""''"P^^* ^^^his ;econd circle within the ormer f. T^'^' ^"'^ ^^^ « third crcle, which immediater«.' 1 ' '^"'" f*^™ « 'nfra muscular arteries arpThl-."^''^*^--The supra and f hy the ophthalm c and at .'."/V^* '^ branches given 'be eye, the periosteum h '2 "*!;' 1 ''' ""-'-Tf nabs oculi. ^"e orbit, and the tunica vagi- 7i^. -Ethmoidal Arteru ^T\ OP THE EYE. 13 8th. Superior and Inferior Palpebral Arlen'es.—These branches are the eighth set given off by the ophthalmic; they supply the palpebrffi, the caruncula hichrymalis, the con- junctiva, and the lachrymal sac. 9th. Nasal Artery.-The nasal is the ninth branch of the ophthalmic artery; it passes along the side of the nose, and inosculates with the labial artery. - 10th. Frontal Artery—The tenth and last branch of tlio ophthalmic, IS the frontal artery ; it and the nasal are the terminating branches of the ophthalmic,-af(er passing out of the orbit, It ascends to the eye-brow and forehead. ANATOMY OF THE NERVES OF THE EYE AND ORBIT. The nerves connected with the eyes and orbits are the optic or second pair of cerebral nerves; the motares oculorum, or third pair of cerebral nerves; the nervi pathelm, or fourth pair of nerves; the ophthalmic branch of the fifth, and the sixth pair of nerves ; and the orbital branch of the superior maxillary. Optic Nen,e.-The optic nerve (or second cerebral) en- ters the orbit through the optic foramen, where it becomes surrounded >yith a strong sheath derived from the dura mater: after this nerve enters the orbit, it is surrounded by the four recti muscles, but separated from them by fat cellular tissue, and the ciliary vessels and nerves Its' course, when in the orbit, is forward, and a little inwards so as to form a slight curve, the convexity of which looks outwards ; it then pierces the sclerotic and choroid coats of the eye, and terminates by expanding into the retina. In addition to the dura mater, as a covering, this nerve pos- sesses a very dense neurilemma, which sends in num. rous processes to form small canals or tubes, in which the nerv^ ous substance is contained, so it is to be remarked that this .3 not formed like other nerves whose several filaments are placed parallel to each other. If the white substance of h ^^1 II u ANATOMY fourth, .hc„ ,„o .mlmcZtitr ,t ir '; ,"' "■" tile sixth. TIiosc nnrvM .,„ i . "*''' ""^^ '"""y, Ihereby formil? , l J'f V'~'^ ™™ected together foramen' lace 1 ..L,! T" • ' ","'' »' ""^ «»'«- "e fourth. „e,t thefr r 1 .n,'' "'°'r"f"*rlj. the 'l>e li(»h; then the siilr f- • • ° °>"'""'''"ie kranch of branches, vis •_; ,"'„,„ "'°f ""es divide. i„,o !„„ i» the ™ lie .'and Z "It '"l"" "'■'•"eh. The fonner rectus n,„,ci;, andC e olr ?* <" "•external "•en divide, in „ t™ b" et, T ""i """ """''' '* "l.ioh .upplie, the superior r In, TZ '"t """^ "^ Plynglhe levator pa'pebTam"Sr;h "•'/':'""'' ""^ rCoro:;r„ri::d!:r;^"-^- downward,, f r,v r| .d I'T'' """P""" obliquely '"en getting ,„ the h, er d?',??"* "" »P«« "'"»^ ■ii'lribnted to the 1^ 'l rl ! ^^ """= """«> « ' branch goes directly t™ r' """'"• ™' '"''"'fe --' branch p,rdt:tr„:t™?;„™^ OP THE EYE. 15 surface of the inferior rectus inuscle, (but giving no fila- ments to it,) till it terminates in the inferior oblique muscle. This last mentioned branch gives off, at its root, a small filament to the lenticular ganglion. The reader will per- ceive that five out of the seven muscles of the orbit are supplied with branches of the third nerve. The name of the muscles being, the superior, inferior, and internal recti, the levator palpebra, and the inferior oblique. TrocMeator, or Fourth iVm>e.— The fourth nerve enters the orbit by the foramen lacerum, then ascends obliquely forwards and inwards, above the levator and superior rectus muscles, and is then distributed to the orbital sur- face of the superior oblique muscle. As this nerve enters the orbit, It mounts above the third and fifth, becoming the highest nerve in the orbit. As it passes^ over the fifth it IS usually connected to that nerve by a fine filament. ' Trigemini, m- Fifth iVert-e.— The fifth nerve having form- ed the semi-lunar or casserian ganglion, separates into three, viz,~The ophthalmic, the superior, and inferior maxillary nerves. The Ophthalmh iVeryc— The ophthalmic nerve, or more properly, the ophthalmic branch of the fifth nerve, passes along the outer side of the cavernous sinus, below the third and fourth, and above the sixth nerves, in which situation it receives some filaments from the sympathetic nerve ; as it approaches the foramen lacerum orbitale it separates into three branches, viz :-the lachrymal, frmtal and nasal nerves. Lachrymal Branch of the Fifth Nerve.—Tho Iachr3'mal is the most diminutive and external branch of the ophthal- mic; it passes forwards and outwards to the lachrymal gland; in its course, it passes over the external rectus muscle, is surrounded by fat, and accompanied by the lachrymal artery. This nerve, in its course, sends off two small branches, one that passes through the spheno^masil- ^o 16 ANATOMY '•our or five branci.e to t^.P • - '^''' ''^'''^''^ ''^^' and terrnl„at:rf : era J'rr^'"^, '' ''^ ^'-'^^ the cellular membane'h? ^ f. ''"' " "''" ''^^"^« *< '>^ the ophtl.i:;e bll" te7;' ^-^ ^^^^"^ ^"-- ''hove the superior ye,Z , ' '* '''*'" *''« orbit -.-ds along ^re'Tp^lretj t f'"." ^'^^"^ ^«^- "earthesuperciliarrarol 2vip« . ''"'"' P''^^'^''*' the supra-orbital '""^'''''''^^''^'^ 5 the other e.te^nal, ^uprarTrochUatw Nerve — I1.n in* . • hranch of the frontal neTve • il Is f"'' ? "^' ^'"""^^^ «hove the trochlea of T ' ' ^^''^^'"'^^ ^"'^ '""^ards distributed to c r^^^^^^^^^^ f '>« muscle. It i« hr-. and occipitoSat ^r;'"',;:?r'-^H^^^ 'nteguments of the forehead «n, !? • '" '"^^''^^ the nninicates with the Tnt L m ?T '^''"''^- ^t corn- nerve, and sends onVor^oTm^^^^^^^^^^ '?"' ^' '''' "-' sinus. "^ ^"''" branches into the frontal Supra Orbital Nerve.—Thh U ih. more properly, the true front nerve T ''''''f'^ '' the superciliary notch tvhirh iIh ^t passes through to its fonnation, som Ji™ till I "^''''''' ''' '^^''^'^^S It then ascends oT h for ^ T'^^^^^^^ hranches, which aglubdS/"'' ''^'^^^^ ^'"*« two ^'" of which are diftribut ^ t '^^ ?"'"""" ^'^'^^"ts, of the scalp, many of th m tat n ''' ""^ integuments communicating wUh the port !? ' ''T ''"^ "«"''«« «n<^ -ves and th^ fello": o^^ o^S^sid^ ''' "^^*' Of THE EYE. 17 y^asat Nerve.~The nasal nerve is the third and last branch of the ophthalmic division of the fifth cerebral nerve. It enters the orbit beneath the frontal nerve, and between the two heads of the external rectus muscle. It then continues Us course obliquely forwards and inwards, above the optic nerve, and below the superior rectus muscle. It next runs along the inner side of the orbit, below the superior oblique muscle, where it divides into two branches, viz;-^^e infra-trochkator, and nasal nerve prefer. The nasal nerve, before it enters the orbit receives a branch from the sympathetic, and, after entering the orbit, wh,le on the outside of the optic nerve, it gives off a l^elicate branch (about an inch in length) to the lenticular ganglion. As it passes over the optic, it gives off the two cthar// nerves. InfrarTrochleator Nerve.~l^\,Q infra-trochleator is the first and external branch of the nasal division of the fifth It runs forwards beneath the pully of the superior oblique muscle, and divides itself into several filaments, wE mmunrcate with the supra-trochleator nerve, 'and fialy distributed to the lachrymal passages, and to the inte- guments and muscles on the side and dorsum of the nose. Nasal Nerve Proper.-^h^ second or internal branch of the nasa division of the fifth is the true nasal nerve I passes hrough the anterior of the internal orbital holes into the cranium, crosses the cribriform plate of the .ethmoidal bone, and descends by the side of the rista gain mo the nasal fossa, where it divides itself into po I wan anterior filaments; the former are distributed tt c eptum, the latter descend behind the nasal bones, and a>e los ,n the integuments in the tip of the nose. Srxth or Alducens iVm,e.-The sixth nerve, when in the ^^avernous sinus, is joined by a branch of the sympathet c .t afterwards enters the orbit through the lower^r of iL' foramen laceriim orbitale, beneath all the orbital nervoi^ 18 ANATOMY fn'rfh "'\-f '''"'"''^' '''' "•'"•^'^ '^ P«««es. After enter It ,s worthy of remark that all the motor nerves in tho orbit are distributed to the ocular surface of ^J- ^li'^Zl/r-r'^' ™perior mamillary nerve temporal branch passes thronrrh it in*. 1- ? ^'^'^ pierces the temporal feslanS hrl '^^"''^ ^''''^ joining some branches othrL, '=»*aneous,-then the temporal arteTand is t /.."'•''' " ^^'^«'»P«nie« temple and head ThP ^ ^ z- ,' •''teguments of the terminating branc'h oHhP f '"•'"^''^^ '"^^ '' '^' '"^^ <^' along the floor of the oH^/T^T^^^ '* P^«^««^« escapesthrou7 he X'i"^^ "'"■"'^"^' ^^"^•' -"^' itself into several balr^? ^''""'"' ''''"■' " ^'''^'' orbit between tL 2; '" """' "«' '"'* P"" «f Ibc At it. superior anrie il^el- » ■mgular square form. krancb of tbe onbfhal^ ^ 7 f '""™"'™"' "'» "^'«l ophlhalnuc, and, at its posterior and inferior OP THE EYE. 19 After enter- ards, and is ernal rectus 3rves in the 'lelr respec- ts branches 'ary nerve, ich join the •anch which md divides poTol. The ''e, passes distributed •one. The oral fossa, aus,— then companies Its of the le last or proceeds »nal, and it divides tl to the Bse diffe-' with the he nasal I a small t of the muscle J re form, te nasal inferior angle, a twig from the inferior oblique branch of the third cerebral nerve. From the anterior angles of this ganglion, two fasciculi of fine nerves proceed, which are termed ciliary,— the inferior being larger than the superior. Ciliary Nerves.— "IXiQ ciliary nerves are about twenty in number, eight or ten of which are in the inferior fasciculus and about six in the superior, and there are three and some- times or four internal, which arise from the nasal nerve. The ciliary nerves twine around the surface of the optic accompanied by the ciliary arteries, and with them pierce' the back part of the sclerotic coat ; they then become flat and proceed forwards in parallel grooves on the inner sur- face of the tunica sclerotica, having but little connexion with the choroid coat: at the anterior part of the eye, they meet the ciliary ligament, in which most of these nerves are lost, but on each side, one or two branches may be traced through it to the iris, where they divide into numer- ous filaments of extreme minuteness. GLOBE OP THE EYE. The globe of the eye is situated in the orbit behind the conjunctiva. It is surrounded by the orbital muscles already described, and is connected posteriorly to the optic nerve The axes of the eyes diflFer from those of the orbits, the former being parallel to each other. The globe of the eye IS nearly spherical, its antero-posterior axis being about two lines greater than the transverse axis; this difference is due to the cornea being a segment of a smaller circle than the sclerotic. The diameter of the eye in its axis is about one inch. The eye is composed of fluids or humours enclosed in different tunics, of which the first is the sclerotic or fibrous coat, the second the choroid or vascular coat, and the third the retina or nervous coat. ao ANATOMT ■■•queous; the second or ml,M r "'"""■ ''"'"°"'' '" "•« or posterior, the^telT ' ° "^"'"""'' """ ">" "'« .he'':ot«i*;r.'b'etf "^ "■"°™'' '•™"' "•« *'i nerve m^stCZiZ ^l7. T'*'' ""'"■' ">« "P"" .-enX,^£;-ir:rte£l^ wherlthi,:;:; plta^; "K"7"^. '» "» «'™, an.hedo„itsconcaveISea lal ™!-°'r ~' ""^ "' -nttag a cribrita appea™" mlZZT!^- '"■ pearance s due to ihp P^mfmi * "oserved. 1 lug ap- which accompany the odTA .7 '"^ '^'" ^^ *''« ^etinS, «heath of the^S t Je 3";::;*'''-«"^''"''^^ The sclerotica. 1( alZ'Zle2TeT! ^'^^ ^^e fibres of the front, backwards,tS be r;^^^^^^^^ '"^^^ ^-m the optic nerve, that it bccmne thin in tT ^''' '' '' '^' thiclcened a't its anterior part bv hVf 7^^^'' '"^ '^ «^^'" the muscles inserted ilT ^ "'"' '"P""«'"°» «<" The tunica sclerotica consUf« «f ak ^'irection, but do not fomdtr f' •'"'''''^ ••""'" ^^'^^X -rface is' concave, sll7\'fr. ??""' '^^ '"^^^"«' -between it and IheeiiT:;;/;;^^^^^^^^^ and nerves. Anicrinrlv (h. . , '/"" "'« Miliary vessels »ca; both areXeioff ohn„ 7''" ~' "«'™» *« "■- the selerotica overial L 1'^^' """ "''«'"'^ S™"'); "ill fnrther seen™ Z J Z"""' ^"^ """' """""'I'"' > membrane of the aa7eo„, nt" '" ""'*"^' '"'> ">« -ly be separated byTera "" '°'''"°"'- ""'^ «" OF THE EYE. 21 V.5 , rT ' '"'■"'^ '' "•^«'''>' "^"•^"'a'-; its trans- verse diameter, however, is a little greater than its vertical. It constitutes about the anterior fifth of the eye, and though not of a fibrous texture, consist of lamina, con- neced together by a fine cellular tissue. It is smooth and perfectly transparent, its convex or anterior surface is covered by conjunctiva, which is only separable from it by maceration ; its posterior or concave surface is lined with a fine elastic membrane, which is not, as some have supposed, a part of the membrane of the aqueous humour but is one sui generis, that continues to preserve its proper curve and transparency, after the cornea has been separated by maceration. That it is endowd with true elastic cartila- ginous properties, is proved by its curling upon itself when it 13 cut. In the child the cornea is thick and pulpy, while jn the adult ,t .s often so hard as to cause the point of the knife to bend on it, while the operation for extracting cataract is being performed. The lamina of the cornea are connected by loose cellular tissue, which can be easily demonstrated by rubbing the cornea between the finger and thumb, when .t will be found that the layers glide freely over each other. ^ & ^ / The cornea is supplied with blood vessels, nerves, and absorbents. Blood vessels and absorbents, however, can- not be dissected in it, so their existence must be proved by physiology and pathology ; but the nerves can be seen in Irr I I ' P]"" recommended by Pappenheim bo adopted who found that he could distinctly trace the nerves from the sclerotica into the substance of the cornea, after having immersed the cornea in acetic acid, or a solu- tion of caustic potass. He gives three facts in proof that the nerves thus traced belong to the cornea. l.^-If the corneal conjunctiva be removed, the nervous filaments are on the inner and not on the outer surface of the corneal epithelium. 2„^.-The removal of the iris and mumbran. 22 *• ANATOMY of the aq,,eou8 humour makes no difference as to the facih'tv w. h wh,ch the nerves can be seen. 3.^.-The nerves a e J.S .netly v,s,ble entering the margin of the cornea, bu le 3 so towards Its centre, M.ere they are ultimately' hJb tween the lamina,. T« see the n.rves, he placed the cornea between two plates of glass, and Immersed the whole n water making gentle pressure, and keeping the con ave surface turned upwards ; he found the Hghf of a lamp necessary and sometimes a slight magnifying" l.ns. ' Choro^ aa/.-The choroid is the second a a 1 vascular sect o^n T '' r 'r ' "^" '^ "^^'"^ ''^ fol Wing d . sect on .-The eye shonid bo placed in a shallow vessel con- a.n.ng a sufficient quantity of water to allow ofrbeT; trTor.""""?';' -^" --'-on must be then mTdf cle^ tiea " [rt^ ' ™""^' '' ' '"« *"^^' '^^ ^^us'the scjerot ca w If become separated from (he choroldea after stttr'asTh"" "" ''f'''''^' off with apahof": to fL 1 ' '"•■"'"' ^'''••^ '' ^^'» be found adherent at d wtl 'TT' '^°" "^■'^^ '^ «^" b« «««•> sepa- rated With the handle of a dissecting knife. Half of Z cornea may then be removed, when the chordd c' ' and S appendages wil, be fully brought into view. I fs pp nd g the^tl a t "*V" f"^^^' ^^^"^^^"the sclerotica and sclerotica, by the cilmry vessels and nerves, and also llie facility nerves are Ja, but less y lost be- placed the the whole the con- of a lamp IS. I vascular 'Wing clis- essel con- its being hen made ected, air I thus the Jea, after r of scis- adhcrent ily sepa- f of the i and its endages is. tica and 3 ciliary Is inter- lied the in the ling are poste- nected id also OF THE EYE. 20 by fine cellular tissue. It is divisablc into two layers, an external and internal,— on the external arc numerous fine vascular ramifications, running in parallel arches; these are chieily formed by veins, and are termed the vma vortkosa. The second coat of the choroid is called after its discoverer, the membrana Ruyschiana. It can be separated from the outward layer by dissection ; its internal surface, which is next the rctinaj is covered by a brown pigment which ia thicker anteriorly than posteriorly ■ this pigment is defi- cient for a small space round the o, tic nerve, and can be washed off the surface of the membrane with water ; it is totally wanting in those anomalies called Albinos, and they are therefore unable to see distinctly in broad daylight. The ciliary arteries supply the choroid coat with blood. Ciliary Ligament.— Iha ciliary ligament corresponds to the junction of the iris and choroidea, and of the cornea and sclerotica. It forms a ring of a grey colour about two lines broad, and of a soft cellular texture. Ciliary Muscle.— -Thh is a muscle described by Mr. Todd in the third part of his work on the Physiological anatomy and Physiology of man. I have soughi for such a muscle but could not find it ; indeed I conceive it to be nothing more than a part of the ciliary ligament ; however I would hesitate before doubting such an authority as Mr. Todd. It would appear as if the search for this muscle was caused by the received opinions of old authors that the change which the eye underwent, to adapt itself to near and remote objects, was produced by some change in the lens ; but they were unable to point out any means whereby this lens could be moved. According to Mr. Todd's idea, however, this ciliary muscle moves the lens and the ciliary processes towards the cornea. The following quotations will explain, his views {Page 21.) " The choroid, on coming up to the cornea, gives' off its process the iris, and it there adheres intimately to the sclerotic by a very narrrow ring of white tissue,— the ciliary i ,- • 24 ANATOMV ' choroid «ow' given refer oTlvf 7 ''^"^'^'•'Pt'O" "f ti.e responds to tL reti m and H '' ^"■'^" '''"'' *^'»'^'' ^<>r- a line (ora se.::!^ :!.::' Jz:zr::'7' r-' -^ margin of the cornea Jn fron r ., f '"''' '^''""^ "•« *'"eiriMl,ochoroidT;k/:: :'';;^ - as far as di«ed to form the c^e«.^ ^11 ll^^^^ '^^'"^ «"«■ outer surface by a semi IZ ' . ^ '* " "^^'^'''^J «" its at the anterior edge f'S^^^^^^ ''-"Mhe ."^^^ ,^,,,, the *^ i^^anJ„J ''' " ' '""''« '^^^ white ring, vering the outside of the cHia v f ^ P"''"^' ""^ «»■ cribed as muscular by manv oMh t '' ''"^ ^^«" ^es- cially by Porterfield imZhl u ^^'' '"^^omhts, espe- tbrent cLracter Latelv ll'' "'' ''''^'''^ '' " « ^if- a."i Dr. Wallace of N^ y ^ and" " \T''' '' ^«^"- belongstotheunstripervarietvofl ,''''"' '"'''''^y- '' pear to radiate back«^rds 70^1 ' '^ "'^ "^ ^'^^^^ «1>- and cornea, and to lose eS CZ" V'"" "'^^^"^ the cii ary bodv Tha ™ '""'^"'es on the outer surface of -A but'scatiy a'tr?;: 7:T !^''' ''' '" -^- '•nto the posterior part f the ci arvtT''' '"'^ ''' '"^'^"e'J o-s seem to dip'behl he ^rh :th^ '''''''' '^^P-' parts of the ciliary processes ILT' "'"'"' Prominent -iiary muscle must'ha e , ^ oTT' ^'° ''''■ ^'^^ processes, and with them the W I ^"'"'^ *'^« ^''iary cd arynervespiercethi?m see ou h^ ' "^''^""^^- ^hl *ributi„g to it many filarems wl, , """^ '' '^'' '"«' ^i^" raost part to cross L HHZ' "''^ ^' '''^' ^'^ the Ciliary Processes .Tl OP THE EYE. 90 forepart of tho vitreous humour; they arc about sixty or seventy ii. number; each of them cxtcn.Is as far as the lens runnmg inwards and baclcvvards fron, the ciliary ligament' Those processes, as well as the interstices between tl.em, are covered witli pigmentum nigrum. To this part Sir C Hell gave tlie name of corona ciliaris, or ciliary circle. The an- terior edge of each process is connected to the ciliary liua- ment and iris; the posterior edge is attached to the vitreous humour, and the internal e.lges are perfectly loose and floatl ijiff, forming the circumference of the posterior chamber of liie eye. If the vitreous humour and lens be removed from the eye, there will be seen a striated mark on the vitreous humom' and round the lens, called the ciliary dM, and is formed by removeT'"'"^ P'^ment, after (he ciliary processes have been The ciliary processes are of a vascular structure, and their contorted arteries can be traced from the ex rcme ne2 r : T ''""'' ''''' ^'^'^ processes. are eon! nected to the lens ^nd^recay, that is, their posterior edges are attached to the layer of the hyaloid membrane, covi- ng the vitreous humour, and passing over the lens. By these processes vessels are conducted to the lens im.-The iris is a very delicate membrane of a circular tTcallvlf WK ' ^q"^«"«h»n^«»'-,and is suspended ver- and^hP , ?"'"''' '' '' '' ^'^'^^ "^^ «P '<^« between It and the lens into two apartments, viz :-the anterior and posterior chambers of the eye. Th^ iris is fixed, by ts ex- rnal border, to the ciliary ligament; part of it's po erlr surface IS attached to the same and to the ciliary pfocessTs toits nasal than Us temporal side, which aperture for,ns the • R. R. Todd on the Physiology of Man.-Part 3, page 24. Pm 26 ANATOMY »vcre„ With p'^7„ •„, ^,^;, P.-"'-, surface of .he'ria if The a„.eri„,. f„ fa^e tf ^'j '"Ju" "'T-' " '*" "■= «"«• «'• other, thea separate IT,™'^ ' T' "'"°'" ""J' «™»s bordering the p„pi|. '™'*' """•«» of a darter tint djg' fXTrSr .h": :-*■ -»»* «nd nerve. 'b»"...scnlartibrerZ4''°rr''"''^ "' «>» '•"■'! tat •erior snrface, large enTnrf, .„^ '''■?™"™'ed, on itspo,. W'l^pnttingthff™" tnd .1 ^k""'- » »»* or ho-tofore exited on t e Sfet w!*!,"';''"'' "'^ '^'^ •we derived fron; t|,e i,Z' a '"""^ "' "e iris »"7,withwi,ieh ;::|;;"27"-07il.-ary, and „, "«> nerve, and lenticnil;" "Pj;^^^' "« ""■«" f™" 'te '" ".eJbt:: caK' *"" "''' ««'» -^ va,o„- ™P'»red eilhe at, or a ,h„rrr "" «"''"' """eb i» Beli,a.~Tb, retina i7 .1 •"" l"'"'""' '» W* °f «.e eye, "d U redt "."hlT' ""' ""™- '""- or external is ,he lamina el»?l.° '"^"^ ' ""'*»' «." to dist'bnTi, :;";"'"■'' '^^ *""»'» «■"' dia. Vpre..nre n^onlTth'thMZrf ''•°"' *"'»"'' C Doctor J«,„b, of D„b7„'" •'«*. "fterils diaeoverer f»^«tiirrtS:;:7r""''"'»«™^ ^s therefore the true retina. *''' "P*'' "^'-^^^ ^"5 e eye, and the iris is 1 the uvea. ' different «rse from they cross ig to form, irJcer tint I nerves, iris; but 1 its pos- eedle or ay have the iris and its i'om the vascu- hich is tunic ! optic le fiist amina diffi- layer ater ,• k'erer, gray I and OF THE EYE. 27 The internal or vascular layer is very delicate and lies on the hyaloid membrane. The three coats of the retina run forward, in conjunction, from the optic nerve to within two lines of the lens, where the outer and middle coats terminate in an abrupt line, along which a small vessel runs. The internal or vascular coat continues its course over the lens, accompanied by the hyaloid membrane, to which it adfeeres. This vascular lamina of the retina is formed by the terminating branches of the central artery of the retina. The concave surface of the retina is best seen by cutting a fresh eye transversely, and allowing all the humours to fall out. When looking at the concave surface of the retina there is to be seen in the centre of the optic nerve a small dark point, which is the central artery of the retina, and is gen- erally called the 2)orus opticus. In the axis of the eye, which is about two lines external to this point, there is a small yellow or orange spot, called the punctum aureum, or spot of Soemmering ; around this spot the retina is thown into folds. The retina is transparent in the recent eye, but it soon becomes opaque after death; it also becomes slightly opaque if immersed in diluted spirits of wine, which it should be for dissection. Aqueous Hummr.— 'The aqueous humour fills the anterior and posterior chambers of the eye ; it is a perfectly colour- less fluid, and is about five grains in weight. This fluid is secreted by its own capsule or membrane, which membrane lines the concave surface of the cornea, and is continued from it over the anterior part of the iris, then passes through the pupil, and lines the posterior surface of the iris from which it is reflected to the anterior surface of the capsule 2fi AHATOMr "'it wf • ^'','' '"'"™"' ""P'"'" '^ " =«««» membrane than anteriorlv wl • ' ^ ™*''^ '^^"^^^ posteriorly had bee^a ,S;tH ?' '"'^"^'^ ^PP^^ring as though it in the vLl . "'"'^ "^ P''^^'^'^- This lens is imbedded haX hf '' *' "' "^^^' ^'^^'^ "« ^"'"Poral Bide and having Us axis corresponding to that of the pupil ' and f;";:j:X'^tt'^^ ^ '7 eapsuIe:w'hJch is thin «ty of fluid, whi"h is caHed •' " ' ''''^ ''""" 'i"*"- i^ept in its kce hv t^ I ?T '"''■^'^^"^' ^hc lens is arrival a th^ ed^^^^^^^ ^'^'^ ^ '">"^' ^^'^''' «° '*« running .riSl and h 7^ '^i'^' '"*° '''' '^^«"' «°« the vascdart at of 1 .r '' ^''"'"° ^°""«^'«^ ^'^'^ the aqueous humour, he says "TlS?™-?h' T"^'^^ "^ ">« membrane df OP THE EYE. 29 Us discoverer, the canal of Petit. It is intersected by fine septa composed of vessels and nerves of the lens so that when it is distended with air, it presents a cellular or vesicular appearance. Although the lens is called one of the humours of the eye, yet it is very different from the others, for it is a com- pact substance, soft and pulpy externally, but dense towards Its centre, or rather a little internal to it. It Is of a fibrous structure, and, when boiled, separable into wedge or triangular shaped pieces, each piece composed of successive plates, and each plate of fibrous structure. The lens IS supplied with vessels and nerves from the ciliary by the ciliary processes. The capsule is supplied with arterial blood from the extreme branches of the cen. tral artery of the retina. me cen- The lens in the foetus is very vascular and soft : in the aault, it IS perfectly transparent ; and in the very old it has an amber or yellowish tint towards its centre. Vitreous ITumour.-The vitreous humour is so thin in consistence as to be almost watery ; it derives its gelatin- ous appearance from being enclosed in the hyaloid mem- brane. This membrane not only encloses the vitreous humour, but sends processes into it, dividing the whole mass into numerous cells, all of which communicate so freely wi h one another, that air, injected into; one, will rapidly distend the whole, or if one or two openings be made into the capsule, the whole of the fluid will gradually 6SCap6« The vitreous humour, with its capsule, fills the two pos-^ tenor thirds of the globe of the eye. Anteriorly the crystalline lens is connected to it, as has been already described. External to the lens, upon the hy- aloid membrane, is the ciliary disk. CHAPTER in. PHYSIOLOGY OP THE OEBIT AND ITS CONTENTS. • AuTHOiiS, generally wlien writing on the pliysiology of the eye, have sulTered nearly all their attention to be given to the globe, to the exclusion of its appendages ; in acting thus, It ,s unnecessary to say, that they have committed a great error; for indeed the globe of the eye would be of but httle use, if it were not for its appendages. In this chaptei- will be given the physiology of every part connected with the eye, both separately and collectively, and it will be shewn that the different conditions of the retina arc accompanied by appropriate conditions of the surrounding OEBIT. As a general rule, in the animal economy it is found that the more important a part is, the more carefully it .8 secured from external violence ; of the many examples to prove this, the brain is the most striking. We thus see that one very important use of the orbit is that it acts as a protective to the eye Secondl^,^lt forms a socket in which the eye perform its diflFerent motions, nirdlv -It gives attachment to its different muscles. And fourfhly,- By its foramina, it transmits and protects the vessels and nerves going to and from the eye ; hence the orbit is indis- pensable to the well-being of the eye. PERIOSTEUM. The periosteum covering the bones of the orbit, is of the same use as that adhering to any other bones of the PHTSIOLOQY OP THE EYE. gi body. It transmits the nerves and nutrient vessels to the bones, and gives attachment to some of the muscles, and forms a smooth surface for the parts in connexion with it to move ui)on : but the periosteum of the orbit does even more, for it becomes a protection to the anterior part of the eye, (for which it is well adapted by its great elasti- city ) m consequence of its forming the palpebral ligament tor the attachment of the tarsal cartilages. PAT OP THE ORBIT. Tlie fat in the orbit serves, combined with the cellular tissue, to fill up the interstices between the muscles, to form a cushion for the eye-ball, and to protect it from being injured by the spasmodic contractions of the muscles of the eye, and by the concussion of blows. It is also of use in supporting the nerves and vessels supplying the eye-ball. ^^ ^ *= ^ TUNICA VAGINALIS OCULl. The use of this tunic is to prevent the muscles of the eye lonTra^'''"^ '" *''' '^'■*''"' '''^'" "'' '""''''' ^""''^^y VESSELS OF THE EYE. There is but little to be said on the physiology of the Xh ?uf T ^""''^ "^ '"* '""^ '^' g^^-t -ssels, of which all the others are branches, namely, the ophthalmic artery and vein; of course their u.^ - to carry blood to and trom the eye and its appendages. Cor^ttions of the -E^e.-Before entering into the physio- ogy of he muscles of the eye, either separately or collec ively, ,t will be necessary to examine the different condi- tions and motions of the eye. 82 fJlYStOLOGY 01 the e>e is given up to one class of muscles, namely, the ctSheTl.' "^ -'"^ f "^'^•^^' '"^'^"<" -^'^^»'- ther h" n ' /"" ''^'"^^ ^^ ^^'^ organ,-and that, on the other ham], , ,s assigned to the tutelary protection of the other class, the so called involuntary, during rest, by h Lh .s mean s eep, fluntness, and insenslbilit; N vv I c n' .s.dertha a is not very difficult to shew^hat both tl e statements are in a great degree wrong. As to the eye -oing given up altogether to the controul of the voluntary although the statement rests upon the authority of SW t. lie I. That the involuntary muscles constantly oppose the voluntary,and that too very successfully, even againsUhe strongest efforts of the will, I will endeavour to prfv Tn he ourse of this chapter; and I will endeavour also to de demonstrate that it is actually necessary for the pre erva- t on of the eye, that such should be the cLe. The musdes vakmg state, are most certainly strictly voluntary,* and •dways connected with the exercise of the sense of^'vision but the involuntary motions of the eye have nothing in^sifth: If iT^""'' ''' p'^^--^ ^ • nyelloH of the will, solely and entirely for the nreserva- |on t e eye Wishing to prove that during teTnd. tn of sleep, famtness or insensibility, the eyes are given "P to the power of the involuntary muscles. Sir C. Bell a duces heir vacant appearance, want of direction and he.r whites being disclosed by the revolving of the eye- iKdl upwards. The fact is otherwise; during sleep The ••ye-balland^tsm^ .ie;i^wUh7henX„"al%tS r^ti which cannot be ^.rKionZCoUi^^^^ ''" t.o external OP THE EYE. 33 consequently in its natural position, tliat is to say, the cor- nea is turned a little upwards and inwards, but not nearlv so much as when it is turned up during our waking mo- ments by the action of the inferior oblique, which is an involuntary muscle, and acts only in obedience to reflex stimuli, or central irritation as in epilepsy. This is easily ascertained by examining the eye of a person asleep, when It will be found that the whole of the cornea can be explor- ed on raising the upper eye-lid, and on the other hand, that no part or hardly any portion at least of the cornea can be seen when it is turned up by the action of the inferior oblique, however high we may raise the upper eye-lid Some of the muscles of the eye possess a compound function, that is, they are both voluntary and automatic, or in other words, they act both in obedience to, and indepen- dent of, the will. The different motions of the eye will be better explained, when giving the physiology of the mus- cles. EectiMmcles.—The four recti muscles of one eye, without considering, those of the other, may be said to be all volun- tary, and their action, either separately or collectively is completely under the influence of the will; still they cannot, at all times, obey it, in opposition to any of the involuntary muscles of the eye in action, as, for example, when the inferior oblique is acting. This can be understood by a very common illustration- If a foreign body gets under the eye-lid, causing pain or irritation, the cornea becomes turned upwards through the reflexaction of the inferior oblique, (which is an involuntary muscle), in opposition to the strongest efforts of the will that can be made upon the inferior rectus muscle to bring the cornea down, and keep it in that position. The use of the four recti muscles, acting collectively, is to fix the eye when looking at any object; in this action, they are perfectly voluntary and obedient to the will THav "~^ tl.i 34 PHYSIOLOGY likewise prevent the cye-ball being protrnded during the action of either of the obliques. The separate actions of these muscles are as follows :- The superior rectus turns the eye upwards, the inferior downwards, the external outwards, and the internal in- wards; and alluding to one eye only, all these separate actions are voluntary. v ^^ The recti muscles are the only voluntary muscles of the • eye-ball, but under certain circumstances, they perform their action without the stimulus of the will; they cause the eye not acted upon by the will to rotate in the direction of the eye moved by the will. This movement is called «,«- sentaneous, and the muscles are said to act automatically, not voluntarily; tlie stimulus is probably reflex. The follow- ing are all the automatic movements :— Eight eye acting voluntarily. Left eye acting automatioallT. Outwards. Ext Reetus. Internal Rectus. Out and down. Ext and Infr. Recti. Int and Infr. Recti. Out and up. Ext and Supr. Recti. Int and Supr. Recti Ana vice versS, In opposition to the opinion of other Physiologists I maintain that these muscles, (the internal, superior and mferior recti,) are the only automatic muscles of the eye. The two oblique muscles, supposed by Carpenter and others to act sometimes automatically, or to be partly voluntary a..d partly involuntary, act alwai/s tnvolmtartly : and are as I shall presently show, absolutely dependent for their action, upon the movements of the orbicularis, or levator palpebrsB. The superior recti always act consentaneously to turn the eyes upwards, the inferior recti consentaneously to turn them downwards, the internal recti acting together volun- tarily, as will be seen when we examine a very minute object, turn the cornea towards the nose. The external recti never act consentaneously; the volun- taiy action of one external rectus being accompanied by the OP THE EYE. 35 automatic action of tho internal rectus of the other eye, as already stated. The obvious harmony of this arrangement in preserving the axis of vision perfect, is abundantly evi- dent. It must be remarked, that any intermediate move- ments of the eye-bails, when the eyes are open, such as turning the eye upward and outward, upward and inward, &c., are due to the combined action of two recti muscles, and in no such case to the action of either of the oUiquea. The rapid consecutive contractions of these four muscles, give that appearance to the eyes which is called rolling^ and is perceived in persons when in a passion, drunk, or insane. But the appearance is deceptive ; there is no such motion in the eyes as rolling. Physiologists have assigned another use to the recU muscles, viz. to retract the eye-ball into the orbit when the eyelids are closed* ; but they have no such power, nor is there any occasion for such an action, for the eye-ball is no more protruded when the eye-lids are open, than when they are shut. The cause of this deceptive appearance will be explained hereafter. Superior and Inferior Oblique Muschs.—lhQ two oblique muscles are purely involuntary or reflective, and are always antagonists to one another. The action of the inferior oblique is to turn the cornea upwards and inwards; the ac- tion of the superior being to turn the cornea downwards and inwards. It will be now necessary to prove, that these muscles are involuntary in their action. If there be the slightest irritation produced on the lower part of the eye-ball, the cornea is &t once seen to turn upwards by the action of the' inferior oblique, and to be retained in that position, in op- position to the will, as long as the irritation is kept up. That it is the action of the inferior oblique, which thus *It is furnished wittj muscles capable of moving it towards any side, and of protruding or sinking it." Physidogy of Man ;%y R. B. Todd.-.Part \fa, page 15. 86 PHY8I0L0OY elevates the coinea, is proved by the fact that it is turned upwards nearly altogether out of view — a power which the superior rectus has not ; for if a person wills to look up, ho can do so but cannot turn the cornea out of view. If the superior rectus of any animal be cut, it will be at once seen, that the voluntary power of looking up is lost ; but let the same eye be irritated, and the cornea will be found to turn upwards out of view, as much so as though the superior rectus were uninjured. Then let ihe inferior oblique of <\nother animal be cut, and the superior rectus left uninjured, and, no matter how much the eye is irritated, the involun- tary power of turning up the cornea is lost. But the question will naturally arise. What is the great benefit to be derived from these Involuntary movements of the eye, and would not the voluntary motions answer all purposes ? No I The involunicry motions of the eye are (as it has been akeady stated) altogether for its protection, or nearly so ; a use which the voluntary muscles do not pos- sess. If danger threatens the eye, the cornea turns upwards for its protection, by the action of the inferior oblique, at the same time that the orbicularis closes the lids. Sir. C. Bell supposed another benefit to be derived from this action, viz. that it stretched the lachrymal ducts like a nipple, and thus produced a greater quantity of tears to lubricate the cornea, and wash off any offending matter that might have adhered to it, causing irritation. When it is remembered where the lachrymal ducts open, it will be at once obvious that the above statement and inference are correct. The inferior oblique always acts consentaneously with the orbicularis palpebrarum, for at the very moment that the orbicularis acts in closing the eye-lid, the inferior oblique turns upwards the cornea almost entirely within the orbit ; and thus proves a protection to the retina, for it darkens the eyp, and prevents the light, which in passing through OF THE EYE. 87 the lids becomes red, from reaching the retina, upon which the continuous action of the red ray is always hurtful. The orbicularis palpebrarum thus acting at the same time, the effect is to carry any simple foreign body that may have got under the eyelids, and produce those actions, into the internal canthus, where it is protruded from the eye by the caruncula lachrymalis and semi-lunar mem- brane. The direct action of the superior oblique is to turn the cornea downwards and inwards; lis anatomy will show that this must be the result of its action. That it is involun- tary, is evident from the fact, that no exercise of the will can produce the same effect. It has been stated that the inferii r oblique acts in unison with the orbicularis palpe- brarum, for when the orbicularis closes the lids, the inferior oblique turns the cornea upwards and inwards. The superior oblique acts consentaneously with the levator pal- pebraj superioris ; for when the levator raises the upper Jid, the superior oblique turns the cornea downwards and slightly inwards. This action, with that of the inferior oblique, takes place every time the eye is shut and opened, as in winking, but the actions are so very rapid as not to be observable. But if a person awaking out of sleep, be watched (when there is no will exercised,) it will be seen, that the moment the levator raises the upper lid, the superior oblique turns downwards the cornea, which thus depresses the lower lid, so that the superior oblique muscle is the true but negative depressor of the lower lid ; this is a novel state- ment, but of which conclusive evidence will be presently adduced. Previously to the views set forth by Sir C. Bell, anatomists and physiologists, perceivingthat in opening the eyes the lower lid is depressed, sought, but in vain, for a depressor for it. He looked for a direct muscular depressor, and thought that he had found it in the levator palpebr® superioris, which u PHYSIOLOaV he said not only raised the upper, but depressed the lower lid. The following arc his words (page 153, third edition of his work on the nervous system :)— " The muscle, elevator palpebrffi supurioris, opens wide the eyelids, depressing the lower eyelid, at the same time that it elevates the upper one. If we put the finger upon the lower eyelid, so as to feel the eyeball when the eye is shut, and then open the eye, we shall feel that during this action the eyeball is pushed outwards. Now, the lower lid is so adapted as to slip off the convex surface of the ball in this action, and to be depressed, whilst the upper eyelid is elevated." He then gives a plate of the eye and levator muscle, shewing that the muscle, from its origin to Its insertion, is In con- tact with half the circumference of the globe ; and infers the above conclusion to be the result of its contraction ; evidently having forgotten at the time, that the Jevator was not in such close contact with the globe of the eye as he stated— the superior rectus muscle lying between them, 80 that the contraction of the levator could not produce the effect he alleged. He was wrong in supposing the eye-ball to he protruded at a\l If the finger be placed on the lid, as he recommends, it would appear as though the eye-ball were protruded ; and certainly the lower lid is depressed, but not by the agent to which he ascribes it : it is effected in this way,— The globe of the eye is composed of the seg- ments of two spheres of different dian eters, of which the cornea is the segment of the less sphere ; in consequence of which the antcro-postcrior diameter of the globe is much its larger diameter. Hence it follows, that when the orbi- cularis closes the eyelids, and the consentaneous contrac- tion of the inferior oblique takes place, by which the cor- nea is upturned, the situation previously occupied by the cornea, which is filled by the rising of the lower eyelid, due partly to the elasticity of its structure, and partly to the contraction of the lower orbicular fibres. But OF THE BYE. M when the eyelids open, these fibres of tiio orbicularis being relaxed, the corwca pushes the lower eyeh'd outwards and downwards to its original place ; and as this is effected by the superior oblique, acting consentaneously with the leva- tor palpebrffi superioris, my position Is maintained, that the superior oblique is the muscle whoso action is the real cause of the depression of the lower eyelid. (Under ordinary cir- cumstances, when we look at any thing In the line of the cheek bones, the rectus inferior, by still further depressing the cornea, becomes in a similar manner the voluntary de- pressor of the lower eye-lid.) That this is the case is easily proved ; thus, hold the upper and lower lids of a person close to the edges of the orbit, so as not to allow any voluntary effort of the orbicularis to close the lids, then let hira make the effort, when it will be found that the cor- nea will turn upwards and inwards under the orbit. Then et the person relax the fibres of the orbicularis and bring the levator palpebrsE musclo into action, when the cornea will at once turn do^- ,,d8 .^d outwards by the action of the superior obliqiu , and in so doing bring the cornea against the lower lid, and depress it. My attention was lust drawn to this fact by observing a man, who presented himself at the Eye and Ear Institution with ectropium of both lids . • one eye. T directed him to shut his eyes, knowing that he could not do it. When he made thJ effort. up went the cornea out of my view, so that the man was u. complete darkness, and fully under the conviction that he had both his eyes shut ; and when I asked hira to open them, the above detailed action of the superior oblique was shown, by the cornea turning downwards and i, wards and then instantly assuming the ordinary appearance of the eye when regarding an object. Again, let a person close both eyes, and put a finger upon one so as to feel the eye-ball through the lids, then let the other eye be opened, when it will be found that the 40 PHYSIOLOGY cornea of the closed eye will come down and press against the lower lid upon which the finger is. It may be asked, how is the cornea turned down when the eye-lid is closed, if, as has been already stated, the superior oblique acts in unison with the levator ? The answer is, in the same way that the inferior oblique acts, when the orbicularis cannot close the eye-lids. It does act, but is prevented from rais- ing the lid by artificial means. Another answer is, as has been already explained, viz :— that the eyes act consenta- neously, so that one eye cannot be kept motionless while the other is in action, even though the former should be blind. Levator Palpebrce 8upenorts.~Thia is a compound muscle, acting both voluntarily and by reflex stimuli, its use be- ing to raise the upper eye-lid upwards and backwards, and to expose the ball of the eye, by which it is made to appear protruded. It is an antagonist to the orbicularis palpebra- rum ; and, as has been already stated, it acts in unison with the superior oblique. Its reflex action takes place during the rapid motions of winking. During sleep this muscle is relaxed. OrMculansPalj3ebramm.~T:h\a is also a compound mus- cle of the same order as the preceding, and its antagonist. With it we close the eye-lid, its superior fibres drawing down the upper lid, and its inferior fibres drawing the low- er lid upwards and inwards. It also, by its reflex action, endeavours to expel, and usually with success, any foreign body which may get under the eye-lid, by directifjg it to- wards the internal canthus. This reflex action is some- times so great (blepharospasmus) as to defy every efi"ort of both the surgeon and patient to get the lids opened. Indeed, this effort of nature to remove foreign bodies from the eye, sometimes acts, very injuriously : for instance, should the offending matter be a particle of glass, the action of the or- bicularis can only make the glass penetrate more deeply into the part with which it is in contact. When danger OP THE EYE. 41 threatens the eye, the rapid reflex action of this muscle pro- tects it by closing the lids. That the orbicularis acts con- sentaneously with the inferior oblique has been already explained. During sleep, the orbicularis muscle, like all others of its class, is relaxed; therefore the eye is not shut in sleep by the action of the orbicularis palpebrarum, but by the relaxation of the levator palpebrae superioris, suffering the upper eye-lid to drop down into its natural position over the globe of the eye ; consequently the upper eye-lid covers more of the eye in this state than when the lids are closed by the action of the orbicularis palpebrarum, as in the latter case, the lower lid is always drawn a little upwards. A strong proof that the eye is closed during sleep by the relaxation of the levator palpebrae, and not by any sphincter properties of the orbicularis, is derived from the patho- logical fact, that a person with paralysis of the portio dura nerve, cannot, when awake, close the eye-lids by any volun- tary action; although the lids are perfectly closed; i. e., the upper lid is perfectly relaxed, during sleep. Tensor Tam.— The use of this muscle is to draw the puncta towards the nose, and to compress the lachrymal sac, and force out the secretion from the follicles of the caruncula. It is thought to act independently of, as well as in conjunction with, the orbicularis palpebrarum. I cannot conclude ihe physiology of the muscles of the eye without mentioning a use that has been assigned to the orbicularis; it is an error, and the more dangerous be- cause it rests on the authority of Sir C. Bell, an authority which one hesitates to dispute. He attributed to the orbicu- laris palpebrarum the power of pushing the eye-ball back into the socket when the lids are closed, and asserted, that It, with the oblique muscles, kept the eye in its place, and prevented it from protruding. This mistake will not be wondered at, when it is remembered that he attributed the power of protruding the eye to the levator. He was 42 PHTSIOLOQY well aware, that no muscle in the orbit had the power of retracting the eye-ball ; consequently, he was forced devise some means of pushing it back ; so he invoked ill !iu orbicularis to perform that office, and thought he was right, in consequence of perceiving the eye In ^TJ.^"'' '^' ^'^' ""''' '^''''^' '^'^ ^hen they Jre open But this appearance has been already accounted for by the tact, that, when the lids are shut, the long diameter thing to do m keeping the eye from protruding, is easilv shghtest degree; whereas, if it were kept pressed back by '^';'^r^''':^'^P'^'^^^rn, of course the ball would pro^ rude when the pressure by the lids was removed. In addi- lon we have the further support of the pathological fac . l^rvesofth Eye, PalpebrcB, and Orbit.-^lr C. Bell by nnwearied and enthusiastic exertions, in dissection of dead bodies experiments on living animals, and by pathological reasoning, proved that the body is supplied b^tr kse iltr^' ^'r ""'tive and motor, 'k also'sho^edX mipressions borne to the sensorium are conveyed throu-^h the b"? "™ 'I ')f '"""' ''''' ''''' *"»•« •^•ff--t motions of latter. But it must be borne in mind, that the motor nerves also act independently of, as well as in ob d enTe to tbe wd,, «y„ thising with one another through the Ted um of the sensorium ; thus, if a person be pricked with a needl «o that at the same moment, both classes of nerves are whcTn^ ^'■'''"" '^ '" '"J"''^' '•e^^'^ed, to remove which, the sensorium issues its mandate through the moto OP THE EYE. 4a nerves which causes the person to recoil from the injury either in obedience to, or independently of, the will To prove that there was no direct sympathy between these two dasses of nerves, Sir C. Bell divided the motor nerve, and hereby produced paralysis of the part which it supplied ; still the sense o feeling remained, although there was no power in the part to resist or escape from injury. Pathology fully sustains the correctness of this theory we every day see cases, where there is such disease of some part of the nervous system, that there will be sensation in a part, and no power of motion, or the power of motion, and no ense of feehng. But the necessity for an indirect com- munication between these two classes of nerves is at once evident for it would be of but little use for us toknow that w^ iu . the power to remove our hand or foot out of a fire - ■ 43 consuming it, if we had not the sense of feeling, to communicate to os that such an injury was taking place and vice versa. ^ ' fhn!?''^ ^V"" ''*?f ''*'''' °^"''""^^' 'l""^ distinct from those already considered, viz.-nerves of sense, and the ympathetic ; of the former are the nerves of sight hearing, smelling, and tasting. These possess neither 'volition, no rthe'^ll."'''''*^'^'" ^"^ ^'^''' ""*^^'' '^' '"fl"^'^"^^ As some of the nerves of the eye have connection with the sympathetic, and as the lenticular ganglion belongs to the sympathetic or ganglionic system, I do not consider it syslem'." ^'''' ^''' ^' ^^' "° "°"'"« «f ^^at The sympathetic nerves are two in number, each doscen ing from the base of the cranium along' either side of the spine and terminating in a small ganglion on the coccyx. In their course they form cervical, dorsal, and lumbar ganglia. The superior extremity of each nerve is connected by numerous filaments to several of u PHYSIOLOGY tl cerebral nerves, some of which have been improperly termed the origin of the sympathetic. In their course along the spinal column they regularly communicate with every pair of the spinal nerves ; with each of the cervical by one filament, and with each of the dorsal, lumbar, and sacral, by two. The sympathetic nerves may be considered either as an mdep-ndent part of the nervous system, communicating by numerous branches, with every part of tha. system ; or each may be regarded as a nervous cord, formed by the union of branches from all the spinal, and several of the cerebral nerves. The ganglia are small nervous centres, which have been designated diminutive brains. They are of a very irregular shape, but generally speaking, they are round; each ganglion transmits nerves upwards and downwards to the ganglia which are nearest, and. other nerves to the cerebral and spmal nerves. The sympathetic or ganglionic department, presides over the human economy, with powers altogether independeat c? the will. It has two important uses to fulfill, viz :-to sup- ply parts, such as the brain, heart; &c., with nervous influ- ence ; and keep up an involuntary sympathy between all the difl-erent nerves, with which it has any communica- tion. Optic Nerve.~-The optic nerve is a simple nerve of sense, having but one office to perform, viz :-the bearing to the sensorium the impression of the external objects that are pictured on the retina. Motares Ocuhrum, or Third Pair of Nerves.— The third pair of nerves are compound motor nerves, being both in obedience to, and independent of, the will. This nerve gives motion to five muscles of the eye, viz :— the levator palpebrae, superior rectus, inferior rectus, internal rec- tus, and i.iferior oblique. The filament to this last is the H i OF THE EYE. 45 involuntary branch of the third, and it is the branch which gives a twig to the lenticular ganglion. Sir C. Bell, with many other physiologists, considered the third nerve to be completely under the influence of the will; but ,f such were the case, how could the inferior oblique, which is supplied by it, be an involuntary muscle ? that It IS such has been already demonstrated. But that bit 0. Bell should suppose this nerve to be altogether uudei the influence of the will, is not much to be wondered at as It does not appear that he was even aware, that it give ;x twig to the lenticular ganglion. For be said it was given to no other parts but muscles, whereas its communication with the lenticular ganglion is the only possible way to account for the great sympathy that exists between the in- voluntary action ofthe inferior obliques and the fifth pair of nerves; and that there is in reality a great svmpathy between them, will be shewn when the physiology of the fifth pair of nerves is given. Trochkator, or Fourth Nerve.-ThQ fourth is a simple in- voluntary motor nerve, giving motion to the only muscle which It supplies, viz :-the superior oblique, oir C Bell attributed to It all the involuntary motionj of the eye • but if such were the case all the involuntary motions of !t'h'^? JO"ld be performed by the superior oblique, although Sir C. Bell himself was well aware, that the inferior oblique was an Involuntary rauscSe. But one error generally leads to many ; he was not, it would .ppear, cog- nizan of the fact that the fourth received a branch from the fifth nerve. That it does has already been mentioned when describing its auatomy. «"«onea iV^'f J ^TLtf^"""' ^'"'T' ^'^r^eouZar^y the Ophthalmic mZ*^ J. \ '" ^ "^''^ ^"^P°'^""^ "^'''^ ; " possesses many properties, but more particularly, that of sensation. It gives feeling to all the parts to whi.h it is distributed 46 PHYSIOLOGY the head, face, and skin covering them ; the eyes, nose, tongue, mouth, &c.. Pathology proves that this n'^rve is also a nutritive nerve, for if it be paralysed the parts which are suppl'od by it become emaciated ; and if the part be mucous membrane, its natural secretion ceases, and the parts ulcerate. Indeed the parts supplied by this nerve are dependent upon it for all their healthy actions, more particularly the eye ; for in- stance, if this nerve be in an w healthy state, absorption cannot be excited, except by restoring the nerve to its normal state. (This subject is fully explained in the chapter which treats of cataract, opacities of the cornea, &c.) It is to Sir C. Bell that we are indebted for the know- ledge that this is a nerve of sensation. If it be injured, either by disease or accident, at the spot where it escapes from the cranium, the result is, that one side of the face loses its sense of touch ; so that the parts may be eut, but the patient does not feel it, although the pow«r of motion is retained. The ophthalmic division of the fifth, separates into three branches, viz: — the lachiymal, frontal, and nasal. The lachrymal gives a branch to communicate with the superior maxillary, and another to the facial ; it supplies the lachry- mal gland, and conjunctiva lining the superior palpebir^; The frontal supplies the corrugator supercilii, orbieulanb palpebrarum, and occipito-frontalis muscles, and the integu- ments of the forehead and superior eye-lid ; it also commu- nicates with the injra-troch leator branch of the nasal The nasal or third division of the ophthalmic, before entering the orbit, receives a branch from the sympathetic ; and after it has entered the orbit, it gives off a branch to the lenticular ganglion ; and as it passes over the optic aerve it contributes the two ciliary nerves to the ciliary ligament and iris. It then gives off another branch, whic . Is connected with the supra-trochlcator, and is distributed fi h a C( OF THE EYE. 47 to the lachrymal passages, and also to the integuments and muscles on the side and dorsum of the nose. The prope? nasal branch is distributed, and gives sensation, to the septum of the nose; another branch is lost in the integu- ments on the tip of the nose, to which it gives sensation. The inferior palpebra is supplied by the terminating branch of the second division of the fifth, which also gives a branch to communi-.ate with the nasal nerve on the side of the nose. From the diflerent connections of this nerve we can easily understand the sympathy that should exist between the conjunctiva and the inferior oblique muscle. The infe- rior oblique dcriv«% its motor nerve from the inferior oblique branch of the third, which also gives a branch to the lenti- cular gangUon, and this ganglion receives a twig from the nasal branch of the fifth, which nerve imparts sensation to the conjunctiva. The connection of the fifth nerve is more direct with the superior obUque muscle, whose motor nerve being the fourth, receives a branch directly from the fifth. It is the sensitive properties of the ophthalmic branch of the fifth nerve which occasions the profuse lachrymation, redness of the conjunctiva.,, and sneezing, when the nose is stimulated by any irritating substance. That this effect is caused through the fifth, is evident, from the pathological fact, that, if the fifth be paralysed, although odours are perceived by the first or olfactory nerve, atlU no tickling or irritation of the nose will produce sneezing; indeed the person so afflict- ed does not even feel the irritation. Among the many offices of the ophthalmic branch of the fifth, I believe it be the protector nerve of the eye ; and here I conceive the following very important question arises, viz. : — Does it protect the eye in any other way, than by dis- covering bodies when in contact with that organ, and thus 48 PHYSIOLOGY exciting its involuntary motions, for the purpose of rejecting: the foreign body ? I hold that it does, and my views will be explained pre- sently. There is an involuntary motion of the eye for its protection, independent of the fifth nerve, which is the ac- tion produced by sight ; danger is seen to approach the eye before it touches it, and as soon as received, by the senso- rium, it issues its mandate thro gh the portio dura (which is the motor nerve of all the muscles of the face) to the orbicularis palpebrarum, which immediately closes the lids to ward off the approaching danger. But when notice of danger is conveyed by contact upon the eye or lashes, the muscle will contract in precisely the same way, the impression having being borne to the sensorium by the fifth, and the refiex action accomplished through the portio dura. I shall now endeavour to explain in what manner I believe the fifth to be a further protection to the eye, in addition to the modes just detailed. I hold that the ophthal- mic branch of the fifth pair of nerves preserves the retina from more light than it is able to receive without injury ; and this is caused by this branch being sensitive to the stimulus of light, independently of the retina. This is a novel statement, but I think I can sustain it by facts. If such be not the case, how, I would ask, can we account for contraction and dilatation of the pupil in persons who are totally blind, whether owing to paralysis ui the optic norve or retina ? If the iris were dependent for its action upon the reflex stimulus from the retina, this could not be the case ; for the amaurotic retina, it must be remembered, is incapable of discerning even the very strongest light. An objection that may be started against this theory is, that in the majority of cases of amaurosis, the iris is motion- less and the ^ apil fixed. Such, truly, is the case, but we must call to mind the many different causes which produce OP THE EYK. 49 amaurosis. The cause may be injury or derangment of the fifth nerve itself, or even of the third. How often do we ee Uns caused y wounds on the eye-brow, eye-lid, or forehead Supposing he cause to be paraly.s of the optic nerve o tina what IS there more likely, than that the same disease should also frequently cause derangement of the lenticular ganglion or of either the third or fifth nerve, or both Again why does light give pain in conjunctivitis, or such excruciating agony in strumous ophthalmia? The retina surely can have nothing to do with it. But it has b en tt' h' T""r '' ''' P"P" ^'-« ''^ pall, because hat when the app ication of belladonna dilates he pupil he patient is relieved. I certainly cannot understand how contraction of the pupil can give pain ; I am rather .nchned to think that it is the pain which causes the con ^:^ '"P" ' "J '''' '" *^« "^« ^' ''^ '^^''^Za Its application removes the morbid irritability of the fifth pair of nerves, and the pain being relieved the pupil dilates. Th scan be proved as follows: In strumous ophthalmia instead of using belladonna, let the irritability of the S be removed by the application of nitrate of silver to its e"- ternal branches, in the integuments of the superior Xl br» ; after which it will be found that when the pain hat been assuaged, the pupil will be dilated: now, certail th nitrate of silver has no specific power over the iris -it can therefore only dilate the pupil indirectly, that is, by reliet- mg the pain of the fifth nerve. ^ fac?'?h!i" "'"''' v' P;P" *' ''''''''' '« «^'^«°t fro'n the iact. That m couching for cataract, tb > pupil having been previously well dilated with belladonna, no sooner does he operator commence to pierce the coats 'of the eye, than he pup. begins to close, and before the operation is'c mp "t d he finds It much more contracted than he desires. But hov^ thatT! ?'^"*^^?*«db3^the stimulus of light; Theansw.r •s, that the ins receives sensation from the ophthalmic branch 00 PHYSIOLOGY of the fifth, and motion from the involuntary branch of the third; branches of those two nervosi, form the lenticular ganglion, which in turn suppliestheiri^ with nervous power in addition to that furnished by the two branches given off from the nasal branch of the fifth. Hence it is clear, that the iris is supplied with both a sensitive and an involuntary motor nerve, that the stimulus of light on the iris is borne to the sensoriura through the fifth nerve, and that the sen- sorium issues its commands through the third, which causes the involuntary action of the pupil, thus it is that the iris is found to possess all the properties of an involuntary mus- cle, supplied with a sensitive and an involuntary motor Berve. The iris acts as a curtain bet'veen the cornea and the posterior chamber of the eye, suffering no rays of light to pass but what enter through the pupil, and then only so many as are necessary to perfect vision, which is another great proof of its sensibility to light, independently of the retina ; and fortunately such is the case, for, were it otherwise, the retina would often suffer from the shocks of light it would receive. If the retina received the impression before the iris acted, a most important use of the iris and the pupil would be wanting. According to ray theory 'the sensibility of the iris to the stimulus of light through the fifth pair of nerves, it can be well understood, that the iris acts as a safeguard to the retina, by instantaneously adjusting the size of the pupil to the intensity of light, and allowing only the proper amount of light to pass through. This end it always accomplishes, except when its mobility is temporarily impaired by a long exposure to great light or profound darkness, and the op- posite state is suddenly assumed. I also hold (contrary to the received opinion of physiolo- gists in general^) that belladonna possesses no power over the retina. I know the question may be asked, does not OP THE EYE. 51 ill belladonna possess a specific nower nvor *h »« produce .empor.r;.,„.„ :r rlt'Tui 'l""" 'loes produce temporary amaurosis b„ 1, k'"™"' of nerves, causing tlie nnnil «« k "" P*"" admit a greater nultr7 ', TlZ'' ''V «« ^« than it is prepared to receive Tr ^ "^"" "'' •■«"»* tracts the alros Tn ^ ^ " t" ^ ^'•« P"P" con- being a correct thporv ., "°'^*''- ^"o'''er proof of this request of DocL S 7's u ''''"""'"* ' '"^'^^ »»* ^he »rtiflciai p„pi,, i„ "tU bouor'l, ox' Th' ''T"' " mo "hen she looked lhrou *»cl • 01 PHYSIOLOGY OF THE EYE. It was ray intentiun to have given the physiology of the lenticular (janglion, and ciliary nerves separately, but (luring this chapter 1 1 )und it necessary to combine their physiology with the third and Jifth pairs. They are referred to again in the physiology of the globe of the eye. Lachrymal Organs. — The lachrymal gland secretes the tears which lubricate the front of the eye, and wash away offending matter. The ducts conduct the tears from the gland, and pour them over the eye. The puncta take up the tears, and any mucus that may be secreted on the eye, and carry them through the ducts into the lachrymal sac, from whence the whole is conducted into ihe nose, through the nasal duct. Conjunctiva. — One use of the conjunctiva is, as its name implies, to bring the palpebra and globe of the eye into intimate contact ; it thus affords free motion to the eye-ball, and prevents any foreign body from entering the orbit. Its second use is to secrete a peculiar fluid, which lubricates itself, thus making its motions over itself smooth and free. Its semi-lunar fold is something like the haw or second eye- lid in the quadruped ; it, in connection with the caruncula, helps to protrude foreign bodies from the eye when such bodies are lodged in the inner canthus. The conjunctiva possesses great sensibility, which is caused by its being so liberally supplied by the ophthalmic branch of the fifth pair of nerves. It is a mucous membrane. Meibomian Olands. — The use of these glands is to secrete a thin sebaceous fluid, for lubricating the eye. Cilioi. — The use of the cilite is to act as a shade for protecting the eye. Eye-brows. — The use of the eye-brow is also to protect the eye, particularly by preventing any moisture, such as perspiration coming off the forehead, from getting into it ; the eye-brow being so formed as to direct the course of the moisture outside the external canthus of the eye, down the cheek. CflAPTEK IV. OPTICS, AND rnrsiOLOQY OK THE EYE. Pbeviously to giving ti.o physiology of the globe of tLo eye, I feel that ,t is nec-,sar> -o say something on the sub- ject of (,{,tics, an acr-iainfunce with which is advanta- geous every one, wl ii, t is ac; ally necessary to all who des.re to understand ho.' ;!.■ eye ■ .ceivcs the impression of ex ernal objects. I shall r.a.mence the subject by the followmg very beautiful extract from the Enr,,dop<,d, Bn^ tanmca:--^ Optics, from the Greek word optomai, to see, is he name given to that branch of natural philosophy wh ch tr ats of the nature and properties of light ; of the changes winch , suffers either in its qualities or in its course when ransm.tted through bodies, when reflected from their sur- Z''Jxn T ^''?^ "'''^'" ^'^'"' 5 of the structure of the eye and the aws of vision ; and of the construction of those ins ruments m which light is the chief agent, tho,. of' TfTl" ^o"fo""ded the phenomena of vision, with ects « ' ^ '"'^P^''"" '''^' ^^''^^ ^^-^ ^'^ «^ternd ob- jects, something passes from the eye to the object The Ph..mena of lighj, however, are\otally independent o hose of Vision, and have a real existence in nature : whe- ther we suppose them to be objects of vision or not. bodies'^ rif \ ' r""'"' ^^ '"'""-^ '^ ''^''^' ''' ««« «^ternal bodies, r lese bodies may be divided, in reference to ll^ht uto two classes, self.lu„u>u.us and non-lununou. oVS bodies The first cl. ,.s includes the ..., the ..u^Xmes of a I kinds and bodies which become luminous by r on Sle bTthe'S^ '''-''' '^'' '^'^^^'^^ visible by the light which they themselves emit ; and we 'S^ m'\^ u PHYSIOLOaT hen Obtain a knowledge of their apparent form. The sun. for example, ,s seen to bo round, and the flame of a ca2 to be a con cal shape. The second class of bod es howeve are never visible but when placed in the light of seuZZ' ous bodies ; it includes the moon and all ?he pr ma yTd secondary planets, upon which the sun's light d r X faUs and all the other objects x.pon our globe ' " When we bring a lighted candle into a room, its hVht fans upon all the objects in the apartment, and leV becfm visible wherever we place our eye. But objects also bT come visible by the light thrown off by non-En^^^^^^^^^^^ When the moon has the form of a sharp crescent we see he the , ' r ;? '' "' "^'* ''''' '^"'''' ^""^ ilUiminated by the sun. In like manner in the room lighted with a candle objec s are seen in corners and places u^pon which the ight' of the candle does not fall; Those objects, however are ^mnmated by the light of the candle thrown ba I ^^ the mon ww^th? r"^ ''?' ^^P"^™^"^' -^^-nc^et e reason why the ceilings and walls of apartments should a ways be white, if we wish to attain theUaTest q„ttt of hght fij3m a given flame. The light thmvn off frmnaU bodies, whether self-luminous, or non-luminous is onhe same colour of themselves ,• a red hot b«dy, or a s'til of ed " But though coloured bodies throw off light of the sama CO our of themselves, bodies do not appear of the same colour as that light, which falls upon them aU b dfe such llt^'' "'"^'^ 'T "P- t^'-^ J I>»t other bodies such a led wax, appen.- red even in white light, a pronertv which they have from a peculiar structure acting ui on t^e different colours of which white light is composed OP THE EYE. 55 Bodies of this kind, when illuminated with lights of different colours, always appear brightest in light of the same colour which they exhibit. Thus a stick of yellow wax IS more luminous than a stick of red wax, but the yellow wax will be less luminous than the red if we illu- parent. An opaque body is one that stops Iht light that falls upon it, such as a piece of coal, or a plate of s Iver and a transparent body is one which transmits the light' hrough It, such as glass, water, and air. The most opaque suffiintrT' "T.'^ '"ade transparent hy makfng i sufficient^ thin, and the most transparent one may become opaque by making it sufficiently fhick. The opac ty of tti^LiedrTd^' 'Tr^""^ '^'^^ ^^'^ "« wnat IS called the shadows of bodies. As the shadows of bodies are of the same size as the bodies, we thence deduce he fundamental optical fact, that light moves in Ts'ra g ^ne. The same fact may be proved in a thousand ways bu mos simply by placing three small holes in a str^ 1 ne. In this case the light will pass through them bu •f any one of them deviates from the straightline the ligh will be stopped. The same thing is finflv seen wit 1 any experiment, by admitting light into' a dark room hrough an aperture of an inch wide, its path, marked ou^ by the floating dust which it illuminates, will be seen to b« a straight line. Light issues or radiat'es in ever^ d'ret tion and rom every point in the surface of luminous and visible bodies. This fact is proved by the circumstance that we see such bodies wherever we place our eye S dTk^Zt:: r '"^^"^^^ "'^ »>4htpartorthesun^ dltu;eoflig^^ "«-^ -->-P-t " Light consists of separate and independent parts which when reduced to the smallest magnitLe, are'cat'd r:y' 56 ^ PHYSIOLOGY of wav, Ti,„ " , "'^^ '"to smaller portions n a variety l^rtios a, the u/JtlT' """"" "" '""■« P'"- "Light moves at the rate of 192 nson,..at, IS similar to that of a sphere Ih- on!v vf ^-oe -„, Uiat tl. two sur/aces are L,^l n^/l^ .CwP , ^^^''"'"^ ^'"'«'^'' ^''« effect of which is to Foduc. a change in the position of the focus. ■-^H_j:..-G Let L L be a double and equally convex lens of glass a M. Lad there been no second surface, these ravs wnnM have converged at a focus a i».,f oo +i ;^ *'"'" 3nanner but not in the axis G. For example 7 OP THE EYE. 61 Let L L be a double and equally convex lens of dasa. Us axis A B C, it will be found that parallel rays D L t B, G L, and M L, K B, H L, falling obliquely on the lens will have their foci at the same distance behind the lens at I and E. For these and all other cases the rays F B, A B, K B, which pass through the centre B, will be found to proceed to I G and E, without changing their direction. Wow in what manner the operation of a double convex lens forms the image of any body in an inverted position, upon a surface situated at the opposite side of the lens, can be easily understood. If, for example, there be a lighted can- dle held with its flame at D F G, and the candlestick which holds it at H K M, (L L, being a double convex lens) and a sheet of paper be held as a curtain at I C E according to the law just laid down the flame of the candle' will be pictured on the paper at E, and the candlestick at I, both of them inverted. But as the candlestick is not alumi- nous body its picture will not be visible. This can be exhibited by holding a double convex lens, between the flame of a candle and a sheet of white paper, at such a distance as to bring the light to a focus on the paper ; the picture of the flame will be distin ly seen on the paper, its position there being inverted. 62 PHYSIOLOGY DOUBLE CONCAVE LENS. Let L L bo a double concave lens whose axis is C D F and L Its middle point, if parallel rays, A L, G L, fall upon It, they will be found refracted in the directions L B, L H rJ.Z2l I'^'^ r^'^'^''^ fr«» D, a point befo're the lens which IS the principal focus of the lens. When converging rays proceeding to a point F, beyond the pnncipal focus 0, of a concave lens, are intercepted by It, they will be made to diverge in lines L B, L H as if they proceeded from a focus D, in front of the lens be -ond K. When F coincides with 0, the refracted rays L B, L H will be parallel, and when the point F is within the refracted rays will converge to a focus on the same side of the lens with F, but on the other side of 0, these foci, F and D, are called congregate foci. The effect of a 7neniscus upon light is the same as that a convex lens of the same focal distance. And that of a con- cavo-convex lens, of is the same focal distance. 8un-ltght.— Sir Isaac Newton proved that the light from the sun was white, and that it was made up of seven differ- ent colors, viz :-red, orange, yellow, green, blue, indigo, and violet. These colors often appear by themselves, and OP THE EYE. AO 'he white light from which they are produced is decomposed or separated into its elements by different processes. That branch of optics which treats of the colors of light of their physical properties, and of the laws according to which white light is decomposed and recomposed from the elements, is called chromatics. Rays of light of different colors have different degrees of refraction, or, as it is expressed, different refragibilities The method by which Sir Isaac Newton established this fact was as follows. In the window-shutter, E G, of a darkened Dm 64 PHYglOLOOY room, !k' inade a hole F, about one third of an inch broad, behind u hich he placed a glass i-risin, A B C, so that the beam of the sun's light, S F, mightenter and leave the prism at equal angles. Before the interno«:*Jon of the prism, the beam S F, proceeded in a i..i,g.u i.ae to Y v Jiero (, form- ed a round white spot, but when refracted by the prism it formed upon thf screen M N, an oblong image P T, con- taining seven colors as enumerated in the figure, the red being least, and the violet most refracted, from the original direction S Y, of the solar beam. This oblong image P T, is called the solar and sometimes the prismatic spectrum. By making a hole in the screen M N, opposite any one of these colours, so as to allow it alone to pass, and by letting the color thus separated fall upon a second prism he found that the light of each of the olors was alike refrangible, because the second prism could not separate them into -n oblong image, or into any other color. Hence he called all the seven colors simple or homogeneous, in opposition to white light, which he called compound or heterogeneous. Having thus decomposed light into seven primary colors, he shewed that these seven colors, when again put toge- ther or comMned, recompo:;ed white light, which was done by the removal of the prism. That these colors mixed to other mako white, can be proved in a . (f. wa^ by mixuig together seven different powders in due relative proportions, having the colors and properties indicat'id above; the mixture will be a sort of greyish white, oecause the color' employed cannot possibly be obtained of the proper tints. Having entered more deeply 'to tlie science than I originally intended, I sh-' now consider that part of optica which relates part.. ^ly 'o the eye. Th( eye is that organ which mak- us isible to the rays of light. It consists of two parts, viz :— the or^r'n of sense, (the retina,) which receives the impression, and the OP THE EYE. 66 optical parts, by which the rays of light are made capable of forming an impression upon it. The first principle in the constitution of the eye is that te rays of light must be so concentrated a trimping s rougly on the retina. To produce this effect, there' in the eye a double convex lens (and it has been alrl K shewn that a double convex lens concentrates he ra; of light proceeding from an object, so as to form a ifvely mage of the object at its focus, when the focus falls upon a shoe of paper or anyoth., curtain,) therefore rays oSt passmg through the cornea, falling upon the lens,^will b eby It convergerl to a focus upon the retina, and there fo m the .mage of the object from whence the rays of light nro^e^l But that this effect may be perfcct,«Z^ th'e optiXa tol tt eye must be perfect also. Firstly, the cornea mu't be p r fectly transparent, having a proper convexity and forming a large segment of a small sphere, (thereby taking a greyer dr! cumfcrence mto the sphere of vision than could be doTe f he large spher. of the eye-ball had been continued on the fore part of the eye) so that the greater number of rays o ith W.I be received upon It, which rays passing through iiZ il uom humour, are refracted till they fall upon the lens IntiT'T ';"r"^'""«* ^'« ^'e---, and of a sufficen quantity; ,f not clear it will refract the rays of light oo Tv^^ Tr^ /" ^"^""*^ it willmakeLcor'ea too onvox; ,f too httle the cornea will not be suffJn.n " convex ; ,f dense, and not perfectly fluid, it will also ..event the free mot.ons of the irK The iris must be perfect allownoraysof llghttopassit,exceptthosethnt enterthroui^h an arecolectedbythe pupil, whichraysmust striked eel upon the lens s.tuated behind it. The next part of the eve tha .s necessary for perfect vision, is the c^stallin lens which should be at a proper focal distance frl th re na retina. It 13 also necessary that the perfect shape of the I '4 i . 66 PHYSIOLOGY eye shouM be preserved, therefore the vitreous Lumour must be perfect in quuiitity, and on itnlso depends tlio lens being kept at u proper fucal distance from the retina ; the quality and consistence of the vitreous liuuiour must be per- fect also. While each of the humours of the eye have dis- tinct characters, they also in proportion to their density, possess diflferent degrees of power in refracting the rays of light entering them, it being a law in optics that rays of light, when they pass from one medium into ijuother of greater density are refracted and the greater the den- sity of the second medium, the greater the degree of refraction ; consequently, as the cornea and humours of the human eye are more dense than atmospheric air, (the medium through which the rays of light come to the eye) the rays of light, thus entering the cornea and humours of the eye, must be refracted. But rays of light entering the cornea of fishes, will be refracted in a less degree, be- cause the medium from whence the rays reach the eye (namely water) is of the same density as the aqueous hum- our, and this evil effect is counteracted by the cornea of the fish being very flat. Therefore the more equal the density of both media, the less will be the refraction. In this way it is easily understood why persons, v/hen they open their eyes under water, see objects so imperfectly. It will now be considered what is that state of the eye which produces short-sightedness (myopia.) There are many c auses in the formation of the eye which conspire to produce this effect, which cannot come under the name of disease : — Firstly, If the cornea be too prominent, whether it be from too great a quantity of aqueous humour or otherwise; Secondly, Should the lens have too great a degree of conrexity ; Thirdly, Should there be too great a quantity of the vitreous humour, making the antero-posterior diameter of the eye greater than it should be ; And Fourthly, Should any of the humours not be perfectly transparent. But this / OP THE EYE. 67 latter state is generally the result of disease. |„ any of these cases, sight must be imperfect, because the powers of the humours in concentrating the rays of light are too great consequently the image of the object is not formed on the retina but before it. The short sightedncss of youth is in- deed generally the result of the cause first mentioned, viz — too great a convexity of the cornea ; which evil is iounter- acted by the use of spectacles with double concave glasses he effect of such glasses being to cause the rays of ^I • o a 1 upon the surfece of the eye at an angle so far diverging from the perpendicular, as to adjust the degree of conver- gence caused by the too great convexity of the cornea. If the cause be too great a ,uan%, or too great a conveant, of any of the humours, the use of a double concave glass J|| be of equa benefit^ To short-sighted persons, on'their bring ng an object sufficiently near to see it distinctly, the oS appears as large as it would to persons whose ight is not defective if they looked at it with a magnifying gLs. Such persons always see a distant object Indistinctly, and 1? it should be of a pointed shape, or a shining nature, It wi always appear double. How this occurs is well explained in the following quotation from the work of Sir C. Bell • " The horns of the new moon, or the top of a distant spire', or the mes upon the fece of a clock, appear double or trlp'le, and sometimes much more multiplied to a short-sighted person The same appearance will be given when an object is held too near the eye for perfect vision. If light Is seen through a narrow split in a board, and the board's brought nearer to the eye than the point of distinct vision, the aperture will appear as tu,o luminous lines, with a dark line between them; and as the distance is varied, two, three, or four dark Imninous lines wil» be observed. To explain this, s"r Isaac Newton taught that ' in the progress of rays of light, there .an alteration, by fits of easy transition or refraction or in other words that there is a change of disposition in If 68 PHYSIOLOGY the rays to be either transmitted by a refraction or to be refracted by the surface of a transparent medium.'" To explain how this occurs, Sir C. Bell gives a diagram of the eye, shewing that when direct rays strike on the convex surface of the cornea, part of them are reflected laterallv and those transmitted strike on the surface of the lens In lummous rings, which are multiplied and diminished in diameter, on being in part transmitted and in part rejle,cted from the surface of the lens and vitreous humour. These eflFects of the alternate disposition of the rays, for transmis- sion and reflection, would not be perceptible, did the con- verging powers of the cornea and lens bring the focus of the rays exactly to the surface of the retina; but as the focus is formed before the retina, the rays decussate and spread out again before they form the image upon the retina ; in- stead, therefore, of forming an accurate Image, they are spread out into concentric circles, and the person experiences a confused outline of the object, which becomes surrounded with several rings or false outlines. The reader must re- member that Sir C. Bell speaks in such a case, of a person short-sighted from too great a convexity of the cornea. The following is a note of Sir C. Bell's:— "By fits of easy transition, it was not meant by Sir Isaac Newton that the rays must necessarily be transmitted through every pellucid medium, and at any obliqnit- of incidence, but only that the rays were more easily transmitted and with more difficulty reflected ; nor was it meant that during its fit of easy reflection, the ray was absolutely incapable of being transmitted, but only more readily reflected than trans- mitted." It is worthy of remark that short-sighted persons, when looking at distant objects, always frown or knit their eye- brows, so as partially to close the eye-!ids; the reason is obvious; the cilia change the direction of the rays, and thus correct the Inaccuracy of the image, as if the person /i»tM:-JviAif-:Sm6siiM,i,'..!^'j!ii&! OP THE EYE. 69 and the consequent lessened convexity of the cornea T ■fi-«iy 72 ** PHYSIOLOGY adaptation to the iris, the motions of which mi^ht „ K.. supposed, alter the curvature of the lens nT^ ' I ^"^ Sir David Brewster, cause the Lt t " an \- rS^J^ come forward during contraction of the pupH I chan ' in he position of the lens has also been s'uppo^ed o fee ? from contractions in the ciliary processes^ on a Z many have contended that the entire eye-ball nmv alter h^ relative dimensions by the action of its muscles 'it con ceivable that any of these changes, could they ll "oZ ac ua^^y to take place, might be sufficient to'accou'nt fo^ he effect ; but m estimating their relative value, he geS- est importance is to be attached to the anatomical evidence by which they may be supported. In the eye of the bTrd the ciliary muscle, from its position and attachments S necessarily approximate the lens to the cornea nd the in^'if^rf ""^?J.^ ''^' P-* muscular in mam! ma la, and if so, for ascribing to it the same function as in It^ ImT 1"'^ "^""°'^«'^> -^ appear to " CO " elusive. We therefore, on anatomical grounds alone adoni this view, ably advocated by Porterfifld, co ce iving tj contiacted, the lens advanced towards the cornea, and the atter membrane, perhaps, rendered more convex bv h! ract.onof the muscleon U borders, by means ^ coLg of the posterior elastic lamina: while in visinn „! '^''^f elasticity ot the neighbouring narfs Jt Sa ;.,* ^. notice that this adjuring fac JtyT Ihe V T^X'i: paired or altogether lost by extraction of^he fens o^ t" paralyzing the ciliary and iridal muscles by be Hadonna ^ I no attempt made to^.^. that the lens is drawn back- wards towards the retina by the elasticity of the neLhbour and It IS actually necessary to prove this, fo mak " t co I OF THE BIE. 73 elusive that the lens is drawn forward when the eve is engaged examining near objects. It appears t J h the changes are altogether dependen upon tiri traction and dilitation of the nnnii. r i tZnU • ^ tl^'s Change takes place is easily understood when It ,3 remembered that the iris is sensible to Thn Ail vi.,Me bodies, except I„„,i„„„s ones which are see« matter bowhrge or mall, or of what color it may be LnJ he u arer the object the stronger will be the rays refllt d from u „po„ the eye. Therefore, when we \2k at a dis tant object, the pupil is dilated, tat when we reld .he" so di el as ™; T ■'•™"'""« ''™"' ""= ""i^' ™w :s:^f:^;tta:i::-tti£r^ l»mi,..droom;ineithcrcj:hal!r:ir^^^^^ son to discover object, clearly, in fact not till the pup I has had „„ to conform itself to tho sudden chang Snex 'h.«g to be considered is how the eye sees e«ry I e f „ 74 PHYSIOLOGY Sii! ill its own proper color. From what has been already said, the reason is quite obvious. Each body reflects rays of its own colour, and is seen by its own reflected rays, as has been already explained ; if it be a luminous one it gives ont rays of its own color, and If transparent, transmits rays of its own color; it therefore follows that the design pictured upon the retina must be of the same color as the object. I shall next consider the .physiology of the dififereut parts of the eye separately. Tunica Sclerotica.— The sclerotic coat, from its tensity, and elastic nature, is well adapted to preserve the slmpe of the eye, and to be a protection to its internal parts, either from external pressure or from the violence one part would do to another internally, by the displacement which would ijocvr if there were no external case or regular pres- sure to keep them in their own place. Another use of this tonic is, tfeat by its fibrous texture it is well suited for the insertion of muscles to move the eye-ball. Thirdly, it is well adapted for the transmitting of vessels and nerves to and from the Internal parts of the eye. Fourthly, by its opacity it renders the eye a dark chamber, and it permits no rays of light to pierce it. C/ioroid Coat.— "Lhis, the vascular coat of the eye, is a secreting membrane, and like all others of that class divisible into laminae. It secretes that pecular fluid called pigmen- tum nigrum, which is a black raucous substance, situated between the choroid coat and the retina, and so enveloped round the latter membrane as to absorb any rays of light that may fall upon it ; from its color it also darkens the chamber of the eye. The external lamina of the choroid appears to be solely for the purpose of protecting the vessels and nerves, or of supporting them in a proper position. Giliari/ Processes.— The use of these processes, which are formed by the choroid coat, appears to me to be for the purpose of conducting vessels to the lens. OP THE EYE. 75 Retina. — The use of the retina is to receive the impres- sion of external objects, and although insensible to touch, the smallest ray of light will make an impression upon it. All parts of the retina are more or less sensible to the im- pression of external objects, except that part perforated by the optic nerve, where in reality there is no retina at all, for it is only there the optic nerve spreads out into the retina; of course the porusppticus, or black spot in the centre of the optic nerve, cannot receive the impression of light, as it is only an artery * But the punctum aureum, or spot of Soemmering, being in the very axis of vision, would lead us to suppose that that particular spot is more sensible to the impression of external objects than any other part of the retina ; we are strengthened in this view by the fact, that if by any accident the axis of vision is changed, as occurs in strabismus or luscitas, the sight is not so perfect. It is very difficult to say what it is that gives this spot its peculiar color; some have considered that it is owing to some peculiarity of its organization ; others, that it is a perfora- tion or deficiency of the retina. I am free to acknowledge I cannot satisfy myself as to the actual cause, but I think there may be an absence of the lamina vasculosa in that spot, and thus the nervous coat or true retina is exposed. There is one thing certain, that there can be no absence of the true retina for if such were t^^e case the conse- quence would be blindness,— this spot being in the axis of ■ r "I' appears, by a simple experiment, for the principle of which we ar* inUebted to Mr. Manotte, that the small portion of the retina corresponding to the entrance of the optic nerve, is incapable of exciting visual sensation, though It receive the image of an object Place the thumbs together at arm s length, shut the left eye, and fix the right eye steadily on the left thumb ; then the right thumb, if moved gradually outwards (so that its image on the retina of course traverses inwards) ceases to be visible in a particular spot, but is again seen beyond it. It will be remembered that the hbrous lamina of the grey nervous layer of the retina is here evolving itself trom the nerve, and » not yet invested with the vesicular or other laminae : a circumstance of great interest in regard to the modus operandi of the con- stituents of the retma in vision. "—PAy«ofooyo/Afan, bvR.B. Todd^Part 3, page 54. 76 PHYSIOLOGY Vision The vascular coat of the retina not only supplies he TA "'";r^"^' '"^ ^'^" '''' Moid membrane'and tne capsule of the lens. hPi^rrT?' TT' '"•■"" '^' ^''^«* transparency, and be ng situated ,n the front of the eye, forms the window of that organ, and owing to its convexity, is well adapted for the reception of rays of light ; from an extended periphery by Us tensity and elasticity it protects the internal parts o the eye and from jts laminated structure and vascularity it 1" d " That th"' "" '"^-T ^"' ^'^^^^^^ - ^"^^^ f,T ; J ' '"""'* '' '"'■^^'^ ^"PP"«J ^'tb nerves, Inf ^«r.^ P™7'^ ^^ "' ^''^^ sensibility when diseased and as has been already stated in page 21, they can actual- V «tlf "T'''*\^- ^^'' '' '^ ^'''^y P^™«^t«d with blood vessels, is shewn by the rapid progress with which ulcers knowTf .1" '?' "'^^" properly treated ; and i is an a t iTa hr '.^'"''^' ^ furtherproof of its vascularity IS that a b ow on the eye will often cause elTusion of blood between the layers of the cornea, and the fact of the Styltlnr^^^' ''''''' ''^'-''-'^ ^^^^^^^« -I^ Ague fv 1» 6^ .V ,5^""^ «> l/u 80 PATHOLOGY becomes oi secondary importance. While, therefore the surgeon's attention is drawn to the direct injury of the bone, or the soft parts which invest it, he must watch close- y for any head symptoms that may present themselves, as their appearance is sometimes very sudden, and the fatal consequences equally rapid. Contusions of the temporal angle of the orbit have been sometimes followed by the growth of tumours within the orbit. Should a blow causing a contusion of the edge of the orbit also occasion a wound, that is a breach of the integu- ments the termination of such an injury is generally worse than if there was only a simple contusion, for very frequent- ly it produces erysipelatous inflammation, which too often ends m death. This complication, however, depends much upon the state of the patient's general constitution. ^mftnc««.-The only treatment that is found necessary m simple contusions ofthe edge oithe orbit, is cold appli- cations of the acetate of lead, rest, and perhaps a gentle saline laxative. r r & «= Fractures ofthe tldge of the Orbit.~-3l0WB on the edge of the orbit sometimes cause fractures of it. When such is the case and there is not much swelling of the soft parts, the Surgeon can easily feel the loose portion of bone. Tr^tment.~U the hom be displaced, it should be re- placed m its natural position, which is sometimes very diffi- cult to do, and it is even more difficult to provide mechanical means to keep it in its position. The best me. chamca means I have found, is a piece of white leather well smeared and softened in either starch or the white of an egg. This leather should be stuck upon the part, and when It has become dry, it forms a good splint; should moist applications be required to the surrounding parts, the lea- ttier may be covered with oil silk * notbeingactedonatallbywuter.antt^bSanis^^^^^^^^ ( i s F c d h b; w OP THE EYE. 81 Compound Fractures of the Edae oftlt> fM«; o skin, or there wiU be a wnnrj T. u ^ "'™"8'' ">« forming a communicl„ toweea Zt "^ '"'t^"™"., pberic air. The brolten piece^n ' ?■ '"^ "■" *"»»»- .bo^rarc7eit;:rL°ii'e=rL r r- «r:?\rira^-r.'~^^^^^ of the cavities are onpnp/1 o«^ • . ''^'^"^"ce. When any b7 puncturing the part wUh , ane" i^t^" ""'"'«' "01 a practice that I can recommend r 1. ' '°™"''' Ibat cold annlicalion. »i.r ? ' '""" "'""J'' found course, depend, ^tL'^ul^r^ilT^r inflammation tliat follows sneh «rj„f ^- ™« acute, and the pain ve-^'J^^T 'JthSh'. ""^ pearance may seem vprv nfm^u *i, . *""''"Sn their ap- cbiid.„, pro5„c:T,„"ir V :a.h "ir'^'"^ '^ death in the adult bv fhp \rZ f. ^''^^ even cause ^-, and »Pread^.t.t:tCro Xtr'- ba.^r:jr„'SdnTrri~- wound, it should be healed by he TJxTt" '"°'""' puucured wonnd, suppuration^'htid'f r^ged"; S2 PATHOLOGY warm poultices, and the wound brought to heal by granula- tion. The surgeon should always make sure to remove any foreign body that may be in the wound ; rest and quiet- ness must be rigidly enforced. Gun-shot Wounds of the Edge of the Orbit. — When the edge of the orbit is wounded by a gun-shot, if it be a ball, it generally carries away the part ; but if it be only by small- shot, they more generally lacerate, without much loss of sub- stance. Treatment. — Remove any foreign body that may be in the wound ; should the bone be broken and detached, it is not to be quickly removed, as the bones of the face are sometimes found to unite, although they may be perfectly shattered, but after suppuration sets in, if any loose splin- ter should be found acting as a foreign body, the sooner it is removed the better. As much of the wound as possible should be healed by the first intention ; the rest of it must be left to the second intention. If the shot is lodged in the wound, it should be carefully removed, if at all practi- cable. Any wound of the edge of the orbit may injure the ')-'"- thalmic branch of the fifth pair of nerves, and the produce amaurosis. A direct consequence may be inii' »»'' CHAPTER VI. FRACTURES AND INJURIES OP THE WALLS OF THE ORBIT. Fractures of any of the walls of the orbit frequently ex- tend to the skull; indeed if the roof of the orbit h fractured, it constitutes a lesion of the cranium. Any of the walls may be fractured by a blow of a heavy blunt instrument, but this accident is almost always caused by a gun-shot, or by a sharp-pointed instniment thrust into the eye, such as a foil or a sharp-pointed stick. When such is the case, the fracture becomes a compound one; cases have occurred in which a ball has traversed both orbits posteriorly to the eye, and in- its course divided the optic nerves without producing death; array surgeons see many cases of fractured walls of the orbit from sabre cuts. As already stated, these fractures frequently extend into the skull, frontal, maxillary, or sphenoidal sinuses ; and very often there is merely a crack or fissure which can only be discover- ed after death. In penetrating wounds causing fracture of the walls of the orbit, it may happen that the instrument remains buried in the part, and is not only hard to discover but even difficult to remove. Fractures of the external or inferior wall are not so dangerous as those situated in the roof or internal wall, for they are not in such immediate connection with the brain. Where the missile sticks in the orbit, the eye-ball generally protrudes, but such may occur without the instrument remaining. In these cases, the trifling appearance of the external wound very often deceives the surgeon. PITHOMOT OF THE EIK. 05 The .Sect prodaced by such injnrios may be either im- me^-'e or remote. The ^mediate effect, .„ ilZZ .««.«», «&.W,^W^^, and not „.„3y ST Pr^n..«, The sargeoa must be guided in his prognosis sho. H .r ''r "''" ^'^^'^ *^« «^*«"t of the injuT for Sw^^^^^^^^^^^ -^"^the prognosis is S waror floor If 1 ^''''*''" '"'""'^ «"'^*«'J •'^ the external r, 1 fr . *^' symptoms lead the surgeon to sud- p e tha he brain, or its tunics, are injured, fhe prlosU will be still more unfavorable- anrl ♦«*».. i "'',*'™6no8i8 If a foreign body be lodged ^n the\l;^t« ducng no immediate bad symptoms : for he iu tremlb^ that It may cause death, either by beinff left thpr« f Ti or, on the contraiy, by its removal AnifK • '°^' necessarv fnr fi,o 1 ^'novaJ. Another circumstance ?xt::d::r::!:-.rbS"T ."ch. Probing .be „S IrAl •/T'' '°"°« ■" P«s.>b.e; „„i.f„g tie eZn^t I'd by'ti" irelti" is reprehensible as it nro,r««* r ^ ^ intention ofpAwhiehX'CtttinSra;!',!""'^' 11 86 PATHOLOGY OP THE EYE. The surgeon should endeavor, without using unnecessary force, to replace the parts in their natural position. The best local applications are emollient cataplasms, and soft light dressings, such as lint wet in tepid water, and covered with oil-silk. The dressings must be frequently removed, and the wound kept perfectly clean, and occasion- ally examined, lest any piece of exfoliated bone should be keeping up irritation. After the sloughs have been cast off, and when the inflammation is moderated, the surgeon may begin cautiously to draw the wound together. Cases may be met with where it will be necessary to divide the soft parts, and even trephine the bone, to give exit to extravasated blood, purulent matter, or detached pieces of bone. The general treatment will depend upon the symptoms that present themselves. Upon reaction setting in, blood-letting may be required, but it is a remedy that should be employed with great cau- tion, that is, neither too soon, nor too profusely, and occa- sionally the use of the lancet may be superseded by tartar- emetic in nauseating doses, or the sedative influence of the former may be maintained by the judicious use of the latter medicine ; quiet and rest should be particularly observed ; spare diet, laxatives, and gentle diaphoretics should be given, with an occasional dose of blue-pill or calomel. Sometimes an anodyne may be required to give the patient sleep, and relief from pain. CHAPTER VII. DISEASES OF THE OkBIT (PERIOSTITIS, OSTITIS CARIES, AND NECROSIS.) Periostttis.~-T:he bones of the orbit, like all other bones of the body, are liable to disease, but as the periosteum possesses greater vitality, so it is more liable to inflamma- tory action. Inflammation of this fibrous tissue is more frequently of a chronic than of an acute nature. There are different causes which may produce ostitis or pertostttts of the orbit, such as injuries, cold, syphilis, scrofula, or the spread of inflammation from the surrounding parts. Inflam- mation of either the periosteum or bone may end in resolu- tion, suppuration, caries, necrosis, hyperostosis or bony node, and finally, it may terminate fatally. %mptoms.~U the inflammation be acute, there is pain in the temple of the affected side, which extends down to the teeth; great circum-orbital neuralgia, and pain along the course of the fifth nerve, which pain is increased by pres- sure on the eye. This is followed by nausea, head-ache, irregular attacks of fever, loss of appetite, want of sleep the eye-hds eventually become swollen, and when the case 18 to end fatally, delirium and coma supervene. Morb^ Appeamnces.-A quantity of purulent matter will be found between the periosteum and the bone : the perios- teum Will be detached and the bone denuded at the seat of the inflammation; the dura-mater will also be detached from the bone, and its surface covered with puriform flaid; the pia-mater will be found unusually vascular, as well as the substance of the brain; serum is sometimes 88 FATHOLOOr discovered .n the ventricles. If the Inflammation has been whlh T' .-^u''^"' P"' ^'" ^«"«'*"^ ^' f«""d there, which, during hfe, had caused the protrusion of the eye-ball In chronic ostitis or periostitis of the orbit, there are four disi tmct stages :-lst. Inflammation ; .W. Abscess ; 3rd. Fis- ulous opening; 4.A. Distortion.' In the first 'stag^ht ey^hds are red, hot, painful, and swollen, and somet mes edematous. In the second stage, a spot on the lid points tTm«?r V ?"^'°^ '^ ^'^'^ ^^^^^ "«"er; and seme- mes the skin becomes extensively ulcerated. In the third stage the aperture becomes fistulous, surrounded by fungous onenit ?''-./^ ' ^''^' " ^''''^ '^''''Sh this fistulous opemng it will come in contact with the bone, which will be found m either a state of caries or necrosis. After long continued suppuration and exfoliation, the fourth stage has aken place, the parts heal, the external aperture closes, and he .nteguments adhere to the periosteum. A cicatrix is bus formed accompanied by shortening of the lid (Lagoph- thalmos) with more or less ever8ion(Ectropium) Such chronic inflammation is generally found in children of a scrofulous diathesis, the usual cause being falls or blows on the outer angle of the orbit. It is accompanied by more or less fever, and a strumous inflammation of the con- junctiya, which produces great intolerance of light ; and when the conjunctivitis subsides, it leaves the cornea 'nebu- ous. The general causes of secondary inflammation of hose parts, are inflammation of the orbital cellular tissue, the lachryma gland inflaming and running into suppura' ^on abscess in the orbit not bdng opened, orbital tumours running into suppuration, and severe inflammation of the eye-ball spreading into the periosteum. Secondary caries is sometimes found in scrofulous chil- tZl ^.'""''i^'^y •» '^' f°««* lachrymalis. When this takes place, the case always terminates in lagophthalmos and ectropium ; caries within the cavity of the orbit is more OF THK ETE. ^ K general ;pX "del "t''^rV°'° ''■'"^^^ theSorvo 'h« ! ' ' ""' ''' ^'"^'•^"J^ ^«P«°d«°t upon .» .he .ibi., Jon .h:t V™„r'" °™ """^ '° "' f™"" . Cooper makes the following remarks :— "The bones most frequently affected with exostosis are those of the cranium, the lower jaw, sternum, humerus, "JelT Aia.r '' ''' ^-P-' -^ P-"-iarly the « There is however no bone of the body which may not become the seat of the disease. It is not uncommon to find all the bones of the cranium affected with exostosis and the ossa parietalia sometimes an Inch thick." Exostoses differ very much in respect to size, shape, struc- ture, and consistence. They are sometimes small and cir cumscribed ; others are of a conical shape with a broad base; others again are of a styloid figure, projecting in a greater or less degree ; some are found to be cellular, formed of a few broad plates or laminae, intercepting extensive spaces which are filled with matter, to which variety the name of laminated exostosis is given. Another variety is called craggy,-it consists of a mixture of osseous lamL. with cartilage but no shell, the matter deposited being phosphate of hme very imperfectly organised. As regards the third variety, the matter deposited is pretty perfect bone • the surface of the tumour is sometimes smooth, and often m m 96 PATHOLOGY studded with little projectibns ; its consistence is perfectly solid, exceeding that of the hardest bone, and often equal- ling that of ivory, which with its appearance, has got for it the name of ivory exostosis. Sir A. Cooper found hydatids in an exostosis of the tibia. Causes.— ThQ causes which produce so formidable a disease are not perfectly understood. It has been imputed to scrofula and syphilis, like every other disease that is imper- fectly understood : it has been known to succeed injuries. ^^mptonw.— Exostosis occurring in the bones of the orbit, is the same as when it occurs in any of the other bones, but according to the situation of such a tumour will be the severity of the symptoms. The progress of the disease also may be either acute or chronic: but the acute form generally appears in the laminated exostosis. When an exostosis forms within the orbit, the following are generally the symptoms :—lst. Pain, which varies much in its situation and severity,— at one time, it is in the eye-ball ; again, in the temple, or deep in the orbit, or sometimes the whole course of the fifth nerve is affected. Some persons expe- rience great pain from a very small exostosis, while others do not suffer so much from a much larger one. 2nd. The eye- ball is protruded to the opposite side from that on which the exostosis grows, and should it be in the bottom of the orbit, the eye will be protruded forwards. Zrd. Such pressure on the globe of the eye produces amaurosis. Ath. Should the tumour continue to enlarge, it will press upon some of the neighboring cavities, and if it be on the cranium, it will produce death. The constitutional symptoms are irregu- larity of the bowels, impaired appetite, broken rest, great debility, and sallow complexion. Diagnosis. — As the general symptoms which appear in exostosis of the orbit will be found to exist, when the growth of other tumours takes place in that cavity, it is OP THE EYE. 97 nearly impossible to diagnose the disease until the tumour be exposed by a section of the soft parts covering it. Prognosis.— Yitxy little encouragement indeed can the surgeon hold out to his patient. Spontaneous destruction of the tumour may take place from inflammation ; but such an occurrence is very uncertain, and if it should happen very tedious. The ivory exostosis sometimes seems spon- taneously to stop growing. Treatment.-ln the treatment of this disease, the object of the surgeon should be to get the tumour, if possible absorLed, ,o which, if he fail, he must remove it by opera- tion To remove it in the first way, the means to be used are both local and general. If the system bo tainted with syphihs, mercury must be given, leeches applied to the part, or near it, and friction made over it with the cam phorated mercurial ointment. If, on the contrary, the system IS tainted with scrofula, alteratives, tonics and lod.ne, must be given, leeches applied to the part, and change of a.r recommended. If there be no inflammation, some benefit may be derived from electricity. Difl-erent modes have been recommended for the removal of the tumour by operation, but as to a choice, much depends upon the size and situation of the tumour, and the state of the surrounding soft parts. In the removal of such tumours it may sometimes be found necessary, first, to include the eye ; but a very free opening through the soft parts IS always necessary, so that the base of the tumour may be well exposed. When the tumour is denuded of its covenng the following are the different modes recom- mended for Its removal ;- a strong sharp scalpel or a bone forceps, saw, or chisel and mallet. Some recommend filing It down with a rasp ;-other8 advise stripping it of its periosteum, and then destroying it by the application of CallSllCa 98 PATHOLOGY If the surgeon roust operate, I would recommend the bone forceps, scalpel, or a small circular saw, as the safest instruments. The after treatment is the same as t'lat recommended in wounds of the orbit ; but as a general rule, the surgeon must be guided by the symptoms that arise. Rest and quietness must be particularly enforced. Osteo-Sarcama.— This and what Sir A. Cooper called the fungus exostosis of the medullary membrane is one and the same disease. Boyer gives two specimens of this disease, one proceeding from carcinomatous deposit in the neighbouring soft parts ; in the second, the disorder com- mencing in the bone, the soft parts becoming secondarily affected. In this disease, the bony texture disappears, and its place is occupied by a homogeneous mass of a fatty or lard like substance, its color being of a greyish yellow, and its consistence that of cheese. Bone, muscle, tendons, vessels, cellular substance, all are confounded in this dis- eased mass. When the disease is not so far advanced, portions of the bone will be met, with its texture nearly natural, but merely enlarged. In the centre of this diseased bone, its substance will he found softened with cysts interspersed, which contain a foetid ichorous fluid ; sometimes a gelatin- ous substance is found occupying this position. Symptoms.— In all cases of this disease, there is deeply seated pain, which frequently continues for a long time before any swelling of the part becomes perceptible; as the disease advances, the pain increases and becomes of a lancinating kind, which very much impairs the general health ; a tumour is then felt, which is hard and tubercula- ted to the touch, pressure does not lessen the size of the tum- our, nor increase the pain. The soft parts next become inflamed and painful, after which the skin ulcerates ; but if the disease be in the orbit, before this latter stage can OP THE EYE. 99 take place, vision ,s lost. The ulcer that forms, presents a cancerous appearance. If by this time, the disease has not caused death by destroying the bones of the skull and a^ tackmg the brain, hectic symptoms are induced, the strength gradual y fails, and the patient, at length, aft r muh suf- fering, falls a victim to the disease. Treatment.~^o treatment is of any use excenf in oil. vi.te the patient's sufferings by pallfatresra'dUke h s" passage from this life as easy as possible.' This is be accomphshed by giving anodynes internally, and applying soothing applications to the part affected. The emploS of escharotics, or any attempt at an operution, onhrcau " matters to become worse. "/causes its CHAPTER IX. DEFORMITY OF THE 0K13IT FfiOM EXTERNAL PRESSURE. Under this head I propose to treat of pressure on the bones of the orbit, from disease of its surrounding cavities. It is a physiological fact that all abscesses or tumours situated in any part of the body, as a general rule, proceed towards the surface, and in their progress destroy both soft and hard parts, causing them to be absorbed by the pressure which they produce. Tumours forming in bony cavities, as they increase in size, must produce one of two effects, — either they may tear the bones asunder, or they will cause them to be absorbed. If tumours of a malignant nature form in any of the sinuses connected with or adjacent to the orbit, such cases must terminate fatally unless the whole of the surrounding parts are removed by an operation when the disease is in the early stage. I shall therefore make no remarks on them, more particularly as those which I have made in the preceding chapter on osteo-sarcoma will ap- ply to them. Absorption and deformity of the bones of the orbit may be caused by pressure on them, from the nose, the frontal sinus, the maxillary sinus, or the cavity of the cranium. Tumours of the Nose.— The tumour which forms in the nose, and which is likely to affect the orbit, is nasal poly- pus. After a polypus has filled the nares, it presses upon the nasal duct, and thus obstructs the flow of tears ; it may then displace the os unguis, and form a tumour in the situation of the lachrymal sac. At this stage there is pain- ful pressure experienced in the orbit, and often through the PATHOLOGY OP THE EYE. 101 bead, If the tumour be allowed to grow, the nasal bonos will be separated from the maxillary, the orbit will bo pressed upon, the eye-ball displaced, and vision des- troyed ; finally the cavity of the brain may bo intruded upon, and death the result. During the progress of the dis- ease, cpistaxis will often take place ; but generally speak- ing, the bleeding is a sign of the tumour being more or less malignant in its nature. Prognosis.— If the case be seen in its early stage, the re- moval of the tumour will produce a cure, even though the bones should be a little displaced ; but should any of the bones have been absorbed, deformity will be the result. Treatment.— When a polypus is discovered in the nose, it should be immediately extirpated, if allowed to become large, and displace the bones, this is not so easily effected. There are many who would not submit to its being extirpat- ed. In such cases, I have succeeded in removing it by apply- ing to its surface the acetas plumbi every morning, and plugg- ing the nose with a piece of sponge, so as to make direct pressure on the tumour. By this means I have removed such tumours as completely as if they had been extirpated. How- over I would not pursut such a treatment from choice except when the base of the tumour had a great attach- ment. If it were a pendulous polypus with a small root, the proper treatment would be to twist it out. It is astonishing how readily after the removal of such lumour" the displaced bones will return to their natural position. ' MaaMlary Sinus.— 'l\m cavity is often the seat of all sorts of tumours, and of abscesses. When a polypus grows in this cavity, its root is generally from the roof of the cavity, which is the inferior surface of the floor of the orbit as this tumour increases in size, the part which first gives way is its internal boundary, and the polypus passes into the nares, when it is often mistaken for a nasal polypus. The body of the tumour having thus escaped from the m PATHOLOGY "nu., and ihcn make tlmV , , "f " '""'"'" "■"" «f ""•» the check. "■" "PP"''"'"™ under the eye, upon fore « produce. aVJrsC;;™^ ^e Covered be- I'lis information," savs \fr « V^ qu-Ved by examining wheth r an^ r *?"'^"''. ""^ ^' ««" 'oose, or have spomaneo'l^^ '''"' '^'^^ ^'^^"'"^ alveolar, Proeessesle L la^^rej/ 1, "'^^'^^ "'« fungus excrescences maHn„*i-'^'^ "*^''<' are any whether there is any habS^^^^ TT'' '' '''' '^'^^''^ nose ,. any sarcomai^uf It n u^^ ^l« '^'^ «^ ^'^^ or towards the great anir e of L 'if' "^ ^^' "««*"' ing however has attained / • '^'- ^''^^ "'« swell- of the antrum a W^^^^^^^ fMhe bony parioties tumour be situated iMheCt.H ' ", T •''' '''y '' *'- trum. This case however 7s vL '^^ ^ "' ''"' '" "'^ «"- ColJectionsofpurmLu3inr"'T"""-" the result of blows, or cold 'V ""''""' ^^^ S^^^^^ally mucous membrane Trl'^r"? '"«^™"^ation ofth the effects will be imHar tn , ""'" "'* "^ ^ ^^use,- >%«.^^.--fhepa in^-^^^^^^^^^ f^^^^^^ by tumours.' pain extends more „to he^ t • '''^'"^''' ' ''' "'^ bad tooth, and it oft^ te„ 3^?"! T\ '''' '^'^ ^ and eye; asthediseaseadvan ' a n^n '"'' ''""^' ^'-'^'^ on the cheek bone sompfrr^^ • "^ ^""°"'' '^ Perceptible OP THE EYE. 108 tlie mouth ; or It may render Its floor carious, and may burst an the „,, ^i, ,„^,„^^^^ ^^^^^^^ .^ cseap s, it glr "y pushes up and destroys the floor of the orbit ^ or Srf 7^'",^''' ^'^ '' ^''*«"««<^ ^''^ther a tumour fluid ,s .n the antrum, is to extract the last molar tooth but one from the upper jaw of the affected side • U e bv pushmg a probe through the aperture, left by he' m vt I of the fangs of the teeth, up into the cavity, If It is matle that is collected, it will be thus dls<>harged,lif t I a tl our,^the touch with the probe will shew^hethl; it is Tard" Proffnosts-U nothing but mucus or pus is In this cavitv aoie, irom the difficulty there s of jrettino' at U - «n,i :p •* • emovTl „f . '""'"" ■nalignanl, nothing but the »nL."'° "'"'" -""'"'"^ ■«- ""' -- thl ™»rr;ret;Ltati^;;r7r.t'"'=^"'" aid i thu r?J ""'""""« ""^ "' '"» »f 't» -"lar teeth ana It this should not evacuato Ihr. m.i... I ' ^^rt'„rro:7:jr - ""'"^'^■•- «^»"-« »" wi or thi,oi,j, „d 1 b,Lri ,st5?ii :i'""s ■■'■ '^•- »•■• '■■ »«■ 104 PATHCI-Ooy Wthe (llsense bo polypus or any otiior tiimonr, it must be ext.rj)ate(l from tbe cavity. To accomplish this, an open- ing must he made into the cavity, which, at all times, is a nice and delicate proceeding. The mode of performing the operation is as follows ;_tho patient being seated, the sur- geo.. IS to form a triangular flap, with its base upwards, ex- ternal and inferior to the infra-orbital foramen ; two oblique mcisions should bo made, one outwards and downwards the other, downwards and inwards,-both incsions meeting at their inferior extremity, and thereby forming a V; tho flap should then be dissected up from its apex to its base ; In making tho incisions, the knife should reach at onco to the bone. The bone should be perfectly cleaned ; then tho surge;.!! moy v.ith a trephine or other appropriate cutting instrument, remove the bono from the front of tho cavity and thus expose its contents to view. When the operation has proceeded so far, no matter hat the contents of the cavity may be, they should be removed as quickly as pos- sible, the operator taking care that he removes every par- ticle of the diseased mass : during which, and after, there may be such hemorrhage as will be found very difficult to stop,— indeed, sometimes it requires the actual cautery. However, generally speaking a dossil of lint pi-eviously di> ped in the liquor plumb! diacetatis and applied to tho part, will be found to succeed in stopping the hemorrhage ; which dossil should be removed after two days, when tho cavity will be found secreting a white foetid discharge. The after ti-eatment will consist iii healing up the cav-i,-, which will not be found very difficult, if the tumour ha ' i been malignant ; the aperture should be kept open by the most convenient means, so as to allow the free escape of the matter ; and to accomplish this, one side of the flap and its a,, - may be united by the first intention, the other side kept fi-oui -"H: .;: by n small plug of lint placed between the '■'lb wv:!v:d. There should be free injections of a ed^CiK OF THE EYE. 100 weak solution of the nitrate of silver into tlie cavity; or if the (lischarg.i is very foetid, a solution of chloride of lini'o will be fouiKltl.t best means to correct it ; (strength one scruple to TWO pints oi n ater.) These means, and iniprovinj? the general fiealth by tonics, change of air, i^c, constitute the alter treat- ment, and if all should go on well, the bones will gradually return to their natural position, and all deformity disappear- but such a termination is not to be expected for a long time. When the tumour Is found to be malignant, the bony cavity should be well scraped after its removal, or what perhaps would be better, the cavity might be seared with the actual cautery, and, if the bones be found diseased, V ; superior maxillary should be removed. In such cases Desault recommended the removal of a con- siderable portion of the alveolar process with a gouge and mallet, and Mr. Liston recommended the removal of all the bone and tissue found implicated in the disease. I do not see the propriety of Desault's treatment, unless the part to be removed is affected or tainted with the disease. Mr. Liston's advice no doubt is good, but cases may occur when to fol- low it, it would be necessary to remove the half of the face. Mr. MacKenzie, in his treatise on disease of the Eye, mentions two cases given by Mr. Pattison, of aneurism by anastomosis in the maxillary sinus, where a cure was peformed by tying the common carotid. Frontal Sinm.-Th^ frontal sinus is liable to similar dis- eases as those found in the maxillary ; and when we re- member It? close approximation to the orbit, we will not wonder that disease of it should affect this latter cavity When inflammation of the lining membrane of this cavity IS produced by cdd or any other cause, it generally ends in suppuration : this matter may discharge itself into the nose and thus produce a happy termination ; but if it should not be so discharged, it will separate the two tables of the fron- fill nnno tlmn /l^.r>../^,. ,ii (•<•,! .. ... talbone. then depress the roof of the orbit, which wiU of iij ^,,' I' ^^^ PATHOLOGY course press upon the eye ; the bone will then become per- orated by caries or absorption, the matter will run down at the internal canthus of the eye into the cellular tissue, and so near the lachrymal sac, as to resemble in appearance disease of that sac. Biagnosis.-Uhe diagnosis in such a case is very diffi- cult. Inflammation of the lining membrane of this cavity is generally accompanied with inflammation of the Schnei- derian membrane. The patient complains of bavin- a cold in lis head, a heaviness in the eyes, &c.; as the disease advances, these symptoms increase, sometimes to such a degree as to cause much fever. When matter is fully formed, great ten- derness of the part is complained of on pressure. Progmsis.-lHhB disease is discovered in its first stage the prognosis maybe favourable, and not even very unfavourl able If caries has taken place; but if amaurosis has been produced by the pressure of the bones on the eye-ball, there IS much doubt whether vision will ever be restored even though the pressure should be removed. Treatment-Anixi^Uoghtk means should be adopted in the first stage of the disease. Leeches over the frontal sinus, ni to the inside of the nostril, will be found of great benefit • warm vapoui^ drawn up into the nostril will also be useful' and suppuration may be prevented by counter-irritation to the external parts covering the cavity. When suppuration and distortion has taken place, the sooner the matter is evacuated he better, either by a trephine or strong knife • after wh,h the unhealthy state of the lining membraL' must be improved by injections of the nitrate of silver solu- tion ; then the parts must be allowed to granulate and heal. Should this cavity be the seat of any tumour, the same remarks that have been made respecting the antruL wTu equally apply to it ; but the surgeon, when operating, must remember its close proximity to the brain, anS be gutd^d h his treatment accordingly. OP THE EYE. 107 n(I stage ; d the deli- ick of the aate either 1 the edge generally c and fifth ave been 3f matter 3 various cavities, *>ould the )f course tage sets tter will a, which • mptoms in the IS, gen- he dis- ision is ng the I vision layers degree arged. but if to fear d con- .n.n ^ 7 " *^' ^''^ '^^^' '" ^'"'« d'"«««^e the general and local treatment must be bold and decided, for f^da ,ed with, It IS sure to run rapidly into the second ta^. T letically. Five or six grains of blue nill with V. * "P'''' quantity of the extract of hyosciamu:?ay big vet^tM me. It may sometimes, but not frequently, be nece sarJ ^ give more mercury. To keep up the actioL of h ki7 bdneys and bowels, I generally give the following mixtu e' with the best effect : Sulph. magn. ?i Anlim T«^ ^ 'r "r "' '■ ^"■' ""™ '-' '■mMur.zi' sumat coch, mag. tertia quaqua hora. ' «i'8iura. The local treatment consists in applying leeches to ih. orbit ; evaporating lotions of the liquor'pluVbTaceta^^^ he same part, cold to the head; and a largo blister t' ter as oon as it is discovered, even before the abscess points If ther ,s a choice of parts to evacuate the matter through the conjunctiva should be prefeired to cutting through "he eye-hd ; as to the mode in which the opening should be Ide the operator must be guided by circumstances, but more par ticularlyby his anatomical knowledge: at allevenrth? must have free vent. After the mattfrLsbleva?^^^^^^^^^^^^ dossil of hnt should be put into the wound to keep i from healing, and a warm poultice applied three or four't L « a day the pa lent lying in such a position as to favou h« discharge of the matter. On no account shonld iZ ! from the bottom, to favour which (after some tLf) Tmav be found necessary occasionally to inject the cavitv ^th stimulating lotions. If during the fi st or co„d Ig" ^f ?5 ' f I 116 PATHOLOGY the inflammation the chambers of the eye become distended with pus, so as to endanger the burstii.j of the eye-ball, I would recommend an opening to be made in the cornea and the pus evacuated : but if the quantity of matter in the chambers be small and not presentingall the characters of pus, it may be left to the absorbents to remove. Four or five days after the matter has been evacuated, the dangerous symptoms generally disappear, when the strict antiphlogistic regimen may cease ; and if the patient is very weak such tonic treatment may be required as will not excite the vascular system ; a light nutritious diet should also be ordered. A person of scrofulous or syphilitic constitution is the most likely to suffer from chronic inflammation of the orbital cellular membrane ; when this does occur, it is slow in its progress, and matter is formed without any ^vin As the matter accumulates, the lids become swollen, reJ, and ever- ted, and the eye-ball protrudes more or less. The abscess finally bursts, and for a length of time there remains an ichorous discharge. The following is a remark made by Mr. Mackenzie, (page 296 of his work) : " It sometimes hap- pens from the indurated and adherent state of the cellular membrane, consequent to orbital abscess, that the eye-ball remains permanently protruded and motionless. In this case the tears run over the cheek, the eye-lids cannot close, the surface of the eye becomes inflamed and tender, and the patient continues subject to head-ache, watchfulness, and great anxiety." Mr. Mackenzie mentions no treatment for such a case. I have never seen a similar one, but if I should happen to meet with it I would not hesitate to eva- cuate the humours of the eye, and let it collapse, for I see no reason why the patient should be left to suffer such tor- ture when all chance of cure is past. Infiltration of the Orbital Cellular Membrane. — Exophthal- mos is sometimes produced by the infiltration of serum into OP THE EVE. 117 the cellular mcmbrano of the orbit. Here the eyc-lkls arc generally found swollen, and all the severe symptoms of abscess of the orbit present themselves. The surgeon indeed generally supposes that he has to do with an abscess, and only disco'/ers the true nature of the infiltration after he has made a puncture. Such caaes are generally found in per- sons of a scrofulous constitution. Treatment. — If there are severe head symptoms he gene- ral antiphlogistic treatment must be resorted to, avoiding blood-letting, however, if possible ; but generally speaking it will bo sufllcient to give an occasional purge of rhu- barb and calomel, apply leeches to the orbit and behind the ear, and produce counter-irritation on the nape of the neck, by means of a seton or otherwise. If the subject of the disease is young, and the case chronic, the chylo- poietic viscera will be found deranged, requiring particular attention. Iodine will be found useful in this disease. Scirrhus of the Orbital Cellular Membrane. — This diseased state of the orbital cellular membrane is found in persons predisposed to scirrhus. The exciting cause is usually a blow or other injury. A hard tumour forms in the orbit ; and it is with much difficulty that its nature can be diagnosed till its white striated structure is exposed at the period when an attempt is made towards its removal. Treatment. — To extirpate every portion of the diseased mass with the knife ; and the sooner this is done the better ; for there will be the less to remove, and a greater chance of a successful termination. Ivflammation of the Tunica Vaginalis Oculi. — I. M. Fer- rall, Esq., M. R. I. A., Adviser in Ordinary to St. Vincent's Hospital, states that this membrane is sometimes the seat of rheumatic inflammation, and in support of his opinion quotes three cases that came under his observation. In the first case relief was obtained in some degree by bleeding and general antiphlogistic treatment, but there was no perma- % r- 118 PATnOLOGY nent relief until the system was affected with calomel. The symptoms in that case were want of sleep, intense pain in the eyc-hall, forehead and temple ; the eye projected three quarters of an inch, the lids were swollen, cedeniatous, and of a dusky red color ; the conjunctivo protruded over the cornea, in the manner of a chemosia, its color pale amber, and evidently distended with serum ; the cornea and iris were perfectly healthy; pain was increased by pressing the eye-ball directly backwards, but was not augmented upon pressure of the eye-ball upwards, and towards the periostial covering of the roof of the orbit. His second case was a man aged 32 years. The follow- ing are the symptoms he gives of it :— " Violent inflamma- tion and protrusion of the right eye ; the cornea and iria healthy, vision confused, conjunctiva projecting around the cornea and of an amber color, the eye-lids swollen and of a dusky red hue, suriiice marked by a number of distended veins. The patient complained of agonising pain in the globe of the eye, and a sensation as if it were being dragged out of the orbit ; this sensation always continued, but the pain was liable to severe exacerbations; moderate pres- sure on the eye-ball, with the palm of the patient's own hand, seemed to relieve him, although he could not bear any one else to touch it. Pressing the superior palpebrse towards the roof of the orbit gave no pain ; at the beginning of the attack there were occasional flashes of light before the eye." The patient had been suffering from rheumatism in his knees and legs, six weeks previous to the attack in his eye, and at the time Mr. Ferrall saw him there was slight fulness from effusion in the capsule of the left knee joint, and ten- derness with tumefaction about the middle of the right tibia. The man was of intemperate habits, and six years pre- viously had suffered from syphilis, for which he had taken mercury largely. li OF THE EYE. 119 The trcfttmcnt in this case was the same as in the pre- ceding, and with the same result ; the only difference was bleeding from the temporal artery instead of the arm. His third case was a woman of 48 years old, who pre- vious to the attack of the eye, had been for a week in hospital for rheumatism with swelling of the knee joints from effusion into their capsules. The swelling of the knees had nearly disappeared, when she was seized with acute pain in the right eye ; there was no appearance of inflam- mation for twenty-four hours after ; on the second day the pain increased, with occasional flashes of light ; the eye-lids were inflamed and swollen, and the eye projected. The cornea and iris were healthy, and looked clear in the midst of a prominent chemosis, which was of a yellow amber color. The lids were swollen, and did not cover the eye ; the upper lid presented the dusky red colour, and tumid appearance described in the second case. The superior portion of its surface did not, however, participate in this change, two parts being separated by a very distinct line of demarcation. Pressure directed towards the roof of the orbit produced no pain, and the sight was not impaired ; there was swelling and great tenderness over the left tibia. The treatment that he adopted in this case, was to give ten grains of the hydriodate of potass every three hours ; after the woman had taken seventy grains she declared herself better, although no difference could be perceived in the state of the eye. The fifth day the medicine was stopped, as all traces of the disease had disappeared ; even the tibia had recovered its healthy state. In 36 hours following, the left eye became attacked with the same disease, which, after ten days, yielded to the same treatment ; the dose of the medi- cine was increased to 15 grains every three hours, and gradually reduced again as the eye improved. The following arc the conclusions drawn by Mr. Ferrall : " That protrusion of the eye-ball which when attempted to ■'■ill ISA "*" PATHOLOar be explained by uncomplicated periostitis, requires some stretch imagination, appears a very simple and ineviaSe resu t of inflammation of the tunica vaginalis ocul The e are here no soft parts to receive and divide the pressure or protect the globe. The tunic is supported by otherTbr'ous ayers on Us outside, as well as by the muscl's wh Lh c n sUtute the sheaths. Inflammation of this capsule must then be immediately followed by pressure; and when we recol- lect Its conical form, and that, as happens in the cases of inflammation of other fibrous tissues, effusion at once takes place in the cellular membrane connecting it to the ball o aZ^^'' '^f '° '"*' ^^' ''""^^' *'^«»« ^''»™ake itself evi- dent m another way; the conjunctiva, at the place where iTwill n.? Z "''''^ '^'^'"*"' '° fr'^"*- At this point bu will become separated from its connection with the scle ' roticcoat by the extension of the infiltration hence the iX thi' • '^""'^ ^' ''' ^^"J""^"- without vas'u- !n^- ^I'f.'^"''^' originating in conjunctivitis, always pre- treat is in uncom&cL l'e^:Xrncf o7^L: from a deeper source. I can easily imagine the xten ion of mflammation from the fibrous structure of the Id to Us tTvrt;ls"^'"r°' *'^°^^ *^ thes^erotL cl „. T !!;„.. ^ <=omplication did not occur in the cases which I have related. In distinguishing these cases I would not be supposed to mean, that inflammation of thil Tunic is a dsease apart and never combined with a similar ondiL of the pe losteum or cellular tissue, on the one hand or inflammation of the eye-ball itself in the o her I am aware they may exist together, for I have seen su'h case" OF THE EYE. 121 All I mean to assert is, that inflammation of the tmiic described, may be the primary affection, and the point of departure from which the diseased action may spread to the other fibrous layers in the orbit, and finally reach the periosteum ; and that the attack may even be limited to the tunica vaginalis oculi, that it may here produce a train of symptoms of the most dangerous kind, and which have been hitherto supposed to reside in the periosteum, because the existence of other fibrous membranes in the cavity was not suspected." In the first part of this work, page 4, the anatomy and physiology of this tunic is given as described by Mr. Bonnet. I have never seen the disease so well defined as des- cribed by Mr. Ferrall, but previous to reading his remarks, I had seen two cases in which all the symptoms described by him were present, in the early stage of the disease, but the whole of the parts in the orbit soon partook of the general inflammation ; one case was that of a strong young man ; the case yielded to mercury ; the other case was an old man ; I trusted to antiphlogistic treatment in his case, and he lost his eye. The diagnosis in such a case must always be very obscure; I must confess that 1 do not see the diflference between it and sclerottitis ; certainly it is very difilcult to draw the line of demarcation between the two diseases. i.'hl .^»S CHAPTER XII. DISEASES OF THE SECRETINa LACHKYMAL ORGANS. from Lit T" •"" u'' '^'^ "^^ ^' ^«""ded, although rora their situation they are not very h-able to be o, indeed, Znt i °\!' '"'' *" '^^^P«5 «^ »»!««« the wound penetra es the orbit from the outside at the superior and external angle. There are two sources of dangef to be ap- ZnZ *'^tt^*'"'°^ «f the tears through the external fZ a til T'f r ^"* " '^«™ ^«^"°^' -^ thus Z.^ *™' f*"'^ lachrymalis; to prevent this accident ?hl f '*f ' "^r^ '^""'^ ^' brought as close as pos- sible together With adhesive plaster, and if necessanr a couple of stitches ; then the whole should be covered with a compress and bandage, and every effort made to cause union by t e first intention. Should the surgeon fail in h efforts, and a true fistulous opening be formed, I would recommend a fistulous opening being effected b; seton, or otherwise, through the fold of the reflected conjunctiva, which ma^on't^r;^^ ^7^""- ^'""^ '""'^ "" '"J"^J^ '^^^''^ ^e inflam- tm ion nZTl^ '" «"PP»ration of the gland, and obli- InZm r 'rT.'^T'' '^'^' 'y'' The treatment of inflammation of the gland will be spoken of under its proper PATHOLOGY OF THE EYE. 123 Xerophthalmia. — By this term is meant dryness of the eye, which may be owing to different causes. There are two descriptions of the disease; the one is to be referred to a want of tears, the other a want of mucus. The first description may be caused by inflammation of the lachry- mal gland, causing its secretion to be suppressed ; secondly} the secretion may be suppressed from a want of nervous energy in the gland ; thirdly, if the gland becomes indu- rated, it will cease to secvete ; as people grow old, all their secreting glands become shrunken, and cease to secrete in a more or less degree; therefore this disease is occasionally met with in the aged. Obliteration of the lachrymal ducts is another cause of the first species of xeroma. The second species, want of mucus secretion, is caused by some derangement of the ophthalmic branch of the fifth pair of nerves, and is generally accompanied by amaurosis in a greater or less degree. From the conjunctiva not secreting, although the tears pass plentifully over the eyes, the patient always complains of their feeling stiff and dry. Mr. Mackenzie says that in such a case, the conjunctiva con- tinues to secrete mucus, but my expe deuce leads me to a different conclusion. This description of xeroma may be produced temporarily by deep grief, which is nothing more than a sympathetic nervous affection. Treatment. — The treatment of this disease will depend upon the cause. If it be inflammation of the gland, as soon as the inflammation is removed the disease will disappear ; if it is owing to obstruction of the ducts, some good effects may be induced by causing a fistulous opening in the reflect- ed portion of the conjunctiva ; if it be from induration of the gland, or from old age, the disease is incurable, and in these two varieties the best substitute for tears is (ccasionally dropping on the eye-ball a weak solution of the nitrate of silver, which will also prevent ulceration of the cornea. If the secretion of mucus cannot be restored- the same ireat- 8 V' ■ »■ 124 ment PATHOLOGY it be adopted. If there be suppression of either mucus or tears, from want of nervous energy, every effort must be made to restore the nervous vigour ; for this purpose I have found electricity of the greatest service. This should be used every morning, by drawing sparks from the affected eye and orbit, or by the use of the electro-magnetic instru- ment ; a strong solution of nitrate of silver, eight or ten grains to the ounce should be also dropped on the conjunctiva once or twice a day; blisters should be applied before and behind the ears ; the eye-lid and all round the orbit should be brushed every day with a ten grain solution of veratria prepared as below.* Sternutatories should not be neglected ; indeed it is from the great benefit that has accrued from the action of this class of remedies that so many patent sauffs have been puffed up by quacks as cures for all diseases of the eye, including even blindness, no matter from what cause it may arise. The constitutional treatment in such cases, is tonic, keeping the bowels and all the secretions regular; and if possible the patient should have change of air. The same treatment is necessary if the cause be grief, but antispasmodics should also be given. However time change of air and scene, constitute the best form of cure' since, as it has already been shewn, the disease in such cases is only temporary. From what has been said on the subject of xeroma, the reader will perceive that in reality it is not a disease, but the symptom or effect of a disease. The disease to be next considered may be regarded in the same light. I^iphora.— This disease is in its characteristics the exact opposite of the preceding. It consists in too great a flow of tears, arising from increased action of the lachrymal gland ; but this must not be confou nded with stilicidium •I}i VeratisBgr, x setheris sufph. 5ii Spt. vini rect ?i. Solve reratrium in aethere deinde adde spiritum vini Rectificatum. OP THE EYE. 125 lachrymarium, which is caused by a disordered state of the excreting lachrymal organs. Causes. — The causes of epiphora, or an over-flow of tears, are innumerable : any thing which excites or stimulates the ophthalmic branch of the fifth pair of nerves, may produce it, let the cause be, chemical, mechanical, sympathetic, or otherwise. For example, any foreign body touching the conjunctiva, will produce it. Strong sudden light on the eye will also cause a flow of tears. Irritating the nose, and thus exciting the nasal nerve, will also act as a cause, as every one knows. Sympathy with the sorrows of others will produce epiphora, also grief, joy, teething, disor- dered digestion, worms in the intestines, pain, &c. Hence it is evident that of all the nerves of the bouy, none sympathise more with the rest of the nervous system than the fifth pair ; and when their Intimate connection with the eye is considered, the numerous remote causes which pro- duce disease of that organ will no longer cause surprise. It is not unusual to find epiphora accompanied with par- tial amaurosis. The most frequent cause of persistent epiphora is stru- mous ophthalmia. Treatment. — To first discover, and then remove the cause, is the cure for this complaint. If a foreign body be under the eye-lids, it should be re- moved ; if teething be the cause, the complaint will disap- pear when the teeth have cut through the gums. In a word the treatment will, in all cases, vary with th** ' ie. If the eye be weakened after removing the cause, the four or six grain solution of the nitrate of silver, may be dropped on the conjunctiva once or twice, every day. Injiammoition of the Lachrymal Gland. — True idiopathic inflammation of the lachrymal gland is so rare, that Beer met with it but seldom in a practice of twenty-seven years standing. According to Mr. Travers, however, it often i I If 126 PATHOLOGY occurs, particularly in children. As far as my own expe- . nence goes I must coincide with Beer's opinion, and con- :;»: taizr^^^"^^- ^-^^^^^^^ ^^^— - fyy->ns. -The secretion of the gland becomes lessened and xeomr -s produced. This is followed by acute throb- eSra df%"r'^^'^'^''' ^'^'^'^ shLTstot eye-ball and forehead ; there is also a great feeiinff of ful ness, at the superior and external anglf of th S Tht conjunctiva becomes inflamed, and the eye-lid tensp Ta swollen particularly at its external angle ';!^io„T next jmpaired,andthe free motion of the eye^ut ward "refuted by the pressure of the swollen gland upon the eye-bal as It advances, the eye-ball is pushed downwards and inwirds owards the nose ; the pain is greatly increased, tie pu^ IS contracted and immovable, and it is nearly imiossiWeTo raise the upper lid. This U the first stage, anVirnot Ir st ed It soon runs into the second or suppu'rative stage A l th symptoms already enumerated are increased, fllhes o sets m,) , gors follow, which shew that suppuration has commenced but the other symptoms do not abaL ^a length the matter is found to fluctuate, it points and finaly bursts junctiva. After this it is more than probable that the peri- o^steum and bones of the orbit will be found to have'suL Cau.es.— The general causes are injury by blows wounds, or cold. Inflammation of the surrounding paTts' sometimes spreads to the gland. ^ ^ Treatment.-ln the acute stage, the antiphlogistic treat ment must be adhered to; general kedlng,TeXpS" to the orbit, an emetic, followed up by an a tive purgaUve and nauseating doses of tartarized antimony, with 2e Ide and rest; these, with cold lotions of the ace'^are XT t OP THE EYE. 127 the part, constitute the treatment in the first or inflamma- tory stage. Blisters before and behind the ears may be found useful. If tears begin to gush from the eye, the sur- geon may feel pretty sure that the inflammation will ter- minate in resolution. When once the second or suppurative stage commences, the moment fluctuation is perceptible, the matter should b» evacuated, if possible, through the reflected conjunctiva, bui if this cannot be done, through an opening made in the up- per hd. After which poultices may be applied ; the dis- charge, after continuing for some time, gradually diminishes, and finally stops, and then the parts heal up. If the ab scess is allowed to burst, and the matter to evacuate itself spontaneously, it is more than probable that the bone will have become diseased. In children of a scrofulous habit this gland sometimes becomes enlarged, and runs into suppuration without any of the symptoms of inflammation, except a sense of fulness above the globe of the eye. The eye-lid becomes turn d and cedematous and there is an inability to move the eye outwards. This state of the gland differs also from tha already described, ,n its being generally accompanied by a copious flow of tears, and often with frequent attacks of pustular conjunctivitis. The progress of the disease is sometimes very slow: the gland often takes months to suppurate. The matter will be found, on opening the abscess, to be of a cheesy floculent consistence. ' In the first stage of such a case, leeches should be applied to the part, an occasional dose of rhubarb, soda and the hydrargyrum cum creta should be given at night. Iodine, both internally and externally, should not be neglected, and perhaps there is nothing of greater importance than change of air, and partaking of light but nourishing diet. When the second stage sets in, and vhen the skin over the abscess hi T^i 128 PATIIOLOaV IS thin, the matter should be evacuated, a poultice applied, and quinine given internally. If at any time the pressure of the enlarged gland threatens the destruction of the eye- ball, the gland should be extirpated. Chronic Enlargement of the Gland.— Hio matter what may be the character of a chronic enlargement of the lachry- mal gland, whether scirrhous or otherwise, the symptoms at the commencement will be always found the same ; viz :-epiphora, burning and lancinating pain in the region of the gland, and a small hard lobulated tumour, to be felt in the external orbital angle. This tumour soon elevates the skin of the eye-lid; from which time its growth pro- ceeds with great rapidity; as it increases, it pushes the eye-ball downwards and inwards, the sight first becomes dim, and is soon totally lost. At this stage of the disease, If something be not done, the eye-ball inflames, suppurates, and bursts. The tumour continues to increase till it fills up the whole orbit ; the lids become everted and expanded, finally, if the patient is not worn out by pain and fever the tumour will press upon the brain, and in that way cause death. "^ magnosts.—The diagnosis in such a case will be always difiicult, as all the above symptoms, or nearly all, may be found to take place with any form of orbital tumour. If in the first stage the lobulated form of the tumour can be distinguished, it is a certain sign that it is the gland that IS affected; but when the eye-ball bursts the tumour may be mistaken for fungus haematodes. It is very hard to diagnose between scrofulous and cancerous enlargements of the gland ; age in some degree will be a guide, cancer being only found in old people, and scrofula in the young. If it be scrofula the tonsils or glands of the neck will be found enlarged, in fact the whole lymphatic system IS deranged ; when the tumour presents a green color it is ' called chloroma or green tumour ; which is just as malignant as cancer. L OP THE EYE. 129 Treatment. — While the tumour is in the incipient staffc, and not pressing upon the eye-ball, benefit may be derived from the use of leeches, iodine frictions, and iodine inter- nally ; but when once it presses upon the eye, the sooner it is extirpated the better. If the eye has been displaced, some time will elapse after the tumour is removed, before it regains its natural position. If during the operation, the eye-ball is found destroyed, it should be removed at the same time. We must expect that the removal of tlie lach- rymal gland will produce incurable leroma. Encysted Tumours in the Lachrymal Gland. — This ia so rare a disease, that Beer in his practice only met with three cases, and Schmidt vrith two. So similar are the symptoms to those that are found, when the gland is the seat of other tumours, that I see no means of diagnosing between them. Nor do I consider it of much consequence, as the treatment must be the same, viz. :— extirpation. However, Mr. Mackenzie recommends a palliative treatment in the following words— page 100 of the third edition of his work : « A palliative treatment, it is probable, will generally be adopted ; by employment of this remedy we may save both the life and the eye of patient. It may even happen that by the early employment of this palliative regimen, we may be fortunate enough to cure the disease completely. No hope of this however jieed be entertained, if the eye-ball should be already protruded from the orbit, the power of vision lost, the eye-ball begin- ning to appear dusky and lifeless, or if it be violently inflamed and in part disorganized. " The palliative cure consists in puncturing the tumour and evacuating the accumulated fluid. This should be done, if practicable, from under the upper eye-lid with a lancet, or small concealed bistoury, directed towards the seat of the lachrymal gland. Should the tumour return after the healing of the wound, the operation mast be I k^l 71 130 PATHOLOQT repeated I should think any attempt to keep the wound open and the tumour constantly empty by the introduction of a bougie or other foreign body would be out of the ques- tion If the incision, were made from under the upper eye- lid. But If the protrusion of the eye were such that the upper eye-hd becomes firmly stretched over the eye-ball and thus admitting of no instrument being passed between them, the tumour would require to bo opened through the upper eye-hd, and the wound might bo afterwards kept open by a bit of catgut, so as to give exit to any re-accumu- lated iluid, and perhaps produce a radical cure." There is one great satisfaction in this palliative treat- ment of Mr. Mackenzie, which is, that if it does not suc- ceed. It does not prevent the extirpation of the tumour- but for my part I would not trust long to it, if I found the eye in danger of being pressed upoi.. Another benefit, by the way, is, that it is a good help towards forming a diagnosis. Encysted Tummrs in the Vicinity of the QUndulce Cm- gregatm and Lachrymal i?Mcte.— The difference between this and the last mentioned disease consists in the situation of the tumours. In the former the tumour is in the sub- stance of the gland, and derives its fluid from it; in this disease the tumour is in the vicinity of the glandule con- gregatae immediately behind the conjunctiva, and according to Schmidt it derives its fluid from the lachrymal ducts. Symptcms.—ThQ symptoms are by no means as severe as those mentioned in the preceding disease, and they exist but a short time before the tumour can be felt which presents a circumscribed elastic swelling behind the upper eye-lid, and on its temporal side. As it enlarges it impedes the motions of the eye-ball particularly upwards aod outwards, but if the eye-lid is taken hold of and raised from the eye-ball, the motions of the eye will be free- finally the cyst becomes so thin as to seem as if the OP THE ETE. 131 slightest touch would burst it. At no period of this disease is there much pain. Treatment. — Beer recommended laying the cyst bare through the conjunctiva, then passing a seton of a thread of thick silk througli the tumour, and thus obliterating the cavity of the cyst by exciting inflammation in it. But the treatment generally adopted at the present day, and the one I would recommend, is extirpation, and that as soon as the tumour can be felt. True Lachrymal Fistula. — This is a callous fistulous opening, leading from the lachrymal gland through the upper eye-lid. The tears trickle through this opening, which is generally at the external canthus of the eye, and so small as with yreat difficulty, and even not at all, to be discovered by the naked eye. Cause. — The cause of this disease is badly treated abscess of the upper eye-lid, orbital cellular membrane ; or wounds of the lachrymal ducts. Treatment. — The treatment consists, in producing inflam- mation in the fistulous canal, so as to get it to heal ; and many modes have been recommended to accomplish this end. Beer in one case passed into the opening a red hot knitting needle, and turned it several times upon its axis. In five days afterwards the fistula was completely healed. If the opening is large enough to admit the point of a small syringe, injections of the nitrate of silver will cure the disease. Another mode of treatment is to lay the sinus open, and then heal it by granulation. Morbid Tears. — The following statement is made by Mr. Mackenzie : " The tears are at all times an irritating secre- tion; the conjunctiva is instantly reddened when they flow ; and although we were to grant that this was consentaneous with the determination of blood to the lachrymal gland pre- ceding the discharge, yet we observe that if the tears are so profuse as to run over on the cheek, the skin with which Hi; *"* PATHOLOUY they come in frequent contact beconica inflamed and eico- riated." As well might Mr. Mackenzie Imve said tliat saliva was an irritating secretion, because if it was constantly running over the chin it would produce excoriation, or the discharge from the nose running over the upper lip would produce a similar effect. The simple fact is, that the part which those different secretions are meant to protect is mucous membrane, which will inflame if not kept moist, when the cuticle, or rather the true skin under it, not requiring any such provision, will i„iame if kept moist by those secre- tions ; indeed, simple water would do the same if kept con- stantly applied, for It is well known that the legs of raftsmen and the arms of^vasherwomen are very red with scaly erup^ tions upon them. Mr. Mackenzie must have forgotten that m cases of epiphora, where the tear is constantly on the eye, very frequently the conjunctiva is not in the slight- est degree inflamed. For my own part, I never saw a case of inflammation that I could attribute to the acridity of the tears, but at the same time I do not say that such may not sometimes be the case under peculiar circumstances bangumemia Lachrymation.—Tlih disease is one of which many authors doubt the t xistence, and as I have never seen it I shall make no comments, but give the fol- lowing quotation from the work of Mr. Mackenzie : "Dr. Clopton Havers relates the case of an ictorical dis- contented woman, who, having a desire to die, wholly reject- ed the help of medicine. Being well nigh her end, there appeared an eruption of blood out of the glandula lachiymalis of one of her eyes without any external injury; there was an evacuation of two pounds of blood within the space of thirty hours : about a week afterwards the same sluice was opened again, and she bled till she died. "Professor Rosas refers us to a case of this sort related by Dodonacus and to another by Lanzorei. In the former OF THE EYE. 188 instance the disease accompanied suppressed menstruation in the latter It occurred in a lad of twelve years of age, who' soon after died of malignant fever. " Professor Kosas himself witnessed the disease in a child of nine years of age, of scorbutic diathesis, and in whom it yielded to antiscorbutic treatment. " It is doubtful in all these cases, how far the discharge of blood was really from the lachrymal gland, and not from the conjunctiva." Lachrymal Oo?ct«?M«.— Calcareous deposits being found In the sinuses of the conjunctiva, their source has been attri- buted to the tears. Although cases of this sort are very rare, yet when they do occur it is wonderful with what rapi- dity the calculi form ; as great a number as thirty have been removed from the eye in twenty-four hours ; they resemble mortar, and their average size Is something greater than the head of a pin. They are composed of carbonate and phosphate of lime, cemented with coagnlable lymph or albumen. Tre(Ument.~li is unnecessary to say that those deposits act as foreign bodies, and if allowed to remain will invari- ably produce inflammation , thev therefore should be removed as fast as they are formed, but If possible their formation should be prevented altogether, .^o carbonate of potash was found 8o:useful in calcareous affections of the kidneys Walther prescribed it in this disease with the best eflfects! from which we may conclude that the best treatment in the former disease will be most successful in the latter, and I believe the best treatment is acids and, perhaps none comes before the nitric. Extirpation of the Lachrymal Gland.— In this chapter I have frequently spoken of the necessity that sometimes arises for the removal of the lachrymal gland. I will now describe how this operation is to be performed. h it) 134 PATHOLOGY OF THE EYE. IS There are two modes of doing it. The first through the conjunctiva, the second through the up- per lid; the former I consider the preferable mode. To remove it through the conjunctiva the upper lid should be everted by an assistant, and drawn outward from the eye-ball ; but sometimes this is impossible, in consequence of the great size of the tumour ; in which case an incision should be made from the external angle of the eye towards the temple ; this incision may reach half an inch beyond the external angle of the orbit, and suflSciently deep to separate both lids at their external angle ; it should go through integuments, muscle, and ligament ; the reflected conjunctiva must then be tut through, after which there will be no diffi- culty in completely everting the upper lid, when the tumour will be brought into view : after it is exposed it may be taken hold of by a hook or forceps, dragged downwards and outwards, and then cautiously dissected out of the orbit, the operator taking care to leave no part of the gland behind. The eye-lid should then be restored to its natural position, and the edges of the wound carefully brought together with a few stitches and adhesive plaster. A compress and ban- dage should be next applied, and the patient ordered to re- main quiet. The second mode of operating is to make an incision through the upper lid, exlternal to the conjunctiva^ and parallel to the fibres of the orbicularis muscle, along the upper edge of the orbit. When the tumour is thus exposedj it is to be removed in the mode already detail- ed, and the after treatment is the same. The objection I have to this last operation, is the diflSculty of making the wound of sufiicient size, and also the diffi- culty, anatomically speaking, of getting at the gland from this part : however, the size of the tumour, with the extent of injury in the surrounding parts, must guide the surgeon as to which mode of operating he should adopt in each individual case. CHAPTER XIII. 1 i<; DI8E4SE8 OP THE EXCRETING LACHRYMAL ORaANS. Acute Dacryocystitis.—^y this term is meant acute in- flammation of the excreting lachrymal organs, in contra- distinction to a chronic form, which will be explained in the next article. %mpto»is.— Redness and a hot itching pain at the inter- nal angle of the eye, which soon extend into the side of the nose ; there next appears a small round tumour over the lachrymal sac, which is hard to the touch ; then the inflam- mation is seen to extend along the palpebral conjunctiva, the lower lid being first attacked, and afterwards the upper ; if at this stage the puncta are examined, they will be found contracted ; as the disease advances, the tumour over the sac increases in size, and becomes red, and so tender that the slightest touch will produce the most acute pain ; the eye-lids and cheek next become so swollen and red, that the eye-ball is nearly concealed, but if visible the conjunctiva will be seen to have partaken of the inflammation. When the lachrymal passages become obstructed stillicidum lach- rymarium supervenes ; the red phlegmonous swelling changes its color, and becomes of a purplish appearance ; the matter is now felt to fluctuate, and if it be not discharg- ed through the nasal duct or puncta, which is a very un- usual termination, the skin covering the abscess will slough, or the abscess will point and burst, below the tendo oculi ; the discharge will be puriform mucus, and as previous to bursting some of this matter will have found its way be- tween the muscle and integuments, though the discharge may be of great quantity, yet all the swelling will not be 136 PATHOLOGY I removeil. After the discharge has continued for some time, its character changes, and tears mixed with pus are dis- charged, which in time again changes, and pure mucus h discharged instead ; this matter becomes thinner, and finally the sac heals, either leaving the nasal duct impervious, or the parts in their natural state. 'Hie constitutional symptoms in this disease are sometimes very severe, head-ache, fever ; and the second stage is often accompanied with delirium. It commences with inflamma- tion of the mucous membrane lining the lachrymal pas- sages ; the first effect of which is a suppression of the secre- tions, and the second an increase of mucus secretion ; the outlets of the nasal duct and sac being obstructed or obli- terated by inflammation, the mucus collects in the sac, which from its lying upon a bony surface, appears as a tumour very early in the disease ; suppuration next sets in, and follows the course already detailed. Oauses.— The only causes that can be assigned are, odd wind blowing on the side of the fiice, or some mechanical injury. Froffnosis.— During the first stage, if the patient is of a healthy constitution, and not tainted with scrofula, scorbu- tica, or syphilis, the prognosis may be favorable, but when once the second or suppurative stage has commenced, the great probability is that it will terminate in some part of the canal becoming obstructed. Treatment.— In the first stage every effort must be made to subdue the inflammation, by antiphlogistic means, such as local bleeding, purging, nauseants, diaphoretics, and cold or hot evaporating lotions of the acetum plumbi applied to the parts. In the second stage the matter should be at once evacuated by a puncture of the lancet, after which the sac should be well washed out by means of a syringe and warm water ; this treatment should be conti- nued, with emollient poultices, for a few days ; it wif! be also OP THE EY€. 137 necessary to examine the nasal duct with a probe, ^to see if it be pervions ; after syringing and poulticing for a few days, simple dressing may be used, under which the parts gene- rally heal in a short time, without further trouble ; however, it is sometimes necessary to excite the sac with stimulating injections, before it can be made to heal ; and after this is effected, to correct the secretions a drop of the six grain solution of the nitrate of silver may be dropped into the internal canthus of the eye, once or twice a day. Chronic Dacryocystitis or Chronic Inflammation of the Excreting Lachrymal Organs.^lhh is a more frequent dis- ease than the acute form, and much more difficult of cure ; indeed very freoui tly every effort to cure will be found unavailing - , ^ patient having to wear a style in the nasal due; • ■■. life, can be said to be cured. It is said to be more frequent in women than men ; I have not found this to be the case. It will attack persons of all ages. 8ym.ptoim.—l)iQ first thing the patient complains of is being constantly annoyed by having repeatedly to wipe away the tears which collect in the internal canthus of the eye, more particularly if the weather be damp or cold. If the eye be examined at this period, the redness of the parts is so trifling that it is only observable when compared with the sound eye, and then the only parts that appear a little inflamed are the puncta and carruncula lachrymalis. After some time the patient discovers that by pressing his finge. on the internal canthus of the eye, he can force the tears down into the nose, or cause them to regurgitate through the puncta. This may go on for years before the second stage, which is called hhnorrhcea, sets in ; then there is pain, red- ness and swelling at the inner canthus, which when pressed upon, forces the tears back on the eye, mixed with mucus, or down into the nose : as the disease advan- ces, the tears cease altogether to pass into the nose, but always regurgitate on the eye. This constantly occurs 188 PATHOLOGY spontaneo, iy, through the action of the orbicularis muscle ; at this penod there is a dryness of the nates on the aflFected side, from the want of tears passing into it. If then the conjunctiva of the lower lid be examined, it and the meibo- mian glands will be found inflamed, and not unfrequently the skin of the cheek will be excoriated by the mucifomz fluid dripping over it. Repeated attacks of inflammation will now take nlace in the sac, terminating in suppuration, so that where mucus only had existed there wil' be pus formed, and the integuments over the sac will become in- flamed, red, and extended. Finally, the sac points like an abscess, and bursts, discharging a muco-purulent fluid; and, as, at this stage of the disease, there is obstruction of the nasal duct, either from adhesion of its sides or thicken- ing of the membrane, the opening thus made will continue to pour out pus mingled with tears, and thereby form a fistulous opening ; and if the opening be not in a proper position to favour the free exit of the discharge, it will bur- row under the integuments, and perhaps form two or three additional fistulous openings. If a probe be passed into any of these openings, the surgeon is very likely to find caries of the bone, particularly if the patient be scrofulous or tainted with syphilis. Causes.— The causes of ihis disease may be either local or constitutional, but, generally speaking, the latter are the most frequent. The local causes may be injury or congeni- tal smalJness of the nasal duct ; the constitutional causes may be a scrofulous diathesis, natural weakness of the con- stitution, syphilis, small pox, measles, scarlet fever, teeth- ing, worms, or a disordered state of the digestive organs. Prognosis.-- The cure of such a case, without an operation, is always doubtful, even under the most favorable circum- stances ; nevertheless I have frequently succeeded in curing it in the second stage without an operation, but when the third stage has st. in, any means without operation are not only useless, but sure to increase the evil. OF THE EYE. 139 Treatment.— liumeroMs as the causes are which produce this disease, yet there is no diflFerence in the local -treatment to be pursued ; constitutional treatment is only useful in the first and second stages, and it must be adapted to the condi- tion of the patient's health. In the first stage, or watery eye, the state of the constitution should be carefully enquired into J if the digestive organs are found deranged, an emetic and purgative, with some astringent lotion to the eye, may at once cure the disease; gentle alteratives may also be found useful. If the habit be scrofulous, syphilitic or scorbutic, medicir.es that are known to correct such morbid states of the system must bo given. Local treat- ment must be directed towards reducing the inflammation, which IS the cause of the flow of mucus and tears ; therefore It must be antiphlogistic ; leeches should be applied to the sac as well as evaporating lotions of the acetate of lead and m addition an astringent lotion should be dropped into the internal canthus oi the eye once or twice a day, to be taken up by the puncta, carried into the sac, and there correct the nature of the secretion. The best lotion is the saturated solution of the acetate of lead ; but before it h used, the sac should be well cleared out, and when the drop Js put into the eye, it should be allowed to remain there, with the patient's head thrown back, for eight or ten min- utes, making him at the same time respire strongly and frequently, through the afl^ected side of the nose. The secretions of the meibomian follicles and glands should also be corrected, and this is best done by smearing on the ed«re and inside of the lower lid, every night at bed time,asmali portion of ointment, composed of equal parts of the citriue ointment and the ophthalmic ointment of Jannin .* *Jannin's ophthalmic ointmcDt : ^ Boh armen. Xn Tutiaeprep 3ii Hydr precip. albi. gi Axungio 3i mt. fl. C/uguentum. II- I ! 11 I' if'' J 140 PATHOLOGY The consMtntional treatment that is adopted in the first stage, will be also necessary in the second. It is astonish- ing What efficacy a simple constitutional treatment will sometimes have in removing this disease, even in the second stage. I remember, about nine years ago, a lady consulted me for this disease ; I found it in the second stage ; whec the sac was pressed upon, the whole of the eye was imme- diately covered with mingled mucus and tears ; she told me, that the tears had been annoying her for about eight months, but that the matter had only appeared, about four ur five days previously ; seeing some ant -arcous swelling about the eye-lids, I ordered her a purge of the compound powder of jalap, to be followed by a teacup-full of cream of tartar water, two or three times a day. In four or five days, the disease entirely disappeared and has never since returned. The lady's age at that time was about 48. If during the progress of the disease, the nasal duct be- comes obstructed, or if obstruction be the original cause of the disease, no cure can take place unless this condition be removed. To accomplish this, many plana of treatment have been recommended, some of which have succeeded at one time and failed at another. If the cause is a collection of mucus ; stopping the mouth and nose, and giving a forced inspiration, very frequently succeed in removing it, and where this does succeed, it should be constantly done during the day. Sternutatories have been recommended in such cases, but I have never seen any benefit to be derived from their use. If it arise from a collapsed state of the mucous membrane, or from a morbid condition of the oph- thalmic branch of the fifth pair of nerves, it will be generally found to be accompanied with amaurotic symptoms, such as a dilated pupil with sluggish action. Along with other means, in such a case, electricity, and counter-irritation, by means of blisters before the ear, will be found very useful. If the cause of the obstruction be a spasmodic contraction of OF THE EYE. 141 the duct, from any irritation of the fifth nerve, smearing the outs.de of the sac with the extract of be ladonua ami jnhahng through the nose, warm camphorated u^lg^ .ons may be found serviceable, and a smart purge Zrl- ton-oil W.1I also help to allay the irritability ot the ne fh"f •rrnT'^'^' '" ''^" ''''' ofobstrucUonofthod c* that U should be opened by passing a small gold or si le; probe through the puncta down into the nose. For Is purpose he :nvented six differon. sized probes, varying f 1 ^ to ^ of an inch in thickness; they a e round Z smooth but not bulbous at their extremity luLont mended that one of these probes should be pa^ssed eve^ day and after their withdrawal, the passagJ to be inTected through the puncta, by means of a syringe, which hTa^Io mvented, and which bears his name. Of this atment I can only say, that although I have found it succeed '"a onallym incipient cases, I have much oftener found to more than once, not only pronounce it a useless but an .njunousmode of treatment, as the use of eithe t .e pro e or synnge would be likely to split the puncta, or tear a^dlis organize the mucous membrane. The foil w nT tateltt" - made by Mr. Mackenzie : "I have occasionally st eS .n completely curing slight incipient cases by I'tions w. Anel'ssyringe,butmuchmorefrequentIyIh'veS^^^^ If the puncta be obstructed with mucus, removing the mucus with a small probe will certainly be correriuf he puncta cease to perform their office,'l do no ee h ^ either probes or injections will restore their actinandTf he obstruction be in the nasal duct, a probe th^Zuld pass through the punctum would hardly remove it. ^ JnL tZ"^'"v^/- "^^ '^ using Anel's probes and sFinge The eye-hd is to be put on the stretch, by draw 2e o7;h rS S°^"^ ''''' ^^"•^ ^--^^ the t^m^eX edge of the lid being drawn at the same time a litUe for! 142 PATHOLOGY ward, so as to bring the punctum into view ; the probe being now held in the other hand, its point is to be carefully inserted into the punctum, (I speak of the upper lid), and then pushed upwards, and inwards towards the nose, until it reaches the angle of the canal, when the hand holding the probe must be turned upwards, so as to bring the point of the probe obliquely downwards and inwards, the lid at the same time being drawn with the hand which holds it, up- wards and outwards ; the probe may then be pressed down- wards, a little outwards and backwards in the direction of the nasal duct, till it strikes the floor of the nostril. If the probe is passed into the inferior punctum, it must be intro- duced perpendicularly from above, downwards ; the handle of the probe is then to be lowered to a horizontal position, then pushed into the sac ; when the point strikes the side of the nose it should be a little withdrawn to prevent its being entangled in the mucous membrane ; it may then be turned in the direction of the nasal duct, and the operation proceeded with as already described. If the nasal duct is found free, the surgeon, after withdraw- ing the probe, may use thj syringe by introducing its point into the punctum, in the same manner that he did the probe. The syringe being previously charged with tepid water, its piston should be slowly pressed down, when the water will be found to run down into the throat. But if the nasal duct is obstructed, the water will not run down, hut i main in, and distend the sac, when the surgeon must endeavour, by pressing on it with his finger, to force it down the nasal duct, and if this cannot be done, it must be regurgitated through the puncta. After the water passes down the duct, stimulating injections may be nsed in the same way, the best lotion being the saturated solution of the acetate of lead. Laforest recommend i probes to be introduced into the nasal duct from the nostril, and from the same part injections to be thrown into the sac. However, from the difficulty of intro- ducing a probe in this way, the practice is now abandoned. i-#!' OP THE EYE. 148 When all the above methods have failed, the only thing that remains to be done, is to make an opening into the sac, and dilate the duct by mechanical means. Different me- chanical means have been recommended, such as styles tubes, bougies. Ware recommended the style— Dupuy- tren, the tube-and Pott, the bougie ; in the present day the silver nail-headed style, of Ware, is what is generally nsed. Mr. Mackenzie, Dr. Jacob, (unless he has altered his opinion since I was a student under him,) and Mr. Lis- ten, all recommended it. As a general rule I give It the preference, but In young subjects I adhere to Beer's plan of treatment, which is as follows : There being an opening into the sac through the integu- m'>;its, either spontaneously formed or made by the knife of the surgeon, a piece of cat-gut, of the ordlaary length and ■size of a small fiddle-string, is passed through the duct into the nose, one extremity is brought out through the anterior nares, and fixed to the ala nasi by means of a piece of adhe- sive plaster, and the other secured to the eye-brow by a turn or two of a bandage. Every day a fresh portion of the cat-gut is drawn through the duct, until several sizes have been made to pass ; when the cure is considered com- plete, the gut is withdrawn, and the external opening allow- ed to heal. The only difference I have ever made in this mode of treatment, is, instead of forcing the obstructed duct m the first instance, with the cat-gut, I do it with the probe! and in addition to keeping the duct dilated with the cat-gut I syringe the duct every morning with warm water, and afterwards with a two or three grain solution of nitrate of silver ; as soon, however, as the discharge becomes healthy, 1 only drop the nitrate of silver solution into the internal canthus of the eye, and allow it to remain till it Is taken up by thepuncta. One great advantage from the cat-gut is that being put into the duct in a dry state, it very soon becomes moist, and swells to nearly double its orf^inal size, f H 144 PATHOLOQY and from being so soft cannot possibly injure the mucous membrane as much as a metallic style. Doctor Paraish, one of the surgeons to Wills' Hospital, revived the practice of Pott on an improved plan, which treatment he speaks of with confidence. He recommends, if there he a fistulous opening to have the inflammation surrounding it removed by means of emollient poultices ; then to introduce a small piece of wax bougie, having an acute point, down to tlie strictured part of the duct ; its blunt end is then to be secured to the forehead with a strip of adhesive plaster. In one or two days the bougie is to be removed, the parts washed out, and a similar bougie of a larger size to be inserted in the same way. He says by persevering in this plan, an ad- vance will be made from day to day upoa the strictured surface, until at length a bougie can be passed through the whole extent of the canal. This plan of dilatation should be continued until the bougie pass freely and until all hardness and inflammation have disappeared from around the fistulous orifice ; after this has been accomplished, the use of the bougie may be discontinued, and the external opening allow- ed to heal, which it usually does in a short time under sim- ple dressing. Ho recommends the urgeon to make the bougies himself, by dipping a piece of fine linen into white wax in a melted state, then suddenly withdrawing the linen and allowing it to cool : a strip is then to be cut off and roll- ed tight to whatever size the bougie may be required. He says his reasons for this mode of treatment are, that by this process the canal is gradually dilated, and its mucous sup- face restored to its natural condition, without doing violence to the parts, while the duct is placed in a state to resume its natural functions, without the necessity of permanent dilatation. He recommends, if there should be a disposition to relapse after the external orifice has healed, to endeavour to counteract it by the use of stimulating ointments applied to the inner* surface of the lids, or by astringent washes. I OP THE EYE. UG have used these bougies very frequently as a substitute for a Sliver style, when the latter has produced irritation, and have derived the greatest benefit Irura them ; I have not however, used them to relieve the stricture in the way re- commended above. When the surgeon is Hatisfied that he cannot remove the obstruction of the nasal duct without mechanical means, and he determines on using them, if there be not an opening already into the sac, he must make one, after which he is to discharge its contents, and wash it out; then taking a common probe, he is to direct it into the sac, in a horizontal position, till it strikes the nasal side of the sac ; the hand is then to be turned upwards, and the probe pushed down- wards and a little backwards and outwards, into the nasal duct till It enters the nose, below the inferior spongy bone If there be no stricture in the duct, the probe will slide easily into the nose, but sometimes it will require a steady pressure to be kept up for some time, in order to remove the stricture, and, more than once, I have found the probe ob- structed m Its passage, two or three different times. Indeed m some cases I have found it necessary to withdraw the probe, and pass a small bistoury down into the duct to reheye the stricture. After the duct is opened, the probe should be at once replaced by whatever mechanical means the surgeon intends to employ, but if the case is not such as heretofore mentioned, I would recommend the nail-head- ed style, it being first passed through a small piece of court- plaster, of suflScient size to cover the external wound, so as to prevent the head of the style from slipping into the sac and als to favor the healing of the external wound, so tha no part shall remain open except the space occupied by the style Every day for four or five days in succession, the style should be partially withdrawn, and the duct syringed out with warm water, after which an astringent lotion should be used. As those styles are made of either ,*.;■ m ,r, \ i '-.If?- 146 PATHOLOGY ?"W or silver, they will cuirode if the patient docs not take them out, and wash them clean, at least every second day ; after a little practice the patient will find it no trouble to r('^)lace the style. I have seen Dr. Jacob when performing this operation, instead of withdrawing the probe, and replac- ing it with a style, bend down the probe, and cut it off with a bono forceps, leaving in the duct a hooked head style. When a tube is used instead of a style its head is pushed under the skin, and the parts allowed to heal over it ; how- ever, after some time the tube acts as a foreign body, and the parts become inflamed, so that it has to be removed, which is sometimes very dilBcult to perform. Styles and tubes are of different lengths and thicknesses, the greatest length being one inch and a quarter, and the great- est thickness ^\jth of an inch. The use of the style is to con- duct the tears, when collected in the sac, into the nose, the tube is for the same purpose, although it carries the tears in a different way, but its good effect is often counteracted by the funnel becoming plugged up with mucus ; thus there are many reasons why the style should be preferred. Different modes of opening the sac to get a probe into the duct have been practised. Sir A. Cooper recommended that it should be done with a phyraosis knife, after which a blunt pointed bistoury is passed down into the duct, to remove the obstruction : other operators simply open the sac with a lancet, and then pass down the probe. Owing to the diflS- culty there is sometimes found in getting the probe into the sac, the late Mr. Liston recommended the opening to be made into the sac, with a narrow bistoury, which should at the same time be lodged in the canal ; and while withdraw- ing it, the probe to be passed down. The following are his words : — " Knowing the direction of the canal, you put your knife behind the margin of the bone ; behind the nasal process of the superior maxilla, push it down at once, and lodge it OP THE EYE. 147 fairly In the canal. In that way you are in a position to make the passages pervious. If you follow the knife with a probe, withdrawing the knife while you introduce the blunt instrument, you come at onee into the nose, and there will possibly be some slight How of blood from the nostril; If after a few days, you close the nostril and make the patient respire forcibly, the blood and ran., oi hi.! he thrown up into the corner of the eye, and then you ar.^ 'ire that you have properly effected your objec< » 'nwse /emarks of Mr. Listen refer to the case of a Nfulou- opening from the cheek to the sac, but I belies ihem equally applicable where there is no fistulous opening, and we want to get a style into the nasal duct ; and 1 must aay, of all other modes of performing this operation, that I have ever heard of, I consider Mr. LIston's the best, and always prac- tise it. Fistuh. Lachrymalis.— There are many cases of the two preceding diseases,— chronic and acute dacryocystitis, that do not come under the surgeon's notice until an abscess of the sac has formed and burst, leaving a fistulous communi- cation between the sac and the cheek. To this state of the disease, the term fistula lachrymalis is applied, and as it has been so often alluded to in the two preceding articles there remains but lUtle more to be said on the subject. In such a case the opening must be enlarged with the knife before any attempt is made to pass a probe into the duct • as soon as a style is inserted, a poultice should be applied to the parts, and renewed frequently for a few days, until the hardness round the edge of the fistulous opening disap- pears. If there is any other fistulous opening, it should be laid open, (if superficial) and allowed to heal by granulation which can be accomplished by simple dressing. But if the fistula be deeply seated, a probe should be passed into it and the end of the probe cut down upon so as to form' a counter opening, when the fistulous canal can be healed m 3l 148 PATHOLOGY by syringing it with a lotion of the nitrate of silver or vinura opii, either of which should be used daily ; poultices should be also applied until the hardness and swelling disappear, then a compress and bandage applied. There are some cases, where the style may be removed, and the extamal opening allowed to heal up after a few months, in other cases not for as many years, and others again where the style can never be dispensed with. But if at any time, the surgeon is satisfied of the effectiveness of the nasal duct, he may remove the style, and allow the opening to heal up. But if before using the style, there had been a fistulous opening from the sac to the external parts it may not very readily heal up after the style has been removed ; by touching it, however, from time to time with the nitrate of silver, the surgeon will generally succeed in getting it to heal, but if not, the edge of the orifice must be made raw with a lancet, and then drawn together with adhesive plaster, or if necessary a stitch. It not unnsually happens, that when there is a fistulous opening, if the surgeon passes a probe into it, he will find caries of the bones in connection with the canal : here au operation is of no use, and as to putting a style among a lot of rotten bones, it is worse than useless. In such a case he must attend particularly to the general health, and state of constitution, which will be generally found tainted with scrofula or syphilis, when such medicines as possess control over these cachcxiae must be given. In either case change of air will be found of great bene- fit. The local treatment muet be directed towards correct- ing the chronic blenorrhoeal discharge, repressing the ten- dency to fungus, and improving the condition of the bones. Injections of weak solutions of nitrate of silver will be the best local treats .at, and if a fungus should appear, it must be kept down by touching it occasionally with the pure nitrate of silver OF THE EXE. 149 When the surgeon is about to operate for fistula lachry- malis, or to remove an obstruction of the nasal duct by operation, there are some cautions to be observed,— First, he should be sure not to make the puncture anterior to the nasal process of the superior maxillary bone, instead of pos- terior to it : this may appear a very useless warning, but I have known it done more than once by surgeons who held no mean opinion of their acquirements, and moreover after making such a puncture, force a probe down between the muscles and the bone, and wonder why they could not feel the probe in the nose : of course, such treatment will always bo followed by severe inflammation and suppuration. The surgeon should take care not to cut the tendon of the orbi- cularis palpebrarum muscle, which, though easily seen in chronic dacryocystitis, cannot be felt at all, when the parts become swollen and inflamed, the state in which the surgeon generally sees it ; so he must depend upon his anatomical knowledge of the parts, as he may not be able to feel the edge of the orbit to guide him. He must also remember, that the parietes of the nasal fossa and duct are so thin, that if the knife or lancet which opens the sac be pushed hard against them, the bone will be broken ; even the probe, if directed too much backwards, will penetrate the aithmoid bone, and be lodged in the nose, above, instead of below the inferior spungy bone, and consequently it will not pass through the duct at all. The next and last thing for the sur- geon to attend to, is to have a style of a proper size ; it should not fit too tightly nor yet too loosely, but with exact- ness. In regulating its length the rule should be, that while the head merely appears at the corner of the eye, its point should approach, but on no account rest upon the floor of the nostril. The following case of acute inflammation setting in, where chronic dacryocystitis had existed for four years, I - it -I ill 150 PATHOLOGT consider interesting, from the fact of the ireatmeut of the acute inflammation having cured the original disease : October 2/, 1846.— R. P., Esq., aged 33, called upon me to treat him for disease of his eye. He told me that for four years he had been annoyed with water collecting in his eye, and that whe-i he pressed his finger on the side of his nose near the crraer of his eye, matter and tears used to gush out, and riearly blind him. That four days previous to the time I saw him, he found a small hard tumour form, where he used to press his finger, since which time he said that he suffered most agonizing pain in the whole side of his face and head. He was travelling all the night, previous to his calling on me. When I saw him the tumour fluctuated, the whole of the lower lid was swollen and purple, the side of the cheek presenting an erysipelatous, appearance. — In three days afterwards he was perfectly well, and the old disease completely removed. The following mode of treat- ment was adopted in this case : — I made a free opening with a lancet into the sac, and discharged a great quantity of muco-purulent matter. I then passed a piece of cat-gut down the nasal duct, which I again withdrew, and washed the sao and duct out with a syringe and warm water : I then applied a warm poultice all over the part, first putting a tent into the wound to keep it open. The next day the swelling had entirely disappeared, and the small quantity of matter secreted proved quite healthy : I removed the tent, and dressed the part with a little simple dressing ; on the third day the wound was healed, after which all went on well. Mucocele of the Sac, {or the Ht/dropa Saed Lachrymalisof Beer.) — This disease is a tuihourof the lachrymal sac, caused by the sac, becoming distended with mucus, which mucus is secreted from its lining membrane, and kept pent up in the sack by the obstruction of the lachrymal canals and nasal duct. In such cases the sac cannot be emptied OF THE EYE. 161 by the strongest pressure, which circumstance, together with the hardness and purplish color of the swelling, form the characteristic symptoms of the disease. This tumour sometimes becomes as large as a pigeon's egg, but there is no pain felt until it appears as if about to burst, which it is not likely to do for years. The disease, .. ^m its com- mencement, is accompanied with stillicidium lacbrymarium. Treatment.— A free incision must be made into the tu- mour, and the sac laid open, out of which the collected mucus is to be removed, which is sometimes so inspissated as to resist water and a syringe, and will require to be re- moved by a forceps ; the nasal and lachrymal ducts should be then examined, and, if found obstructed, their impeding matter to be gradually removed, until they are found to con- vey the tears. The wound in the sac should be prevented from healing, by a tent being kept in it. If when the sac is opened, it is found greatly enlarged, a part of it should be excised with the scissors ; when the tears are found to run into their proper channel, the external wound may be allowed to heal. Relaxation of the Sac, {Hernia Sacci LachTymalis of Beer.)— In this case there is also a tumour at the corner of the eye, or side of the nose, of about the size of a horse beiTi, or less ; the color of the integuments covering it is natural ; it is soft, and yields to pressure, while its contents are readily discharged through the puncta or nasal duct. This tumour is formed by the relaxation of the sac, which from having been over distended with either pus or puri- form mucus, loses its contracting power and elasticity. The sac sometimes becomes ruptured, and when this happens the skin covering it is folded round the parts, and has a flabby appearance. Treatment. — Beer found these cases curable by compres- sion of the sac ; the application, however, of stimulating and astringent fluids to the Internal part of it and also to the integuments covering it, does much towards hastening a ,:■! mi\ 102 PATHOLOGY cure. Many astringents might be mentioned, some an- swering better in one case than in another : but perhaps, as a general rule, there is none better than the saturated solu- tion of acetate of lead ; which may be dropped into the in- ternal canthus of the eye once or twice a day, and allowed to remain there, with the patient's head thrown back for five or ten minutes, until the puncta have time to absorb it. The same lotion diluted, may be applied to the integuments covering tae tumour. The surgeon must use his own in- genuity as to the means he will employ in exertinK' pressure upon the tumour; the mode recommended by i .. ft\ackenzie, is one of the best, and has the advantage of bemg very sim- ple, and is easily applied. The following quotation will explain it : — " Graduated compresses then are to be prefer- red : over these a firm leather pad of a proper form is to be placed, and the whole is to bi supported by a narrow roller passing round the head." Polypus of the iSlac.— Where a polypus forms in the lachry- mal sac, the nature of the tumour cannot be known until the sac is opened. The cure will be completely effected, after it is discovered, by taking hi of the growth with a pair of hooked forceps, and twisting iv out. Calculi in the Excreting Lachrymal Parages. — When calcareous deposits are found in either the lachrymal or nasal ducts they should be removed. The constitutional treat- ment will be the same as that recommended in the pre- ceding chapter, under the head of " Lachrymal Calculus." Obstruction of the Puncta Lachrymalia and Canals. — One particular symptom of these parts being obstructed, is, of course, stillicidum lachrymarum. As there are different causes, so there are different modes of treatment. If there b e congenital abscess of these parts, the case is incurable ;* ♦ The followine statement is made in the Dublin Quarterly Journal o* Medical Science for May 1848. " A case of the congenital absence of *" :. four puncta in a barrister in Paris, aged 25, has been related by { Blanchet, who has succeeded in establishing a punctum in communicat •>> with the Ischrymsl duet upon fhe right side-.— •GozcWc Medicals jo: u il/ay, 1847. r o j OP THE EYE. 158 if the puncta and canals are closed by adhesion, as the re- sult of inflammation, it will be equally so. If the cause has been a wound of the duct which has not united so as to leave the canal pervious, it will also be incnrablo. If the puncta and canals be simply stopped up with n^ucus, one of Anel's probes will easily remove the obstruction, after which may be dropped into tho puncta, twice a day, a solu- tion of tho nitr *te of silver. If only a small part of the duct be obstructed by adhesion, the probe may be pushed through it, and the obstruction, will be thus removed, after which the probe should be passed daily for some time into the duct, it being previously smeared with any mild oint- ment ; tumefaction of the mucous membrane lining the canal may obstruct the passage, nevertheless as the tumefac- tion is only a symptom of the inflammation, it must be obvious that by subduing the latter the obstruction will be removed. Rehxatton of the Puncta and Canals. — In this disease the puncta are wide open, and do not contract when touched, as in the healthy state : as some of the tears find their way into their natural channel, there is only partial dryness of the nostril, and partial stillicidum lachrymarum. The puncta being turned out, do not touch the eye-ball. Causes. — Erysipelatous inflammation of the eye-lids or any of the purulent ophthalmias may cause this disease. Treatment. — Stimulating lotions dropped into the internal canthus of the eye once or twice a day ; Beer recommends a solution of the sulphate of iron, to which a small quantity of camphorated spirit or tincture of opium has been ad^ J. There is nothing preferable to the vinura opii. Injuries of the Excreting Lachrymal Organs. — These parts are exposed to every species of mechanical and chemical injuries : wounds of them may be either incised or lacerated. The puncta, in unskilful hands, are constantly being split, by the use of Anel's probes. Loose eve-iashes have been fM 154 PATHOLOQY OF THE EYE. ,V known to get into the puncta. The sequel of lacenised wounds in those parts are iuflansmation and suppuration, terminating in adhesion of the cansls. When one of the canals is cut across by an incised wo.mA, it is v. - v ^lifficult to heal it so as to prevent obstruction. The most approved method IS to keep a bristle in the canal during the hv;„lint of the wound. Every effort should be made to heal it by the first intention. Tho sac may he opened by an incised or laeu- rated wound ; h di, Jn^rcase care must be taken lest in healing It should degener..... Into a fistuloii. opening. Mr. Macken- zie says « a blow over ! lie sac will sometimes rupture it without the skin beir,? uivMed, md emphysema of the eye- lid will en.ue on blowing the nose." Severe blows may break the bones of the nose, and obliterate the nasal canal. Ithmk in such a case, it would not be bad practice to open the sac, and keep a style in the canal until the parts heal. A short time since, I operated upon a boy for chronic dacryocystitis^ when I had got the probe about half-way down the canal, I found the remair'-^g part so completely obhterated, that I was compelled to _iill a hole through it • I afterwards learned that five years before, the boy had his' nose broken by the kick of a horse, from which time the tears used to run over his cheek. When any affection of the lachrymal organs renders it necessary to use a stimulating lotion, I usually prefer the saturated solution of the acetate of lead, or that recommend- ed by Beer, which is made as follows :— 3^ Subacetatis cupri, potassae nitratis, aluminis aa gr iii-vi,camphorffitrit«grii-iv,aqu« distillate gss; solve et cola : liquori colato adde vini opii 3i-5ii ; aquae rosae giv M Professor Beer made a mass of the three first articles melted together in equal proportions, which he terms the lapis dwjnus. Of this mass, he made the lotion, and then added the other ingredients. When stimulating ointments are required, I prefer Jan. , either diluted or of fui. strength to any other ointm^ CHAPTER XIV. l")} JURIES AND DISEASES OF THE MUSCLES OF THE EYE-BALL. Injuries. — The muscles of the eye-ball, from their posi- tion, are not very liable to be injured, indeed they cannot suffer without other parts being implicated. To discover if one of the muscles of the eye-ball be wounded or lacerated, is a very diflBcult matter, but the diagnosis is here of little consequence, since the treatment will be the same as that pursued in injury done to any other parts within the orbit, viz :— soothing applications to the part, and general anti- phlogistic treatment. Paralysis of the Muscles of the Eye. — That the six muscles of the eye-ball may be paralyzed at one and the same time, is by no means an impossible occurrence. But such cases must be very rare, as I have never read of any one seeing it, except Sir. C. Bell, who only witnessed it once. In such a case there is paralysis of the nerves that supply them with motor power, viz :— the third, fourth and sixth. The eye will be fixed, motionless, and in some degree protru- ded ; it is very prpbablc that the iris will also be motionless and dilated, causing partial amaurosis. And it is equally probable, that the same cause which produces paralysis of those parts, will also operate similarly upon the fifth and optic nerves ; we may also expect that the constitutional symptoms will be, derangement of the bowels and stomach, with vertigo. Causes. — I know of no causes that could produce such an effect, except some disordered state of the brain, or some tumour growing in the back of the orbit. Treatment. — If a tumour should exist in the orbit it must be removed ; if there be not, I would recommend the treat- ment to be directed to the brain. 169 PATHOLOaY 8trahsmus.-By the term strabismus, or squint, is meant, that distorted state of one or both eyes, in which the axis of vision is displaced by the involuntary diverging or converging of one or both eyes. If the eye be turned in- wards It IS called convergent strabismus; if outwards, diverg- ent strabismus. Much has been written upon this subject since the years 1838 and 1839, the period at which the operation for its cure came so much into vogue. This opera- tion IS called myotomy or tenotomy. Stromeyer was the first to recommend it, but it was Diffenbach who proved its advantages. In the year 1841, 1 first saw the operation performed bv my friend Dr. Wilde of Dublin, who is now an occulist of noted repute for his tact, judgment, and skill in that branch 01 the profession. It was he who kindly provided me with the requisite instruments for performing the operation when 1 was about to leave Ireland. %mptoms.— In all cases of strabismus, both eyes are more or less affected, although the deformity of one is usually so conspicuous as to cause no notice to be taken of the other. A person with strabismus always looks at oIh jects with but one eye at a time. If one eye is much worse than the other, the person when reading will hold the book m the usual position before both : but he uses at the same time only the best eye, and leaves the other idle. But if both eyes are similarly affected, the book will be held to one side and the patient will read with the eye farthest removed from the page on the opposite side, that is if the strabismus be convergent. But if it is divergent strabismus, then the eye that is used is that on the side *he book is held on,— that is to say, if a person with convergent strabismus,' of both eyes, reads with the right eye, he holds the book to the left side, and if with the left eye to the right side: but in divergent strabismus the book is held on the same side as the eye with which he reads. OP THE EYE. 157 If in strabismus the best eye be hoodwinked, then the bad eye becomes straight, but the patient finds that it id wealc, and that he cannot see objects with it as well as with the other eye : if the blind bo removed, and the good eye suddenly exposed, it will be seen to be very crooked, but it soon acquires its usual position, and the other becomes again distorted. Convergent strabismus is more frequent than divergent— I have found the average to be about six cases in ten. In all cases of strabismus the person afflicted has defective sight to a greater or less extent. Causes. — The direct causes for strabismus, or squint, are only two, viz. :— contraction of the rectus muscle on the side to which the eye is turned, or paralysis of the opposite rectus (Luscitas.) The remote causes are many. When the disease occurs in childhood, which it generally does, I think that, as a general rule, what first takes place is luscitas or pa- ralysis of one of the muscles, then its antagonist draws the eye over, and although the paralysed muscle may in time recover its tone, still it does not regain sufficient strength to restore the eye to its natural position, against the here- tofore unopposed action of its healthy antagonist. In this state of things years pass over, and although the paralysed mus- cle may have regained its full power, still the other having been so long permanently contracted, continues so. Again, the cause at the first, may be spasm of the muscle on the side to which the eye is turned, which keeps the fibres of its antagonist so much upon the stretch as to deprive it of its full power of contraction, even after the spasmodic state of the muscle has ceased to exist. The remote causes are intestinal and cerebral derange- ment, produced by teething, indigestible food, worms, &c. Habit is another caust ;■ imicking others; constantly look- ing at a speck, such a. a mole or wart on the side of the Bose, or a curl of hair hanging at the side of the eye, are !*:| 158 PATHOLOGY not unusual causes. Ti, ihis way one muscle beinfr employ- ed more than its antafronist, becomes more powerful, accord- ing to ii well known physiological law, and retains it by becoming contracted. In the same way it i,i.uu ou in children who, ufTcrlng from scrofulous ophthalmia, acquire the habit of lodking side-ways. An opacity of the cornea in the axis of vision, paralysis of the retina in the axis of vision, or ar irtificial pupil in the side of the iris; any of these will act as a cause ; for the person habitually turning the eye nside, and thus from habit, the muscle at length becomes contracted. Diagmsls. — It does not require a man to be a surgeon to ascertain that a perjun squints, and whether the squint is conv£rgent or divergent, but it is not alwaj's so easy to know the actual cause of the disease : "n other words to diagnose between true strabismus and luscitas. The best way to discriminate between these two varieties of the disease is as follows : — If, for example, in a case of convergent stra- bismus, when the better eye is shut, the patient exercises no power over the external rectus in drawing the eye outwards, but when told to do so turns it upwaru;^ and downwards, then the surgeon may be pretty well satisfied that the cr.se is paralysis of the external rectus ; if. on the ontrary, he can draw the eye partially 'ward., but not mpletely ; o, then he may conclude that there is contraction of the inter- niil rectus. If the patient, under the above circumstances, shows that he has full power .-^er i,he weaker e'o,, then the probability is, that it is dependent upon some affection of the retina, except there be an opacity of the corrr , ^. arti- ficial pupil, which will at once lead to the f ause. ProgTwsis. — There are so many remote sep to produce strabismus, that a prognosis must alw s be autiously given. However, if the surgeon be perfec ly conviiiced that he '■<-x^ nothing to contend with, but a contraction of the muscle, he is justified in promising that, if all other treat- *<1 OP THE EYE. 109 rnents fail, the opcriition of myotomy will prove success- ful. But at the same time the patient should be informed that after one eye has been operated upon, it is possible the other may require the same treatment. Treatment. — The treatment will depend upon both the direct and remote causes. If the direct cause be contraction of the muscle from habit, let the habit, if possible, be interrupt- ed ; for instance, if it arise from an opacity of the cornea, or paralysis of a part of the retina, let these 1 emoved, and the strabismus will soon disappear ; if from artificial pupil on the sic. ■ of the iris, the case should not Be interfered with. If an operation be attempted where there is either opacity of the cornea, paralysis of a part of the retina, or artificial pupil in the side of the iris, matters are made much worse, but fornmately the operation cannot succeed, for if it did, it would dfirive the patient of the only source of vision he possesse •rabisums in such cases, being the work of nature to give the patient all the light possible. When in a child, the case is se<' , at tho early stage, and that it is a simple spasmodic jntractio' of the muscle, caused by visceral de- rangement, the curf 'I most probably follow removal of the intestinal irritation. . lave had manycases of children from three to five years old, who liad strabismus, of from four to eighteen mutiths standing, and who got quite well after a few emetics of ipecacuanha, followed by a couple of smart purges of rhubarb and soda. When strabismus ul this character has lasted a few years, I have found much benefit from fumigatingthe eye with camphor, blisteringijefore and behind the ears, dry cupping on the nape of the neck, and making the child wear goggles, the glass of which should be covered with a piece of card, having a very small hole in the centre of it, so that the child could not see except by looking through the hole. If the cause of convergent strabismus be any h.ark on the nose, it may be in some degree counter- acted by placing something at the external side of the eye U**^? 160 PATHOLOQY to attract its attention ; a curl of hair may answer this pur- pose. Wlicn a shocic or fright produces sudden strabismus, the whole nervous system will bn found deranged, and must be treated accordingly. If strabismus be of long standing, and the direct cause is a contraction of the muscle, and if none of the objections already mentioned exist, the treatment from which any benefit is to be derived consists in dividing the muscle. Operation. — Since division of the muscle for the cure of strabismus has been first described, many surgeons have performed the operation, and for the want of success in the majority of cases, it has in some degree fallen into disrepute, and many have endeavoured to find out the cause of so many failures. M. Bonnet, a French surgeon, and Dr. Fer- rall of Dublin, considered that the want of success was in consequence of the muscle not being separated from the tunica vaginalis oculi. The following statement is made by Dr. Lucas : — " Not- withstanding that the muscle be divided in the most satis- factory manner, and even a portion of it cut away, the eye in many cases will be found still inverted. I have ascer- tained beyond all doubt that this inversion is owing to the condition of the sub-muscular and snb-conjunctival fasciae. When the inner rectus muscle is fairly divided the mark of its semicircular insertion, with minute fuzzy-tendinous fibres adhering to it, are as plainly discernible to the naked eye as the scissors with which the operation is performed ; the inversion of the eye, therefore, cannot in such cases be owing to the inner rectus muscle ; but if the sub-muscular and sub-conjunctival fascia be examined, they will be found strong and dense : and upon freely dividing them, both upwards and downwards, with a forceps and a pair of scis- sors, the eye in most cases will become perfectly straight, — I say in most cases, because it sometimes happens that these fasciae are intimately adherent to the sclerotic coat, for its OP THE ETE. 161 inner extent, and the operator will be obliged to dissect them from it, leaving the sclerotic coat completely bare." The Medical Gazette for July 24th, 1840, page 689, relates that Dr. Frariy found it necessary in some cases to divide the tendon of the superior oblique, as vyell as that of the internal rectus ; it has been reported, but I do not know with what truth, that Mr. Liston found it necessary to divide the inferior rectus eithercompletely or partially, wheo he found the eye still retaining an obliquity inwards, after the division of the internal rectus. Now I cannot conceive what benefit could be derived in such a case, by dividing the inferior rectus ; and as to cutting the superior oblique I consider the cure much worse than the disease. I am of opinion that there are six causes, any of which may prevent the operation from being successful. 1. The muscle being merely cut across, instead of a piece being taken out in the act of dividing it, it unites again and the disease returns. 2. When the disease, in the first instance, has been caused by paralysis of one of the muscles, which having in some degree recovered its tone is not yet sufficiently strong to keep the eye straight, after it» antagonist has been divided. 3. When the eye is not turned from contraction of the muscle, but from some other cause. 4. When both eyes are affected, and one only is operated upon. 5. When the case is not strabismus, but luscitas. And, 6. (The most common cause). Whi n the whole of the fibres of the muscle are not divided, and the muscle is not separated from the sclerotica. DiflFerent men have performed this operation of myotomy in diflferent ways, all of which appear to me to be equally good, the same object being present to all, viz :~ the divi- sion of the muscle, the cutting a piece of it out, und ^para- ting it from the sclerotic coat. The following is the manner in which I saw Dr. Wilde perform it, since when I have continued to doit in the same *i" ll' II & 'h 162 PATHOLO0T way, and I have hitherto found no occasion to make any change — the number of instruments required are seven, viz :— a pair of small curved' scissors, a small toothed for- ceps, two blunt hooks, one small sharp hook, two specula, one for the upper and the other for the lower lid ; the two instruments last mentioned are not necessary if the assis- tant be steady and intelligent, as his fingers, in that case, are even super '->r to the specula. To perform the operation, two assistants are required. The patient being seated, one of the assistants stand? behind him, for the purpose of rais- ing the upper and depressing the lower lids ; he should also support the patient's head against his chest, if it be not previously supported by a proper operating chair. The patient's better eye being hoodwinked ; the upper lid is raised and the lower depressed by one assistant ; if the muscle to be cut: is the internal rectus, the patient must be directed to turn 'iis eye outward as much as possible, when the surgeon holding the sharp hook in his hand must suddenly hook the eye-ball at the internal canthus, about the fourth of aa inch from the internal edgQ of the cornea ; the hook is intended to pierce through the conjunctiva, and tunica tendinea ; with this instrument the eye-ball is to be drawn towards the external angle, and the hook given into the hands of the second assistant, with directions to keep the eye fixed in thftt position: now the operator, holding the forceps in his left hand, lays hold, of the conjunctiva tians^ wersely;, about half way between the edge of the cornea and the caruncula, and raises it in a horizontal fold, then with the scissors, whichi he holds in hisrighthand, he cuts through this fold of conjunctiva,, vertically, and then enlai^s the inoisioni upwards and downwards, 30 that the incision will be ab«^t) half an inch in length. (Here there may be a little bleeding, which will stop in aifew minutes by sponging the: wound.), Tlhfroperator will thenj with the largest of the blnnt hooks dissect through the cellular ti^ue, till he reaches the OP th6 ey6. 1-63 lower edge of the tendon of the musclej and then slide up the hook between the muscle and the sclerotica, till it appears at the superior edge of the muscle, where if the cellular tissue prevents the point of the hook from coming through, it may- be freed by a snip of the scissors. The operator having the muscle on the hook, holds the eye completely under his control, so he should at once remove the sharp hook and dispense with the second assistant. At this stage of* the operation some surgeons take hold of the handle of the blunt hook, which has the muscle on it', in their hand, and direct it across the eye towards the external angle, then with one stroke of the scissors divide the niuscle, by put- ting one blade of the scissors under the muscle, the con- vexity of the hook acting as a director to it; but other surgeons prefer, before dividing the muscle, to pass another blunt hook under it, whose arch being narrower collects all the fibres of the muscle together into a small space ; the riioscle is then put a little on the stretch, being well dfetached from the sclerotica, and with a pair of curved scissors; it is cut from under the hook, so as to remove that piece of it which is foand lying in the convexity of the hook. Thus the operation is performed, after which the patient's head may be released, and the bandage taken from the other eye, when if' both eyes are found to have their a:tes perfect', a- is well, but if the otber eye is found converged the sooner it' is operated upon the' better: If immediately after the operatibn, however; the eyei is not found to cbrae straight at oiice, tlie operator is riot to be discouraged, for it often takeS a feW days for the antagonist muscle, to the orie cftt, to recover its toiie. The reader riiiist' at oiice perceive, that' tlie remarks mad6' on conveigeHi strabismus, are, With few exceptions; equally applicable to tHe divergent form ; some consider cutting the external muscle the more difficult operatioOj in consequence of the narrow sjiace existing between the eyelids at the 164 PATHOLOGY external angle, and also on account of the insertion of the external rectus being farther removed from the cornea, than that of the internal rectus. I, however, consider these diffi- culties more imaginary than real. If the patient is a child, the operiitor will find great ad- vantage from having it rolled in a sneet, and laying on its back. AJkr-Treatment.—GeneTa.ny speaking, fl-ere is very little danger of inflammation, so that after the operation is per- formed the person may resume his ordinary business. If inflammation should set in, it must be treated on general principles ; should any fungus growth make its appearance, It should be kept down by occasionally touching it with the nitrate of silver. Some recommend after the operation, the edges of the wound in the conjunctiva being brought toge- ther with sutures ; I cannot sanction this practice. ZrMsci'to.— By this term is meant distortion of one or both eyes from paralysis of one of the recti muscles, the conse- quence of which is that the eye is turned over by the an- tagonist muscle, as in strabismus. In the article on strabis- mus, the diagnostic symptoms by which to distinguish between it and luscitas, vvere given, therefore they shall not be here enumerated. Luscitas generally occurs suddenly, and is nearly always accompanied with a disordered state of the system ; indeed it should be looked upon more as a symptom of a disease, than as a disease in itself. Causes. — There are many causes to produce this disease, such as chronic or acute aff'ections of the brain, and tumours in the orbit ; gastric or intestinal derangement is a very general cause, particularly in producing paralysis of the ex- ternal rectus, which is the most frequent, in consequence of the union between the sixth nerve and the sympathetic. Frojnosis.~Th\s must altogether depend upon the cause. Treatment.— The treatment must be directed to the cause ; after the removal of which if the muscle remains in a palsied OF THE EYE. 165 state, n 'hing will be found of such benefit as electricity, either in the ordinary way of insulating and drawing sparks, or the electro-magnetic currents. Blistering the temples, and brushing the raw surface with the solution of veratria, is often useful. The following case will be found interest- ing :— January 9, 1847— Mrs. Hooly, oet. 36, a poor woman, presented herself at the Montreal Eye and Ear Institution ; she had convergent strabismus of both eyes, and could not see the light with the right, but had suflBcient sight in the left to make her way through the streets ; she told me that three weeks previously her eyes became suddenly turned, and that she partially lost her sight, which continued to get worse every day since, although from the beginning she was under the care of Dr. . On further enquiry, I found that she had been severely blistered on the nape of the neck. Her countenance wore a haggard expression, and her tongue was furred. She had suflFered, she said, from a foul stomach for many years. On examining her eyes, I found that the pupils were fixed and dilated, and the left eye not quite so much converged as the right ; conceiving that the pri- mary cause existed in the stomach and intestines, I gave her an emetic to be taken immediately, and a purgative powder, to be taken at night, composed of calomel and rhubarb. The next morning, when she came to the Insti- tutiun, her left eye was perfectly straight, and the sight of it restored ; the right was a little improved ; I gave her another emetic to be taken at once, and I ordered her to take a teacupful of the following mixture three times a day, and to return to me when it was finished :— IJ. supertart. potass gss tart. ant. gr. i aquas bullientis, lb. ies On the third day following, this woman returned to me quite cured, her sight being perfect, and having full power — r ,.{ft vo.ujiiary niotions of ucr eyes. m m I li h'A X^ PATHOLOGY Oscillation of the Ih/e-BalL— By this term is meant a constant rapid involuntary motion of the eye, which ap- pears to be rotary, but which is in reality lateral, with an upward and downward action, caused by the contractions of the recti muscles following each other in rapid succession, these muscles at the time acting involuntarily, the will hav- ing no power over them. The patients are unconscious of this motion of the eye, but they sometimes complain of an apparent unsteadiness of objects. It is generally attended with short-sightedness, and sometimes a tremulous iris; during sleep the eyes are at rest. Cow^es.— Congenitajl cataract is always accompanied with oscillation ; amaurosis, either partial or complete, is some- times a cause; scrofulous inflammation of the eye-ball sometimes produces it ; fatiguing employment of the sight is another cau^e, and it is sometimes symptomatic of cere- bral derangement. Treatment.— If the cause be congenital cataract, the sooner the cataract is removed the better, for no matter how soon this is done it will take some time before the oscilla- tion ceases : but if the operation be delayed, the oscillation will become incurable. When the cause is injudicious use of the sight, rest, with tonic medicines will be requisite, in fact in every case attention must be directed to the cause, but at all times it is a disease for which little can be done, no matter from what it may arise. Cawe.— February 16, 1846.— Bridget Fitzgibbon, cet. 14. Blind of both eyes for 13 years, could not discover light from darkness, although the pupils contracted by the stimu- lus of light; she had oscillation of both eyes, but was not aware that they moved. Her parents informed me, that when she was one year old, she took a fit of screeching when in the cradle, thai her eyes commenced immediately to roll, and that since that time, she had never shewn any symptoms of sight. OF THE EOTC. m I treated the I '''' '"^^^ P— on the pr^ apsed iris, then suddenly exposed the pupil to a strong ^ght, when it contracted, and the iris and choroid coa^ ther he edges of the wound in the lid, with strins of adhesive plaster, and covered the whole ^irh a compress and bandage; I dressed the right lid in the same wa> and then ordered h m to bed, with directions to lie as mJih as possible upon his back. I gave him a good purge ocalo me and jalap, which was followed up by nauseadng do es than r '°'"'"^- ^""''^ ^«« "0 ^ore inflamVaZ than was necessary for producing adhesion. OP THE ETE. 178 ^^If^onous InflamrnaHon of the Eye-lids.-lhh doHcrip- on inflammation more frequently att.rks the unner than the lower eye-lid. The evils likely to arise Tom neglect, or improper treatment, are shortening of the lid and ectropium. ^ "'^ "" ^i.m^^ >^ ^1. ^^ l/u ^ 174 PATHOLOGY cuated with a lancet. The opening ought to be made parallel to the folds of the skin, after which, the poultice should be continued until the swelling subsides, and the discharge ceases ; then a little simple dressing finishes the cure. • I have treated numerous cases of this description, not one of which ever terminated badly, which I attrifcate to having always evacuated the matter, the moment I dis- covered fluctuation. Erysipelatous Inflammation of the Eye-lids. — It is very seldom that the eye-lids alone are the seat of this disease, but when such inflammation attacks the face, it generally spreads into the eye-lids. Symptffm8.—t\\Q local symptoms of this form of inflam- mation, when situated in the eye-lids, are the same as would be presented in any other part of the body. The lids become so swollen, that they cannot be separated, their color varies from a pale to a deep livid red hue ; this color momentarily disappears, if pressure with the finger be made on the part, but it returns immediately after the pressure is removed ;. the pain is of a burning, stinging, kind; very frequently serous effusion talces place under the cuticle, forming vesicles that burst and discharge the serum, which hardens into a crust over the part ; this crust eventually falls off and leaves the skin in a sound state ; and the swelling at the same time subsiding, the disease is removed. This is the most favourable termination the disease can take, but unfortunately it too often takes a worse form, namely, suppuration, with slbugbing of the cellular membrane ; the same local symptoms will then be present, as have been described in the last article, headed' " Phlegmonous Inflammation," the only difference being, tHat in this disease, the color of the integuments is of a more livid hue, and fluctuation is not so distinct, the matter is not, as in phlegmon, bound by a sphere of adhesive inflam- mation, but sprcids in different direction!?., producing j;.!: OP -rHB EYE. ff$ sloughs of the cellolar membrane. Instead of pointing in one spot, and bursting as a phlegmon does, there are one or more points of the integuments, which give way, through which disorganised cellular membrane will be discharged, or may be extracted ; this is the sort of case which gene- rally leaves the lids so altered, that it is long, if ever, before they recover their natural state. In these cases, the excreting lachrymal organs, meibomian follicles, and con- junctiva, always suffer more or l6ss ; the internal canthus of the eye is generally found every morning filled with puro-mncous secretioni Impediments to the absorption of tears, and slight accumulation of mucus in the lachrymal sac, constantly take place ; and in very severe cases, the diffiised suppuration will sometimes penetrate even the lachrymal sac, producing such destruction in it and the lachrymal canalSj as ever after to rendfer them unfit to carry on their functions. Cases have been known, where death was the result of erysipelatous inflammation spread- ing from the eyelids to the cellular membrane of the orbit. Gonstttuttonal Symptoms. — The constitntional symptomsf are rigors, followed by febrile irritation, the tongue ig loaded, and the digestive organs deranged. When the case terminates fatally, death is generally preceded by delirium. Causes. — The local causes are blows, wounds, stings of insects, sudden alternation of heat and cold, &c. When' there is no local injury, the cause is generally obscure ; it' may be owing to some peculiar state of the atmosphere, (MP to conta^on. Treatrmnt—lhe general treatment consists' in, firs^*-- emptying the stomach and bowels^ with an emeto-cathw- tic; after which gentle diaphoretics and naoseatlng doses of tartarised antimony are to be employed ; some recommend' blbod-Jettlng, but' it shonld never be practised, unless the" patient is strong and' robust ; and soch are rmtly the sub^- jects of this disease. Rest, quietness and a low unstlmu- lating diet should be rigidly observed. if il ' (i. 176 PATHOLOGY m: Local Treatment.— mmerona local applications have been recommended in this disease ; from my own expe- rience, I cannot sa)- much in favour of any of them ; I give the preference, however, to the mild soothing appli- cations. French wadding is the substance I generally use for this purpose; it encourages moisture on the part, which always gives relief, and if bullae form it acts as it does in scalds. Some recommend cold evaporating lotions, some painting the part with tincture of iodine, some laud the powers of nitrate of silver; others puncture the parts with a lancet, and others again recommend making deep scari- fications. A deep incision through the integuments and subcuta- neous cellular tissue, may sometimes prevent suppuration from setting in; at all events such an incision is most bene- ficial where matter is actually formed, after which warm poultices should be applied ; should the symptoms indicate that matter is formed in the orbit, it should be evacuated without delay; should chronic dacryocystitis continue, it must be treated according tothe instructions contained in Chapter XIII. The inordinate secretion of mucus may be prevented during the treatment, hy dropping once or twice a day upon the conjunctiva, the four or five grain solution of the nitrate of silver. When persons have died of this disease, post mortem examinations have shown, in some cases, the veins in connection with the scalp, eye, eye-lids &c., to be full of pus. ' Carbuncle or Anthrax of the Hye-h'ds.—The eye-lid sometimes becomes the seat of anthrax. The symptoms are heat, violent pain, and a pimple is formed which is at- tended with great itching ; below this pimple a hard cir- cumscribed tumour can be felt, which soon assumes a dark red or purple color at its centre, but which is pale towards its edge ; there next appears a blister upon its apex, which breaks and discharges a thin brown serous fluid. 'e OP THE EYE. 177 UluZT disease most frequently occurs in old de- blitated persons whose health has been broken by volu^ tuoushving I the patient be not an old person he is u^ to possess a bad, weak, and irritable consUtuUon. Exan he matous fevers, such as measles, small pox, &c, act t exciting causes. ' ' ' ^ Treatn^.-Th, local treatment consists in making «, early and free incision into the tumour, so that the mft^ and sloughs may readily escape, as much as possible^ which should be at once pressed out ; the part is^en n b^ covered With a warm emollient poultice, wll^ ,Cm^ enewed every six or seven hours, until ill the sloughs ar^ ca t off, and the surface of the cavity appears red and '^ nulatmg when it may be dressed with any mild uniJritaE ointment, spread upon lint, over which a ^ZT2 bandage may be applied. compress and The constitutional treatraejit should be of a tonic kind such as quinine ami the aromatic sulphuric and a S' wine will be found necessaiy, and when Te »!' ., g^at,opium will he usefu^both as^L'JSvnXil^^ be the seat of either primary orlecondary s^S JT Sr; •?'.". ''." ''^^^ «"* *«a(*s the eJ^rof^- bds, It IS hardly distinguishable from ophthalmif tarsi ^ S PiP^^""-"""' ^»t "« true character soon de We« tsef, liie destructive process being generally very^r ^IZ ^r.l '''.?«'' ''^ ««°J«»«^'^- altoge 7er. The' part of be lul that I have most frequently found aff^ ed is the conjunc iva; I do not remember ever having wUnWd a case of primary syphilitic ulceration of the eye-irds^J have seen a few of the secondary. ' ' Diaffnom.~The history of the case will generallv ^iv. a clue to the surgeon. Its true nature may b'eTmfsfdTf the orduvary treatment for ophthalmia tar J failsTa;'!- M ;i 178 PATHOLOGY ing the progress ol the disease. Generally speaking, syphilitic eruptions or ulcerations are present on other parts of the body; indeed this affection of the eye is almost always accompanied with either chancre, sore throat, or some other unmistakeable syphilitic symptoms. Causes.— When the ulcers are primary they owe their origin to direct contagion. The virus is usually communi- cated by the patient himself, who, perhaps, rubs his eyes after having recently handled a chancre. A child may get it during parturition if the mother is affected; it is then generally found to make its appearance two or three weeks after birth, when the infant's organs of generation and its arras will generally be the parts tainted. Treatment.— U the ulcers be primary they may be got to heal by the application of the nitrate of silver, either in substance or in solution, followed by solutions of either the sulphate of copper or zinc ; whether the case be primary or secondary, this is the best local treatment. The constitu- tional treatment consists in the administration of either calomol and opium, the ioduretted iodide of potassium, or turpentine; most cases yield to mercury, but I have succeeded in a few with turpentine, where the ulcers were on the inner part of the upper eye-lid, and about the size of a threepenny bit ; in two of the cases there were vascular nebula. If the patient be an infant, great caution should be used in administering the calomel and opium ; one grain of the former with the one-twelfth of a grain of the latter may be given twice a day ; and the best local treatment will be tepid ablutions, and brushing the edges of the lids with a weak solution of the nitrate of sil- ver, or smearing them at night with a mild precipitate salve. Scirrhus, and Cancer of the Ui/e-lids.— This disease in the eye-lids, as in other parts, presents two stages :— viz : induration, and ulceration. It may attack any part of the OF THE EYE. 179 lids but the most frequent part is the internal or external angle of the lower lid. The part at first becomes thickened tt : "If '.."'r, ''' •"««--««" or discoloration of he sk.n ; the hd also becomes as it were contracted, having mob.l ty. This ,3 the first stage, which may continue for a considerable length of time before the ulcerative or cancer- ous stage sets in; it is generally slow in its progress, but bail tK;rr''"'^7^^'-^P''^' ^'^'^^r^-S theeye-lids,'eye. ball, orbit, lachrymal passages, nose, and the whole of the cheek; its progress will in some instances suddenly stop at this stage, and the patient linger on in this condition foV years. Ihe ulcerative process presents different appear- ZM T'"T '''"''' ''''''''''' '''^' ^'» sometimes lorm, the ulcer becoming deeper and more painful each time • when it ceases to scab it eats awayall the parts indiscrimi- nately, but generally speaking in one direction only its progress appearing to be checked in the others ; somethnes the whole ulcer puts on a healing appearance, throwing out healthy granulations, which last for a considerable time, the pam becoming greatly abated ; but at the very time that it appears most healthy, ulceration again sets in, and probably goes on more rapidly than ever. Blood is not effused from the surface of the sore, but occasionally one of the veins gives way and there is considerable hemorrhage. The discharge differs very much at different periods, changing from a healthy to an unhealthy appearance; some peLif suffer much greater pain than others, but in some cases i? IS not so great as the ravages of the disease would lead an observer to suppose. Dr. Jacob says, and I think with much truth, "That the principal distress seems to arise from the exposure, by ulceration of nerves and other highly sensitive parts." When the constitution begins to break up, there is much fever, and sometimes diarrhoea either of "•h;^v >. 11 kills the patient. ' " generally iH.'i ^1 180 PATHOLOGY It is very doubtful in which texture of the eye-lid the disease commences, whether the conjunctiva, meibomian glands, cartilage, integuments, &c., but the general opin- ion is, that it begins in the conjunctiva and that the neigh- boring textures gradually become involved ; I have, how- ever, seen it commence in the integuments on the external angle of the eye. Diagnoeia. — The diseases with which this may be con- fused, are true carcinoma, lupus, or syphilitic chancre. Dr. Jacob says, it may be distinguished from true carcinoma by the abscence of lancinating pain, fungus growth, foetor, slough, hemorrhage, and contamination of the lymphatics, —and from lupus, by the absence of furfuracious scabs, and inflamed margins, as well as by the general appearance of the ulcer, its slow progress, and the absence of swelling injthe integuments around the ulcer, as well as by its history. Treatment.— l\ie only treatment from which any benefit can be derived, is extirpation of the whole of the diseased part with the knife; it is quicker, less painful, and more certain than the use of caustic, or the actual cautery. I see that there is a case recorded in the Boston Medical Journal, of a Medical man curing himself of this disease by living upon bread and milk for two years. This is certainly an easy cure for cancer. Inflammation of the Edges of the Eye-lids. — The general terra by which this disease is known is ophthalmia tarsi, or as Dr. Jacob calls it, tinea palpebrarum. It has also been termed psorophthalmia, scabies palpebrarum, lippus, and blear eyes. The local symptoms of this disease, are a glotinous secre- tion bewMning incrusted on the eye-lashes during the night, and binding the eye-lids so close together, that it is with very great difficulty the patient can get them separated when be awakes in the morning ; even after frequent «bln- OP THE EYE. 181 tions of warm water the eye-lashes will be pulled out from the root, producing great irritation. This discharge is secreted by the conjunctiva, meibomian glands, and follicles. The itching of the eye-lids is sometimes Intolerable, and the consequent irritation excites a greater flow of tears than is natural, which, with the discharge, is carried over the cheek, chapping and excoriating the integuments and producing ulceration and scabs ; when this state of things continues long, the whole substance of the edges of the lids becomes thickened, indurated, and distorted,— to this the term tylosis is given. Tlie seat of the disease seems to vary in different cases ; In some the morbid changes take place in the ciliary glands or bulbs of the eye-lashes, in others the meibomian follicles, but, generally speaking, the inflammation begins in the roots of the hairs, and terminates in little abscesses and ulcers, the Ihilbs of the eye-lasbes becoming destroyed, so thai the few feeble lashes that remain are weak and irregular. In- tolerance of light and partial amaurosis often accompany this disease: the inflammation frequently spreads to the conjunctiva covering the eye-ball, and if It be neglected or badly treated, It may result In total obliteration of the meibomian apertures by their orifices becoming skinned over, and the inner margin of the lids being rounded off, instead of defined, which stateis Incurable, so that the person will have blear eyes all his lifetime. Eversion of the lower lid may be caused by the excoriation of the cheek and eye-lids healing up, leaving the skin contracted by a cicatrix. Tri- chiasis is not a very unusual consequence of neglected or badly treated tinea palpebrarum. Causes.— This disease Is very generally found In patients of a scrofulous diathesis :. measles, scarlatina, small pox, cold. Impure air, smoke, filthiness, &c., all act as exciting causes, not forgetting the habitual use of ardent spirits, which keeps up the disease in adults ; the knowledge of this fact has procured for it the name of " the whiskey eye." 182 PATHOLOGY Treatment.— The treatment will vary according to its stage, and indeed must be regulated according to the nature of each case, inasmuch as that whicli would cure one patient would often be injurious to another. During the inflam- matory stage, scarifying the palpebral conjunctiva, and applying leeches behind the ears, will be found useful. Emollient, refrigerent, astringent, or evaporating lotions are all useful, and the surgeon may employ them according as he finds them give relief to the patient. But whatever the applications may be, the parts must be kept well cleaned, by frequent ablutions of warm water during the day, for on no account should the crust be allowed to collect ou the edges of the lids ; all applications would be useless unless applied to the diseased part itself, and not to the crust that covers it. Generally speaking, cleanliness is the most important, and at the same time most neglected, part of the treatment. To prevent the edges of the lids from becoming encrusted and adhering together during the night, the patient should, before going to sleep, smear the edges of the lids with a little fresh butter, and he should not attempt to open them in the morning, until he has first washed them with a sponge and warm water. When the second stage has commenced, cleanliness is just as necessary, and every morning for a few days the ulcers may be touched with either the pure nitrate of silver or the ten grain solution ; after which it may be changed to the ointment composed of equal parts of Janin's ophthalmic ointment, and the citrine ointment. During the evening the patient may bathe his eyes with a weak solution of the sulphate of alumn, sul- phate of zinc, or the oxymuriate of mercury ; but I would give the preference to the alumn wash.* If the edges of the lids become indurated, all the hairs • Note. I have found much benefit from a lotion composed of an infusion of green tea and a Uttle alumn in it, not only in this disease but in other in- flammations of the eye requiring astringent applications. OF THE EYE. 183 should bo extracted, and the parts touched once or twice a day with either a stimulating ointment, or lotion, which ever is found to agree best with the case. Mr. Mackenzie speaks highly of the value of counter-irritation to the nape of the neck, behind the ears, in the arm, &c. I must say, I have never been fortunate enough to find any benefit to arise from such treatment, but, on the contrary, in the ma- jority of cases it has proved worse than useless. ConsHtutwml Treatment.— In the first stage an emetic followed by a purgative, will be found useful, after which tonics and alteratives should be resorted to. Pure air, regular exercise, warm clothing, and wholesome food, are particularly indicated ; and, as necessary precautions, cold, damp, sitting up till late hours, and artificial light, should be shunned. I constantly find that this disease disappears at the age of puberty, particularly in females, unless it has run into the second stage. In all cases while there is the slightest prospect of a cure, the treatment should be perse- vered in, even for years. Porrigo Larvalts of the Eyerlida.—li never seizes the eye-lids, without previously attacking the head or face, from which it spreads,— such cases are rare. As a general rule the head and face are affected while the nose and eye-lids escape. Infants are usually the subjects of it ; this is true tinea. Symptoms.— Tht symptoms are the same as v a;iy other part of the face, except that, in addition, there is often accompanying it a puro-mucous conjunctivitis. It begins with an eruption of numerous minute whitish pustules, which break and discharge a viscid fluid that concretes into thin yellowish or greenish scabs, which become thicker as the disease advances, and glueing the eye-lids together, produce great irritation ; the patient's greatest suffering is from the itching of the diseased parts. It is not unusual to find, in such cases, the lymphatic glands 194 rATHOLOOT affected, and if the patient is a child it sometimes dies of rieetic or Irritative fever, and diarrhoea. Treatment—The local treatment consists in Iteeping the parts well cleaned, and the edges of the lids smeared with a sthnulating ointment, such as Janin's ophthalmic, and the unguentnm citrini. If the conjunctiva is affected the four gram solution of the nitrate of silver must be dropped on It, once or twice every day. The constitutional treatment consists of alteratives and tonics. I have never discovered anything superior to quinine, and very minute doses of the tartarised antimony: an occasional purgative of rhubarb and soda is also very necessary. IHaeaae of the Meibomian Glands.— The meibomian glands wmetimes inflame and form abscesses on the inner side of the lower lid. They should be opened with the point of a lancet, the matter squeezed out, and a stimulating ointment applied, to the little sacs, with the point of a probe. When a film growing over the mouth of the meibomian ducts, as a consequence of ophthalmia tarsi, obstructs them, the secre- tion in the ducts accumulates and presents the appearance of a small abscess : the treatment of which must be the same as if it were a real abscess, viz : to open them with the pomtof a lancet. When the ducts are plugged op with calcereous deposits, they also should be removed with the point of a lancet or cataract needle. B»rdeolvm.-The hordeolum, or stye, is a small boil on the edg« of the eye-lid: it is of a dark red color very painftil and hard. It rarely ever terminates in resolution and Its process of suppuration is very slow and imperfect' having very little tendency to burst : when this happens spontaneously, it generally leaves a hard tumour in the part, which deforms the edge of the eye-lid, in some degree • and IS very l.kely to bring on a renewal of the stye In delicate and irritable persons, it is frequently accom- panied with fever and restlesness. OP THE EYE. 185 Causa,.— The subjects are generally of a scrofulous dia- thesis or otherwise unhealthy ; late hours, worshipping at the shrme of Bacchus, or living on acrid irritating foods, act as exciting causes. Treatment—^When the inflammation is in the first stage resolution may be attained by the application of cold lotions, such as ice, vinegar and water, &c., but when the second stage has commenced, suppuration should be encou- raged by applying warm emollient poultices : and the moment the abscess points, it should be laid open with a lancet, and the pus and dead ceHular membrane squeezed out. The cavity generaHy heals up in about twenty-four hours ; but if it should not, it ought to be touched with the nitrate of silver, which will remove any dead cellular tissue that may be remaining. Any person subject to styes, should avoid ail the exciting causes that would be likely to produce PMyctenuh.~-There are sometimes found on the edge of the eye-lids, either singly or in groups, .mall transparent vesicles, which are filled with a watery fluid.-these vesi- cles are called phlyctenula. The cure consists in cutting them off with a pair of scissors, and then touching the part with the nitrate of Silver. 3f»«^Mm.— These are small tumours, containing a suet- Iike substance, which are generated at the roots of the ciKa • they are to be opened with a lancet, and their contents squeezed out. ^^r^fr S ^"^ '^'^' Ltds.-W^ns growing on the edge of the hds sometimes give great annoyance. They may be cut off with the scissors, strangulated with a liga- ture or destroyed with the nitrate of silver; I prefer the use of the scissors. Tumours m the Ey^hrm, and E^e-h'ds.-The eye-brow and eye-lids, particularly the latter, are vjry frequently the 186 Pi^THOLOGY seat of encysted tumours ; according to Beer, the external aijgle of the upper eye-lid is generally the seat of the atheroma and nieliceris. The steatomata are sometimes situated in the vicinity of one of the eye-lids, and at other times over the lachrymal sac. These tumours may be seated either in the sub-cutaneous cellular tissue, under the orbi- cularis muscle, or on the cartilage. Generally speaking, they are very movable, but when on the cartilage they are most frequently attached to it. The only harm ordinarily occasioned by these tumours, unless when they become in- flamed, and suppurate, is to prevent the eye-lid from being opened by coming in contact with the edge of the orbit. The steatomata npver grow to so large a size as the atheroma and meliceris. Treatment. — The general remedy for these tumours is extirpation ; when it can be accomplished they should be removed from the inside of the lid, but if they are superficial they should be removed from the outside ; on no account whatever should the cartilage be cut through to reach the tumour. For a few days previously to their removal, the patient should constantly move the tumour about under the integuments with his fingers, so as to loosen it from its attachments. To remove it externally there should be made through the parts covering it, a horizontal incision the full length of the tumour ; then a sharp pointed history should be passed between the tumour and its covering, so as to completely detach them from one another ; the tumour can then be squeezed out, and the attachments to its base easily separated with a pair of scissors; if, however, it should adhere to the cartilage, it may then be shaved off with a knife ; the wound in general is made to heal very easily, by covering it with a small piece of adhesive plaster ; or by bringing its edges together with one or two stitches, according to the size of the wound. If the tumour be very large, the redunvlant integiment should be removed by two elliptical OP THE EYE. 187- incisions. During the operation, the surgeon ought, if possible, to avoid bursting the cyst, for it wouhl render the operation more tedious ; should this happen, however, he must take hold of the sac with the forceps, and dissect it out; if the tumour be seated near the palpebral conjunctiva, it is easily extirpated, by everting the lid, and cutting through the conjunctiva. Mr. Mackenzie says, that instead of attempting a regular extirpation, it may sometimes be advisable merely to lay the cyst open with a lancet, squeeze out its contents, and then introduce into its cavity for a few seconds a pencil of lunar caustic or pure potash, after w*>'ch, in a few days the sac will come away and the wounc al. Velpeau recommends the same treatment, but adds that extirpation is the most prompt method. It is a treatment I can speak of from experience, and never hesitate to adopt it, always opening the tumor on the inside of the lid. Other tumours not encysted may form on the eye-lids, which it would be useless to think of regularly extirpating: they sometimes burst and get well, but if they do not, they may be opened with a lancet, and their contents, which will be found to be either gelatinous, or albuminous, squeezed out. Adults of an unhealthy constitution are generally the subjects of the former or gelatinous tumor ; and scrofulous children of the latter. When in the incipient stage, these tumours may disappear, under the use of tonics. Tylosis, or Callosity of the Eye-lids.— Mr. Mackenzie divides tylosis into three varieties, viz : scrofulous, arthir- tic, and scirrhoid. He says the second description rarely occurs except in those whose digestive organs are deranged by the habitual use of ardent spirits,— that its seat is external to the cartilage, and generally situated in the upper eye-lid, — that he never saw it end in suppuration or ulceration, — and that it slowly increases and then becomes stationary. As a local treatment he recommends leeches, and frictions 18a PATHOLOGY with camphorated mercurial ointment. He recommends laxatives and alteratives in the general treatment. Even this practice he acknowledges to be generally unsuccessful. His third variety, which he calls tylosis scirrhoides, he says, is of a white or slightly yellow color, more or less tubercu- lated, and apt to run into ulceration ; from which fact, with its appearance, intractable nature, and occurrence in old per- sons, it is liable to be confused with scirrhus. He con- cludes by saying that although the progress of the disease may be arrested in some cases by Fowler's solution of arsenic, taken internally, the application of lunar caustic and red precipitate ointment to the edges of the lids,— still in other cases the tumour has caused such irritation of the eye, increased so much in size, and produced such deformity, as to warrant the extirpation of the indurated portion. Now I must say this, to me, looks very like scirrhus ; certainly there is no line of df marcation : and it appears of but very little consequence, as the treatment is the same in both cases. — (See Inflamnation of the edg^ofthe eye-lids.) Noevus Matemus, and Amuriam hy Anastomosis of the Eye-brow, amd ^e-Zit/s.— There is a vast difference be- tween aneurism by anastomosis, and najvus. The latter is simply an organic malformation of the skin, while the for- mer often proves a very serious disease. The French give to it the name of erectile tumour. I do not mean to enter into the description of a disease, that has been already fully explained by every author on surgery ; it will be suflBcient for me to say, that when it occurs in the eye-brows and eye-lids, it is exactly the same as when it occurs in any other part of the body, somuiimes remaining stationary, caus- ing no inconvenience, and consequently requiring no treat- ment ; and at other times, from its increasing size and the danger of its causing death by hemorrhage, requiring ac- tive treatment. 1 OP THE EYE. 189 Treatment. — Various methods have been recommended for the cure of nsevus, and aneurism by anastomosis, all of which seem to have occasionally succeeded, and as often to have failed. There is one of two objects to be attained in the treat- ment of aneurism by anastomosis, — Ihe first is to produce obliteration of the part, either by producing inflammation in it or cutting off the flow of blood into it ; the other is the removal or destruction of the affected part. The choice of treatment will depend upon circumstances, such as the size, situation of the tumor, &c ; some have succeeded in curing naevus by constant and well directed pressure, combined with evaporating lotions of the acetate of lead ; this treat- ment was recommended by Dr. Sigmund, and I can bear testimony to its good effects, so far as the acetate of lead is concerned, but pressure I have always found to aggravate the disease. Puncturing the tumor with needles, and then keeping up pressure, is another treatment highly spoken of ; I cannot testify to it from experience. Professor Pattison of New York, says that the safest plan of treatment is the one he practises, which is the ac- tual cautery. The mode in which he operates is by passing repeatedly through the tumor red hot needles, the operation to be renewed at intervals of a week. He says the result is, that in the course of a month it entirely sloughs away, and the part heals, without a vestige of diseased structure being left. The naevus he thus managed was situated upon the shoulder, but of course such treatment would never do for a naevus of the eye-lid or eye-brow, as it would cause such a loss of substance, as to produce ectropium and shortening of the eye-lid. M. Pigoaux and M. Carron du Villars speak highly of vaccinating the part, particularly if the person has not already been vaccinated. The former says, that to ensme R/..V 190 PATHOLOGY success the points of insertion should be sufficiently numerous to produce a confluent pocic, and shouUi any portion of the erectile tissue remain after the scabs fall off, it must be destroyed with some such caustic as powdered alum. M. Carron du Villars inoculated the tumor and its circumference witii vaccine virus, by traversing it with a thread impregnated with the virus. He found that five pustules appeared, on the fifth day, round the tumor, and that the whole tumor was inflamed ; the tenth day it was covered with a black crust, which came off on the twentieth, leaving a healthy rosy surface beneath it, all traces of the erectile tumor having disappeared. The patient was a girl of fourteen ; the tumor was on the upper eye-lid. M. Carron du Villars also used the actual cautery, but in a different way from Professor Pattison. In his case he fixed in the tumor three entomological pins, and bound their three extremities together with sliver wire, which was then exposed to the flame of a wax-candle ; the tumor immediately swelled, cracked, and then sunk ; on withdraw- ing the pins they brought away a portion of the parenchyma. In eight days after, the child was well. Some recommend that the tumor should be inoculated with some stimulating substance, particularly if the person has been previously vaccinated. N. Sofarque speaks highly of croton oil ; he recommends that five or six punctures should be made on and around the tumor, with a lancet, that has been previously dipped in the oil. He states that the punctures immediately cause a pimple, v/hich in thirty- six hours is developed into a little boil, all whlc?i unite and form a hot, red, and painful tumor, covered with a white crust, resembling a small carbuncle : two days afterwards the scabs separate, and in the place of the naevus is seen an ulcer, which is to be treated on general principles. He concludes by saying that it would be dangerous to make more than six punctures on a very young infant, as the irri- OF THE EYE. 191 tation and fever are considerable. Some recommend that tartarised antimony should be used, instead of the croton oil, in a similar way. M. Carron du Villars gives another case of such a tumor on the upper eye-lid of a young woman, which he cured by the coagulating method ; he accomplished this by injecting a styptic solution into the tumor by means of Anel's syringe ; the result was that the tumor became of a black color, which soon after faded away • on the fourth day it was surrounded by an inflammatory circle, and covered by small phlyctuna ; and the fifth, a por- tion of it separated, and the rest dried up ; on the eighth day the entire crust fell off, leaving underneath a rosy new skin, similar to that of a cicatrised blister, without deformity or loss of substance. Previous to performing this operation of injecting the tumor, it should be com- pressed so as to empty it of its blood, The aperture in the skin for the point of the syringe should be made at the edge of, and not in the tumour itself; when the fluid is injected, it should be retained in the tumor for five or ten minutes, after which n may be again discharged. Mr. Lloyd, who has used an escharotic fluid in this way, recommends pres- sure to be made round the base of the tumor during the process of injection, lest the fluid should be forced into the contiguous cellular tissue, where it might excite inflamma- tion. Mr. Mackenzie thinks there is a greater danger attending this mode of treatment, viz : the passage of some of the fluid into the veins, and thence to the heart ; such an accident may be possible, but I certainly should say very improbable. However, the caution should by all means be observi 1, therefore pressure should be made round the tumoui with a small hoop, or what Mr. Lloyd recommends, the cover of a small pill box with a notch in its edge for the passage of the point of the syringe. For my part I never should think of using an escharotic lotion, a styptic being all that is necessary to produce coagulation. 192 PATHOLOGY The most powerful cscharotics have been applied to the surface of these tumors, for the purpose of destroying them liy sloughing : no matter how successful the treatment may be, there must always be a great loss of substance, and this objection will apply with greater force if the tumor hap- pen to be situated on the eye-lid. Dr. Marshal Hall recommends incision of the vessels with- in the tumor. He effected a cure by this method, although before it took place a half year had elapsed after the ope- ration. His theory was, that he expected it would produce inflammation, and a cicatrix be formed, whose solid texture and progressive contraction would in time obliterate the tumor. The manner in which he performed the operation was by introducing a couching needle, with cutting edges, at one part of the circumference of the neevus, close by the healthy skin, and from this point he passed the instrument through the tumor in eight or ten different directions, the first puncture being the only one that was made through the skin. After he had withdrawn the needle, a little pressure was made on the tumour with strips of adhesive plaster. He mentions that there was neithw pain nor hemorrhage; and attributes no particular benefit to the employment of the pressure, but says the operation may be repeated at shorter or longer intervals, as occasion may require, or according to the degree of inflammatory action necessary for the obliteration of the neevus. Mr. Favvdington, of Manchester, recommends the use of a seton. It is painful and uncertain, and in arterial cases dangerous, nevertheless it has this advantage attending it, that when successful it leaves very little deformity. If suffi- cient inflammation be not produced, any escharotic can be applied to the internal part of the tumor by means of the seton, without destroying the integuments. Some think the ligature the most useful means for re- moving {bese tumors ; there are two methods of applying OF THE EYE. 193 ; It, VIZ :_First, by transfixing the tumor with two needles passed through its base,, the needles crossing each other- the hgature is then placed under the needles, round the base of the tumor, and drawn tight, so as to strangulate the tumor after which the needles are withdrawn. The second method consists in passing a curved needle, arm d wUh t^o ligatures, through the base of the tumor, so as o d.v. e ,t mto t^o parts, each portion of which is o be con- stricted by its own ligature. When a ligature is employed, the tumor cenerallv shrinks, turns black, and falls off iil the course o'f S ve ' SIX days ; after which the exposed surface should be poul t..d,u..,itgranu.^^^^ For many years the radical cure of nsvus and aneurism by anastomosis, was excision, which, under every crd stance, IS a dangerous operation; for no mattei^ow f!r the knife be kept from the tumor, the blood-vessels in U vicinity are always so enlarged, that there is much dlnge fiom hemorrhage : however, should the surgeon decide on this mode of treatment, he must be prepared to remove all the diseased part; and if it be the eye-lid he mlv Z tl \r '' "'^''^"" '^' *'^« 3Ma.Wc opTra' t.«n, taking the new portion from the temple of the patient To obliterate an aneurism by anastomosis in the orbit Mr. Travers tied the common carotid artery; Mr. Wardro.' followed his example, but in his case the'Uvu; was t- u\ ^,''%"P^''^"«" is certainly a bold one, and one I >vo«ld be far from undertaking, except to save life. Having described all the different modes that have been recommended for the cure of this disease, I have only to add that circumstances, such as the size'and situat ^ of will adiTpt ; If circumstances would permit, perhaps there i! no better treatment (if evaporating lotions of the acetate ol N 194 PATHOLOGY lead fail) than the actual cauteiy, as recommended by M. Carron du Villars, or injecting the tumor with styptics, or astringents, as in neither case is there any loss of sub- stance. (Edema of the Eye-lids. — This disease may be either general or local, but it is more generally the latter. The local causes are acute ophthalmia, wounds, bruises, or erysipelas of the eye-lids, disease of the orbit, pressure or abscess in the neighborhood of the lids, emollient fomen- tations and poultices long continued to the lids; any of these may act as exciting causes. The constitutional causes are general anasarca, consequent upon any eruptive fever, scrofula, &c. Bymptoms. — The lids are swollen, smooth, pale, semi- transparent, and soft, and their motion is impaired ; they will retain for a time the depression caused by pressure of the finger. Treatment. — If there be any local exciting cause, it must be removed ; if there is anasarca, a general treatment must be adopted, such as diuretics, diaphoretics and purgatives, followed up by tonics, &c. When there is no evident cause, gentle stimulating applications to the lids will excite the action of the absorbents ; blisters before the ears, or on the nape of the neck, will also be found useful. Emphysema of the Eye-lids.— Mv in the cellular tissue of the eye-lids is the cause of this disease; it may be either gen- eral or local;— general, when the air escapes from the lungs, and spreads through the cellular tissue of the whole body, — local, when the air escapes from the nose, in consequence of an opening in the nasal parietes, into the cellular mem- brane of the eye-lids. Treatment. — Evacuating the air, by means of an opening in the integuments, is recommended as a palliative treat- ■'iy! OP THE EYE. 195 / ment ; but, of course, a radical cure must depend on the re- moval of the canst , whatever that may be.* Tiottchinff of the Eye-Uds.— Some persons suffer great annoyance from a constant invohmtary twitching of the eye-lids, which is generally confined to the lids of one eye The eye-lid, goes at a most rapid rate, and though the patient is perfectly conscious of it, he still cannot by any effort stop it; indeed every effort seems only to aggravate it Some cases are worse than others, as in some the twitching .8 confined to the eye-lids, while in others all the muscles on that side of theface are affected, drawing themouth toone side. Grrief, joy, or any thing which will agitate the mind aggravates the disease. Some authors have seen it accom- panied with pain,— I never have; but all the patients I have ever seen afflicted with it, complained of great weariness of the affected part, and more or less weakness of vision Causes -The direct cause is derangement of the portio dura of the seventh nerve ;-the remote cause is generally some deranged state of the digestive organs. Persons of in- temperate habits are generally the subjects of it. Old cooks who have been accustomed to take ardent spirits, are the persons I have generally found afflicted with this disease Treatment— Laxatives, alteratives and tonics, have been found the best general treatment: I have found croton oil the best laxative, and quinine the best tonic. Bleeding and mercury seem only to aggravate the disease, particularly the latter, unless given as an al terative. It is very impor- j£v 12fh^l74?'T V^' e^e-lids caused hy blowing the nose: intimate friend I did not recognise him *PP«ara»ce that although an that all the swelhng ha. disease locally by counter irritation at the angle Of the jaw brushing the com-se of the nerve with the eight gram solution of veratria every morning, and using elecfri- city by insulating the patient, and drawing sparks alone the course of the nerve. Several recommend me'rcury " may bo given a8 an alterative, but if there be scrofula or disease of the ear, I would not either give or recommend it. on«hr~.^Tr^^'''^*^^^''"^---P*««»J«aninability on the part of the patient to raise the upper eye-lid The consequenco of which is, that, if both eyes are iected, he is bl nd, and If only one eye is affected he is blind of that eye although the organ of vision may be perfect. ' Causes.-T\m disease may be either congenital or here- ditary, in addition to the many other causes which may pro- duce It ; it may be caused by relaxation and extension of he common integuments of the eye-lid ; if such be the case the patient will be able to raise the lid, if the redundant portion of integuments be taken hold of between the finger and thumb, so as to remove the weight from the lid. Wounds of the levator muscle may also produce ptosis, par- ticularly ,f they are badly united. The worst form is It caused »y p.raly.is of the levator muscle, or rather by para- ImL .r ,""■'" ''''''^ '"PP"^« •^'"'^'^'^ '"'''^ '« ^branch of the third pair: a node on the edge of the orbit is not an unusual cause of this disease; and sometimes it is only a symptom of disease of the brain. Treatment.-U the cause be relaxation of the integu- ments, the cure will be made by removing a transverse fold 200 PATHOLOGY of ihe integuments, and afterwards uniting the ed-V mornine attended I brushed the same "I, / ' """■''' of the time hf reratria, I also used Xtrltv T""^ '"°'""'°? ^•"' 'he solut on of dance. The constitutiolltTaS wasTwT'"'"^ .^"""^ h'« atten- mlT^^'^''^''^''"'' P^'o^siumCee imesadav^h'' ""'l-«P°""f"l of the mended him to continue after he left m" ^ ' '"*' ""^ *'''''='' ^ >■«"«»>• OF THE EYE. 203 accompanied with eversion. A person with this deformitv cannot close the eye-lid, hence the name lagophthalmos, o • hare eye, from the supposition that hares sleep with their eyes open. The evil consequence of such a state of the eye-hd ,s that the eye being constantly exposed to light Ihfse pa;ts ^ '''"'' '' '^''''y "^«"« '' ^''^ «*■ CbM^es.— Wounds or burns of the eye-lid or eve-brow or canes of the bones of the orbit, are the gener 1 caust'ln Uie wo first the lid is shortened by the cicatrix formed wh ■ the injured part is healing. In the latter there is adhesion of the lid to the bones of the orbit Treatment.~Tme seems to do much in such cases, par- .cularly in adapting the eye in some degree to the los of us natural covering. If a cicatrix be the cause of the shortening, I consider the best mode of treatment is that recommended by Mr. Whar- ton Jones, nevertheless the success of the ertatment will depend in a great degree upon the looseness of the cellular issue in the eye-lid, eye-brow, and forehead. If the short- ening is combined with eversion, previous to performing the opera ion, about to be described, the swollen conjunctiva ecropium.''™" '" *''' ^"^ '"'""^"'^•^ ""'^'^^ the head of For a few days before the operation, the cicatrix should be constantly rubbed over the cellular tissue, for the purpose of loosening it. The operation is performed as follows - Two incisions are to be made, with a sharp scalpel, through the skin, one from each angle of the upper eye-lld,-these incisions t^o converge, as they ascend, till they meet at a point on the forehead, about one inch above the eye-brow • the triangular flap thus formed is to be pressed down, witln out detaching it from its subjacent parts, till by the stretch- ing of the cellular tissue "■ " ' • • • - il ca if' Hi?-- eyi roueht ght to Its natural 'il Hi :■!. 204 position ; this will lep PATHOLOGY a gaping wound of a triangular to be brought 'tomhp'rir'^' '''^'' °^'^'''*='^ wound are that this p'a r mfj h a iTfi ^ ''' '^'^^'^' ^'^-e, so prevent Z rec.r^:::l^lj::^:-^^^^on, and thereby bandage. ' •'^ ^^"^ O' » compress and When there is adhesfnn nf *i.„ ij -bU, fro. caries „*a„7o". ,,''!'" ''■« ■="«« «f '<■» «.e best in addilion to LZliTo^'i^ "'""'° "■="""="' '' iy a subcutaneous inc „„ Z" « '''""' "'''*= *■■"» •nechanical raeans as w rke ' The f-J'''":''' """« *»" In addilion to the Vlf "^ ,'"" °" ""' "«'*■ Mackenzie recoltd ~ f ""j "r™^. Mr. <>"< of the whole thickness of Ef eveTid ^^ "'k''"' "''^ wedge at the edse ind ,1," , t ^ ''' ""^ ■>"»« »f Ibe brought .ogethefVl.' e" ':o an"" ^'" °' "^ «"P first intention. He savs Z -n . "'""" "»'"" 'J' «be •be eyc-ball, and eo„re'r it ^ "^ "" '''" '" *'" '» '" ■•' l» again eont act t,«2. ? h™'^ '^' ""'^'" '»' must confess I do not ,ee hJ i "'^^ °' ">« "bit. I o" ; if indeed the M «, eTerTed a?™,',' '""" "» "r-'' wonld alter the case hnf 7 ',u """ " »l>ortened, it i«%me„,„„„,d be :-,„ d "rif' h'e '™' ™""°" -" too large, it would produce fU •. •""" """"''"1 «s pion or inversion ° "'''"'"^ "«». v-'z.-ectro- vaSr:r.Msi:re nf. h^^:'*-™- - -» cause exists for it, whUe ,he " '■" ""' ""'«''' ""l^ «"« «». operates i„ p;od: -^'TheronT'^ """ '" »"*'»-' of Iho lid, or lids wh ht™ ? °' ""= "»'■"« ™en>b.ane OP THE EYE. 205 c her. When confined to tho ioHor lid the lining of it r ses m the shape of a semi-lunar fohl between the bal o t .e eye and the lid, evertin. and depressing the latter as .t continues to increase. When both lids arf disea the swelhng assumes an annular shape, and the eye appe rs •f sunken; finally the lids become everted, causi?g.^eu pain and deformity ; this swollen membrane become InC ed, tears and mucus pass over the inferior par^o t „' upon the cheek, causing it to become excoriX; Tel from exposure, becomes dry and inflamed, and if al owed to continue long in this condition, the termination u^M ulceration, and destruction of the Cornea ^" When the lower eye-lid only is everted, the eye-ball does not sufTer much as it has its covering, uanJyZZZ l.d. Thus vanety of ectropium is generally occasioned by obstmae chronic inflammation of the conjunctiva such as is found m scrofulous subjects, or those whose eyes ha^e eon attacked by small pox. An eversion of tie '1' M ,s frequently caused, in infancy, by the awkwardness of persons cleansing and examining the eyes of children af^cted with purulent ophthalmia, the screams of the hi S a.dmg to produce the eversion ; the friends comple e he nnschief by neglecting to bring the child to a surgeon who can reduce the eversion, until the membrane ifs becrme swollen and strangulated. ™® The second variety of ectropium is that which arises from contraction of the integuments of the eye-^ds orT neighboring parts, after which the palpebra \ ;„^, ^ umefies, and presents the same appearances that are seen .1 n/: r,Td ^^;'>'.«^^''.— es Which produce sho.^^ ening ot the lid, will give rise to this form of ectroninm such as scars, abscess, burns, excoriations, &c ; ev n the first species existing in the low.r lid is verv iahll ' .nto the second, as the tears and muL " si g oVe: Z nw-nrV'^'"^"^ ^^^^"^^^''' -/if allele:,!^' on will finally terminate by forming a cicatrix. ^ 1^ 206 I'ATHOLOGY The surgeon slmM be iblo t. ,r tvvo varieties, which is no at, ti^"^"''' ^«^^^««n these ;v. I always find that tJ.e hil'" ?,? «° '^'^y «««)', but he In the first species the skin of 11,'^' ^''" «««'^'t '"''". '«not greneral/y disfigured w ul ? ^ **"'"ff P«^'« eye-h-d be pressed towanis ZjT'\rt '' '^' ''^^^^ be seen that it easily cover L' T' 1 ^^' ^"S''' '* will species of this ^Hsease , o ,, .^^^^^^^^^^ I" the 'second but there will be evident shorl-""? ri.? ^« «»'-«-, «"re be made on the svvollen con '£ ^' ''^' ""'^ '^ ?>•««- •nentioned, although the Id maTvtn ';'" !''« ^^^^ ^'''eady ff'obe of the eye as in the firsTsnl ' '* ^'" "'^^ ^^^^--^he ;een whether the margin of hi KT.'^" J' ^•" be easily the orbit. *" °' ^'•^ I'd js adherent or not to By this time the carpfni ..«„j the first species of eclop l^f a^^^ ^^^t ' downward, or the unner iT. ^1''""^ '^^ ^''e lower lid innctlva; whereas, X sconS?^': '^ *^« swollen con- "P or down, (according to he h7'^'''' '^' "^ '« dragged on the external part. ^ ' ''^ '^^^^^d,) by the elcaWx An evorsion of the lower lid ;« d persons, the lid appearing o allT'*""'' ""'' ^''^^ in of tenacity or support, instead „fL°''" -'""P'^ ^'' ^«nt dragged down, rj th se Ises thp ^^ '''^'' P"«''«d or the cilia arc destroyed or 2 P""'*"™ '' t»™ed out ■emaining, the edge of he t' b'"' °"'^ ^ ^^^ -^^k ones 'ears and mucus pfss o er th cheeH?;'""'^'^' ^^ '^^ conjunctiva, from being exposed ^ .^^'^''^^ ^''^ P^'Pebral biU finally becomes harS andnea;,'- '"'^''' '"'^ '''"tated, P^^'-ent will pass his finrel ove^r?*^''' ^« ^'^^^ ^^e' annoyance : after some time he c eek T'"' '^^""^ ^^ "•om the tears and mucus passL .! ^^'''^'' excoriated, case to terminate in the second '*' ""^''^ ^^"«es the OP THE EYE. 207 Prognosis.— \f tlic eversion be of tho fire* surgeon may encourage the paUen t^ "T'^ ^^' the deformity may bf remove^ at M 7? "" "^* degree, by an operation ; but if t be of h ' T^ ^'''^ the fewer promises he makesVhe lL° '"'""'^ ''''''y^ means eertain under the m st k /' ' "T'''' '"« '^^ "" variety which occurs in ImZl ! ^'^''^'ment. In that successful resuU P'"""' "'^'"^ '« ''"'« h^Pe of a its^~V7r]Id"flT ' '''''''' '' ^ «-^-n -ith should take ho d of't e ovf K?'? ''""'^ "'^"^'°"^^' '^'^ and thumb of both la^d 1: ' ''^''" *^^'"^«^ «i«'- eye-lid, and squl'tn; f ?m;:r"'" ^t" ^^'^ "'^ effused fluid, then sndrl<.nW k ^'. '""''' ^^ possible of the ball, taking care a « ^ ^^ ''' ''^^^ ''''''^' "'« eye- Htti; from L eye nlil^^^^^ *« ''^^ ^^e «d'a push np the swri;;^uv;/^;;r tS: r^r^ restored to its nafnroi «^-*- "® '"^ 's thus irriSle% l^rr:^^ ^«. »"^ 'he child the infixed TlnTv? i '°. 'r*'' "'• "»"««'"»" of »nd a .mart Zr Aft ' t f?^ '"""""S «PP'«tio„,, manner J„», rae„«™ d m1 ".''''' P°""™ i" 'he to it. proper S „ ,„ Ihf fi% """•' "' "'""'"^ ""= »1 heen ?ocLnfe„d d ' Scarpa 11"' "^ '=*°'""'»' '■^"' growth of conjnnctiva hvThe freal?™"'?- "'.'' ''""«°°' nitrate of silver R».r „, r jT ' "PPhcation of the the tincture o7„„i„m"lT'T'' '*'■ ^'>' »PP"««o" of ened hy the adSft .* whLThi"';^''' "" "™^"- » had recourse to the ES 1?^ /.^r^B .T of'f ■*■ 'he Whole Of tt SorswX'raTai";.'" '""' a bistoury. *' P*"^ **' scissors or i' ^v t-'n /: ! 208 TATHOLOGr Otlier escliarotics Ikivo been extolled as well as the u.trato of silver, such as sulphuric aci.l, &c.; but I think that, when an cscharotic is to be used at all, the best Is he nitrate of silver, as it is more under the control of he surgeon. There is one evil that may be produced by the use of either the knife or an escharotic, and must be cautiously guarded against, viz :-inversion by the removal ot too great a quantity of the conjunctiva. When the surgeon determines on excision, the mode of operating is as follows : The patient being seated opposite the ight, and the hds being held in their everted position by the fingers of an assistant, who supports the head of the patient with his chest, the operator takes hold of the lungous growth on the lower lid, at the internal canthus, with a sharp hook or pair of forceps, which he holds in his left band (supposing the eye to be operated upon to be the right, and that both lids are everted,) then with a small sharp bistoury or pair of scissors, which he holds in his right hand, he removes the fungus clean off the lid ; he then pursues the same course with the upper lid, taking care not to wound the punctum in either. The object in begin- ning with tlie lower lid is to avoid the annoyance the effusion of blood would create, if the operation were com- menced on the upper. After the bleeding ceases, which is generally very soon, under the use of cold water and a sponge, the eversion should be reduced, and the lids restored to their natural position, and kept there by mechanical means, for which reason the lids should be closed and kept ' 80 with a few strips of adhesive plaster* and a compress and bandage, all of which may be removed after twenty- four or thirty-six hours, when, generally speaking, the lids will be found to retain the position, or very nearly so, in which they had been placed. The after treatment consists in kee ping the eyes bathed with a little milk and warm water * The cleanest and best adhesive plaster is the isinglass on oiuilkT" •~-C„ OP THE EYE. 209 for a few days, and afterwards, if it be found necessary, more of the thickened membrane may be destroyed by the apphcation of the nitrate of silver; at all events its appli- cation w. I secure a strong cicatrix. To ensure that no relapse takes place, it will be necessary to remove the chro- deformUy"'*'"""'' '''"'''' ""'' ^^' °"^'"^' '""' "^ ^^^ If the surgeon or patient prefer trying escharotics before having recourse to excision, and the nitrate of silver be used, It should be applied every third or fourth day in the following manner :_The fungous growth should be first wiped dry with a piece of fine sponge or dry rag: then the pijre pencl of caustic should be passed over its surface, which instantaneously causes it to become white, after which a little cold water or milk may be allowed to pass over it by means of a syringe or camel-hair-brur'i. The best way to apply sulphuric acid is with a silver probe or wooden spatula ; a greater quantity of water is necessary after It has been applied, than after the use of the nitrate of silver. For that description of eversion of the lower lid which occurs in old persons, very little can be done. It has been recommended to shorten the lid transversely by removing a wedge-shaped piece out of the whole thickness of it the base of which would be at the edge of the lid, then to brinff the gaping wound together by means of sutures ; and thereby (say those who recommend it) prevent the lid from falling down. For my own part I must confess I have never seen any benefit arise from this treatment, but what I have found to give most relief was the daily application of the ten grain solution of the nitrate of silver. In the second variety of ectropium many modes of treat- ment have also been recortraended, all of which appear to have both failed and succeeded at different times, the success Hi ' '^-1 ^V ' ^ «l H'. * '1 ^hI^j ' ■ ^1 ^^^H^^ ~"^H UQ PATHOLOGY seeming to depend more upon the quantity of integuments lost, than upon the mode of operating '"teguments All authors agree that whatever operation be oer- formed . .s first necessary to remove the thickened cc^.ju'nc- tiva, .n the manner already described for the first spec L of cctropium Indeed, both Scarpa and Beer pursued the same treatment for both varieties, with this addifion that n the second speccs, they endeavoured to stretch theTd by mechanjcal means, having, previously to the operat on soft^ ned .t by the application of emollient poultic'es, nd,' after the operation, kept the lid and cicatrix rubbed with o y mbrocat.ons Both these men were decidedly of pin on hat dividing the cicatrix was of no permanent benefiLTu" ather the reverse, since, when the wound healed, the 'con traction was always greater; and most certainly heir idea was a correct one, for where there is actual loss of substance and consequent shorteni^^ ren^e 'Vr^w-r^'?. """' ''^""''^^ *° P^«^«°t "* recur- rence, S.r Wilham Adams proposed that a wedge-shaped piece should be taken out of the lid Pnr ^^. ^ '""P^^t doing this, see Ectropium in old persl " *'' "^'^ '' The treatment most valued in the time of Celsus was, to make an mcsion through the cicatrix down to thrdrU- lage; then, causing the wound to gape drawiU th« rd to an- on, but cicatrix cicatrix, en found t in con- ' part of bat it is OB- THE EYE. 211 the operation Of all others entitled to our confidonce esoe- mIymcK.atnccso the neck, check, eye-lids, no The following are h,s words :-"!„ all such operat.on we are governed by the same principles, and pretty mucl tie same mechanical details ; they consist in " 1st. Dividing the cicatrix so a, to produce a raw sur face .n some parts of its extent, or cutting .t entirely out 1 proposed by midanua. ^ *^"*' ** ;' 2nd In applying to the raw surface a piece of healthv skm, taken from the neighboring parts. ^ " 3rd. In attaching this skin by suture to the margins of the wound m which It is inserted. ^ wwlt'Ih/l-T't'"'""^ ^^' '^^'' '^ ^he wound, from which the skm has been removed. « 5th. In separating, by appropriate agents, the parts too closely approximated, and keeping them in this condT tion some time after the flap has united. " 6th In applying oleaginous frictions, and motion to the new parts, so as to give them flexibility and softn ss '' This operat.on failed in the hands of Juneken h,u «n^ ceeded with Lisfranc, Dieffenbach, Ammo^'and' F^ k " Dieffenbach called the operation bl^haroplJtic. The only difference of opinion that seems to have existed between these surgeons, was as to where the new part should be taken from, the shape the piece should ^ Tf and whether U should be altogether detached, previously to Us be ommg adherent to the part into which it is ingrafted If tlie eye-hd is the part affected, I would prefer taSth;' new lid from the temple, as bein^ a part ea'sUy h :M sufficiently near or the purpose ; as to the shape Ind size of he piece It should agree with that of the gape it is des^ned to^fiU, which var.es in different cases. There is ZX that must be always observed in the operation, whiS is to preserve as much of the eye-lid as is 'possible part cu arly the cartilage, puncta, lachrymal ducts^ilia. Ind "^1!^ ' J ,.' , il f ■' I 212 PATHOLOOY It 18 sometimes difficult to brinff the edaoq of th. „ i made wound toffpti.er from iUn\\ c, *"° """^'^ Ininr tn t '"s^".'^'^> '^0"! tlic wiiut ol iooseucss in the ccI- Jular texture, or in consequence of tlie size of fh« S covered with lint. I'lasier, ami Mr. Wharton Jones recommended the same treatment for the second variety of ectroninm «.« fn. 7 , f 7^"^ The treatmpnf I .K„ii '^''^'^'''"""'' «8 for Ugophthalmoa, The orbital edges of the tarsal cartilages took the lee o^ the.r chary margins, and the palpebral conj netit pre sented a fungous mass. The cause of thf, ^Tr •! ^ YPhills, whieh disease had ^ClTl^^Z^Z the soft palate. The treatment I adopted was as fo lowf - first removed the thickened conjunctiva by mea s o7a scalpel and a pair of forceps, in the manner aCy recom mended when treating of the first species of ectropium l' hen separated both lids from their unnaturl adhlTois vh ch enabled me to restore them to their proper nos 1' then pared off the ciliary edges of both E the ex ternal angles, to about one third of their extent bro„l" he raw edges together with a twisted suLef d vefed the whole with a compress and bandage: on the second day I removed the two needles, when I had the sS"- - i : the six rules ition of cold )f the newly 3s in tbc cel- of the flap )0 drawn as )la8ter; and treatment lophthalmos. hich I 8UC- id before I )f it in his 1 ectropium ary margin iry margin ■ the orbit, e place of ictiva pre- rmity was whole of IS follows, eans of a 3y recom- opium ; I idhesions, position, their ex- , brought covered B second satisfac- OP THE EYE. 218 tion find an anchyloblcpharon, of that pari of the lids >vhich I had cut perfectly forn.ed. The after treatment consisted in dressing the wound of the lids every day with s.mp e ointment and lint, till it healed by granulation', an formed a firm cicatrix. I applied to the eye every da^. for some ime the ten grain solution of the nitrate dsUver My object in this case was fully ofTected wl.i,.|, «,.. t ..revcn. .„. n* f,„ ,,eo„,-„g „/.,■„ .C a ^^'l' ^4 „ act against the other.* ^ ** M.W« and Dustich{asis.~l consider these two as one and the same disease, or rather one disease split in two by det:d'tf;;f ^ '""'^v r""" ^«"--- ^^^ dellned to be a growing of the eye-lashes against the ball of the eye ; and by the term distichiasis is La. a ouble eye-ball I believe, however, that what is called a double ow IS simply an irregularity of the bulbs of the tir causing one hair to turn in and another to turn out thus presenting the appearance of a double row. ' folFowng case, ^hich we ?rS in^tie ve" ' «°»°^^^ ^^^ this subject. The ODerating, possesses sufficient interest for Tf?! .•' ''^u * ""^^ '"^'hod of of the deformity represented in thTi * '.nser ion here. The subject fourteen years LdHcrfi " b 0^^^"^^ ' "^'r'"'- ^ ^irl aied of the orbit, when about five years of a<.P A . T '"' ^""^' "«*•■ ""e «dge exfoliated; the integuments became invfrlp.lV''" P^^""! °f 'he bone hfd process, so that the skin and perfosteum werJ .-nZ'"!'', '"'''^''",''"' ''^'"'"K means the lower Jid was drawn down fr^m the ^T^^\ ■"""''^- % ""i! greatly everted. The coniunctiv^^lJT^ the globe, and its outer portion ance, which it assumes rrthusexDosedl' ""T^ 'l^ ^"'°"« ^P^^r- first examined wo found the inte^um«Z • .-""^ ^.^"^th of time. When that it did not seem possible to E "nv^v'"">""*'*'^ ""«'''«d »" the bone of a fortnight the patient. bvnnrH^ *^^">'"g l^otween them. For upwards aWe by drawing fhe' Idjof^ing sk nl ;"d^fl•'■r''.";'^ ">« ?"'« moreCve- cellular membrane seeme-'d thuf t, ^",;^\t?fit'?ed''r-.''°"'' 'I ""'' «""■« bone and the thin layer of skin by whiuh ir w„» *' i' "^T' ^^^^^^ ""c bladed and double-edged kn fe such aV ,h„? ""'?''5'*- A «"■»" """•<>*- section of tendons, was^then int oduced at the di^r \ ""* ?"bcutaneous the ou er s de of the pip«tr;^ ^ j l,. ^'stance of near y an inch on pushed forward 2 the oueanLiroTtJe°ai^^^ 1°"" l"- '"/bone then" operation the parU both abov7a„V be W "hfSi'.' S^.f ^''^ "^ '"« -le -icairis were luaae as teuse i 4- \ 214 PATHOLOar In either case the hairs constantly rubbing against the eye, act as a foreign body, producing irritation, inflamma- tion, and finally opacity of the cornea, and even in some instances sncfa deep ulceration as to penetrate the cornea, causing prolapsus of the iris, and soraelimes entire destruc- tion of the eye. This diseased state of the eye-lids differs in degree i sometimes all the lashes are turned iu, more frequently the lashes of one lid and not of the other, and in other cases only part of the lashes of one lid. (7a«s^.-The causes which produce trichiasis, are long neglected and continued disease of the tarsal cartilage^ arising from chronic ophthalmia, scrofula, small pox, inju- ries both mechanical and chemical, &c,, &c. ^TVeatoncnt- Whatever treatment is adopted, the object «houdbeto prevent the eye-lashes from pressing on the «ye, to a«comphsh which purpose many modes of treatment have been recommended. The first and most simple is that which IS called the palliative, but very often in young sub- jects It proves a radical cure. It consists in pulling out the hairs with a pair of forceps, which process is to be repeated as often as the hairs grow in a wrong dire ction. It is also depression iad existed, and 3 was taken th'at nr^ % ^T, '^5""? *"** escape throngh the external an«-t^ A ?ii.f * "1 **"* ^^°°^ «''""« ends of it dt^wn up and a«aXd »^ ?h. r i, "^/'i'"^ °*'"8'"' ""^^ the day,. Cold ap^iea?ions were fpied fnd iltA^r""^- r''^""* "?«^ that, within a Vortnight afterwards the dl™i.^„ "aUsfacUon to find the depression of tfe choek7lfi Z anttTe Ksto3'tl""?^*'^ position The thickened conjunctiTa,'howe^r reaS^« .nnV ^"""'^ OP THE EYE. 215 gainst the inflanima- I in some le cornea, B destruc- I degree J lently the her cases are long artilages, ox, inju- le object ? on the reatraent e is that mg sub- ■ out the repeated t is also i«, its flat r manner until the was fully d tfant the awn, and •od which 'here the id should I throng^ and the ext three 1 to find removed, natural cation of scarcely ly inter- valuable the best treatment for adults when there are only two or three hairs turned in the wrong direction. When the hairs are not very irregnlar and not very many tamed in, some practitioners have succeeded in re- moving the disease by cauterizing the skin of the lid so as to make a cicatrix which everted its edge, and thus turned the lashes outward. This mode of treatment is effected by placing a bone or silver spatula under the lid, then the actual cautery (which may be a knitting needle heated to a white heat) should be applied along the skin of the lid parallel to the eye lashes, and abont the twentieth of tin inch from them. The greater the extent of surface destroy- ed, the more will the edge of the lid be everted; great care should, therefore, be taken not to make a greater eschar than is necessary, lest the lid should be too much everted ; the length of the eschar will depend upon that of the inver- sion. The following treatment is recommended hy Mr. James Hunter, of Edinburgh : having ascertained the exact position of the hair or hairs inverted, take a lancet or iris knife, and make with it a puncture close to the base of the hair, and in the direction of its growth, to about the eighth of an inch in depth ; the knife then to be moved about so as to cut the bulb of the hair, and widen the bottom of the wound, which is to be immediately afterwards inoculated with the tartrate of antimony. When so much has been done, he directs that immediately afterwards the inverted eye-lash be pulled out with a pair of forceps. The manner in which he prepared the antimony for inoculation was by dipping into it a lancet previously coated with hot sealing wax. When there is only a single hair misplaced, Mr. Mackenzie recommends a puncture to he made in the skin of the lid beyond the root of the hair, after which a speck of pure potash is to be inserted into the puncture ; of course his object is the same as that already mentioned, viz : — to produce a small slough, and consequent alter the direction of the hair. vivabxiA. TTuiCU TTUUIU nil ne PATHOLOGY When all elae fails there is a treatment that is sure to be successful, but which will, in some degree, disfigure the patient; namely excision of the edges of the lids with either a knife or a pair of scissors. When this treatment is adopted the surgeon should be particularly careful to remove the bulbs of the hairs, in excising the edges of the lids. Some surgeons do not cut the cartilage of the lid but all the parts superficial to it, after which they destroy the bulbs of the hairs by applying to them the nitrate of silver. In performing this operation the surgeon must be cautious not to wound the puncta, or the lachrymal canals. The treatment I would advise, and which I have always found successful, is the same as that recommended for en- tropion— an operation which I consider an improvement upon that made by Dr. Jacob on Sir P. Crarapton's opera- tion. But when the disease is slight, with but a few irre- gular hairs, perhaps the best treatment is that recommended by Mr. Hunter; but circumstances must also guide the surgeon as to which mode he will adopt. Entropion, or Inversion of the Eye-lids.— Entropion is exactly the opposite disease to ectropiura, being an inver- sion, instead of an eversion, of the eye-lid. The evil results of this disease diflFer in no respect from trichiasis, as in both cases the eye-lashes are directed against the globe of the eye, although not from the same cause ; the fault in this disease being in the eye-lid which is rolled in on the eye. As in trichiasis, so in entropion, one or both lids may be diseased, or only a part of either. When only one part of the lid is affected, it is generally its external angle, at least so I have always found it. Entropion is of three varieties, viz i— acute, chrmic, and traumatic, all of which, although producing the same effects, depend upon different causes. The first is generally found in old persons ; the second in young and scrofulous children ; and the third may be in either, as it is the result of injury. * This is the treatment, I understand to be still adopted by Mr. Wildn of Dublin. i. 'I i '■] PATHOLOGY taneous incision for the cure of entropion ; and operated as follows :-At half aninch from the external angle of the eye he inserted a small tenotome, which he carried on to the internal angle, and then turned the cutting edge of the knife downwards dividing the fibres of the orbicularis muscle:-the muscle of the inferior eye-lid was cut in a similar manner, the knife being inserted in the same puncture at the exter- nal angle of the lids. M. Petrequin, of Paris, under the impression that per- manent contraction of the fibres of the orbicularis was the cause of the entropion, recommended subcutaneous myotomy for Its cure and gives a case which he treated in this way with complete success. He placed the instrument on a level With the floor of the orbit, the lid being held, extended, and passed ,t under the skin and the orbicularis up to the free edge of the lid, taking care that no fibres escaped divi- sion superiorly; the instrument was then carefully with- drawn, dividing the fibres, the operation being assisted by pressing on the eye-lid with the finger. When I am satisfied that the cause of entropion is a superabundant quantity of integuments, I operate as recommended by Scarpa, with this difl-erence, that I leave a small slip of skin next the cilia, and use ligatures to bring he edges of the wound together. In all other cases, excep! traumatic, whethei it is Tnchmm or Mitropion, my treat- ment is a compound of the modes adopted by Doctors Jacob and Guthrie I make two perpendicular incisions, as recom- mended by Jacob, and unite them by a longitudinal inci- sion, by excising a piece of the integuments in the manner recommended for simple acute entropion ; I then bring the edges of this last wound together by sutures, and get them to unite by the first intention; but, following Dr. Jacob's plan 1 prevent the perpendicular incisions from uniting bv touching their edges with the sulphate of copper OF THE EYE. 221 The two perpendicular incisions should enclose between them the exact portion of the lid that is inverted ; but care must be taken not to wound the puncta or lachrymal ducts. I conceive that Dr. Jacob's mistake was uniting these incisions by a longitudinal incision through the conjunctiva and cartilage ; as the healing of this wound, whether by granulation or adhesion, must tend to bend the lid still more toward the eye-ball. Symblepharon.— By this terra is meant adhesion of the lids to the eye-ball, which deformity prevents the free motion of the globe of the eye, and, as I have mentioned, when treating of entropion, always produces tnat disease in the traumatic form, though traumatic entropion may exist with- out it. In the treatment of incised and lacerated wounds of the eye-lids, it is explained how symblepharon can be prevented from occurring as a consequence of such injuries. Treatment.— A\l authors agree as to the difficulty of removing these unnatural adhesions, or rather of preventing them from again taking place after separation. There are three modes of treatment whereby this re-adhesion can be prevented,— firstly, by ligature ; secondly, by dividing the adhesion, and placing a plate of thin sheet-lead between the eye-lid and the eye-ball, to be kept there during the healing process ; thirdly, similar to the second, but that a fine soft piece of lint is used instead of the lead, which is much the best, and was suggested to me by Dr. Macdonell of Montreal. The ligature is the best mode of treatment, when the adhesion is small, like a band holding the lid to the ball of the eye ; it is used as follows :— a curved needle, being armed with a double lifeature, is to be passed through the centre of the adhesion, as near as possible to the reflect- ed portion of the conjunctiva ; the needle is then to be cut away, after which one ligature should be tied as close as possible to the eye-ball, while the other mnst be tied just as near to the palpebra ; the ends of the ligatures are to be PATHOLOGY rr^7fh 5, '^ '*".'"/ ^'^ '^^J^^' «"'J '» «« doing remove the adhesions which do not form again. When the adhesion is large it must be cut with a knife, andjf p" si the Hd an^r 'Vr^' ^^""''^ '^''^ ^' ^^'^^^^ between the Id and the eye-ball, and the lids closed and kept in that posiUon for thirty-six or forty hours, by means of a comp and bandage; at the expiration of this time the eye should when the lead s used it must fit the part well, and be per- fectly smooth ; it will then produce no irritation. ^ succesriTi'^ ""'"''■•;"' '"''' '" ^^' ""^y ^'th invariable success, and I now use lint in preference to lead * thf!t^!^^t"T~^y ""' *'™ •« «»eant adhesions of ^ul oV'n- °*^f "' *?'•' '^^''' ""^'^ '« ««°erally the result of injuries. In such a case the surgeon should with •The following case of the successful removftl of tha«> .,«. • "T were altogether adherent^he ?L't oSey' Ln'„'^"^L°?°''' T" had been a natural adhesion. I with muT Hiffs„. i. " ^ I ?' *''°*® ^^ '^ »' the left eye from their unnatural XsTon J£r l.vrT '''* "^«-"<»'' «f plate of lead on the front of the eS° betwe^^ ir^iJ^.K " •5""*' ^i^ *^ » theUds down on the lead with stri^nf.^K •*.'"''* '*^*' »°d '»«n'>d day8lrenK,vedthelead Thel'/ZeraAl^hT ^^'^T ^^""^ '^'^^ w^ severe inflammation of the eya-ball Xh 5 Zl'^''''"*"''. *•" *««» extensive dissecture which I mXatO;* time morL ^h-^'t^**'''"*..'*' *»»« of the lead, which I have used in manrother caleTwWe 5hV£S^'^ were not so extensive, without any evil result tJ:«™^!i il® ^•'f^ions cl«»ed it and the parts every twenty fo J hour^ Lh T"*'' '^^ H"^' '"'«' I. removed it altogether on t?e tffily The^^S^^f 'fl'^'^ ''• •»»» the slightest inconvenience from £ lelS Jng on Wst?"*^'^ °^^" ''^'^ About two months after oDeratina on »i,o i„?. i •'^ . eye and treated it in the^Xwbg^ZntVilTuJaTm'^n^".-'''' ^\^' adhesions every third day till all wlsremoved MtTt. P°"'°° °^ ""» operate ; each time, afte? separating the^dhe'silinwi''''"*", "?'*'' *« lint in the wound, and strapydof n the lid whh JS^ / '"^^ P *"« "^ In this eye there never was 5^ sliZest infla^l?'^ "'^ u^"""" P'"**""- perfectly free, the adhesions never Sfomed^dTt Jhi'f- «^t'"f'l.*" there was as much of the come, olel^ed "L^'Mi^' S'si^'l.t nt "^ OF THE EYE. 223 again united. This may be done by keeping them asunder by mechanical means, such as strips of adhesive plaster &c when the lids are thus confined the edges may be got to heal by applying to them a weak solution of the nitrate of silver twice in the day, and smearing them at night with a mild stimulating ointment. m^nan8.-Phthm, or crab-lice, have been found In the ciha and eye-brows ; they produce great itching and chronic inflammation of the parts Infested. The remedies aje cleanliness, and bathing the parts a couple of Umes ia the day with a weak solution of the bichloride of mercurv say two grains to the ounce. The strong citrine ointment! smeared on the part at bed time, is also a good application CHAPTER XVI. INJURIES, AND DISEASES OF THE CONJUNCTIVA, SEMl- LUNAU MEMBRANE, AND CARUNCULA LACHRYMALI8. Persons frequently complain of suffering great pain from some h.„g having got into their eye, by wlu'ch term it t" be understood that a foreign body has got between ihe eye-l.d and eye-ball. These bodies may bf either ehemic.l or mechanical, or t.iey may have both properties. Such bodies, thus situated, produce great pain, profuse lachryma- tion, redness of the conjunctiva, and blepharospasmus, .h se sj^pt differing in degree according to the amount of rritation induced, and the degree of natural irritabilitv Of the patient. Experience proves that, in persons of nervous irritable temperament, if the most simple body touch the eye, it will produce such a spasmodic contraction of the orbicularis as sometimes to defy every attempt of the patient and the surgeon to get the lids opened. This closing of the Ijds and the flow of tears, are efforts of nature to remove the offending body; and they sometimes do so most effectually by directing It to the internal canthusof the eye, where the caruncula lachrymalis and semi-lunar membrane help to expel It: but if the offending body should be of such a nature as to slick into the conjunctiva, this effort of nature Zmly ''"'^"' '"*""'' """■''' ^^ ^''°^ " ^^''' '"^'•^ The bodies which generally adhere to the conjunctiva are bits o stone, glass, straw, husks of seed, parings of nails, sparks of steel or iron, splinters of wood, &c It is a remarkable fact that all these bodies, generally, adhere to the corneal or palpebral conjunctiva, and rarely to the sclerotic conjunctiva, which can be only accounted for by PATHOLOOT OF THE EYE. 225 the fact, that the looseness of the sdprnfSp „«..• .. render, i. ™„ch ™re dmcul. for ."^h ^IZ Se"i r™ As the upper lid ■« constanlly passing over the eve-ball produce ohLoai i„jnr„Tr:o„™.rr ::„:!' speaking, qnlck lime, metallic acids, & generally it ?*;""'7"'-Wicn a foreign body gets into the eye if o^it^^ould be neutralised or dLj:;rtfltn: general princip,..,t dl'^ld Cn^' b^' a^'of r °" tivitis, in tbe article on ophthalmia wLn,.°T°"^ gets into .be eye, the natdTg for^ '3.!t IS to ran to cold water for relief ,nfl ih, ^T ° ""' ;le..roys the patient, eye", pTSla^ iT^ S 72 mtate Zr '" '?* "'- "•« eye destro^d n 2l^ minutes. When a patient comes to me with lu. !r Scts";he' ,fair:' :^\^zZrTi -"-^^ cam.|.b.,r l^sh dipped inl of „ b off n theT"" ? :rfr?e'';;xri':d''°'""^"''»'^-«^^^^ reflected Airs.:: „3'"l„m2?r 'T "" ralemal canth,«. 1 then e'en the IM ?""'"'" '° ">» »«d pick off ,„, portlV;,". e ,f^ °,"h:,t;''"""'^ ho^rever.mall. Sometimes th«lL.T "^ "main, in the conjunctiva, tTat U^t ^ ^'^sl" 'T''-?" t'ataract needle. P'"*^*^*^ ^"* with a -ospasmus ,s very great, it n,ay be allow'ed to re Jn'tm 916 PATHOLOGY poultice of bread c.un.b sprinkled with a little tincture of Znt w^r f Y~""' "'• ^^^^^^^^ of camphor: oD'at R L " *'"'■'''•' '■'■""' eivinfe' the patient an opsate. But once .n my practice have I found it necessary ltZ"nn7-" '"! ^''^"^'-'•''"'■"g. «"d tl'cn I bled the patient tdl ho fainted, when it was easy enough to open the that was sticking in the cornea. The treatment I now adopt, when the spasmodic action IS very great, is to put the patients slightly under tl e influ s^ble, and thus get the lids relaxed. A fact that should make the surgeon very careful in his examination is, ht foreign bodies sometimes get on the eye that are s" smal as to require a magnifying glass to enable the surgeorto and search well among the folds of the conjunctiva, and make sure that he leaves no particle behind The best mode of everting the upper lid is to take hold of the cilia between the finger and thumb of the left hand supposing the lid to be everted is that of the left eye. and pull It downwards and forwards, then with a probe, hild in he right hand, pressure should be made on the outside ,.f the hd, on a line with the reflected conjunctiva, and, while the pressure is making, the left hand should be raised sud- denly upwards, and thus the lid will be everted When a foreign body is stuck into the cornia, to have It removed the lids should not be everted, but the upper should be kept raised against the arch of the orbit, with the fingers of an assistant, while the lower is depressed >.ith the index and middle finger of the operator; then the particle may be picked off the cornea with a cataract OF THE EYE. 227 When removing such bodies I always stunl i...- . .. I'atient an.l support the um.er lid Im. , """^ ''"' with the cataraJt needle w , Im n^'lT "."'' "'"''' move the foreign body. Th pr v ^ t .. '" '' '" ' •"" assistant, while it elves a Z! "''''"^>' »'" «" eye. A slnall ^:X:m ^^^IT^ 1 "'^'^ '" ^'- the cornea eon unctiva, witl ornrod. ."" """"'^ "» finally a little abscess CrolndUanI ^^ "•"^-t'-, till a little slough. The evil re^nL? f ' c'^ '' '' '^'^ ««" ^"1' between thf ^yl-L7lT^^^^^^^^^^ '^"^^ ^«"'"»^ fla^n^alnn in I greater orTess gT '.'rf tL'bt" '" chemically it may at once destroy not onlv I ! , / "'"^ junctiva, but the entire eve-ball afrii ^! "^'"'^ ''^"•• the conjunctiva is sure to s„ff ' f ^^['''"^'' ««me part of biy, in Vn^bleVar:: ^\;S;,^;-f ^' -st proba- ••s nothing that cause's such a deep stain T'"' ^''''' or such an incurable opacity as that whf h' ^''T''^'^'' va».teJ, I. will „„. detach the ZtctlZ'',^ "'"'- nor from Iho ualnebr»- ih.™. ■'"''"'""™"i we cornea latter appear small andehrlten ™'"'"' """""« "«' e.»:rvrht;r„T:r„T '^'.^'"-™"-, "« ■«„U ^™S r-A IrTZtf '» "■» »'•«• from ^ho ■'"=•" -1- - - -^"^ ^'» sometimes fisc«na •^^ ..•^.. u.aug„ a nactured portion of its pariet7s, 228 PATHOLOGY and make its way into the subconjunctival cellular tissue Ihe treatment in such a case is to evacuate the air, occa- sionally, by means of a slight puncture, till the fracture is united. Suhcmjunctival PhUgmon.-T\ie subconjunctival cellular issue .3 sometimes the seat of phlegmonous inflammation, but It rarely runs into suppuration; when it does, the matted should be at once evacuated. The symptoms are, the con- junctiva becoming red and thickened, which is followed in a few days by the presentation of a small prominence. Sybccmjunctival (Edema.-li is stated by Mr. Mackenzie hat this disease sometimes occurs on the temporal side of the eye-ball in small patches, and that it causes the sensa- tion, as of the presence of a foreign body. He asserts that ^e oedema generally shrinks under the application of the nitrate of silver or wme of opium, but sometimes requires to be snipped off with a pair of scissors ; particularly, as the patches often degenerate and become cartilaginous. I have never seen any such cases as those he describes : indeed the only oedema of the conjunctiva that I have seen is that inflammatory oedema which resembles in every respect sub- conjunctival ecchymosis except in color, the oedema being of an amber color and apparently sero-gelatinous. This is not m Itself a disease, but accompanies severe ophthalmia : r have found it m severe cornitis and general ophthalmitis. Pterygtum.-Thx, term is applied to that preternatural little membrane which is of a triangular form, its apex being always towards the cornea, and its base generally towards the camncula, but it may be either at the external canthus, or he superior or inferior part of the eye. One, two, three or tour pterygia may exist together on the same eye, the apices of all meeting on the centre of the cornea ; but it is very seldom that there is more than one. In two instances Beer saw two on the same eye, and once he saw three. Waidrop saw two on each eye of the same person. I have OP THE EYE. ellular tissue, the air, occa- he fracture is ;tival cellular inflammation, es, the matter are, the con- is followed in ninence. r. Mackenzie iporal side of es the sensa- ! asserts that nation of the s requires to larly, as the 'US. I have ; indeed the ieen is that respect sub- Jema being us. This is •phthalmia ; phthalmitis. •eternatural apex being II7 towards &l canthus, two, three, le eye, the ; but it is instances saw three. 3n. I have . 229 bui r hi '''' ""^''^ '^''' ""''' *^« «" the same eye ey Th! Tr """Z"'''' "^^^« "'^^^ ^«« one Teach eye The d.stmgu.sh.ng characteristics of pterygium are ncZ'at/tir' ''' 'r '^'"^ «" the'scle'Tcon: junctiva, and the apex on the cornea • if thp ovo k» * inio a fold »ii n*». P"^ **' ^^'■'^^Ps and raised Tn to it P. «?"f «««ces of the cornea being adher- ent to t. Pterygjum is divided into two classes vh • Thl .„r^r^"~'.' »«"<"«<"» well "ponlaneously, and i, n„, curable „„te, ,•„ ,he ver^ tooipient sL-.^e, e.nlit T „' °°' tio. i ,„ removal by operation will alwa^ leave a ciS Pteryg,„n> te„^ be removed as cover, . ^11 tu ! »;:ieJ "°°"' """""""'' "■» '«" '-'»-t for 2 230 PATHOLOGY •'irected to turn h/s ey fowards .« "^^^ ' '' *' ^" the base of the pterygfum tl' h? ''"''^'^-^^S to I'oldoftheaDexofthf^^'K ' '"'■^'•'" «'''^»'d take 'Tom its voZlV^jTu"''" '* "''""^ ' ''"« ^"d -half raised off the ba ^rthe eye ui f ' '""''^ '^enbegently fingers of the surJLLT' ^''' f.««"«ation is borne to the indicates the ZSlZ ' 'T^^?"'^ ^ad given way, which cellular n^e.^t^ thT ol'^f^^^^^^^^ ^^«-^e surgeon must then with a kn e or oa ir of '"'"'^ ^"^ should be turned -towlrr Vh ' '°°'*''"^ "^ ^^ich incision wil be thus madf H * 'T'' '"^ ^ ««»'-'»°«^ cornea. After he operltion /h"^ 'ts concavity towards the ordinary business ' SZr ^"'''''' "^'^ ^' «^«"t ^is from fourteen r^en ^t^'lf d ^""f^ ^^"^'^^^ '" i-eels stiff and uncomfortabr'it iTf ^ "'"^ '^' «^'« water. ^omtortable, ,t may be bathed in milk and membrane ; if s lerZ^^^^^^ '"? ^^^"^ '" ''« ^ellula; white of th ey It rarl 1' ' '''"'"' ^"* «° *»>« .^hould, it may L\ken" teh 2 frr "d '"^ '' ^* with a pair of small scissors. ^'' andremoved «4rctf istm^STt*""?: P^"'^*'^*' '' -'-««c r believe the; re^gr^w from th ''' r""'**^'^ ^^^t^' those growing from the sdlror '"'"''' conjunctiva, but to cover the corr ^ p ^'' sometimes so large as accompantrrivar^-TuTuTt'T'"^^^ >aus, out It IS not always present until 11 OF THE EYE. 281 Polypus of the Confuncttva.— The on Iv ^o «« nf *u • j • that I know of on record, is one bv M. f ^'"' f''^^' describes as about the siL Tf a ^ T'"''' '^'^'^'^ ''^ slender stalk to h inner urflrH' '"'' '^""^^*«^ ^y - the 11th of March Tfils I ' "PP'' '>'«-''^- ^n s.ith, consulted t T^^^ hra;:r 't' followed by a few .l™T ] * . 1'°""'' ' ""= ^'^ produce any irr;tali„„, they rtolle ,1' 1m r '°^ pairof forceps, and ,„ip'ped offwUha pai „f ,1 °" °! ',° ' .^\'z "rrer'Tf ™: ™= 'is^ixXn:^^^ tamonr^ i, ,„ remove tl.em byexchU ' "" ""* vj.e„d;f;rsra:drri:sr-- 232 PATHOLOGY exposed to the ,,>, becomes encrusted Th« r "Of a deep red color, and is ant Lh? ' / u ^""^°°' "«»* a foreign substance. The If .k ''^^ ''^''' '""a^d by eye-baiJ sometime^burs^s if !„r ^ '' ^'"^^'^^ <>» the o-ly difference betweerth 'a„d ^t^"^^ ^ ^'«^''- ^he the latter is of a gelatinous an^ '''"^''^ 'P«^'«» '« that brownish color. "' »PPearance, of a light yellow or If ^^^^T'mXlT:^^^^ '" ^''^ -"^^ - both species nitrate ofsil.er or the vUiT"' solutions, such Z Z b"t if these be no fo?„d .7^''"""" ™*>' ''^ ^^^^^^ ^Testing the progress ihpV ' ""mediate effect in the better J S^l7m ^ZITT'T '' P^^^^^e" should be removed, to tcllh l^Jt ^""^'^"^ '"^^^ necessary to separate theTdTwh . •. " ^' ^'^'"^^^'^^ ^itbus, that they may ^ the ml' '"^^^^ '' '''' '^''^^^ *^ich the fungous mass Vol noTh! ^' ^ '"^'«'^' ^^"'""t after treatment consists in k^n ^ ^'"^'^'^ «"t. The «ttle milk and ^at^l^auTZlT T '^^'^'^ -"^ « appears, it should be kept down Tlr*"" "^ **»« ^»°gno» nitrate of silver. mleX.^!:- '^' fPP"«*««« «f the smeared with simple 02^0 T""' '' f «««'ng a probe, eye-ball two or three tte!; ^ ''" "^« ''■'^^ «nd the Pharon, should not be negre^Ld '' '"^ ^'^"* ^^-^^e- semi-lunar membrane Xh?^,''" ^''^ '*'"""<'"'« and 'ated, and of a n^ul^ai;^^^^^^^^^^ ^-n- advanced stage, it emits XnT; ^'" " ^«*« «to the the internal pi of eT h , d nearT'.'^' ^'^'^^ '"'^ along at the same time fillinltie w o,e of !" ''*'"' ''' '"^^ up to the cornea. This tumor nl! f u' '"*'™*' ^authus at the internal canJh , and "vX^^^^^ ''' '''"^ ^'^-^ qnence of which is that Ir? • P""'**' *''« ^^n^e- lacbrymarium and chron c onhthalm' ''"!'"' '""'^''^'»'» OF THE EYE. 233 Encanthis may be either benign or malignant, ih. nea^t.-m be„ig„ encanthU fa alwa™ curabte hv better than the danlr ^L^^ "'''''"■' *"^*'^'"^ '^ should be excsedTh! 1*'°^'"^ ^ ''''''•''"«' therefore it be peXmed tio h!v"t 'r7'"' ''''' '^^^'*«°° ^^ould the low 1^;^'^^^^^^^^^^ 1 ''^ pr" *'^^* '« "P- then do the ame wkh th. '' '' ''^^ ^"^^^ ^' '^'^^^ which he Isttytm holforrr^ *'' "^^^^ "^' ^^*- attached to i wfth a nai of / ^ ^' ^^ "' ^'''''^'^ Ti.„ I . ' P*"^ <^' forceps, and dissect if nnf The only instruments necessary are a nair of f!l J of the caruncula Thp of/» ! T *' '"* *^*^ ^''^ ""^'^^ 7- 234 PATHOLOGY OP THE EYE. tnt?. r^"^^ or injuries may produce inflammation of these parts; when such is the case they become enlarged when tht n" '' ''' "I"- ^"^•'^^^"^'^ P-» - -ffef d when the hds are moved, the tears are obstructed and there IS an increased secretion of mucus. The inflammation sometimes terminates in suppuration of the caZcu «! m :: b': T ': ?' '?r' '^ ^ '""^«"« «-«> whih' scisso s ' ' "" '"'PP'** '^ ""''^ ' P^'^ «f two years ago. "'gnteen years , when this drawing was taken, about p4:t3'zv?h?cor^^sre"a t "br"' '^^\'' ^^^^ "«»" «:-«. close examination it wMfo!,nT;„K ^ h'*^*? " ««^ the nosef Uiion was not very ensUiTet^S touch •Thh'"'^ '"•''^''''^ "° '"• ""rfacefit forward, it 4s found L be attached 'boS t'!?fh*'r« *' "/ ""'' •^'»'*'"8 '« cula and the conjunctival linbrofTheSeriorhdh^F ' ^«t - ^ from the coniunctTvTl n " ''"°^"'^ ''°''^'«" bodies after treatmS ;?„ eX^ ^ere. The only thepatientasmnrf»or ^ " ordinary cases is to give dietfoafer^^^^^^^^ a little rnUk tTZiT.'oV'' ^^^ '' '^^''^^ -^'^ imperative to bleed from th "T' ''"^^^^'•' ^^^^ ^^ continue unabated to .J t T' 'f '^ ^'^^ inflammation tartarised ant mo„; iT« '"'T' ""'^ "'""*« d«««« o^ andlgenerall/finLatw, .r'** ''''' "'"^'^ ^^^^^ ^l^^^* the injurr, and does t n ?" '^' P*"'°* ^°™«« ** «"«« ««« him, th7 nflall . '^""■*"* P^"°"« '"te'-fere with is removed b^m'"" ?'^''^'"^ ^'^^» *»•« ^«>-eign body receiWng tore ni rT 'T' ''''' ' '^"^^ ^^^'^e eye persons ^to remove ThlT.''K"''"P*^ ""^^^ ^^^ '«"«'-«^t itself.* ' *^' '^"'^^^ ^''^^ 't does from the body Penetrating Wounds of the Cornea — Woi,nrl« nf .». sometimes penetratp ;«<« Z^\ yVounds of the cornea eye: the result Tn ' ^"*'"''" ^''*™^«'- «f the wounded th extent' of thT" ^'^ ^'^ ^' *'^« — whether in ^ed ace JL' ''"""'^' ""^ '"^^ ^«««="ption, the cornea 2 Spv f / "' P""'*"''^' ^" ^^-nds o or less'Vj^^ :^f,ir -fj-- a cicatrix of greater to be visible to Z nT.!i ? *'"' '^ ^^'■>' ^'"a" «« "ot wound caused blr, '^'' ^''' '"*'"P>« *»"« P"nctnred made bHh exCinT^^^^^^^ ""/'? " *••« '"^'^ -«-d ming an"^ suppuraTnrMJin!- "^ 'T^''^ """'^^' '"«*- as to interfere w^vistn inT T '"^T' ^^'^^"^ according to it, .ll • / ^'■*^*''' «'" ^««« degree, ___jng_tojt^^Uu^^ There are few tetanus terminating iirdeath^ ''»{!L^ t!,'^il i'"®'®. '" * "ase reported, of cornoafromthelasLfagif^hiJ^rLvnt" ''^^'^'^'^ ^oun^llThe 8 6 n'p. ^1" patient W8» a man aged 33 years. OF THE EYE. 237 penetrating wounds of the cornea, except very small and oblique punctured ones, that as soon as the bodies which cause them arc removed, are not followed by the loss f the aqueous humour, which very frequently causes a pro- trusion of the iris. The loss of the aqueous humour is of but little consequence, as it is soon renewed when the wound heals ; but the protrusion of the iris Is quite a different thing, for restoring and keeping it in its proper position Is not such a very easy matter. IVeatment.—Where there Is an incised or lacerated wound of the cornea, and no prolapsus of the iris, the treatment consists in removing any foreign body, if such exist, then in bringing the edges of the wound together, and keeping them so by closing the lids, over which a few strips of plaster should be applied to keep them fixed ; indeed, as a security against their stirring, both eyes should be covered with a bandage for a few days. The eye should be exa- mined on the third day, when, if all has gone on well, it will be found that the wound Is healed, the aqueous humour reproduced, and no evil has resulted from the injury. If however, inflammation is present it must be removed by the usual means. If the wound is followed by a prolapsus of the iris, it is necessary first to restore the iris to its natural position ; the wound is then to be treated as already men- tioned. Some authors declare that no attempt should be made at reducing the prolapsed iris, if the accident has occurred longer than one or two hours,— others say after as many days ; I think both are extremes ; I should be sorry to consider it hopeless after two hours, although I should consider It perfectly so after two days, for before that time adhesive inflammation must have set in, which causes the prolapsed portion of iris to be adherent to the edges of the aperture In the cornea. The best method of restoring the prolapsed iris is to make gentle pressure on ft, with the fingers, through the 238 I'ATHOLOar the p,.,,n ,„ „,„„.aet „,•„ ,t, '''''' °' 5''.'' "'"* 'l^'-g portion of iri,; but if Ute r ^ ^ . "" l""'"""^ lapsed tlic oye «h„„l j In "^ •" '"^ "'''" "»' '■« P'"" .Lis tLmen! wHl t^t „ f.^S t 'v" "'7' '""^ ■ U -^ly oa„,e, n,o. of the in-J .Tp^'r ™'^ '-'"-«>• nitrate of Xr every day „?"' " "'°'^''"' "i"" «■« brought o„ a leyeM^th^he cS T?" ";{' "" " " uses the seissors he must be^Z*, ^/°" "•" '"''S™" tion has taken plico forrf ., ! *•■" "'""*'''= '■""»■""■«- «.o prolapse ofil^ltrthelrt' "'" °».'^ '»™' be suddeni, restored ,o it's :i:lX^Z^'Z 71 the a,;„„s hu^t t? i 1' ; °ruM hr/' "f'f °" immediately applied to the affleteC. " '° "" tem^erJmh'ST "'"",' '''''°°"''''"'''«»""S.--Sep. iemDerloth,I846,Iwa3consuledbyMr B roi-^,.L. m^ -.e..,k-ir;ytr.re;s:rfh:xt OP THE EYE. 239 his lancet. On examining hia eye with a good light, and the assistance of a lens,! could clearly distinguish that there was .something like a thorn which had pierced the cornea. I removed it with the point of a cataract needle and found that it was a thistle thorn. The punctured wound in the cornea healed up in about forty-eight hours after, without any treatment but touching it once with the nitrate of silver. July 28th, 1847, Patrick Wheeler, aged 38, labourer, presented himself at the Eye Institution, having his ey/- bound up with a handkerchief. He said he had been break- ing stones at a place some miles distant from the city, and that a chip of stone struck his eye about one hour previously. On examination I found the lower half of the cornea raised in a flap, all the aqueous humour gone, but no protrusion of the iris. I placed the edges of the wound together, closed the lids, and kept them so by means of strips of adhesive plaster and a compress and bandage,— all of which I removed on the third day following, when I found the wound healed. The little inflammation that remained dis- appeared in a few days, leaving the eye perfectly well.* Foreign Bodies in the Aqueous Humour.— Thas^Q bodies sometimes pass through the cornea into the chambers of the eye, after which the wound in the cornea may or may not heal up. After passing through the cornea they may lodge ihl ^" 'he Dublin Quarterly Journal of Medical Science, No. 10, page 501 Jrn^n i^°"""^ Statement .8 made by Mr. Wilde, and I regret o'^sfy that' iTn T^^ «'=?«"«'«'« .i.canno' "gree with him in his views of belluTonna when the portion of ins nrotrucftd is at its ciliary edge, nor have I riet tried the remedy proposecf by M. Desmarres. " If the p;otr; Jon is r^cem jtmayfrequentlybereduce/bytheapplicationofbelladonnaZarophLe^ and les^ning excessive action locally ; at the same time carefully aS; all mechanical attempts at reduction. We usually cover up hVeye fnf Tl!& •* W?rh* T ""f T^i'^r*' ^"'P'^'-'S '^' belladonn^a^ fre?uen5; as possible. With the rule laid down in books, of not applyinff the be la ™ f *^'rP-"^'"^'?f' °^""*'^ "^^-^ '^'^ '^^^ "f the cSf we canno S' V^'^ ""^ dilates generally, it must of necessity tend to dr^w "he small protruded portion within the chamber. If the iris has become^her! ent, all such attempts are fruitless ; we must then direct our effZs to ih, removal of the hernia. Unless the patient is very si^4" and I'l al low 240 PATHOLOGY inflammnlion, but if vnry ,Znl,VT',\"''*' '""'™ ^rea^wen^.— If (he foreign l.n^„ • "issoiveU. ?ra.-n of ^un-powder o a iSf'' /? ''"'"' ^"^''' ^« « "ither (he iri or the ao,I» , '"' ""^' '"^'^S^d in 'iace no pain or nflLTr •/'""''"'•' P^°^'^«^ " P^- to wonnd the pa tl doinfV"' ""'"' '^ **'^^" "«' •todies it will be fouid nerpTf , '''^''' ""' "^ ^''^'^ cataract knifej/TelTrja^'rh ?/""" """ « operation of eitraction TelJni „ l'' '"'"'''^u ''' be made large, so that the body may be Lpr"'"'" '^'°'^ some of the huraonr also shmS r n . *'"'"*''*''^'^5 the knife is withdTa^ fo?;/!?^ '".'^^^ '' «»«"?« before none of the humorb; ^ How te"' '"' '™^"' ""'^ the iris is more likely to en a? T. T' * ^''^'^P^"^ ^^ only bo performed under Jike SuluL "'* '^".r'* » «"« need |« can forcible opening of the eyes, s LiurTo ™ «^H «7V" "^^ '■""Kh-handlinror T " J'^i'"??^" hw l4en oiJe f^ more t? r* '"r"'*'' '^^ '"i^hief snipped off the protrusion with V^ j u. " *« ordinary time we h.™ gotridofthecaLofTtaS M Df,'m'""'-Pr"'*«' *"«>« S a new method for reducing iridialherniLhT" '"•"■ l-'^'^ '«?«nn,end^ vessels which feed the edges of tlSo,^^- f""*' '"Aammation of the secretion round the manrin!ff ^l u "• *' " ">duced, and bv an in«,l j chamber. If oneTffo^Trhe tp t?s' the " '^'■'''^ «»d dSwn";^^ ' no expenen. of the P-ti^'buTKt Svol^alllr^^rlir- ^^ ^^^ OF THE EYE. m escapes with the aqueous humour, however, such a favorable occurrence is by no means usual, the surgeon having generally to remove It with either a small hook, forceps, or scoop. And here I would remark that I know of no operation on the eye that requires greater caution and skill than the removal of some of these bodies. The after treatment consists in bringing the edge- uf !a, wound together, then closing the lids and keeping /hm 3■- acred opaaoe no one, « , ""' '""» '" """ ''»- »0 explain r ta ' t '^" ?"""•" "f'"' -veratlempted from L eke"SZ"," *"' f' '""' '"'™""'» "P^l"" is caused by (he Bo„n,l i. .7 '' "'"'""^ buraour, or but that it I the resurlfL ^"' ^"^ ''«'" """'^queuce, ftlWing fact :lr Th jfT'"''™ '' '"'''»'. f'™ 'be ducing fdhesion b .we"" \f ™ r«* '» "■» W»> Fo- And2nd. That well dirLVd ireaJl, ™'''"'' »f 'b»l«»>; allay the iuaammatiou prtenu rfl?r'T' "■'"=' ""' the wound leaving „„ ^ri re°!| h„? "°" °'" "'""•'"='' the capsule of the'^lcns a d e™ mlch" ^ST *"'" "" removed l„ time b, .he' ac^ou'^hTrbso elt °"""-'' " .ic,™brp';^^';zSn'r™r'' '-"'■••'''■«^''- »f both eyes and body T, L tl'ifr \"'"°'" rentraicrTri-t""'""^^™'^"^-"^ cloth wetted with either rolTr l>elladonna, and a as the patient nt^tHllS™'" '^"' °" '"' '^»' .betn;ts;^-tra:r'^;;j--^'*^^^ accident occurs the most ^Pnprli Tl ^^^° '"<='' an in, is either the antZ or ^-^"^ ^'' ^^' '«"« ^« 'o^ge may burst thron^rh ih. u •]. "'^'*"' humour, or bccLe fl«d u™dT.h'e':ot™L'"' ""'"''' -"' """ -^ .oduce in,Xai„ rr ::~t'.r OF THE EYE. 243 t.on hrough the cornea, but if it produce no inflammation it may be left to ti.e absorbents to remove. When U is sUu ated under the conjunctiva, it should at once be removed" as here .s no danger in the operation, and all that is requ I ed ,sto make a section of the conjunctiva down upon t and U w, 1 slip out. The after treatment will be to keep he eye closed for about twenty-four hours. Whenu's thrown back into the vitreous humour, it becomes a que ton whether it should be extracted or not for tl« vtreous humour being broken up, it is verrdiffic It to ZcTth^erTr'" '''''''"''' '•« ^^"^ -^« uon 1 would let it remain quiet, and even if there should be shght inflammation I would try'other means, whth would consjs ni depressing the lens with the needle lepnTtt gi3uc measures. It must be remembered, however thit somefmes the inflammation will run to su h aTeLht ha the lens must be extracted at any risk * Wounds of the Sclerotic and Charoidea.~ln Chanter XV under the head of " Lacerated Wounds of the EyT- ds^' / gave a case where not only the lids were wounded! but also e scierofc and choroid coats of the eye. The t eal t ot the case is also given. cawueu* Wounds of the sclerotic and choroid are not so dangerous as some authors would lead us to suppose, for, if such were the case, operation for cataract, which is so of^n perfored examination. I fourthaUhe ^nl hnH h '^'?'^'"S " '^«' fr"™ " «hoe On in the pupil/one part of it beinS tt aZfor'^'ll.""^ T ""^ «"<» chamber of the eye. Iritis ma VreLT ^t' " ?'''^'' '" ""^ Posterior successful, which^vas taking holfo/ the leS oi't?"""^' ^ ^^"^''^ "'« cataract needle, and depressing it down into he Ci? ^ J*"'"' °^ "'« «""«<1 ,.«.on after d^appeuredPundorfheSetet^^^^^^^^^ TheintI* The boy s eye ,. bow perfectly weU, and his ,°ght wstowj''" "^ potass.un.. 244 PATHOLOGY .. ! eyjl results. The dangerous consequences from wounds of thesep rt depend more upon the extent of the wound than nnyth ng else, and when extensive, the great danger is that ball to shrink up, and sight would be lost for ever IVeatment.~Xny parts that are protruded through thp wound must be :.stored to their natur .1 position byfenl KT rV?^'"^ *^« ''^J^ *>-er them ; the eyelds mu t hen be kept closed with strips of adheL've piLer and a empress and bandage, which may be removed' after th^ty! Sstic t^tCnf '""r' ''"''*""^ ^"'^ ^«"«^«' antiphlo- gistic treatment are always nece.^sary in such cases If be foreign body which causes the wound, be odged in he eye, a„d is at the same time small and not easily eftrac^ or f tf IZ '*'. 'r V'?'^ '' ^"^^'^ «^*'"«t inflammation ; ror If the body .» lodged In the vitreous humour, I think it probable that more injury would arise from search ng for than could result from its being left there ; of course i? produce very great inflammation it must be'removeT Mr. Mackenzie recommends that it should be extracted .f that It be sunk in the vitreous humour, but adds that he has seen several cases where such foreign bodies have been lef w thin the eye the wound cicatrizing and remaining closed for months, after which U again opened, and the foreil body commg into view, was extracted. There is n > doubt that .1 at anytime the foreign body comes thus into vTew .t should be extracted, which h very different from search- ing for it in the vitreous humour. It may be here remarked that gun shot wounds of these parts differ in no respect from wounds caused by other foreign bodies, except so far as respects the force with which he body IS propelled, and the extent of the wound ; also, if emomi ^' ''"' " '""^ * «**'■"' '^"«* P^^-^W OP THE EYE. 245 Blows on the Eye not producing an External Wound.~A blow on the eye-ball often produces sudden amaurosis, with- out deforming tbe eye in the slightest degree, or even pro- ducing an appearance of inflammation. The probability is that in such cases there is concussion or laceration of the retina. The treatment should be antiphlogistic, and the patient got as quickly as possible under the influence of mercury. The ciliary vessels are sometimes ruptured by a blow on the eye, causing the chambers, and sometimes even the cells of the vitreous humour, to become suddenly filled with blood. When such an accident occurs it generally ends in loss of vision, for very frequently, after the blood is absorbed, the retina is found insensible. If, however, there 13 only blood in the chambers, it will be absorbed and vision restored, but if it get into the cells of the vitreous humour the case is hopeless. June 28th, 1849, 1 had a case of rapture of the ciliary vessels, which filled the chambers of the eye with blood ; it was absorbed in a few days. The injury was caused by a cork from a soda-water botUe striking the eye-ball. A smart blow on the eye, such as is given by the lash of a whip, will often cause bbod to be effused between the layers of the cornea, but it is soon absorbed by antiphlo- gistic treatm(Lt andcoH applications to the eye. Blows on the eye, a-: ! have airoady shown, may produce a dislocation of the lens, or they may rupture the iris. 1 Ml f 4 CHAPTER XVIII. OPI'THALMIA. part oflhe':™ Z'l^::'' 'f. "^^"^ '"«-'-tfon of anv '•« the part affel^ T L^ "^^^^^^^ "''^" ''' ^i"-'"- the student or young p act Lir f™ '"''''' '''^«'>' ^« ««t thalmia being applfed 1 ^^ 'f '^' ^'^^'^ *^«* «^ «Ph- without anvdisfJnlr "''^'^^ inflammation of '?- , -deavor:?;at t^a 11:^ Tlf--''- ^ ^^ are the diseases to which the fPr^ • !' *' '^''' ^^«t all such divisions and sub 1 " 'P^''^^'^'^' ^^^••^'•"g practical result, and ca^e Jn"^^^^^^ any And here I think it welHl L. l' ""/ '' '''''' '^'^ ^o particular part of the ey Lav bT ' t' '^'^''^^ '^y <>"« tion, and that of a paTt 12 'ZTlf^T ^''"''-'"- •nflammation of apart it f« "V ' ^ ^ ^^®" speaking of - confined to thaTf^^rt bur b7f ''• *'^ '"''^'""^^^^^ i"flaramation cannot contint ""^^ '^^ ^''^^^ J ^r any part of the eyel' hot L ? ^'''^ ^''"^ '' "'"e ^n first affected. The ; el JJf^^^^ ^ ^^''^ P^' ts, not at -e heat, redness, P^an^swe 1 L; 7 '"''" ''" ' ^^^ these signs are to be found inTnfl^' ^' ^ ^'"^'•^' rule other symptoms are o be found at'"'"'"'" '''''' «^«' ^^' ing to the texture inflam d andT,'^'"^^"^ '^''^ '''''^- these symptoms will noTbe seen wh '"^"''^^ ^"^"^ ^^ f them will be observable he'nce 1' '" "*''''* ^'^^^ "°°« describing the inflammation '.rt' ^' ^'''^* "^^essity of flammation of the eye ^'^^^^^^^^ In- -onoftheeyeisuJliSt?:::^:--^ PATHOLOGY OF THF EYE. 247 the means Which would subdue the former would produce no good effect on the latter. ^ The practitioner must never lose sight of the important difference between mflamraation and its consequences. He must also bear in mind that inflammation may be, from the very beginning, of a chronic form, and never partake of he acute un ess such a state is produced by the erroneous oi:;::72:y:'''' ^^^ '- -^^ -^^^^^-^ ^^^ --^ p^^-- J^rteral Causes of InfloMmatim of the Eye.-Among the rrl-T'r.f '"^^^^^^^tion of the eye are injuries of every kmd, both mechanical and chemical. Either very warm or very cold air will act as an exciting cause. Beer was of opinion that the quantity of electricity in the atmos- phere had much to do in affecting the eye. Amon. the indire t causes he enumerates immoderate bodily exercise, violent emotions of the mind, injudicious clothing, and high mng. He also considered contagion a more frequent direct cause than infection. ^ fnnlV'' '^'pT *""** "^'^*' ""^''^ •« indispensable to the ZtZ '\T>:^'^^^ be a cause of inflammation; neve, theless, such is the case both as respects its quantity and Its quality, but more particularly the latter. All strong artificial ligh s, or reflected light from red or polished sur- faces, are well known to act as an exciting cause of ophthal- mia, but it is ma greater or less degree according to the irritability of the eye. Beer considered the direction of the rays to make a great difference, conceiving that the eye was less capable of bearing them with impunity the more they receded from the perpendicular line, and struck the organ slop.ngly or horizontally. When we consider the position of the eye-brows and eye-lashes, acting, as they do, as a shade to prevent horizontal rays from striking the eye u must be acknowledged that there is some reason in thi theory of Beer's. But he further observes that everv statp- 248 ''ATHOLOOl for the eye of an Tfef t m 'i" ^'"'^ «°«^«^ very ^n .Europeans, and ittZSjT':'' '''' ^^ --" inconvenience by theZ 5 ^''^ '' ""■"« ^'^^ '" t any eye of , «e.borj;|„l„T;;ltl'"'* -"^'^ excite in 21 -hooid produce fnflam«Sttv rK''"""- ^''^^'^^''t «"• bow H produces it, 1 1,2 „. l^r ^^Z ''^^^^ ^^ ^''e eye, anther, «or do I m-.I JtTX^T^ e^P'ained byany' ^e„onthephysio..;of^^:^'f-«;f ^^e 4^ the primary seat of the inP^r > r ' - ''® *^e retina only e-P'anatiou ; but whtr.::^tf i;^:^ '/l^^^"'^ a^-^rt of an part that is gener.Hy ait.cVv wf„ '^/«"J°''«*'va is the ho^ it occurs. , ccnsid.; bai k »!* ' '"'' '' «^P'»''n ^y only, which is, bv Jaminf /h Tk'^ ''P'"'"^'^ '« one of the fifth pairof irJ^TJSbtl^e ^P^^'^-J'nic branch and that under particular !•! *"* *''® """"'aa of liirht .^•nd acting on thLne ZT^'''' "^"^ «^ « PeS •t: and thus acts as an VrZ-r '' * "^''^'^ iiT.'taWlity of ti^o Physiology of"h:s7jrb"^?'^^^^^^^ nerves, in Chapter III ^ ""' ^'^""'^ *he fifth pair of ons fevers, suppression of heat:? d't''' ^^*"*''«'"«- these causes wili be more parS f''^'^' *^- ^U t'eajingof the peculiar k nd of !« '^'^ ^''"^'^^ed when produce. *"*'' ^'^ wflammation which they ey'^tve"L^tr:ta:trit"^ ^--^on of the according to circumstanc Is th« "v ..' ''"'' ""'^'"^ «'oned hreveiy writer onilfvl t '*' '^'" '"«°- other part of the body such IX^/ '"flammation in any dinretics, opiates, di/pCetic i "^' P"^^'"^' ''^"^eants^ juncHva.^ms disease is pa ffv -^^^ «/ '^ ^<>«- Pnrely ,cific, and diflers in m f in 8 relative ^er veiy w«|i 'Jts of many witJ; ,! t any excite in the . Why ught !i of the eye, ined by any ■ the views J'etina only idnjit of an ctiva is the *o explain led in one nJc branch 18 of light, a pecBh'ar tabiJity of tJon. (See fith pair of nation of mthema- &c. All 3d when ich they a of the vaiying n men- in any seants, et, &c. e Can- cers in OF THE EYE. S4d ran» Into nerfrrt ^i,.„„ • . ,^ ^™'' ^'' " "''er hr^'' '„- l™?"™;' """"" "^"■'"bbing of flow ottJ^^Tlt "'"J""""™ 'here .'3 a copion, follicle, USg'™ tt e W",h Th "'%r"«""«" stage ofthe dlseaac the ere L Mamilj .1. , . ""' juncliva will be f™,nrf .„T '"™"'"'' '^e palpebral con- Pi»«a„cra:atbrLt^,rssi^r:r r^^^^ severe opElTa rh!? f ™ ' «'"""" """='» »» i" for -hen'troTi 17*; ! .™Lt7;' -rr'"" -« ,,.voio uoes exist, it is no . '■% ^i n- 'f ; ff >■ y Till ^'"^ 250 PATHOLOGY longer the disease here trpaio^ ^f u i of the conjunctiva At 2 ' "' ''"''"' inflammation the secret onTom tit n-'T'"^'"'"* of the disease soon become opaque thirr,^'? *^«"«P-«"t. »>ut it day time is not so vis bio 'h" ''"'■'^"'■"' '"^ ^"""" *»>« ^orn^ed, by the ^eaTfl"^ ^rfer^t' ?; tf ''I' ''" remain ouiel, will, l,i, im. .1 7? ' ' '"^ "'" P^''™' lepreJng toe W M 1 11? r " "'°'' "™' """■ ™ ing in the tears I h.r »'"""«« will be seen float- placeintheeve ngS-hotr "°"' «"""™"^ ""■« and the patient rSe" 'j W '."? *''""™"^ ''°"°™'', the provaLce f t all' iTo " ''■' ™"- """"« impaired hiw fhom • symptoms vision is not much byrtttotX^^^^^^ cornea. If the patient L 7ul •"'""■ "^^^""^ *« «'« goes on wel orlbl he th J '"?''*' ^"'^ ^'^^ '^'^ foreign body in the p- ul ^^^ ^^' ^^°«»t'«n of k charge is more freely secreted «5„hl ?. ' *''® ^"^ .»«» gradnail, dLn^iS' Iti t ^T^': r^T -XTe::rirehir:er.&^'r: disease he ey in adnt" T " " "^ "»" '°'»'»»" found it i„ it, I'l ' V I ^ "^ experience 1 hare as true simple form more frequent in adults, OP THE EYE. 261 and in its modified form in children, wlien it generally .^TTdT!"'''^^^^^ Ifitbe'modfled •n the adult it very frequently becomes complicated with pustular conjunctivitis. "'l'"caieu with Dr. Jacob .ays it i, epidemic or endemic, and whether same /amily. I do beHeve that if the puriform discharge is ^e, rt w II produce the disease in the second person • and Mr. Mackenzie give, it a. bis opinion that where tL' d.°. ease ,s thus prodnced it i. more severe, more distnc^^ JPrognos{s.-ln the simple form the prognosis mav h« ttrenThr; '^';\''^^^^^ neJlerr^imX treatment, the nature of the disease is changed so as to producefebrileexcitement and constitutionanEsTas "eH .•nflr f'"-'' *'''" '^''' '« ^^"g^-- to the eye. If The JmtrofThl'r "' ''''"^"* opinions as to the best ofTirr/ r . ''^''' '°"' recommending one chiefly of a local s imulating nature, others preferring a parlllv ant.phlog.stic Among those who support the foC "^ Mr. Mackenzie, whilsJ Dr. Jacob favors the latter™ ode thl pff , r ' demed that such applications may have the effect of arresting the progress ofThe disease a7o„ce; i\ m PATHOLOaY bat if they have not that effect they are liable to produce an increase of irritatio...' f fully agree with Dr. Jacob, that, It the progress of the disease is not arrested n^ of irritation will follow ; but such an occurrence can only result from the application of improper stimulants. I know of none that can be used with safety except a strong solution of the nitrate oi' silver, the strength of the solution depend- ing upon the violence of the disease ; I rarely find it neces- sary.to use if stror.ger than ten grains to the ounce, I some- .mes, howe^ c • use it of double that strength. In a case of h.8 k,nd, my pr etice is to clean the eye with a sponge and a httle warm water, then drop on the conjunctiva the ten gram solution and allow it to remain there, keeping the ower lid depressed, for about one minute, then w;pe it off: his I repeat every morning so long as the inflammation is severe, but as it abates I use the solution weaker till I c.mc down the four grain s.^^ution. During the continuance of the diseasel desire the patientto dropuponthe inflamed eye every night the four grain solution, and to smear the edges the eye-hds with a small quantity of the red ointment, to prevent them from adhering together du.iag f he night- I also give him a vial of the following lotion to bathe iu's eyes with on rising in the morning, as twice or thrice .' rwards m the course of the day. It shtuid always be used tepid, and allowed to run over the eye, which should afterwards be made perfectly dry with a fine wa ., loth. The lotion is one^recommended by Mr. Mackenzie, and is made a. foil ft oxmur. hydr. gr, i Sal ammoQiac, gr. vi Vinum opii, 3i ^qua pur IviiiM ft lotion. Mr Mackenzie calls this his soothing lotiou. deauli- ness beiN .: i>f the greatest importance, I always give parti- cular directions to have the puruleilt matter Lstan^i. OF THE EYE. gfig wiped away, (and never allowed to get dry), with a sponge and warm water. If there is much constitutional disturbance, I give the patient an emetic and purgative, or a purgative only, and afterwards a diaphoretic mixture to be taken occasionally, such as the Uqcor ammonise acetatis, with minute doses of tartarised antimony. I have never found it necessary to use a lancet, indeed I do not see what benefit could be d^nved from blood-letting when the inflammation is in a luucous membrane. As 'o leeching or scarifying the eye-lids, I have no confidence in either mode of taking blood, for if blood is to be taken at all it had better be taken generally. Blistering in the acute stage I have always found worse than useless; but when the intlammation is chronic, benefit is sometimes di "ved from blistering the nape of the neck. I always order t) • natient to live low, and keep quiet for a few days, but not tger. I have always found that starv- ing a patient and conf ing him to a dark room aggravates the disease, while ? u u exen ise and fresli air has a more beneficial effect than any trp ment I could adopt. If the light should cause pain I di. the patient to wear a green shade over the eyes. Severe Infammaf'on of the Conjunctiva.— This disease pre^ nts itself in three different forms, not specifically dis- tinct as to symptoms, but distinguished from each other by origin, history, progress, and consequences. They are termed the purulent or E^ptian, the ffmorrh^fal, and the purulent ophtkabntaofmfunts, which is also called ©ph- thalinia neonotorum. These different forms of this disease will be considered in regular order. J^rulentor Egyptian Op/if.hakiia.~Thc purulent oph- thalmia acquired the name of Egyptian, from tue fact tbat the attention -f the profession was particularly called to the disease, upon the return of the British troops to Europe from Egypt, where tbis disease spread among th«;m with 254 TATnOLOOY ob.o,v,.fl r„ .he „„i,„ Za,,z of .re':",; i": encrusted purulent discharge, on awakinir in h! When the inflammation has extended I7l. T,"""? ' pebral conjunctiva the purulent secreHon n " P''" OP THE EYE. 255 portion of .tl.c conjunctiva, particularly that of the upper eyc-lKl, Lecomes swollen as tl.c discharge increases, wl. ch untV!,'"'" K^ '"'""' '"'"^'•'" '''^''"S P'«<^« immediately under he membrane, with the inllu„.matory development of UH papdlary structure : although the inflamniation s.u J .reads so rap.dly from the palpebral to the sclerotic co! 1 va, as to prevent any distinct observation of its progress yet t W.1 very often remain in the palpebral, before spr^ d ng to the sclerotic conjunctiva, for tvvelveor tw'enty hours, andeven some instances will not spread to the sclerotic conjunct " but remain ,n the palpebral, and after weeks or even In h the purulent secretion becomes gradually diminished Id recovery finally takes place. But u hen the sdr ' eon^ unctiva does become inflamed, every part of it e^en uo : l\:t:i': "^"^^ '''"'''' '- ^"^-^^^^^ ^^^^< n itVfi ,? ! '^r ""«^^"P'«''- 'fhu« is this disease ed ess tb^' •^'^-f ''"^ed by the groat and uniform' redness of the eye, without any of that pain, tension or intolerance of light, which accompanies m.' t o her f rms o •nflammatmnofthat organ, the only pain bein^ ha of / on Zl I *^''" '^P'"'"*-^'' •" '^' P'-«viou8 article sta "7:;: '"f "". '' ^'^ conjunctiva). The second eZonll T'^Z^ '? ^''' ^°"'"'«"'^«'' ^^hen serous eiruson into the sub-conjunctival cellular tissue begins which elevates the conjunctiva, forming a chemosiT sof ' ^^s'inufelds' 'T- r': ''^''^ Uran;Z„: f: ces in the lids and gradually extends over the eye till It comes the edge of the cornea, where It ceases o d ,rb the conjunctiva; thechemosis, however, continues to c ge between the lids, and causes them to become slightly invert by Dr. Vetch m the following words :-« The inversion of 1 256 PATHOLOGY U I Ibe cilia may bo explained, by comparing the palpebr. to these combiiiPd eJ^ T . Pa'pebra, so that both sSinTis vet' r o f ''''^'' '[^''-^ ™«gnitude ; and the , '^ 13 jet r e increased by a ereat niinnnL «p *k purulent matter, not escapu.ff over thpfh? t k ? ^ • ^^"^ pent up betwee^ the lids'arld :;::ba,I. '' '"' ^'""""^ When the eye is in this atata u - • Whpti th^ A- . . *^ ' '°^* mischief is goinff on When the disease is thus far advanced tha mn«* «• u, termination that can be exDecfpnT . , '' favorable the svoinfoms !ii 7,f P^^*f '^ 's, a gradual subsiding of ine symptoms, till, at the end of four or five week, thpv altogether dis appear, leaving the palpebral conSaS ing rapidly from one to the other It ^pZi ' ^^^^^^^*^ two honrs,a. o.he?«if„r^/; ;— "J»'« "■ instance, it „i|, oominne witliLt a„y abalemen "iH: violence until the e„„,ea bursts, which'^i, 1^311 „„d l>y a gu,h of scalding „ler from ,|,e eye, and tamS relief from pain, but unfortanalely Ihe'syltZT^U increase in violence in tlie ofher cvf if «.„ T ti.ues unabated .upture of tberii Jl '^r'^nTo"; later, whetber tbe pain be co„,i„„„„, or i„ paro™ This great suffering is increaseJ by pain in the back ofThe lit OP THE EYE. 257 winch s some unes so violent as to surpass that In the eye • the patient w,ll always state that it is confined to a si' winch he can cover with the point of his fing or tb„m thedi:ri;Te?tt"'^'"^^""'''^^^^''^^^-''-^^^^^ mo disease s left to improper treatment, often followed I.v The disease h generally at the height of its violence whm he cornea rnpt^es; „„. u^ iengfh of time before ?Ms lakes p ace varies in dilfcrent eases, for in sme i ha„„en after a few allaeks of pain, while in' others the paro'C may occur daily for weeks before it takes nlacf Tl ■s one remarkable fact attending it, „U i'Ta't d^ tag ttcse paroxysms Jhe pnrnlent dikharge 1 diminlrd although the tears are much more eopionf. Afte ih tr' nea ,s rnptnred the disease generally beginsTabl, .1 J cBJenia and ehemosis .nbsiding, andl Hd wh h dirS^ be d,emos,s were inverted, finally becoming 'e™w Th f p:&::;;:ti:r'^^'''^^™"'»''^-'''°f^e *niL™ aTd :*:t"Lr^rtr "'V— " abo,.t the head, Freqner^'LV'o c^rS: a'lt" able mcrease of heat aronnd the orbit, in a d gree no L' tal pam, .s indicative of the inflammation extendln^rt: ** fe tu tut/ B ri 'k ■[! 'XI WJll 258 PATHOLOGY are so seldom met with that for T i • {^ I ''^ ""^'^^ ance that the eye wo d th ! •^''^'^"Pt.on of the appear- which the eye 'decried .h'r"'' '"^ ^'"^ '"^""'^^ ^'^ Jacob Spea..;:S;tL^^o^^^^^^^^^^^ .^f^ A" consideration should be to tppoII ♦. l- ^^ ' *^'^ ^'"^^ ons consequences he is C Hed 1 o T™7 *''^ '^"^^^■ tute the prominent s m llt^/^Sr Tth "f " or inflammatory period, he is to r collect that til '' be lost by sloughing or abscess of th c „! 'Vr """' puration of the whole eye-ball • in hi ^ ' ^^ '"?" to apprehend the injurror d si c n r. ''^° "^^ ^'' ulceration, or that chan^ f or^X^^^^ ^-"^'^ ^^"^ which precedes the normnnpn^ ^''^ '"'"J""''*'^* receive particular attention : if it be the rhn-f/ • • '''""'^ ing sensation of sand benon 1 f. .•/ '''^'"'*''^ ^^'^'d" eonjunctival inflam^alioH ^, Z '^i^ t '""'^''''^ «^ by intense aching, extendimr to ,.. , ''''"P^"''^ the head, it is evfdenc of "4 Jo^of i"? " ''"' ^''" «^ eye-ball itself j the cornea and fi 1 'f ''""^^t'"" to the yield to the distension of Lmrar^nl-"".?'^'"'"^ '' fascia, and the coverings of inrn^ ? '""' ''"^^ "'"«"''«'' - As sloughing orThs^^'-; Sir ^^^ quencc most to be annrehpnrlnri ' .^^^ ''^ the conse- appearance indicative of this evil I, i ""^y J<" »"/ OP THE EYE. the mischief 259 jasily recognized ; and when subsequently - sphacela ed portion comes to be cast off by the usua^ process of ulceration, and exhibits a line of "^^ep La S »ature of the injury can be entertained. Abscess in fhp s ructure of the cornea, is also liable to ocfur dulg J ffil"l and thf /"' r '""''^'' ^'^^ ^•«"-«- being (iitticult, and the two destructive consequences sometimes ctiraSx.^"^ ^^"^"^"""^ ^ -^^"•- -^- " Abscess of the cornea is peculiar in this respect that It does not appear to consist of a distinct sac of pu'ru'ntta t , bu merely a deposit in the cellular or lanLat d t"ut ture of the cornea; ,t consequently does not open at one point and discharge its contents, but break in^o an ol ucer not easily to be distinguished from the broken surce of a slough. The color of the opacity of the corn a oS bredLt'f ""t"' ''''' '''' '' «^ the uL, Tat colored tint of purulent matter, and not the dull, dirtv whitJ of dead macerated cornea, abscess, not sloug , i Thrroi «ess in progress. Abscess also probably occurs mo.^fre quently in circumscribed spots, and seldom extends o the' -tire circumference of the cornea. The secret on of puu ent matter in the chambers of the aqueou hum m s" easily distinguished from abscess of the cornea atUs in .nencement, by the purulent matter falling cbwn n the aqueous humour between the Iris and the Irnea! and by Velli/'"Th"^^ •''•''V' '"'" '^^ «^««»"^ given bv Dr. Vetch ._ The pa,„ m the second stage arises in part from ■>^.>-w-. ^ 260 PATiioLoar the destructive changes which have corn.neaoed in ,ha nea, aggravated by distension of iho.T *^' '"'"■ an augmented aLuiiZ T.u ^^' "'^"^eq^'^nt upon formatfor" ,J C^ '''' ^T' '""^^"'■- ^he place through t „« 1 oTLT' '"'''' '''' ''''' appearanceoftheco,^ a" ve no ''^'''y ^'''''''' ^^^ the internal surface partakes 1^-'^'" '' ''^^''' '^'' "« aqueous humour LlcreL ^/^^ '"Aammation, or that the distension seems ent 2^^^^^^^ 7 ""''''' «ff»«'«"- T^^^ ;nthesecr.i„g.esse^:^';Ssrc::^:c:;.:s^^ the posteiior chamber. Neither does Zrl * clabber probaWylls H e' ca^fT " "" '"°'"'°' sooner «,a„ i. J„M oiCS^.f'ZZ^^Z the pwuency prevenl „, from „7ki„g anrvertcil SU or wha. take! Z" irXS '^'■^•"^' '» » »"%- When any large portion of the cornea slonxrh, on ^ - L ,e„, a,, r TIS; e.^:r .t ."aTeLt? capsule gives way, the lens and S '„''," ;:"»: '"' liuinom- escape, the eve shrint. ', ' '™*°"''« "treous into a small bok^ol Lit* ' T, s tZI ",""■»* the globe of the eye .enlally J ite sS'r.he Other, and renders it 1p« i;o?j1 * i «r ^ ^' ''^® attacks of mflammlion Wh „„° "* ""?"=" '^ ""•"" lon,a,and the other remain J efoT.t ll;:''^''^': natare has left undone, and Instead'^faLI i„g, fj^' "Jf l-etnrmg it, a. o„co ,„ lay i. o;en fnd e™. OP THE EYE. 261 able Mr Mackcn,,e says:-" The patient is sometimes .„,« even to see objects pretty distinctly after the cornea hTs given way, and is apt to believe his eye to be neaX cured or at least out of danger. The iris is pushed forward S he openu,g or openings of the cornea, and a dense cica tr v rteridf rso"'^' '"' r '-"^'^ -^ ^^t^^ dift ir . "' '^'''' *^° ''"''« '•^"^^i"^ protruding at en burr "r^" ""^^'' ""' ^"^ -'^^-^ -• P-' d ces l.ke the grains of a brambleberry, a state of narts w-ha-h ,s styled staphyloma racemosum.' ' ^ Constitutional S>/mj)toms.-ln the early stage of the dis- ease t e constitution does not suffer in the slightest degr e patent can eat, drink and sleep ,- the pleiffXd ^0 t. But as the local symptoms become severe the consti- cufon begms to suffer, the paroxysms of nocturna pain pre- vent,ng all sleep ; the pulse becomes sharp and frequem and .f the disease continues, great debility ensues '''^"'"''""^ J7a^^._No person in the present day thinks of doubt- ing the ontagious nature of purulent ophthalmia, for it hL been well proved that if the smallest portion of th'e pur lenl ease I could not say certamly that it is infectious, as it is loubted by so many, yet the rapidity with which "Spreads through schools, ships' crews, and regiment of sS X itiMt'r '''' "' ^"'^ -tainly the surge ;' wno acts as if it were errs on the safe side. There is no manlier doubt but that any of the causes a ready on me rated, which produce simple inflammation of t e contervl may also produce purulent ophthalmia; and itTpr ttr TlX bvTad' 7''f " "'^ '' «-^ catarrhlropEii: ma, may be hy bad treatment converted into severe inflam S' dt ^"" ^'r^' ^'" »^"^«'«"' ophthalm a " -^^iX^::^'' ^« found in every climate, but much worst ,n aot than m moderate, or even cold, climates. And 262 PATHOLOGY it is even worse when it occurs in liot and sultry than in moderate or cold weather. Prognom.—ExGn though the eye be saved from sloughing or abcess yet recovery is always both slow and doubtful, in consequence of the great alteration produced in the con- junctiva by the intense inflammatory action. Treatnmit.~lhQ local treatment of this formidable dis- ease must be purely astrinj^ent ; and the constitutional, as a general rule, antiphlogistic ; but circumstances must guide t-.« surgeon as to the adoption of this treatment ; for exam- ple, no man would think of bleeding, purging, &c., a poor half-starved wretch, with a broken constitution, caused by the use of ardent spirits or otherwise ; whereas such means may be used with propriety in a person of a strong, healthy constitution. With referenee to the benefit to be derived from bleeding, the following statement is made by Dr. Jacob :— « Before the practitioner makes up his mind res- peeting the value of bleeding in this disease, he should pause to consider the effect of this depletion in arresting inflammation of mucous membranes generally; and having done so, he will probably be prepared to admit, that, in many cases, the lancet is not so valuable a resource as might be expected, or as it is found to be in inflammation of serous membranes, or other structures. " The advantage of bleeding in croup cannot be denied, but It is to be recollected, that this disease is more liable to terminate in effusion of coagulable lymph, than in secretion of purulent matter, " Catarrhal inflammation of the lining membrane of the nostrils, or the trachea and bronchial tubes, and dysentery in the t^ other of the tumour, by which L eL^ rum ^ allowed to escape, tension is relieved, and generally a «^Mden.ble quantity of blood discha ged. From this practice advantage is frequently derived, Without any inl^ no^ consequence either temporary or permanent.'' "^ ' H.n^ given the above valuable quotation I would just S«r^ particularly the former, as I conceive it does more fcttw, on Dr. Jacob's pnnc.ple, viz :~that of preparing the system for a more important treatment. Opening Leechv •osed tumour, and thereby allowing the se'rum fo cape ' have always found very beneficial ; indeed, I have very fre quently snipped out a good piece of the swollen conjunctiva and had no cause to regret it. J^'^^nva, If the patient bo of a good constitution, and accustomed to n oy t e good things of this life, it will be well to beg L the treatment with an emetic, which may be followed uj by a purgative Indeed, under any circumstances, 17111 b necessary to have the bowels kept regular bv mean of •some gentle aperient, during the attack of inflammTt on Nauseating doses of ipecacuanha may also be given during OP THE EYE. 265 the inflammatory stage, not for its nauseating effects alone, but also for its well known specific action upon mucous membranes. The skin should also be kept moist by means of some gentle diaphoretic, such as the licpior ammo- niffi acetatis, but such a class of medicines should not be pushed liir. Anodynes are sometimes actually necessary to relieve the patient's sufferings, and in such cases mor- phine 13 the best preparation of opium that can be given. In the chronic stage, mercury may be given as an altera- tive, but I have never seen much benefit from administering It in the acute stage. When the patient is of a broken down constitution, it is sometimes found necessary to give tomes, from the beginning, or from the third or fourth day ; but, as a general rule, they should not be given till the chronic stage has set in, when quinine will be found the best tome. The patient's regimen will depend upon his constitution ; if he be a person that requires bleeding and purging, his diet must certainly be purely antiphlogistic : on the contrary, if he require tonics, his diet must be nutri- tious, although it may be of a light kind, such as broths, &c. lerfect rest of mind and body should be particularly atten- ded to ; however, the patient should not be confined to a close dark room, as both light and air are necessary to restore the healthy action of the eye. Should light give pain the eyes may be shaded with a green shade ; but it is rather unusual for light to give pain in this disease. If the patient has been long confined to the house, it is astonishing what benefit he will derive from getting out into the pure air; indeed it is wonderful how difiicult (in this disease as well as all other inflammations of the eye) it is to cure a patient while confined to an hospital, and this I attribute to the irntation which the eyes must sufi^er in the ward of an hos- pital, from the great quantity of ammonia that is given off by the urine that is constantly collecting. 266 PATHOLOGY the r!l r r '"^''''■'^ '"'« ^'^*'^'^"* «?'"'«"« respecti,,. soothing applications; others stimulating, and there art hose that recommend both plans alternatei;. Ther , one ment may be, .f the local ,s not well directed, the eve is sure to be lost, and although ' would not depend toSe eEr he r'/"T"^' ''' ' ' '^' '» tale myS e. her the local or the general, I would certainly prefer the former, as a single mode of treatment. ^ ^ as short I ^''' "'' "'""'°"^ "^ ''^''' J '^^'^^ describe, in as short a space as possible, the local treatment adop ed stage, I first cleanse the eye well with a sponge and warm water, then, if possible, evert the lids one after th her begmmng with the ..,l.er ; I next sponge and dry the " ^^fr^flect.onM...,.i,pe„ci|, previously wett^dand applied to a piece of ih, uifrue of silver, upon doing which the whole part becomes wh(... I leave no part of thf pa^ bal conjunctiva that I do not touch, even the caru'ncS a and semilunar membrane, and if the sclerotic conjunctiva be much inflamed, but not ecchymosed, I pass the brush over i also; I then let a little milk pass over the eye, and, ZZ diate^ after, restore the lids to their naLal p'o Srt Every twelve hours thereafter I drop on the eye, and a low to remain there for four or five minutes, a fa/ge drop of the ten gram solution of the nitrate of silver ; and if, In fortv- eigbt hours after the first application, or even thirty fx hours, I find the purulent discharge not'decreasing I re'pe" the same treatment as on the first day, and use the ten gram solution as before. This treatment I contLe un i e" oZr"? ^'^ '"^ ''''' ' ^^^" ' '^'^^'^^^ the satu- rated solution of the acetate of lead, which I continue until OP THE EYE. 267 the disease disappears. The above mode of applying the nitrate of silver is preferable to using it in pencil • first because it can be applied more generally over the parts • and, secondly, if the patient starts, there is no .1 mger of hurting the eye. On the first day I give my patient a box of Jannin's ophthalmic ointment, and direct him U> -mear the edges ,f his eye-lids with some of it every night, when - .ing to bed. I also give him the lotion hereinbefore mentiuned when treating of simple conjunctivitis, desiring' him to bathe his eyes with some of it on awaking in the morning, and also a couple of times during the day. During this local treatment I adhere strictly to the con- si tutional, on the principles already laid down. When there is chemosis I make no diflerence in the treat- ment, except to open the chemosis, in the manner recom- mended by Dr. Jacob. The following remarks upon the treatment of this dis- ease are from the pen of Mr. Guthrie :-« In the more for- midable affection which runs its course in three or four days, neither the nitrate of silver, in solution, nor the vinum opii, is effective; it requires a more powerful local application. The disease begins externally, and is a local disease of a peculiar character; if wc can set up a new action or alter that which Is going on, we check the origi- nal affection, according to the principle of John Hunter, that no two diseases or actions go on at one and the same time. Acting on this principle I took the nitrate of silver in substance, and made it Into an ointment. I did not arrive at its exact composition at once, but gradually acquir- ed it by degrees ; It was made at various times, of five, six ten, and twenty grains to the drachm ; and after trying all these different preparations, I came to the conclusion that the ten gram ointment was the best. Take half a drachm ot the salt and powder it In a glass mortar, then sift it r^>r. ;i,J ? I, ■ ■! f.'i ,41 ^1 . 'm .%* ^. IMAGE EVALUATION TEST TARGET (MT-3) fe {< :/. V, 11.25 1^ 12.2 ■uuu lAO 2.0 18 JA IIIIII.6 ^^ <^ /^ ^>. %, ^'} Sciences Corporation 33 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ^ r^ZitClT"'Tf eon^c of the affection Jt be^s wi.°h s tlH^' J .^^ rt'''-^'-'M<'«^fl«it^^ nea, ^ith great aggravation of suffering Thus fh^ 7 of t e affection .ay be divided into thfe'e Jages of Xc" tiie limits cannot be marked very accuratelv in .k ^ -»^em:;7tr,r'T^="'"""°°^^ mrk d bv h! ' '' eo">«'encemont of the seeond . •he cornea. The dLtion ofe^rh .ft e raST^; '» '" "-r^ »f *he .rea;mentXtd.'"l^CL:nr c';cr,,s observed less in the Brst and seeoid, S^ ^ .heeorneaslon^hsbeteZ L- -^TheT'' "l """'' :lg aro?;T r '•' ^'^^^'^''^'^'STX: -d it is converted int^ . di^;^:l;:.rorSh' 11 .u I. I !- lii M'-N 274 PATHOLOGY opaque surface, which is immediately recognized as deprived of life. At first it looks like a portion of wetted leather • It 18 soon separated from the living parts, where it has a loose, soft, and ragged appearance. As the lens and capsule, which are exposed by this separation, are transparent, the patient sometimes recovers for a short period tolerably good vision. After the slough is detached the chambers of the aqueoushumour may be exposed by ulceration ; the humours will then escape, the empty coats will collapse, and the globe remains permanently shrunk in the socket. More commonly, although the whole cornea seems to slough, the entire thick- ness does not separate, and the anterior chamber is not exposed." With reference to suppuration of the cornea he says :— "Suppuration of the cornea may be general or par- tial; It is usually the former. The cornea first becomes white and then assumes a yellow color. The efl'used sub- stance is not a fluid, nor is it collected into a cavity : it is a thick viscid matter deposited in the texture of the cornea Ulceration takes place, and exposes an opaque yellow sub- stance, which looks like ordinary matter, but it cannot be wiped off." Of the ulcerating process he says :— " If the ulcer should be spreading, the inflammation remaining un- checked, its surface is white and ragged, or floculent, or of a dirty yellowish cast, with surrounding haziness. When the inflammation subsides it becomes transparent. The com- mencement of the restorative process is marked by the sur- face of the excavation assuming a light greyish tint, with a jelly-like appearance. A soft semi-opaque substance fills up the breach, when the surface becomes smooth, and the regular figure of the cornea is restored." The reader must perceive how very little the symptoms and results of this disease vary from those of purulent ophthalmia. Causes—Such is the justice done by Dr. Jacob to the causes of gonorrhceal ophthalmia, that I conceive I cannot OP THE EYE. 275 do better than to quote his words r-'^n investi^aHn^ m causes of gonorrhcoal ophthalmia, inquirL "^f^^^^^^^^^^^^^ ng, even ,n a genera! point of view, Ire suggested Uh been supposed that the specific form of gonfrrh' tl Infl •nation, existing in the urethra, is transfefred 1 f h! ?""" tiva, by that obscure and mexXlTZ!-^^^^^ there can be Httip rinnh* ♦!. * .l "'"'^» because ».a..er „,■ '^ .h^e, " , trlre' 1 ^°°"??' eye, and i, i, i„p„,.ii„e ,„ pr„Tlm elv t T° °/ ""' •act doe, „„. take place in al; ca ero'^^^ttol "^^^^^^^ m.a Every individual affected with gf„"Xa 1T. t be finger, con.amina.ed by .he disch^ge, row.tadin^ Ibe most scnipnlous cleanliness and care • aTr^Til ,• * ronnbtefrb^rif— "- p:i.°t"nr,c2:r: 'zt^iT' ""■- '^ be .0 attentive to .be prevention ViM ' """" ""^ -.most precantion -/I nts^ 'rSH' h^ ^ '■nprobabie that a particle of matter ha, be™ »t,- . ^'^'^ eye ; bnt the pbyLan can onlysay •„ ,nch?? le t'^ most probably meta,ta.is of gL,^hl To .Ke I' f"' cannot ,afely assort positively tSaTisJ'X'.''-' disease originates. The disease of gonorrhea mJ^ apparent examples of metastasis %T .^ 5 '? '''''«'• ^ 1 it; ',,'f <■ hi! iifi 276 PATHOLOGY han an exfension ^f the mucons inflammation along the lengthened and tortuous tube of the vas deferens. Irritable bladder produced by the same cause, is also most probably independent of a continuous extension of the specific in- flammation along the whole length of the urethra, to the llnmg membrane of that organ; and even sympathetic bubo generally presents a character so different from that which arises from the extension of irritation along the absorbents, to the lymphatic glands, from simple injury' that It 18 not unreasonable to attribute it to metastasis. These metastases are of comparatively rare occurrence ; so is gonorrboeal ophthalmia, notwithstanding the probability of the frequent application of the matter to the conjunctiva or Its vcmity. The occurrence of the disease in one eve without extending to the other, notwithstanding the profuse discharge soiikely to come in contact with the unaffected «rgan, makes it highly probable that the disease depends on a cause different from mere contact of infectious matter. Whatever doubt may be entertained respecting the occur- rence of metastasis, evidence sufficient to prove that the disease can be produced by the contact of gonorrhoea! mat- cr, both in the individual laboring under the disease of the urethra, as well as others, is on record. Mr. Lawrence Mr Wardrop, M. Delpech, Mr. Bacot, and others, state instances m which there could be no doubt of the fact The writer has heard this assigned as the cause of the disease by a young man, who, without any leading ques- tion, or knowledge of the usual production of inflammation of the eye by such a cause, stated circumstantially the fact of gonorrheal matter having been projected into his eye while retracting the prepuce, which confined a quantity of the dis- charge. Dr. Vetch details a solitary case in which the expenraent was made to determine this matter by an hospi- tal assistant, where gonorrhoea! matter was applied to the conjunctiva with impunity. It does not, however, appear OF THE Eru. 277 that Dr. Vetch himself conducted tli« «rn„ • obvious that much confidence could nfl '""'"*' """^ '^ '« accuracy of an individual 7.?! ^ ^' ''P"'*^'^ '" "»« to Incur such a risk VVhr?''"^'"^' *"^ *''«"ghtles8, as contact of gonor tal lauV T ^' ^'^'"'"^^ '^'' ^^^ tival inflammat n,t s Svl '''' ^'''^'''' ^^"J'"°'^ formly has this effectq^ . T"' P'"'^"^^ ^'^^t '* »ni- dange'rous suLpt iu/T/^f '^-'«, -"ay possess this same individuals mav at L"r « "'* ' ""'^ '"«° ^^' «ori, and at anotre7tlTot Thin ^T ''' ""**"'"»■ observation that this i the feet iJ w '.^k ''''''"^'^^'' ''^ "J"stration of the gene al at;/ r ^'"'^ ''"^Portmt that a morbid pois^rr Xn r 1 '"°'"^''^"' P''^^'''^ spot, produces eLr^tetm/^^^^^^^^^^^ ^ ^'""'"^^"''«'* are not observed on n^ho! ^ *"' ^'^^ P^"o°» which Upon a candid eo„SrXnT^h."r^^^"^--^^^^^^ ada^itted that it is TeTtvnL^'' '''^^'''' '' ""^* '^ patients laboring ul^r gl hi' Tf T ^^ ^^^ incur by negligence or inSlJ '. . ^^^ ^^S^'^ they caused by metastS but^ t ^ ^ ^' ''' ^'^«««« heing caused by contaS anV ir'- '''''''' ^''^^ "'" in the fact that fper'son should 1!^'"^ ""'"' ''^^'^^^^^ time and n.t at ano her or thifn '"'''^""' '^ " "* ""^ susceptible of it than another h T'"" '^'""^^ ^' '"«'•« vaccinatedtwoor three tLt'-K?K' *^'* * ^'^"'^ '^'^^^ be it produces any eff t ^ ' l! f ^T '"'^'^"«°' ''^^^^^ vaccinated by the same ' ^''^ '''"'^^^^ ^''""Id be same lancet/a d iS^^^^^^^^^^^ ^"^ ^ « time, with the in-ctedandtheothr::;;:----:^:^^ .i'V->'J ijia Ml 278 PATnoLoay t .at two porsoMs of the same age, habit anj constitution, should be equally exposed to the same contagious disease and one of them become sick, while the other, who was in equal danger, escapes. That these things occur every day there is suflicient proof, but why they occur, is not so easily explained. ' The following statement Is made by Mr. Mackenzie :~ Different views have been entertained of the purulent inflammation of the conjunctiva, which is frequently found to attend, or succeed to gonorrhoea. Ist. This ophthalmia has been ascribed to inoculation with matter from the ure- thra; 2ndly. It has been supposed to be by metastasis ; And drdly. It has been considered, at least in certain cases, as an effect owinfe to Irritation merely, without either inoculation or metastasis. It is quite possible that there may be three jnch varieties of this ophthalmia. The existence of the first I consider beyond all doubt ; but the second and third are somewhat problematical." Mr. Samuel Cooper makes the following remarks •— " If '12l r'."'!,'^ *'"' ^^'^ '" "''"''' ^ «P««'«« «f purulent ophthalmia does originate from the sudden suppression of gonorrhoea, are we to consider the complaint so produced as a metastasis of the disease from the urethra to the eyes. ITiis ophthalmia does not regularly follow the suppression of gonorrhoea ; nay, It is even a rare occurrence ; also, when It 18 decidedly known that the purulent ophthalmia has arisen from the infection of gonorrhoea, namely, in those instances m which the matter has been incautiously com- municated to the eyes, it appears that such an affection of these organs, so produced, is different from the one alluded 0, inasmuch as, it is slower in Its progress, and less threatening in its aspect. Hence there is good reason for supposing, that no metastasis takes place In this species of purulent ophthalmia, supposed to be connected with a sup- OF THK EYE. 279 diirorenco of irritaWiiiv i„ .'l"'"/'"' V«». "nd that the ract violent form, of norl 7 i ? , '' '"'' <"'" "' ">« i. called gonorh™ tm .. h °P''"'»'"'i''. '» *»' which «.n^»fA„„h^:i"';tr;':r?oSr';^'''-'>''''- - n,„ch ™ore liaXltThl^Hr ™' "^ ^-"'" ™" .i... .be priri .ix':r„t- ::i:i; " " '"^^"' but more particularly so if th. j- ° ""^ P™e"»"'. •lage. The folloX . »f '-^ " '" '"^ "''"'"««'• re„«:_"So h rrL-l. -T' " ""'^' "'' "r. Law- mencement and he SI 'f """■ ^"""' "■» »■»- that in many iltlneelL .T™'"' "^ "■= "™P'«'"'. eye before oL S rrr:; L^l?:' '' 'Z '» "« plaint in the first or a«i.n„^ "^^qu'red. If we see the com- its progress bvlL. ^ ^^'' ""' ""^ ^^P^*^* *« "rest on the state of tl etn ^1 fE^^ P"-^"^ turn clearness, the eye may be'sav d t""''^ P^f/^^ '*« ""^t^ral and dull/and mle pa'rt u a ,y if t ! m ' '^'='™^ '^^^^ white nebulous appea Ini ' "'^ BeriouswilIi„evitfb~e' ZlTZ''''' " ^«- Janctiva,nioreparticuIarlvll,S,''' '-'"'"'"^ ^^ *''« ««»- of a yellow coL, rd b^K dtToTih?'"".^'"'"^^ eye-h-d, are unfavorable cifcumTanr *?' ?^^°"«° "PPer ^^^«?^ib of Infants.~Dr. Jacob gives it as ♦hn- • .™^^^°'^ *8 *o the number of children that los.. the r vision from this disease, still I do not aJee with , r as to the cause; for myidea^f the true cale! a^t^^^^^^ on the part of those having charge of the child, to a^r o the proper source for treatment, till it is too late o the pract..oner trifling with the dise'asc, either from h s' sup o Sl^^:;^'' -'y ^'--P'^' - -gnising, bur t soone?o'r7a\er"fh'- ■':?•' " '''''''' ''' ''''' ^'^'^ '^ '"ay be sooner or later, this disease makes its appearance. The eye OP THE EYE. 281 in the inlr clL^^^t^y::^^ •"" ^^^1 '^ -"-' thing that attracts the no^ce of tL ' '5 ^Tf^ "'« «"' at this period the surlnn .^ ^'"'^' ^^^'^^ ^''"'d- If scleroti/con un tfva 1!" T'' m' ''"''^^ ^« "'" ^^^ ^^e «hua the light become r!,. "' '^'r^"^*'"*' ^'^^ ^''i'^ ^i" pain. Allfh e ;i ;r2 "' "^"1 *^ «"^- ^-* redness of the conjunct? .,7 7"''' '" ^'°'«"''«5 ">« iorance of ,i,bt, aiTZZlZlT'"''''^^^^^^^ degree does it differ from n„r,.l ■ , " ' '" """ '" °» conjunctiva rarely if .T. .°P''"'"I""X «™pt In the "■«'ge i. .om«^ tilled S'm I"*"- '"^ ""- •l-onid be jaundiced it b!f, "u""' ""'' """> ">«* Mon of the eve lldtu . ^'f'"'* ""'• '>'''« '""efac- «d. wrt,: i:atr.:tr:'v'r ^-^'"^ »f "■« dT' '^Tp ---efi «Vd"e: wmT r sir » i^^cifjdratdT; tf ""r '"^ "™'^ '«"«- degree of ap7r«h„^^,,,t,"°"' ",''""■' *"<"■»<"» tbe lie comea,7fX „L T " "'t*"'' ^^ ">» "'"''«»' not mean to say that ,°n ZT- . ' <'«'royed. I do Ike cornea isLT'^ 1 '^ '"'"""=' '" "I"* «P»eity of .lougby sf,te ™ ? ' """"' '' ''""" '» P»' into a n-arLutailbyact tacZr^.' """"'^ " *" O. tbe cornea, for the mZ^Z 7°^ """"'' "'« ^«* »f .0 be bailed aV hrpn:l'*"2 "" "'"'' ""' ""S"' peculiar duskiness oHheTo "'ea Ji^,T •''""""'"« "f » progressive «ate of h" X«." 'tb T "' '"""'"" to any l„,s of substance hnTT- J' ^ ' " ""'"edenl -eh loss is aboutTral'e'';. ' ,VhJ T ?'[ "■°' ir '!t1 ll .iiJifcL 282 PATHOLOGY becomes elevated, and apparently lessened in extent- a groove or fissure forms between it and the re J of h. ' that most commonly Xn^uT ',' '" ''^"""^ ^"^« ex.e„d,1 eifTa 1 Sn'TT'J" ""•? "°°^''^"»'' las. lamina of ti c 1 ^"1 t"f ^ """^''' ""'" "" Ihe pressure from wriM„ V V ' ^""^ Protruded from escaiiin7^t„ • ™ ' *"""'"' ^""l «>« "lUMus humour trovs th?n ;? *''''"^"""»^««n 'tself immediately des. Si\r:r£.,:*r.."r7r-^^^^^^^^^^^ ".".ingou .he remarks ofw" Sa„„de"?say X'^ T" :fif,h"„iTt'r T' ' *"« «• " - " oiuugijHig. ur. Jacob savs : " Wh^fiio.. ♦•,„ • n Z'.yeLl7^rV' """/■""'"'J'risWin slating ,1a eye is lost ,„ u,,, j^ease frequently by abscess ; and the OP THE EYE. 283 anthrax. Whatever nninil u *''® character of tie precNe .Star; r^ScL™'"'"'""'''"-"'''"''"'^ "icner should „ever lo e .il „ I" f ""™'' ""^ P™"- liended from it. i, coml* f '"' '''"'«" '» I"' W™- tbe i«fla»™a,i;„/b„ r. : : "™!, '.'■» «'™ period of »«' arrested, ,ermi„a.es mIsTr« Ln In:'''^''''''' '"" '" from a number of cause. ^„: V * . ^'«ease may arise secretion as that IIudeTio j/ -' ""'' ""' ''"^^ «"«" nital predisposition 4;^^^^^^^^^ a little in detail, since a. Jf ff «ase I will state similar one on record alfL?/ f ' '^"'^' ^^''' '« ^o occasionally occ^rrd' Th.?h , r^.''^'^ ''^''' '""^^ have my notice, was Xmonfh l\^' "'^''' ^''' ^''^S^^ ""^er jntelligent^erl'-rrd^^;^^^^^^^^^^^^ 'ts eyes exhibited iha . ^'^^ ^"^^ ^^ birth, observable. Se disease h'T "'T'''''' '' ^«^« ""^ previously to bTr h for 1^^^^^ "^ ^"'^ --- no puriform dischar^f frSr ! ^'' *''^""^ ^''^^-e was noUcedatanytTXturtrCr^^^^^^^^ had completely sloughed the ^4 htuuT^ ""^ °"' '^^ course, not the slightest 1 on „^-:. ^'^ '""^' «"^» of of the cornea oflh oth r T '''^- ^''' '^'^ ««« half remaining transpVre^tttoH p?,! Tr '* ^"^1 ''' discovered, and the iri« ^n^ ^ *°® P"P'' eould be tact. The transn. Jn '"■"'" ^^P'^''^ almost in con- lit 'iH 284 PATHOLOGY was very imperfect when I last saw the child, yet it appeared to be gradually improving. " Now, after duly considering how perfectly the pheno- mena presented by the eyes of this child, agree with those met with, as results of purulent ophthalmia attacking infants after birth, I think that no reasonable doubt can be enter- tained that they were occasioned by purulent ophthalmia which occurred before birth. This is not the only case I have met with aflfording evidence of active disease of the eyes having been present during the uterine period of exis- tence. Some few years ago, I saw a child, then only two or three days old, the cornea of each of whose eyes was opaque throughout, and unusually large and prominent, so that very little of the sclerotica was discernible. The opa- city was of a bluish white color ; there was scarcely any irritation about eillier eye ; nothing like inflammation. I merely prescribed some palliative remedies, regarding the case as one of malformation, and thinking that this would probably be permanent. The child, however, when about two years of age, was again brought to me on account of some slight inflammatory condition of the eyes, and I was surprised to find that they had a perfectly healthy appear- ance, the cornea having become quite transparent and of normal size." There is no doubt but that children have been born with opacity of the cornea, as well as with opacity of the crys- talline lens : therefore there is nothing to wonder at, that the eyes should suffer in other .respects during the time the child is in utero ; but I think the above remarks are not sufficient evidence, to warrant the conclusion that purulent ophthalmia took place before birth, as in the first case quo- ted by Mr. Walker. Although the woman were ever so intel- ligent, I should much doubt her story, for we all know how much people exaggerate In these things ; and even how in- capable a woman is, of forming a sound opinion on the state OF THE EVE. 285 of her child's eyes, immediately after birth. As to the second case, neither the appearance of the eyes when Mr. Walker first saw the child, nor the state in which he found them in two years after, bear much resemblance to the result of purulent ophthalmia. I^-offnosi8.— Although, in the majorityof cases, I conceive this disease to be under the the control of the surgeon, if he sees it in the first stage, still he should be very cautious in his prognosis ; for sometimes, under the very best direct- ed treatment, although the organ may be saved from ab- scess or sloughing, there may be other evil consequences of the inflammation, such as opacities of the cornea, or the capsule of the lens, short-sightedness, oscillation, strabismus, incom- plete amaurosis, &c. There is one termination, of the other two forms of purulent ophthalmia, that is never to be dread- ed in this, viz :— granular eye-lids. Before the surgeon gives an opinion he should clean the eye and examine it well so as to see the whole of the cornea, when, if it presents that dusky appearance, intimating the process of slough he should at once prepare the friends of the child for the worst results ; but he should not send the child away as a hopeless case. If the cornea is clear and healthy, his prognosis must be favorable, but he should always bear in mind that the patient is liable to relapse, which renders the chances of a successful issue even less than at the first appearance of the disease. The surgeon must also remember that, if the cause of the ophthalmia is gonorrhoeal discharge getting into the child's eyes during parturition, the case is much more dangerous than if it arose from any other cause. Dr. Jacob, when speaking of children being brought to the practitioner after the end of a week or fortnight, says:-- " When an infant at this period of the complaint, is pre- sented to the practitioner, he should at once satisfy himself whether the cornea be safe from slough, abscess, or ulcera- tion, or, as this is attended with some trouble, if leisure does 1 'III 1 s^^l m f % 286 PATHOLOGY not permit him to do so, he should inform the parent in plain and inlelllgible language, that there is danger to be apprehended, and that the child may have its vision im- paired or destroyed by opacities of the cornea, which cannot -at the moment be perfectly distinguished. If he dismisses the patient without this precaution, or if he makes any application to the eye without explicitly announcing the extent of the injury, the reproach of having blinded the child will be fastened on him by those who, from culpable negligence, ignorant confidence in their own opinion, or sordid love of money, had caused so lamentable a misfor- tune. If upon examination in this after period of the dis- ease, the cornea be found perfectly clear and free from ulcer of any kind, the practitioner may entertain sanguine hopes of perfect recovery, but he should not, even then, give expression to these hopes, as relapse may occur, or some accidental circumstance interfere with the cure. If slough, abscess, or ulcer, have not taken place in the first week or ten days, there is every reason from experience to expect that no further bad consequences are to be apprehended than the troublesome and distressing vascularity, with profuse purulent discharge, which often, especially if not checked by astringents, continues for six weeks or more." The following remarks are by Mr. Mackenzie : — " When- ever the person who brings the child to me, announces that the disease has continued for three weeks or longer, I open the lids of the infant, with the fearful presentiment that vision is lost ; and but too often, I find one or both of the cornese gone, and the iris and hum\)urs protruding. In this case it is our painful duty to say that there is no hope of sight." Causes. — If we are perfectly satisfied that this disease does not occur before birth, it is easy to account for the causes which produce it, but if, on the contrary, we receive Mr. Walker's theory, of its occurrence before birth, then we •I'l OP THE EYE. 287 are at a loss to know how it originates. A sure way of producing the disease in the worst form is by infection, and this IS generally caused by the mother having either a leu- corrhoeal or gonorrhoea! discharge at the time of parturition Exposing the child's eyes to strong light, or a draught of cold air coming on the child, immediately after it is expelled from the warm uterus, will be sufficient cause to produce the disease ; however, there are some cases of inflammation from the latter cause, only catarrhal, which never termi- nates in purulent ophthalmia, unless it is produced by neglect or improper treatment. Treatment -Previous to making any remarks on the treatment of this disease I would venture a little advice to the accoucheur, that he may if possible use such precautions as will prevent the occurrence of this formidable disease. *irst, he should know, previously to the woman being deli- vered, whether she has at the time any discharge from the vagina, of the character above alluded to, and if so he should have a sponge and warm water ready at hand to wash and clean the child's eyes previously to its opening After the child is born he should warn its friends not to have It brought into a draught of cold air, nor to allow its eyes to be exposed to strong light. At every visit paid to the mother for a few days, he should look at the child's eyes, so that, should inflammation make its appearance, he will see It m the first stage. This disease, like the other varieties of purulent ophthal- mia 18 subjected to a number of treatments difi-ering from each other. I have never found any difficulty in curing it when I see the case in the early stage, and my treatment .8 as follows:-! first sit down and place a clean towel on ray knees, and on the towel I have the child's head laid its body being held in the arras of the mother or friend • Ihis gives me full power over the child's eyes. I then by open- I, ? . 288 PATUOLOGY ing and sliufting the lids with my finger and thumb, and using a sponge and warm water, clean all the purulent matter from the eyes ; this being accomplished, I dry the eyes, perfectly, with a small soft towel, and immediately afterwards drop on the conjunctiva a large drop of the ten grain solution of the nitrate of silver, which I allow to remain there for about one minute, and then remove it and wipe the eye perfectly dry. This treatment I repeat every twelve hours, until both the discharge and irritation become lessened, but as the disease abates I use the saturated solu- tion of the acetate of lead. I always give the nurse a six or eight grain solution of the sulphate of alum, ordering her to wash the child's eyes with it constantly during the day, and to keep bits of rags, wet with Ihe lotion, laid upon the child's eye-lids whilst it is sleeping. The removal of the purulent matter, previous to the use of the nitrate of silver, is of the greatest importance, for if this is not done the application docs not get on the inflamed part. The constitutional treatment that I adopt is as follows : If the child is of full habit, I give, in the first instance, an emetic of the vinum ipecacuanhte, and after this, a dose of oil ; but, under any circumstances, I have the bowels kept regular by an occasional dose of oil. If, as already stated, I see the case at the commence- ment of the disease, I never find the above treatment to fail in curing it in the course of four or five days ; at least the discharge stopt,and nothing remaining but alittle vascularity of the conjunctiva, which soon disappears. But if the disease has been of long standing, so as to be well developed, then if the discharge stops in the course of five or six weeks, without leaving any evil results, I feel well satisfied. My treatment is the same (that is the local) even if ulceration of the cornea has set in, and if the ulcer is inclined to spread, I touch it with the pure nitrate of silver, and imme- diately afterwards bathe the eye with a little warm milk. '■-5>.^' OP THE EYE. 289 The^ constitutional treatment I tlion change to tonics If the .r,s becomes prolapsetl, I treat it as already laid down in tl.o article under that head. Dr Jacob advocates the use of leeches in the inllanmiu- d L; '•'; m' '"y'-'T"^' «-» -« the existence of the l.sease ,s fully ascertained, a leech should be applied over he c eek bono, at the edge of the orbit, and blood allowed to flow ont.1 the effect of the bleeding becomes obvious by the paleness or sickness of the infant " Speaking of the use of calomel in such cases he remarks r - If It be admitted that the administration of calomel •nfluences the biliary secretion, its use is particularly n atcd at this period of life, when the liVer performs an Imn'it'do r'""' T"""^ "' ^"" ^-ter'importanl han It docs a more advanced periods." Speaking of local appl.ca.ons, he remarks :-« Local applications may be resor^d to with two objects,-the alternation of tL ,^tu e of the inflammatory action altogether, or the diminution and removal of the purulent discharge. For thrformer jeet, the nitrate of silver is recommended, an it Inn be denied that it may effect it; but it mu t at the sauL imo be confessed that the practice has not yet been fX submitted to the test of experience. The question fro^ s.derat.on .s, whether a practitioner, as soon as he has ascerta.ned eyond doubt the existenc'e of this severe for n of .nflammation can with safety, and a fair prosper""" advantage, introduce a solution of nitrate of sifver of tm grams to the ounce, or an ointment of ten gra.'n to th drachm, between the lids. That this and othfr a ^ringent Charge, after he first symptoms of inflammatory action have been subdued, cannot be doubted. With this view a five gram solut.on of the nitrate of silver, or a saturlTed solut.o„ of the acetate of lead or alum, ^ay be rSel ■If' I'' { •Mm * * 1 290 PATiioLoay to ; the acetate of lead cannot, however, be employed if slongh 01 ulcer be present." * Phlyctenular or Scrofulous Ophthalmia.— Yiy this title I must not be understood to mean an inflammation of the conjunctiva, which is a specifically distinct disease ; but rather an inflammation of the conjunctiva, modified by a scrofulous diathesis ; the result of which is the formation of phlyctenula; of the conjunctiva. According to the views of Dr. Jacob, (in which I fully agree with him,) " every form of inflammation of the eye is liable to assume the scrofu- lous character, except the purulent ophthalmia of children, which is not so modified in consequence of the organization of the system at that time of life." Symptoms.—lihQ chief characteristic symptoms are phlyc- fenulaj on the edge or surfoce of the cornea, with more or less redness of the conjunctiva, blepharospasmus, and great intolerance of light, particularly of artificial. Exposing the eye to the light, produces pain, sneezing, and profuse lach- rymation. The eye-lids appear as if swollen ; but this is produced by the tears being collected between the lids and eye-ball, and consequently disappears on the opening of the eye-lids, when a gush of scalding tears runs over the cheek, the constant repetition of which, causes the lower eye-lid and cheek, very frequently, to become excoriated. Such is the dread the patient has of the light, that he keeps his head bent down, and if a child, which it generally is, buries its face in its mother's lap, on her shoulder, or any other convenient place, such as a sofa, bed, chair, &c.; and, when in bed it will lie on its face, although the room should be perfectly dark. » In the Rei!ue Medko-Chirurgicale for September, 1849, there is a paper by Mr. Chassaignac,iii which he puts forward the theory that a pseudo- membrane 19 formed on the conjunctiva in purulent ophthalmia ; in the same manner as that description of membrane is formed on tlie larynx in oroup, VIZ.— by lymph being effused. I doubt very much the existence of such a memhrane on the conjunctiva; nevertheless, I would not say but such an occurn-iu'c iniglit tako place under peculiar circumstances. OP THE EYE. 291 If a child suffering with this disease has not all the dmradenst.cs of a scrofulous subject, such as thick uppe I.p, Im-k ala..nas,, occasional ulcers on the corners o( thl nouth and nose, discharge from the ears, or the g an Is of the neck swollen ; yet they will be found to have thrtumid hanl abdomen and irregular bowels, which are ZTt be found .n strun.ous children. If the case goes on f;vo £rL'";„ n"^ '■''''"^'' 'y ''^ Phlyctenr becoX absorbed, and leavmg a small albugo in its place, which ge- "^^rally .s absorbed in time; not always, how ver, for it somL <..nes spreads by additional lymph being supplied to it Zm .- - two vessels which will be seenlo rin no' Z he albugo r.ses above the level of the cornea, its emova, becoming very tedious. To this description of albugo X Mackenzie gives the name of vascular sneck Z\t-' generally called vascular albugo ^ ' "* '* " r„n^,?r"'M^ phlyctenular ophthalmia does not always vesicles found to suppurate and burst, leaving ulcers on the cornea either extensive and superficial, fr "m , in extent but deep into the substance of the cor ^7 Tl i, occurrence causes an increase in the seventy the" sym oms, the pain, Intolerance of light, and proLe lach^'ma c , b .ng much more severe, owing to the extreme 12s f the opht alm.c branch of the fifth pair of nerves bec^ra 2 -i;o-l, by ulceration, to the light and atmosp He t ;.l " r ''■%'"L'"^ ''" consequences to be dreaded from h. i,lcorat,on of the cornea; indeed, some are unavoida Je ^ for exan.ple; the nicer heals, as there has been a los of and can never be completely removed, although it S ^come much smaller as the lymph surrounding it's a s ^ ^d 1 he ulcer may penetrate into the anterior chamber of the eye, causmg a loss of the aqueou. humour and an -o. IW PATIIOLOOY fiSfios of the iris tliroiigli the "nca ; to which the term luyoiiephalon is given, from its resemblance to the liead of a fly. A large portion of the cornea may be destroyed by the ulceration,down to its lining membrane, \vhich,notbeingablc to support the aqueous humour, becomes protruded through the ulcer in the cornea ; to which the term hernia cornea;, is given. The continued inflammation of the conjunctiva, which is always present in this disease, sometimes spreads to the difi'crent tunics of the eye, producing internal scro- fulous ophthalmia. The parts of the eye most liable to sufler first, are the sclerotic coat and iris. When this inflammation spreads to the internal part of the eye it generally leaves the capsule of the lens opaque, the pupil being partially closed, and the eye more or less amaurotic; and sometimes the whole eye-ball becomes atrophic. Children who sufi'er from constant attacks of this formidable disease, become in time more or less amaurotic from the Injury the ophthalmic branch of the fifth pair of nerves receives. It very frequently leaves, an incurable, ophthalmia tarsi. Phlyctenular ophthalmia i? a disease of very frequent occurrence : indeed so frequent that authors have stated that ninety in every hundred cases of ophthalmia in children arc of this character ; my experience in Canada would lead me to the same conclusion, at least so far as concerns the chil- dren among the lower classes, in which this disease is mostly found, although no children are secure from it. 't generally disappears altogether at uie age of puberty, par- ticularly in females, but very frequently at about tl^Lt years old. Adults seldom or never sufi'er from this disease unless the-' have previously been attacked with it in childhood. i ' 'ctonular ophthalmia is generally accompanied with et;:p<'. , i. hot^ the face and head; I have never found OF" THK ETE. 293 . an hor w .„ gave a reason for these eruptions occurring > '-'"I' 'cn of a strumous rliathesis; all have conten | hemselves uith simply stating that snch is the cl b ho natu., of their origin, I consider an in.portant ^ti Utolf the im ";■" ""^ '' ''■"''' '•• son.e'peeuh- «Ut of the ifth pair ol nerves ; the integuments covering he ia..e and head, as well as the mucous membrane lining he eyes, nose, &c., receive sensation fron, the fif n o^f w be ,dc at.on of the eonjunetiva and Sehneiderian mem- bume. I therefore consider that, rcas.ming from an.locv w may suppose that if the whole of the fifth was ara^sfd' ' h rTs"'' " "":""'" "'" "'^" "'cerate; although sarily fdlow paralysis 0/ tte "^m^bu^'^Z^rr member the similarity there is betw'een the egrmen and mucous membrane, and that both are su ,S bv enquiry by those pathologists who devote much of their time to skm diseases. "^ that Its nutritious powers, necessirv fnv ih^ 1 m ' are suspended. Moreover, bel ^tl r if Z;?'"'^ 7'' strumous alTections appear aStlt '1^171^" proof that the whole of the (ifth i • disorl^i / ' " ^ I tne .aiBc cucc.. as u it were partially paralysed. I 1 11 fj ( i-T ^ 4X1 < ' t| r\ 294 PATUOLOGY There are many exciting causes which bring this poison into action, such as improper food, impure air, want of exer- cise, bad clothing, want of cleanliness, and though last not least, a cause which few can guard against, a variable cli- mate. The primary inflammation of the conjunctiva may be produced by cold, wet, teething, injuries, excessive use of the eyes, or any of the eruptive fevers. Prognom.—Ai there is no disease of the eye more liable to a relapse than this, or one that more depends upon the careful attention of the friends of the child, great caution must be observed in giving a prognosis. The practitioner must by no means make light of the complaint, and lead the friends of the child to believe that the case will soon get well ; for the reare many uncontrollable causes to pre- vent it, and if his prognosis does not turn out to be correct, he is sure to bo blamed ; therefore, he should plainly tell the friends all the dangerous consequences which may result from the disease, that there is no security against a relapse, and that the cure may be tedious under the most favorable circumstances. Treatment.— As a general rule perhaps there is not one disease of the eye less under the control of the practitioner than strumous ophthalmia, nor is there one which is sub- jected to more various modes of treatment, all appearing equally successful at one time, and unsuccessful at another; indeed, like inflammation of other parts modified by scrofula, it will at some periods successfully oppose the very best directed treatment. The surgeon must always bear in mind that this disease is dependent upon a constitutional cause, the removal of which must claim his chief attention, while he does not neglect the local treatment. Believing, as I do, that the nutritive powers of the dis- eased eye are diminished, I cannot recommend blood-letting in any way, nor any other debilitating remedies. However there are those who recommend the application of leeches. OP THE EYE. 295 r^n. h t .r" '"^' '-" ^''^^ '^' inflammatory action runs higher than ordinary, or when it is suddenly or vio nT ]y augmented by the formation of nicers on the cornea IS proper to moderate the impetusof the blood y the apnl XiZtlT -"'"'T'' ^'' ^••^^tment better than by vT- hSr^ f "" ■' ''•^ '"^"^« '' his little patient : if possible L r^ '" •'^" '"P""-^ atmosphere, let it, S uarlV w^^^^^^^ T ' P"^' '^"^ ' '«* h'-" »^« ^^» clad g dnt Lrfi!r"n"''* '^' skin, and let him have Ls anlt .,"'1:., I^^y particular attention to cleanli- raTelVtarm ' " '^\^ ^" ' '''''' ^«" ''g^^ted, and mode- S wLn h/''";'.'"^ ''' '^^ '« »''-«"S''t out iL the pure P I7w' tl t " '"'• ^^ ^'^""'^ h« ~aged to EbTriedIil^""P'Tf' '"'^ "«* ^"«^«d to keep his m bed h't M?""' ' ''P' ''• «" '^«'- ^''""Wer ; even when iead raised hv " ™1' *' ''' "P«" '^"^ ^^^^^^ having his Ret the Wot,/ nT\'^ P'"^^^" ^^ '^' praciitioner can he wm b ''^'.'''''^ ^' ^"«°'^ *« tJ'e above directions treaTment ""'"^'''^' ^''^ "«^^ important part of the cautVbvanI ^^j^ abdomen of strumous children is stomach fndK'^ "?''''"^ ^"^^*^"^«' c«"ecting in the ^h oZotin^^^^^^ ?' '"' ''•'"^ '"^'^^tc'J - to get rid Th U n^^^^^^^^ ^'^ 'T' '' P^^^^"* '^^ '-^-^ction. H Pulv. ipecacuanhae, gr. ii. Carb sodaj. gr. vi. Pulv. rhei. gr. xii. M divid. in chart, vi ■■■i t'* 'i I I: f 1^ 296 PATJIOLOGY a well known sedative action upon Inflamed mucous mem- branes : I never give it In nauseating doses, Indeed I never give nauseaiits In tills disease at all, for they debilitate the system as much as bleeding, and produce an evil result. After giving the above powders until the hardened abdomen has disappeared, and there Is a decided change in the secretions, which Is generally after the end of a fort- night, I then give tartarised antimony and quinine,— the former as a sedative and gentle diaphoretic, the latter as a tonic. The largest dose of tartarised antimony that I give to a child is one twelfth of a grain three times a day,1ind the largest dose of quinine half a grain. These medicines are best administered in solution, as recommended by Mr. Mackenzie, but they may also be given In powders. If one twelfth of a grain of tartarised antimony produce the slight- est nausea, the dose should be reduced to one twentieth. Care should be taken not to give too strong diaphoretics, as profuse perspiration in such cases is always hurtful. Since these remarks were written I met with an article in the British American Journal, taken from the Philadel- phia Medical Examiner, on the effects of large doses of quinine, by William Thom, M. D. Among the numerous evil effects produced, by large and frequently repeated doses of quinine, he mentions partial amaurosis, and in describing a case, says :— « The quantity taken in three days is not accurately known, but I should think was not much less than two scruples. As soon as the constitutional effects of the medicine were induced the disease yielded ; but dilatation of the pupil, insensibility to light, and almost total loss of vision, followed. The amaurotic condition slowly improved without remedies and he is now perfectly restored." Now this Injurious effect of large and repeated doses of ^luinine, on the ophthalmic branch of the fifth pair of nerves, should not deter the practitioner from using It In small doses. Nay, I would rather consider this an encouragement to OP THE EYE. 297 use u moderately, as it affords such a proof of its direct |on upon that nerve, which, as has been already sta d believe to be poisoned in strumous ophthalmia. ' onSlmirr'"? ""'■'"•'^ '' '"^ '^''''''^'' '" strumous I u m ?; -7 r''''' '^''' my experience has given me but litt e faith in it ; it may, however, be of use when the inflammation spreads to the iris. Mr. Hamilton of Dul rrenarat'ionr^ " "' '^f ^'''''^''^^' '^ "'^ """^^ The Which he says is to be given in small doses, that it may act as an alterative or tonic. But he afterw'ards 1^'^*^ aluTs'it' 'T''!' f^' r^' '^^^ ^t is as a lonL h ed wl ;";; ''•"" ''' ^ *'"'"^' '^ P^^^-'''^^ *« ^e avoid. utl7y bee d^" l7"'' ^? ™^ P'"^^"^^' "^^^^^ there has cSnnr . T ^'"^"•^"'^"t' I I^^ve not trusted to it, con ideimg such improvements as not likely to be perma- resumed it in much smaller doses » ' or lie ttdfth 0^'™'"'"''' ''' •^'"'^^" '^ ^'•^ one-sixteenth, or one-twelfth of a gram, twice a day: and to adults thp one-twe fth or one-ei/>'hfh it ;= ♦ u . ^ t.'nr.hn.n T • u ^ ^* '^ **^ ^^ combined in a little and f h . r""'""' '' '^''^ °''' ^^-^^f-^^^' spirits of wine and to be taken one hour after meals ' vPr?vT 'IT"'""^. *"'^' ^'^^^ ^^^'^^'"^"t and have found it x^td:^;!^!^^^^^^^^^^ Iodine has been given in Ihis diseaM, and sometimes n.ia,/,™ the nse of .b:;;t:e,s etfr,";rrf :' 1" nothing ofits use a, I have never given i, a'triai S i i 'lit I ,'l'u 1 1 I I'- f 298 PATirOLOQY having been written latterly on tl.o benefit to be derived from the use of cod-liver oil in scrofulous cases, I have, HI consequence, given it a trial in strumous ophthalmia, bu found no beiiefit from it, ' ih^eHl '^'r^y—^^^'^^S that the ophthalmic branch of he fifth pair of nerves is, as well as being sensible to the stimulus of light, the nutritive and secretive nerve of the eye; and that it is this nerve being poisoned which modi- fies inflammation of the conjunctiva, producing phlyctenular ophthalmia, I conceive that every effort should be made in the local, as well as in the constitutional treatment, to re- store this nerve to its healthy action. Finding that veratria was recommended by Dr. Turnbull for the cure of neuralgia, gout, rheumatism, and some forms of paralysis, I was induced to try it in various cases of disease of the eye, where I could trace the affection to any disordered state of the ophthalmic branch of the fifth pair of nerves ; and I have found it productive of the very best effects. Its immediate effects, in strumous ophthalmia, are to remove the morbid irritability of the extreme fila^ ments of the fifth, and thus get rid of the painful sensibility to light, profuse lachrymation, and bler.harospasmus ; and his IS domg much towards accomplishing the object in view. I believe it even does more than this, for, by giving the nerve Its healthy action, it restores the nutritive properties neces- sary for a healthy eye. The manner in which I use this remedy is by brushing the eye-hds, eye-brows, and temples, with an eight grain solution of It, till a slight burning sensation is produced in the parts. I repeat the application every morning until the pain, blepharospasnius, and intolerance of light, are removed Ureat caution is necessary in its application, not to let any ot It get on the conjunctiva, for such an accident will pro- duce great pain and do no good. If the use of it is found to produce twitching of the muscles of the face, it should be at once desisted from. OP THE EYE. 299 JZ \ ^'"^''^^''^'od to say tl.at I consider this tnicdy a euro /or strumous oj.htl.alMua, indoneiHlcnt of cry other treatment; far from it; nor do I say in^ it with other remedies, however we'll directed, will It 1 fmes cure the disease. But this much 1 hold to ta itt one of to most valuable adjuncts, with other eme L in ho treatjnerit of strumous ophthalmia, that I Ze Jv The applications that I use to the conjunctiva depend upon the seventy, or rather the stage of the disease if his i flund L ' ^ '^ "'^ ^' ""P"'*^^ *^'^« - day. If good eilect. The way the acetate of lead should be used iTttre"'"?^' "'"""" ^^ " '" -*-' -d hen file L ,^,f^'^^;\"'^«/^tion of the cornea the best applica- on .3 the n. rate of silver, either in its purity or in si. ^on; generally speaking, the ten grain^olution wiH be ^ound strong enough, and the weakest solution, from which any benefit ean be expected, is the four grain. ' ud, d el advanced in years, relief is often obtained om th 1^ cation of the vinum opii. P^"" The child's eyes should be bathed three or four times a day wah the soothing lotion, and the edges of t c l ds smeared every niirht with ih«r.,i "fe«s "i "it iias ting ointment ^ ' ''''' '' ''"^^ ''^''' ^^imula- mJlIntslotr'' -^'"'r' ^'^^^^ '' '^' '^PP'^^-'^tion of sti- red Dree nit ?/"T Preferring the nitrate of silver, red prec.p,tate salve, and the vinum opii, to any other > 'i i\ I f% ^ 4^ -1^1 f ' 'PI 300 PATHOLOGY riefo lowing ,s from the pen of Mr. Walker :-" Strumous ophthaIm,a according to my experience, always more rea- dly} ehlsto he stmiulant treatment, when properly em- Pbyed, than .t does to the antiphlogistic. I make this observatmn as deHnitely applicable and true whether the I. ase be m the acute or chronic stage; whether it be nore or less intense, whether it be confined to the conjunc va, or have extended to the cornea, or even to the sclero- .ca; the pnnciplo .n all these cases is still the same, viz, the necessity to use stimulants. But the stimulants to be employed must be selected in accordance with the severity of he attack If the attack be slight then the milder sti- mnlants w,!l be sufficient, such, for example, as the sulphate of z.nc solution, and the zinc ointment; if somewhat more severe, the sulphate of copper solution, and the red preci- pitate ointment; if very active, the sulphate of copper in substance, or the nitrate of silver, either in solution, or oint- ment, or substance. ' "In the treatment of this affection it often happens that the more powerful the application the better the success ; wh. e on he other hand, the milder stinudants sometimes appear only to irritate, not to destroy the morbid action. In acute cases I should generally prefer the nitrate of silver pencil applied directly, but lightly, to the conjunctival sur- face ; whereas m one of a less intense character I should probably use the sulphate of copper in substance, as well as some other stimulants before mentioned " Dr. Tanesville speaks highly of the benefit to be derived from the use of creosote in strumous ophthalmia ; I am sorry to say that my experience of it would not make me recommend it. The way he used it was by mixing ten or twenty drops of it in an olince of mercurial ointment (when the case was protracted he even exceeded twenty drops) • a small portion of this ointment was put by him, under the lids, and allowed to melt over the eye-ball ; if it produced if . A, OF THE EYE. 301 violtMit smarting ho baflicd the cvo ulM. r . cold milk* although I should 1 1 f' ''"'''' ^"• silver i„ the saml strett ^ ^ffV" "'"!'' '''''''' '' niarrcs of Paris, still niWn - H . , ^'T'^^'^y '^« ^r. Dcs- Medica. Ga.ette' Tl^^^i^ri;; T''' '"'" ^"^■ g«ving his theory, to nrovo H ! \ I>csrnarrc,s after nitrate of silver to tleclwr ' T*^ ''^''''''' "^ ^''« - the first action cold w ^on "?• ''' "'"^ «'^^^'^ that the effects of cau 'tic or 1 ■■. ^"'"'^'' ""'^ t'^«» to the effects ofll ,7 J ^'^ "'"'"'^"'"^■^ ''' ^'^''"^ "In general I ^^mlZ^tZZrT'''' '^''^ weak form, for the reasons gi be tl . "• " ''''^' much the more f o i,» e i ' ^° ^''" reaction is so strong. It must no ho '' "' T '"'^'^^^ '^'^'^'^^^ '^ss recommend, for i^,' *' P'^^rfsans of the ectrotie method eollyrium, and^a , S^!^ ' r"7 '"'" ^'" ^^"«''- ^' ^^e from comprom s nl a? Wn " "' '" ^'''^''' "'^ '•<^''^'=«on the swelling of t ^ ev e lidT v rT ^"'^' '' "' '^^^•'^««' »>/ application of the caus;t'Ti V" "''^ '^'^^ ^""«^'« ^^e which I employ LTefrl 7n? on'"^"' '^ '''° ^«"3^"»™ tallized nitrate'of "cfr 1' ""''^""""^'^ «'-^- proportions reduced ELi^/'''"'"r '^ ''''''> (these namely 7 to 15 train! nf ^* 'f'^'' ^'' ^' ''^"^ws: of wat'er,) acco'rg a?the"nll^^^^ f " '^ '^ ^-^'-- according also as l U Itetr^ f l^;^ ^ «f ^^^ terate scrofulous ophthalmic affect o .oTeLmnl" '"'" m which we act more vigorously a 'fi'l «^^'"Pc, cases portion the collyriu.n bu? seldom IS, let ^''" membrane of the pvp /-it i, ^vimens tlie mucous b; m ir--* 302 PATHOLOGY diminish the strength of the nitrate of silver, recommending more frequent Instillations). This done, the most Important iiulieatlon to attend to, is to prescribe to the patient repeat- ed instillations into the eye, every half hour during twenty- four honrs, without interruption. In some rare cases it is necessary to go on with the instillation every quarter of an hour during the first two or three hours of the treatment. I take care to forewarn the patient, that during these two or three hours he will experience considerable pain, because this is the usual period necessary for tolerance to become established ; but that after that time the pain will become very supportable, and will be followed by evident ameliora- tion, which is invariably the case. In this manner the dis- eased eye is not liable to reaction, because the force of re-percussion acting in a continual manner, maintains the vessels in a state of contraction, which this reaction is una- ble to overcome. If I can see the patient five or six hours after the instillation of the first drop, I judge by the state of the organ whether or not the reaction tends to supervene, and then if not I continue ; and if it do, on the contrary, I increase the collyrium, one and a half, two, or three grains of tht nitrate of silver. If I cannot see the patient until after twenty-four hours, I prescribe immediately a collyrium a little stronger, and I have nothing to fear. In some cases in which I cannot trust to the perseverance or the good will of the patient, I recommend fomentations of iced water to assist the action of the collyrium. However, I ought to say that this has but seldom occurred to me, in more than sixty cases. After twenty-four hours, reaction does not supervene, but the intolerance of light is not always sub- dued completely, although the external tunics of the eye are usually diminished ; and, in this case, as in the other, I increase the strength of the collyrium, and after forty-eight hours, rarely more, the ophthalmia is in its second stage, I mean the acute form no longer exists. Then the instilla- OP THE KTE, 303 ions arc repeated less often every hour, and at lengtl. dis- cont nued, and replaced by a general appropriate treatment." Ur. Mocker, of London, recommended havin^r the lids I^l^u^kened, by rubbing over them the nitrate of silver in ^..bs ance: h.s object in this treatment was to remove the great susceptibility of the ophthalmic branch of the fifth pair of nerves, and thereby relieve the intolerance of lig achrvmafon, and blepharospasm us; he considered the eatment would finally result in the cure of the disease e g.ves the ease of a boy who had strumous oplX 2 of one eye and was cured by this treatment, but n on wc k after got purulent ophthalmia of the othe^ eye, wh eh h states to have cured, with the same treatment, applying the caustic bift twice, a week intervening between the firs! and second application * ^* Before I discovered the benefit to be derived from the u e veratm m strumous ophthalmia, I constantly made use the nura e of silver in the manner recommended by I never depended upon it as a means of cure. I could len?L t'h , ' ''''''"' ''''' ' '«™'^'^^'« ^'--o. «« puru- lent ophthalmia, in such a trifling manner. Dr. Furnivall, of Hertford, considered the tincture of "f Xo/^'A """' ''': ''^^ '^"^"^ '' S''^' ■'^^ the nitrate he uso 'of r, "'' """^ " ''■ ^'' '^'''^ recommends he use of blisters m strumous ophthalmia; he says, Blstenng which may be resorted to in any of 'the pieced- hllZ f '"Jr™^"^"' '-^PP^'-^rs particularly serviceable ere and should be repeated as often as they heal, either on the temples, at some distance from the eye, or behind the I have always found that blistering in strumous ophthal- imt^M T.'*^'" ^'''^- ^" ^''« ^«"''"" Lancet for 1847, Mr. Morand draws the attention of th e profession to * Lancet, November, 1842. ~ I 'f. ' fill r f :i \4 h ' ' 1 %l r 1 iH- •■If,! 304 PATIIOLOOY the state of the Schncidcrian membrane in this disease, and says : — " In scrofnlous ophtlialniia, tlic olfactory mem- brane participates with the conjunctiva in tlie inlhxmmation tliat is set up ; that it is especially about the turbinated bones, and in the anfractuosities of the nasal fossa;, that the iiillammatory action resides; and this shows itself in the form of an ccdematous engorgement, precisely similar to what is observed in the eye-lids. The more I study this disease, the more convinced am I that this is the case. A little attention suffices to show that the redness and tumefactions of the pituitary, almost always precede or accompany that of the conjunctiva. This can be more positively determined by means of the speculum auris. On examining attentively the interior of the nasal fossa), one cannot fail to observe that the redness and swelling of the nostrils, and even of the upper part of the lip, that are so commonly observed in persons of a scrofulous habit, are merely an evidence of the inflammatory action goji;^ on in that membrane. It is by proceeding in this way that we can best appreciate the degree and extent of this inflamma- tory action, the extension of which, to the palpebral and ocular mucous surfaces is often very rapid ; sometimes, however, it remains for a long time stationary, without showing any disposition to extend." To relieve this in- flamed state of the pituitary membrane, Mr. Morand recom- raendu the application of the nitrate of silver, either in ointment, lotion, or substance. This extract I not only consider valuable in a practical point of view, but also in proving, that my theory of stru- mous ophthalmia, with reference to the ophthalmic branch of the fifth pair of nerves, is amply proved by it. Pustular Ophthalmia. — Although pustular ophthalmia may be found in persons in whom no strumous affection can be traced, yet it can hardly be considered anything more than a variety of the disease; however, the subjects of it, generally •: hi OP THE EYE. 80ff :! iftl speaking, are those who pass the age for strumous ojihthal- mla, viz:— persona from twelve to twenty-five or tliirty years old. It is not so dangerous a disease as strumous ophtlialmia, neither is there the same intolerance of light ; blepharospasmus is of very rare occurrence ; and it is found to yield more readily to well directed treatment. Although the pustules vary in situation, yet thev arc always on the sclerolica, never on the cornea, but generallv close and inferior to it. They also vary in size and num- ber ; are very little elevated, of a yellowish cast although when they burst, they discharge a fluid that is more of u watery than purulent character. The ulcer left by the bursting of a pustule generally forms a groove between the cornea and sclerotica, and although it does not spread, it will sometimes penetrate into the alite- rior chamber of the eye, which may be followed by prolapsus of the iris. Treatment— IhQ best treatment is that recommended for strumous ophthalmia. Unless an ulcer is formed, I have rarely found it necessary to use a stronger stimulant than the ten grain solution of the nitrate of silver. Ophthalmia From Eruptive i^ewra.— By this term is meant such inflammations of the conjunctiva as are found accompanying, or the result of, scarlet fever, small pox measles, or erysipelas. ' The ophthalmia which accompanies scarlet fever and measles, is called ophthalmia scarlatinosa, and morbillosa • altliough the disease, in both cases, may be nothing more nor less than simple catarrhal ophthalmia, which very generally disappears as the fever gets well ; but if it does not, it must be treated as simple inflammation of the conjunctiva for if allowed to go on, it will assume a chronic form, and is likely, after continuing for years, to terminate in an incu- rable ophthalmia tarsi. I 1 ';.i «■> 806 PATHOLOGY When tho inflammation ftHsumca ii chronic form several vessels, of a bluish-red color, will be seen to traverse the white of the eye : the palpebral conjunctiva of tho lower lid will bo of a dusky-rod color; tho lids will be glued toge- ther in the morning whon the patient awakes ; and after some time the sight becomes very weak, which is first dis- covered by tho patient when reading by artificial light. The treatment I find best for such cases is to introduce between the lids every night a small portion of the red ointment, or if the case is severe, Jannin's ophthalmic ointment, without dilution, and have the eyes bathed three or four times a day with tho soothing lotion. The best constitutional treatment Is to give small doses of quinine and tartarised antimony. Any of these inflammations may become modified by a strumous diathesis : if so, it must then be treated on the principles laid down in strumous ophthalmia. Ophthalmia Variolosa.— l\m is not the disease arising from simple conjunctivitis accompanying small pox ; but It arises from an eruptive inflammation of the integuments, spreading to the conjunctiva, and producing similar pustules on the conjunctiva, to those first formed on the integuments. Formerly, in consequence of the frequency of small pox, many people lost their sight, by either partial or total staphyloma, as the result of this formidable disease. The pustules may form on any part of the conjunctiva, but they are generally found on the cornea. When they first appear they form small white points, which gradually become yel- low and elevated ; these in time burst, leaving ulcers of a sloughy character, which often destroy the whole cornea, and frequently penetrato into the anterior chamber of the eye, producing a loss of the aqueous humour, and prolapsus of the iris. A very frequent result of this disease, is, ophthal- mia tarsi, with obstruction of the nasal duct, which, as a matter of course, produces stillicidium lachrymarium. OF THE EYK. 807 From tho conimencomcnt of oplithalinia variolosH, the lids arc swollen with the iiinnmmation and pusfiijcs, some- times indeed so much so as to render it impossihie to examine the cornea. If the piirnlent matter is not kept washed off the lids, they will he adherent together, hut the practi- tioner must boar in mind that though the lids be swollen and adherent together, yet the conjunctiva may bo perfectly free from inflammation and pustides. Authors have described secondary variolous ophthalmia, as occnrring when tho small pox has either subsided, or entirely disappeared j it is said to be much less violent than when it occurs during the virulence of the disease although it sometimes does go on to tho destruction of the cornea ; but that this rarely happens unless there is a high degree of secondary fever. I have never seen a case of secondary variolous ophthal- mia, but I have seen the primary, niodincd by a scrofulous diathesis. Treatment.— U there were no pustules on the conjunctiva I would treat the case as simple conjunctivitis, but if there were pustules, I would open them with a cataract needle and afterwards touch them with the solid nitrate of silver once every day, as long as the ulcer continued to slough, or spread ; but when it ceased so to do, I would substitute the four or six grain solution for the solid nitrate of silver. During the disease the eyes should be kept perfectly clean, by means of a soft sponge and warm water ; and the lids prevented from adhering together at night, by having them smeared, at bed time, with some stimulating ointment such as Jannin's ophthalmic, the red, or the red precipitate.' Some recommend blood-letting and general antiphlogisl tic treatment. I prefer the tonic plan, that is quinine, or the infusion of colomba acidulated with nitric acid. When variolous ophthalmia is modified by a strumous diathesis, I treat it on the same principle as strumous oph- thalmia. fi fif ' 'if ■In,, if ft" t '■ if •■ if f < f 1 i; ■; 308 PATHOLOGY ^ Erysipelatous Ophthalmia.— It frequently occurs that ery- sipelatous inflammation of the head and face, extends to the conjunctiva ; but idiopathic erysipelatous conjunctivitis, is a disease very seldom met with ; it does sometimes, however take place, and may be produced by any of the causes which excite simple inflammation of the conjunctiva. Why injury, cold, &c., will produce simple conjunctivitis in one person, and erysipelatous in another, is not more easily explained, than that from the same causes simple inflamma- tion will be produced in the integuments of one, and erysi- pelatous in another person. All that can be said in explana- tion is, that there is some predisposing cause existing in some persons, that is not in others, when if they only receive the slightest injury erysipelatous inflammation is sure to fol- low. Symptoms.— The symptoms of this disease, are, an increas- ed vascularity of the conjunctiva, but the color is of a much paler red than in any other form of inflammation. This vascularity is soon followed by watery efl"usion into the sub-conjunctiva! cellular tissue, causing the conjunctiva to become so elevated, as to overlap the edge of the cornea and even, sometimes, to protrude between the lids ; this' swelling resembles chemosis in every respect, except in not being so vascular. The pain is generally very slight and of a prickly nature. Intolerance of light, and lachrymation, are seldom complained of, except when the disease is very severe, and even then these symptoms are not very bad. The secretions from the conjunctiva and meibomian glands become increased, and altered in character, so that the lids are glued together when the patient awakes in the morning. If the case be mild, the conjunctiva, instead of swelling iii the manner just described, merely forms yellowish vesicles around the edge of the cornea. When the disease goes on favorably the symptoms sub- side, the secretions of the eye gradually assume their natu- OF THE EYE. 309 ral appearance, the swelling abates,' but for a long time the conjunctiva does not assume its natural color. Treat7nent.~The best general treatment, is, first to give an emetic and purgative ; and, in about twenty-four hours after, tonics may be administered. The local treatment must be particularly attended to. As a general rule, the ten grain solution of nitrate of silver will be a sufficiently strong stimulant; but when the inflammation is very severe, the twenty grain solution may be applied. The patient should bathe his eyes two or three times a day with the soothing lotion, or the eight grain solution of alum, and smear the edges of the lids, at night, with some stimulating ointment. When the conjunctiva is greatly swollen, benefit is de- rived from opening it with either a lancet or cataract knife. Some authors recommend depletion, but It is a treatment I should never think of adopting. Carmttis, or Keratitis.— In treating of inflammation of the conjunctiva, it has been constantly mentioned how these inflammations spread to the cornea, producing ulcer, abscess, slough, and even total destruction of the cornea ; to such cases, however, the term corneitis is never applied', it being only applicable when the inflammation originates in the substance of the cornea : instances of the disease are very rare, yet they sometimes do occur, and so generally is the inflammation found modified, by a strumous diathesis, that some authors seem to consider inflammation of the cor- nea a scrofulous disease ; indeed, Mr. Mackenzie calls the disease scrofulous corneitis ; this, however, is an error, for inflammation of the cornea may occur in any person, whe- ther of a scrofulous constitution, or otherwise. Inflamma- tion of the cornea is generally very slow in its progress, and difficult to diagnose, even in the early stage, but yet more so in the advanced stage, from its being then combined with Inflammation of the conjunctiva. The first observable Li i' I iC, ">i -4t^ 310 PATHOLOGY symptoms, arc, the cornea losing its transparency, and becoming dull and hazy ; objects will then appear to the patient, as if he saw them through a fog, or a piece of mud- dy glass. Sometimes the whole of the cornea will present a hazy appearance, in other cases there will be only a part of it dull. When the inflammation is in the superficial laminae, the opacity is of a light bluish cast, but when deep seated, it is of a milky hue. At the commencement of the disease the pain is not severe ; but there is some slight intolerance of light, and an increase of tears ; as the inflammation advances, red vessels are seen on the cornea, which soon form a vascular net-work over its whole sur- face, sometimes so thick and red, as to make the cornea appear as if it were covered with a piece of red cloth ; to this appearance the term pannus is given : the vascularity of the sclerotic and conjunctiva, is also increased, but particu- larly of the former, the vessels of which show their radiated appearance round the edge of the cornea. As the disease advances, there is great pain, profuse lachrymation, and in- tolerance of light, although such Is the opaque state of the cornea, that not one ray of light can reach the retina. It is rare to have both eyes affected at the same time, yet it does occasionally occur ; it is, however, by no means uncom- mon to have the second eye affected after the one first in- flamed gets well. When the inflammation is modified by a strumous diathesis, instead of the above primary symptoms, the surface of the cornea will be usually found covered with very minute ulcers, forming little depressions on it. The best termination to corneitis is resolution ; It may terminate, however, by matter collecting between the layers of the cornea, forming what is termed an myx or urujuis^ but correctly speaking, is an abscess of the cornea. This mat- ter may be absorbed, but if not, It will either burst on the front of the cornea, leaving an ulcer, or on the posterior part of the cornea, leaving an ulcer there, the matter fallin? into the aqueous humour, and forming a ifalse hypopium. OF THE EYE. 311 and The case may end in ulceration of the cornea, without the formation of tlie deep seated matter. If the inflammation be raodilicd by a strumous diathesis, it is after ulceration has taken place, that we find it well marked, the ulcers becom- ing deep, and having ragged edges. We sometimes find conical cornea resulting from corneitis, produced by an increase of the aqueous humour ; this state of the eye is generally accompanied with partial amaurosis. Albngo, or a deposition of lymph between the layers of the cornea, is not an unfrequent result of corneitis. The same causes, cold, wounds, over exertion of the eyes, &c., which produce inflammation in other parts of the eye, will act in producing inflammation of the cornea. Treatment.— In the treatment of this disease much de- pends upon the state of the constitution; if the patient be of a full strong healthy habit, bleeding, with other antiphlo- gistic means, will be found serviceable, particularly if the acute stage be very severe. However, such cases are of rare occurrence, indeed, generally speaking, such are the subjects in which corneitis is found, that much more harm than good would be experienced from bleeding. There is hardly a week, nay a day, that I have not some case of wound of the cornea, and rarely an instance where it produces corneitis, except in persons of an unhealthy con- stitution. In general the treatment that I find to answer best, is quinine internally ; if, however, I find, on seeing the case, that abscess has formed, I combine with the quinine, calomel, but this last I never give in such a quantity as to make the mouth sore, my object being simply to pro- mote the absorption of the matter ; this being accomplished I discontinue the calomel, and continue the quinine, till a cure is perfected ; but if the quinine should lose its effects, I discontinue it, giving in its stead the ioduretted iodide of potassium, I have also found some good effects from the use of turpentine. When there is abscesa or ulcer if the cornea or ! '.li I I Tm ll 1 1 ' I. 1 1 812 PATHOLOGY even inflammation of the conjunctiva present, local stimulants should be employed, and perhaps the one that will agree best, IS the eight, or ten, grain solution of the nitrate of silver. In all cases, brushing the eye-brows and lids with the solu- tion of veratria will be found of great benefit ; but should the inflammation spread to the iris, the pupil must be kept dilated with atrophine, or some preparation of belladonna. Sclerotitis.— By this term is understood inflammation of the sclerotic coat of the eye, whether it spreads from it to other parts or not. Mr. Mackenzie gives to it the name of rheumatic ophthalmia, but as he gives no good reason for adopting such a name, I conceive it only leads to confusion as we should be very likely to suppose from the term, that it m some degree resembled rheumatic inflammation in other parts, or at least that it only occurred in persons who were at the time, or had been previously, suflfering from rheuma- tism. Now such is not by any means^ the case, for the dis- ease is found just as often in those who have not, as in those who have, suflFered from rheumatism. It is rare to find the inflammation confined to the sclero- tica ; indeed when patients present themselves to the practi- tioner, the sclerotitis is generally found combined with either conjunctivitis, or iritis, or some other part of the eye IS inflamed. Nor is this much to be wondered at, when U IS remembered how rapidly this inflammation spreads. True idiopathic sclerotitis, is most generally found in persons of middle age, whereas that disease, combined with conjunc- tivitis, is generally in persons of advanced years. When the inflammation spreads to the conjunctiva, Mr. Macken- zie gives it the name of catarrho-rheuraatic ophthalmia ; and when it spreads to the iris it is called sclero-iritis. I see no possible use for the first division ; indeed I rather think it only tends to confusion. Symptoms.— While the inflammation is confined to the sclerotica, the chief local symptoms to be observed, are a OP THE EYE. 313 bright redness over the eye, the vessels of the sclero- tica becoming of a pale pink color, radiating, or formincr a zone, round the margin of the cornea. If the sclerotic con- junctiva be moved with the finger, it will be observed that U moves over the vessels, not with, as in conjunctivitis. Ihe pain is chiefly circumorbital and confined to the coarse of the ophthalmic branch of the fifth pair of nerves ; conse- quently there is contraction of the pupil, intolerance of light, and profuse lachryraation. There Is none of that gravelly tee ing m the eye which accompanies conjunctivitis: but there IS dullness of the cornea, which, with the contracted pupil, causes dimness of vision. Although the pain does not sub- side altogether, yet it is much less severe, in the early part ot the day, becoming worse towards evening, and continuing to increase in violence till about mid-night ; towards morn- ing. It begins to abate again ; these exacerbations, however, do not of necessity occur every night; I have seen cases When they occurred only every second or fourth night, and the most obstinate case I ever saw, I have had very lately under treatment, where the great pain only came on every ten days. ' These are the local symptoms in pure idiopathic sclero- titis: but, as has been already stated, the inflammation may spread to the conjunctiva, the cornea, the iris, or in fact to every part of the eye. That it should spread very rapidly to the iris is not much to be wondered at, when it is remem- bred, that the very vessels which are so distended with blood upon the sclerotica, terminate upon the iris. When the inflammation spreads to any of these parts, there is an increase of ihe symptoms already described, in ad^^J^-n to new ones. If the conjunctiva is inflamed, of course there are symptoms not only of sclerotitis, but also of conjuncti- vitis, equally so if it spreads to the cornea or iris. When once the conjunctiva is inflamed, there is no longer the pink zone, nor white line to be seen round the cornea, both being I r ' ^ 'Jl 314 PATHOLOGY hid by the inflamed conjunctiva; and at this stage there maybe oedema of tiie subconjunctival cellular tissue, accom- panied with swelling of the eye-lids, which never happens so long as the Inflammation is confined to the sclerotica. When eclerotiti3 occurs in old persons, the inflammation extends to other parts much more rapidly, than in persons of middle age ; why this should be the case I have never seen or heard explained. My idea is, that the inflammation is modified in old age by the nutritive properties of the eye becoming weakened, as it is modified in children by scrofula ; certainly, the termination of conjunctival inflammation in both cases is very similar. Constitutional Symptoms. — There are generally symptoma- tic fever, want of sleep, tongue furred, pulse hard and fre- quent, skin hot and dry, and the bowels generally confined. Causes. — The exciting causes which produce inflammation of the sclerotica, are the same as those which produce inflammation of the conjunctiva or cornea, viz : — cold, inju- ries, &c. It is very difficult to say, what are the predispos- ing causes, indeed, all that can be said is, that in some con- stitutions the fibrous membranes are more liable to inflame, than the mucons, and vice versd; and we find that this pre- disposition in fibrous membranes to become inflamed, increases as people advance in life, which may have led Mr. Mackenzie to give this disease the name of rheumatic ophthalmia. Treatment. — Bleeding has been strongly recommended in the acute stage of this disease, both by Mr. Mackenzie and Mr. Walker ; and their opinion is, that the more the Inflammation tends to spread to other parts, the greater the necessity for both local and general depletion. How Mr. Mackenzie, after drawing so great a distinction between rheumatic, and catarrho-rheumatic, ophthalmia, could recom- mend depletion in both forms, I cannot understand ; parti- cularly after stating, that the latter disease was more fre- I OP THE EYE. 315 quent in old people. I have found that bleeding, even strong plethoric people, in this disease, was followed by so great a reaction, as to increase the inflammation. Indeed, every day's experience convinces me, fully, how little benefit is to be derived from depletion in disease of the eye,— of course I speak as of a general rule. My treatment is first to give a good purgative, and, if I find no particular objection, the medicine I choose is a drop, or half a drop, of croton oil, for it not only acts as the most active purgative, but specifically by relieving the pain of the ophthalmic branch of the fifth pair of nerves. That croton oil acts as a specific, in neuralgic affections, is fully estab- lished. I then give calomel, combined with quinine and opium, every four or six hours, according to the severity of the symptoms, till there is a decided check to the inflammation. If possible, I avoid producing ptyalism, particularly if the patient has a bad constitution. As soon as I stop the calo- mel, I either continue the quinine, or substitute for it the ioduretted iodide of potassium. During this treatment, I always attend to the secretions of the skin and kidneys ; I therefore give an occasional dose either of Dover's powder, or of benzoic acid, at bed time, ordering the patient at the same time to have a mustard pediluvium. Rest of mind, body, and eyes, being very necessary, I always order my patient to be confined to the house for a few days, and allowed pleasant society. I do not keep the patient on antiphlogistic regimen, but I restrict his diet, allowing him broths, jellies, rice, bread, light pudding, and even a little fis'i, or broiled fresh meat, occasionally. I have found great benefit from dry-cupping the nape of the neck, and behind the ears, and in the chronic form, from blisters to these parts, provided the patient be not old or debilitated, in which case they always do injury. When the case is chronic, I find the greatest benefit from keeping ^ ', ' li t I ■\ >! i ivl f ■ K 'I: "t "'1 !'■'" - ■b m- [,..' fl^^" i y ■fj i 1. ■ t it' l; t JiU~> fflHPt^ ^ ^ ^.3 H 316 PATHOLOGY the eye-lids, and round the upper part of the orbit, smeared with the tincture of iodine ; but, vvhetlier acute or chro- nic, I always keep the pupil under the influence of bella- donna, either by dropping the solution of atrophiiie upon the conjunctiva, or smearing behind the ears with the extract of belladonna. So long as the inflammation is confined to the sclerotica there is not much use in any application to the eye ; if, however, the patient finds that either a warm or cold cloth applied to the eye gives relief, there can be no objection to either ; generally I have found the warm to be the more comfortable. If the inflammation spreads to the conjunctiva, the eight or ten grain solution of the nitrate of silver may be applied to^it once or twice a day, and the eye bathed, occasionally, with some of the soothing lotion, it being first made tepid.* Choroiditis.— HhQ choroid being the vascular coat of the eye, there is every reason to suppose that it would become • In the British American Journal of Medical and Physical Science for November, 1849, there is an interesting and valuable communication, on the treatment of sclerotitis, and sclero-iritis by hydriodate of potash, by Dr. Macdonell of this city, the careful perusal of which I would recom- mend to all who have an opportunity of reading this valuable Journal, which has done so much for the medical profession in Canada. The author of the above mentioned paper shows from his own experience, and mine, what a valuable remedy, in these inflammations of the eye, is hydriodate of potash, when given in large and repeated doses. I have only to repeat here, what I havp already stated to him, that having used it, at his sugges- tion, in acute sclerotitis, I have found it a most valuable remedy, and I have rarely found it to fail in chronic cases. Indeed, since the publication of his paper, I rarely think of using any other remedy in any case of sclero- titis. ' The dose that he recommends is, from eight to fifteen grains, three times a day. There is a note on the paper alluded to by Dr. Macdonell, in which he brings forward a most interesting theory, and one which I am inclined to sub- scribe to. It is on the subject of hypopium. He considers that if a hypo- pium be absorbed, it is not pus that has been in the chamber of the eye, indeed, that a hypopium is never purulent matter, except it be what is termed a false hypopium. He reasons from analogy, and says, that no mat- ter in what part of the body pus is formed it is never absorbed ; in fact that pus globules are too large to be taken up by the absorbents. This is a subject of the greatest practical importance, and deserving of the invest!' gation of every Pathologist. OP TUE EYE. 817 he seat of inflammation, anil no doubt such is frequently the case : nevertheless, in consequence of its situation, it is very d.flicult to diagnose. To find inflammation of the choroid ooml.ned w.th a similar state of the retina, iris, or sclerotica 's by no means uncommon, but I am free to confess that I hic choroiditis without inflammation of any of the other unics Indee , from the situation of this tunic, i carcely possible to suppose It could be Inflamed and none of he other tunics partake of the inflammation. There seems to be some difference of opinion amongst authors as to wh^ consequencesarelikeIytoensuefromchoroiditis.Mr.Macken z.e supposes that it produces staphyloma choroidalis, by he pressure of the choroid coat on the sclerotic, cans n. th alter tunic to be absorbed in a more or less degre^ and then,^for want of strength, yield to the presste'from The tumor thus formed, Mr. Walker calls staphyloma clerohca, and says it may occur without inflammation ofT choroid. There is one thing certain, namely, that if inflam mation of the choroid extends to the retina, we m y x^^^^^^^ equally bad if not worse results than an; that can aS rom pure Idiopathic retinitis,, and if it spreads to the iri serotica, surely the same evils may follow as if the iZZ mation had commenced in either of these parts • so ihTl or any, of the sequel, of iritis, scl.rotitis,'an /et nit^l^ oilow choroiditis. But should the Inflammatiofr 3 om the choroid, I can very well imagine how pressure from the swollen membrane, on the retina, may produce paZ or Ota, amaurosis, and also how by its pres'su're onTsde rotica. It would cause a bulging out of that tunic from either absorption or attenuation. ' "* %m^toms.--In addition to the symptoms that are present n al, eases of internal ophthalmia, I have always remarked that when the choroid is inflamed, i„ connection w th some ! I' liij f ! n i\> .1 818 PATHOLOGY of the other tunics, tlicie is also a peculiar bhiish appearancfc of tiie wliite of tiie eye, as if the sclerotica had become transparent, permitting tlie choroid to be seen through it ; but I have never n^et with an instance in which the symp- toms present would convince me, that the case I had to treat was pure idiopathic choroiditis. The following are some of the symptoms given by Mr. Mackenzie ; speaking of the redness he says : — " One or more of the recto-muscular arteries are enlarged, and running towards the edge of the cornea, ore seen to end there la a broad lf»3h of small ves- sels. There is scarcely ever any general redness over the eye-ball, or much inflanunation of the conjunctiva. The portion of the sclerotica subjacent to the enlarged vessels, frequently presents in the early stage of the disease a thickened and fleshy appearance. The conjunctiva also appears thickened. It is probable that, even in the early stage, a preternatural adhesion takes place between the sclerotica and the choroid." Now the reader will at once perceive that so far as the symptom of redness is concerned, it is not oven pretended by Mr. Mackenzie, that it occurs in pure idiopathic choroi- ditis, or when the inflammation is confined to the choroid coat, for, be it remarked, he says there is an alteration in the conjunctiva, and even that there is probably a preterna- tural adhesion between the choroid and the sclerotica. The other symptoms, that he gives, are discoloration of the sclerotica and iris, the pupil becoming displaced and filled with lymph, — exophthalmos and exophthalmia, intolerance of light, and epiphora. As all these symptoms, however, arc found in other forms of ophthalmia, they are not distin- guishing marks of inflammation of tl»e choroid. He mak€8 the following remarks on pain and vision : " Pain. — This varies much in diff'erent individuals. When there is as yet no protrusion, the pain is moderate ; when the sclerotic is much pressed and distended, and especially OF THE EYE. 319 i i When th,9 takes place suddenly, an.I is attended with con- 8iderable increase of redness, the ,.ain in the eye becomes severe, and sometimes fnrious. Hemicrania is also pre- sent affecting principally the top of the head, the high part of the temple, and the cheek. It is not strictly circun; - hUal nor is it strikingly nocturnal." " Vision is variously affected n. choroiditis, for in some instances the very first symptom complained of, is dimness „f sight. The natient generally complains of photopsia, and not unfrequently of .ndescent vision. Hemiopia, all objects to one or other side of a perpendicular line, or above or below a horizontal line appearing dim, all objects appearing confusedly and as If doiible even when viewed with one eye, are symp- toms v.'hich not unfrequently distress the patient long before th. redness or blueness of the eye attracts attention If the disease go us on we sometimes find that total blind- affected; while in other cases the whole eye-ball is evident- ly enlarged and discolored and yet a considerable decree of vision ,s retained."-" Various degrees of febrile excite' inent attend choroiditis. In the early stage before distension brings on acute pain, the pulse is not affected ; after he patient has suffered much, a cachectic state is apt to fol low with quick pulse, pale or sallow complexion, excessive nervous irritability, and great general weakness. The patient 13 inactive, complains of coldness of the extremities and evident y labors under a deficient cutaneous circula-' tion. The digestive organs are frequently much deranged even from t e very first Want of appetite, frequent^ d y of the stomach, costiveness, flatulency, and foul tongue attend the disease m many instances " ' No matter what difference of opinion may exist amongst authors as the diagnostic signs of choroiditis, there is one tb.ng evident that it presents all the appearances of severe internal ophthalmia, the consequences of which are very » ;•- ^#'^ .i'4 m m 320 PAXnOLOOY dangerous to vision. The subjects of the disease arc gene- rally adults or adolescence of a debilitated constitution ; it is more frequently found in females than In males. The same exciting causes which produce inflauMnation of any other part of the eye, will no doubt act in producing inflam- mation of this tunic. Treatment.- Mr. Mackenzie and Mr. Walker bofli agree that to subdue this inflammation, dependence is to be placed chiefly in blood-letting, purging, and all other anti- phlogistic remedies. I cannot conceive how Mr. Mackenzie can speak so highly of such debilitating treatment, after giving such an array of constitutional symptoms. Who would be justilied in bleeding a man with a sallow complexion, exces- sive nervous irritability, great general weakness, coldness of the extremities, and deficiency of cutaneous circulation ? Mr. Walker speaks highly of the good efl'ects of mercury ; both he and Mr. Mackenzie agree as to the good effect of belladonna and counter-irritation. It must be remembered that I never saw a case where some other tunic was not implicated, as weM as the choroid, and in none of these could I recommend bleeding. I always at first give a gentle aperient, or purgative, and afterwards one of the following pills, until the breath is efTected slightly by the mercury. Calomel, six grains, sulphate of quinine, twelve grains, extract of hyoscyamus, six grains. These are to be mixed, and made into a mass, then divided into twelve pills, one of which may be taken every six hours till the above mentioned efl'ects arc produced. Wlien I discontinue the pills, I give the quinine, or ioduretted iodide of potas- sium mixture; and during this treatment I keep the pupil under the Influence of belladonna, and the eye-lids and eye-brows smeared with the tincture of iodine. When the case becomes chronic I always blister the nape of the neck ; and if the cornea or conjunctiva be inflamed I drop on the eye every day the six or eight grain solution of the ■ li OP THE EYE. 821 nitrato of silver. l( in tlio chronic stage there is i\ tendency to choroid staphyloma, Mr. Mackenzie recoinniomlrt the operation of paracentesis oculi. He operates with a broad cataract needle, by pushing it into the eye in the direction of the vitreous humour, making the puncture in the sclero- tica, and penetrating inwards about the eighth of an inch: this treatment he repeats every eight or ten days according to the state of the eye. I cannot speak of this treatment from experience, but I would not hesitate to try It when every other had failed.* ItelimUs.—TUa reader will do well to bear in mind that the only use of the retina is to receive the Impression of external objects ; in fact, that it is insensible to everything except these impressions. It must also be remembered that this tunic, like every other body, reflects light from itself, but from its situation it is impossible to draw the distinction between the light reflected from it and that from the hyaloid membrane or even the vitreous humour. The following is from the pen of VVm. Camming, Esq., late surgeon i , the London Hospi- tal. It is on the luminous api» ance of the human eye, and its application to the detection of disease of the reti- na:— "The author mentions the well known luminous appearance of the eyes of cats, dogs, and other animals, the reflection from the eyes uf Albinos, &c., and after quoting from the work* of Muller, Beer, and Tyrrell, as to the other cases in which reflections have been observed from the posterior pirt of the human eye, proceeds to say, that the object of tlu' present paper is to show, that the healthy human eye is equally, or nearly equally, as luminous, as the eye of a cat, Ac, when observed under favorable cir- cumstances; and the application of the alteration, or loss of this luminous apparatus, to tho detection of changes in the • Since the ubovp was written I have mot with an article from the pen of I .-.Jacob, in tho Dublin Medical Press, in which he condemns the ppcwitice or i(li'oilin;r. ' UA iw.2:£iiiski- 322 PATHOLOGY retina, and posterior part of the eye. Tiic autlior states that the reflection may be seen in the following manner : Let the person whose eye is to be examined, be placed at the distance of ten or twelve feet from a gas or other bright light ; the rays of light must fall directly on the face, and all rays falling laterally on the head must be intercepted by screens placed half way between the light and the eye examined. If the reflection be bright it will at once bo seen from any spot between the light and the screen. The author having more particularly described the mode in which the observations brought forward in this paper were made, remarks : ' The luminous appearance varies from a dingy red, to a bright silver or golden tint, in some cases of extreme lustre, equalling that of a well ignited coal. It is more brilliant when seen at several feet distant. It was always seen when the eye was healthy, and the pupil easily dilated. The reflection was seen in cases in which the lens had been removed by the operation of solution. Twenty cases were examined indiscriminately, vision being perfect in all ; the age varying from a few months to sixty years. In sixteen cases the reflection was bright and very evident, in four faint, and seen with more difficulty, and in one it was not seen. As to the cause of this reflection,it is attempted to beshownthat the retina, although a perfectly transparent medium in the living eye, is still a reflecting body. The formation of images upon the retina, the reflection from the cornea and lens, and other transpa- rent bodies, are cited as proof of this ; other circumstances would increase the brilliancy of retinal reflection, viz :— the concave shape of the retina itself, the position of the lens, the influence of the vascular anterior layer of the retina filled with red globules of blood.' " The author remarks, that the establishment of the fact of a similar reflection from the healthy human eye, to that from the eyes of other animals, appears important in two OP THE EYE. m ways. First, as a physiological fact, it shows that too much influence has heen ascribed to the tapetuui, that of the reti- na having been entirely overlookeil. Secondly, in a patho- logical view the existence of this appearance in the healthy eye having been recognised, its non-existence or alteration may enable us to detect changes in the condition of the reti- na and posterior part of the eye, heretofore unknown or satisfactorily to see those which we only expected."* ' Notwithstanding this very beautiful theory of Mr.* Cum- "lings, I by no means consider his arguments to be con- clusive evidence, that this luminous appearence is from the retina, any more than that it is from the hyaloid membrane or vitreous humour. But oven granting that such an appearance is from the retina, its non-appearance can be no certain proof of a change in that tunic, as a disordered state of any of the humours, capsule of the lens, or the hyaloid membrane, would certainly obstruct the reflected light even though the retina be in the most healthy condition. ' That the retina is often the seat of inflammation there can be no doubt, and this inflammation may be either acute or chronic ; the acute may become chronic, but there can be chronic inflammation of it without its being acute- indeed this is the inflammation to which the retina is most liable. When the retina becomes the seat of violent acute inflammation, it soon spreads to the whole of the internal tunics of the eye, forming the ophthalmia interna idiopa- thica of Beer, which, if not checked, very sonn runs into suppuration producing destruction of the whole eye-ball. 8ympto,7is.— It can be well imagined that from the very earliest stage of this disease, vision must be more or less alTected, and as the inflammation increases, so does vision diminish, till it is finally lost. From its very close connec- tion with the hyaloid membrane, and anterior capsuFe of the lens, th ese parts soonjai- take of t he^nflammation, all of * Dublin Medical Press. ~~ ~~" 324 PATHOLOGY which becoming swollen, press upon other sensitive parts, and consequently producing great pain, and a feeling of pressure, and tension of the whole eye-ball. There is great circumorbital pain ; indeed the pain extends along the whole course of the ophthalmic branch of the fifth ; the pupil con- tracts and loses its black appearance, and if the inflamma- tion spreads into the iris, the pupil may become permanently closed. Even should the inflammation subside, it may leave the retina so thickened, and adherent to other parts, as not only itself to be completely disorganized, but by its pressure on the ciliary nerves, cause paralysis of the circu- lar fibres of the iris, and consequent dilated and fixed pupil. But it is possible even for the inflammation to spread to all the tunics, and afterwards be subdued, without any evil results beyond slight dimness of vision, which will disap- pear in a great degree with time and proper treatment. From the beginning of the attack there is great intole- rance of light, the inflamed tunic not being able to endure that, which is necessary for the functions of the eye in a healthy state : there is also profuse lachrymation. Impaired vision, and a disordered state of the functions of the retina, is indicated by the patient complaining of red flashes of light darting through the eye, and sometimes lights of various hues, like the rainbow ; these false lights are sometimes circular, with a black spot in the centre, such as can be produced by pressing on the superior and internal angle of the eye-ball with the finger j indeed, these fiery spectra often continue after sight is completely gone, giving to the patient the false impression of seeing. When the iris becomes attacked in the general inflam- mation, besides losing its natural color, it is pushed forward towards the cornea, and the pupil, if not entirely closed, presents a reddish grey color, caused by the inflamed state of the humours behind it, and the lymph, which is generally, at this tiin<'. deposited on the retina. The sclerotic coat is OP THE EYE. 325 also red, and even though the cornea should not partake of the inflammation, it becomes muddy from the pressure upon it from within. Winle this dreadful degree of inflamma- tion is going on, the patient's suffering is excruciating, the pain in the head producing the most severe sympathetic fever, causing him at periods to rave,— until either the eye is lost by suppuration, or the inflammation is arrested, leaving the retina insensible, the pupil closed, and finally the eye-ball atrophied. The suppurative stage is generally ushered in by a severe shivering fit, the eye feels to the patient cold and heavy, the pain not so constant but at times very severe. The pus is seen to collect in the anterior chamber of the eye, lying at firs* '" -^ b.nall quantity at the bottom of it, but as it increase aally rising up, and not only hiding the pupil but . .kiiuraes the whole iris, by its filling up the anterior chamber. The matter thus pressing on the cornea causes it to project, and sometimes to burst. Cases have occurred where the matter escaped through the sclerotica, but whether it escapes through the cornea or sclerotica the result is tire same ; the pain gradually subsides and the eye collapses. These are the general symptoms and termination of acute retinitis, when it runs into general ophthalmitis: but, as has been already stated, the inflammation must not necessarily 80 terminate, for it may be subdued, or it may from some cause put on the chronic form. Causes. — It is sometimes impossible to discover any cause Cor acute retinitis ; but generally speaking, it is pro- duced by a greater quantity of strong light falling on the retina than it is prepared to receive, such as happens when a person, with the pupil widely dilated in the dark, rushes suddenly into a room brilliantly illuminated. The same thing occurs from flashes of lightning, or from examining very minute objects which reflect a strong light. I fWJ a2G PATHOLOGY Tn tment. — Perhaps there is not a disease of the eye In which olood-letting can be resorted to with such decided advantage, as in acute retinitis: but that real, benefit may be derived from this treatment, it must be adopted at the very commencement of the attack, for wiien once lymph is deposited upon the retina, very little benefit will be derived from it. As to the quantity of blood that should be taken, at a time, or the number of times it should be taken, it .fill altogether depend upon the violence of the symptoms, and the patient's general constitution ; but the first bleeding should produce a decided diminution in the vascular system, and, generally speaking, it will be well to bleed ad ddiquium ; such a bleeding at first may prevent the necessity of two or three after bleedings, and all that may then bo required will be cupping and leeching. After the bleeding the patient should get a good purgative, the best perhaps being a dose of croton oil. After the bowels have been well acted upon, the soc ner the patient is put under the Influence of mercury the better, and to attain this object one grain of calomel with a quarter of a grain of opinm, should be given every thre^or four hours, until the system Is affected. If the opium should be found to dis- agree with the patient, hyocyamus may be substituted. Exclusion of strong light ; spare diet, and rest of eyes, body, and mind, should be strictly enforced. The pupil should be kept under the influence of belladonna. When once suppuration sets In, and pus Is poured Into the chambers of the eye, the sight Is gone, and all the prac- titioner can then do is to relieve the patient's suflferlngs, and try to preserve the shape of the eye ; this latter Is some- limes very difficult, for if the chambers of the eye are filled with pus, threatening the rupture of the cornea, and accom- panied with great pain, and much constitutional disturbance, the sooner the matter Is evacuated by opening the cornea, the better, a'":er which a poultice may be applied till the m .^ OP THE EYE. m whole of the humours come away, wheu the eye-ball will shrink up, and the eye-!ids become closed. Chronic Retinitis. — It has been already stated, that chronic retinitis can exist without the acute form ever being pre- sent, indeed such inflammation of the retina is by no means unusual, and perhaps it is the greatest cause of amaurosis that exists. Indeed, when chronic inflammation of the retina continues for any length of time, it is sure to produce such a disorganized state of the retina, that not only is it rendered insensible to light, but, generally speaking, the iris also becomes paralysed, and the pupil fixed and dilated, from the injury wlich the ciliary nerves receive. Thig state of the iris, however, does not always follow, for we very frequently find that the pupil continues to act by the stimulus of light, after the retina has become quite insen- sible to any impression. Symptoms. — The patient first complains of a gradual decay of vision, and a weakness of sight, with intolerance of light : obje<'ts first become misty and confused, then false objects present themselves, such as dark spots, of various forms, floating in the atmosphere, to which the term muscce mlitantes is applied; next a fixed spot, of a dark col ., comes before the eye, generally in the very axis of vision ; this spot {scotoma) which is at first small, increases in size and darkness, until the whole field of vision is covered, and total blindness is the result. Before this takes place, how- ever, objects become very imperceptible, — one day only part of an object will be seen, the ne::i day less, and so on till the outlines only, of large bodies, are discernible. During this time another very distressing symptom is present, viz : — luminous bodies appearing before the eyes like falling stars. As the field of vision becomes covered with the dark spot, the patient will be observed to squint : this is caused by his trying to turn the sound part of the retina to the light : and this part, if the !nflamm.ation I3 then sab- I 328 PATHOLOGY diied, may remain healthy, and thus the patient will have some sight left. The inflammation may spread to the capsule of the lens, and cause it to adhere to a part of the iris, which would give to the pupil an irregular shape ; hut total blindness, gutta serena, may occur without the iris suflFering at all, so that the pupil will continue to act ven after the patient has ceased to discover light. The ciliary nerves, however, frequently suffer during the attack, which causes the iris to be paralysed, leaving a fixed and dilated •lupil. When this takes place there is generally a dryness of the Schneiderian membrane and ci -yunctiva, and some- times so great an insensibility of the latter that the patient will not mind the strongest stimulant when dropped on it : he will even draw his fingers over the conjunctiva, and not pro- duce the slightest irritation. The appearance of the eye varies very much ; sometimes there will be slight vascularity, but generally speaking, there is no morbid appearance. Pain is very seldom complained of. Cawse*.— Those who fatigue the eyes working by artificial light, are generally found to be the subjects of this disease, such as tailors, shoe-makers, dress-makers, printers, engra- vers, and those who read and write much at night. The reflected light from a country covered with snow, as in Canada in winter, is a very common cause. In nine out of every ten cases of this disease, that have come under my observation, the patients had dark eyes, which I consider a predisposing cause ; for I believe the transparent iris allows rays of light to fall upon the retina, when none should reach it except those which pass through the pupil. Treatment.— The following extract is from the pen of Mr. Mackenzie :—« Cases of this disease are often injured by stimulant and tonic treatment, while, on the other hand they are greatly benefited by moderate and repeated deple- tion. A gentle course of mercury is also of use. Counter- irritants seem hurtful. The eyes must be spared, and the patient should try the effect of country air, and exercise.'' OP THE EYR. 329 Mr. Walker speaks doubtfully of bleeding, but very favorably of mercury aad counter-irritation, and tonics when the patient is of a strumous diathesis. In my prac- tice I have met with very few cases indeed, of this disease, in which I could think of bleeding the patient, and in the' few instances in which I have resorted to bleeding, I found no good to result from it. The treatment I have found to answer best is, mild aperients followed up with small doses of calomel and quinine, till iU breath is slightly aflfected from the mercury. After pushing the calomel thus far I either continue the quinine, or give the ioduretted iodide of potassium ; or the infusion of Colombo, with nitric acid. Should salivation be unintentionally produced, it always results in evil consequences Dry-cupping on the nape of the neck I have always found beneficial, but I have rarely found any good result from counter-irritation. Each day when the patient visits me, I make him hold his eyes over a phial of hydrocyanic acid, till it produces slight redness of the conjunctiva, which generally takes about two minutes, when the acid is fresh, after which I make him close his eyes till the redness disappears; my reason for doing which, is, that if the eyes are exposed suddenly to the light after the treatment, pain and intolerance of light will be produced. Hydrocyanic acid acts both as a sedative and stimulant to the eye, and by exciting the action of the ophthalmic branch of the fifth pair of nerves, it restores the eye to its healthy action. With the same object in view," I daily brush the eye-brows and eye-lids with the solution of vera- tria. I have sometimes found good effects from giving an emetic at the beginning of the disease. Rest of the eyes is actually necessary, and benefit will no doubt be derived from change of air. Iritis.— When we consider that the iris is composed of vascular, muscular, nervous, and serous tissue, wo cannot :;ilt *: \f "i ) (1 330 PATHOLOGY wonder that it should very frequently become the seat of Inflammation. This inflammation may be either acute, chronic, or specific ; and any of these varieties may be modified by a scrofulous diathesis, or by any other peculi- arity of constitution, such as rheumatism, gout, &c. But I do not consider that the appearance of the iris explains to us what particular state of the constitution it is that tms modifies the inflammation ; therefore, when I say that such a case is one of iritis modified by scrofula, this other modified by gout, and that one by rheumatism, it is because I find that each of these persons thus afflicted, possesses one of these peculiarities of constitution, and the inflammation of the iris is modified accordingly. Mr. Mackenzie has divided iritis into six dlfl'erent forms, viz :— 1st. Rheumatic iritis. 2nd. Syphilitic Iritis. 3rd. Pseudo-syphilitic iritis. 4tb. Gonorrhoea! iritis. 5th. Scrofulous iritis. 6th. Arthri- tic iritis. Now I cannot see what practical benefit can be derived from such sub-divisions of a disease, and it is remarkable what little dlQerence Mr. Mackenzie makes io the treatment of all these ditferent varieties, with the excep- tion of what he calls scrofulous iritis. The German oculists seemed determined that no one should ever acquire a knowledge of the disease, for they divided it into thirty varieties ; which was enough in all conscience to frighten any student.* By the term iritis it must not be understood that the inflammation is necessarily confined to the iris, to the utter exclusion of otiier parts of the eye ; far from it, for although no doubt such may pos- sibly be the case, yet it is of very rare occurrence ; and so general is the inflammation in the whole eye in syphilitic iritis, or so rapidly does the inflammation spread from the iris to other parts of the eye, that no great mistake would • It was with them ti term gouty iritis originated, therefore they give the arthritic circle as a sign of this disease, although it is an occurrence purely resulting from an anatomical cause. OF THE EYE. 331 bo niado if thd case were called syphi'itic oplitlialinia. There have been many opinions as to which part of the iris the inflammation commences in, but this I consider of very little consequence, since every part of It soon becomes affected. Acute Iritis. — There arc certain symptoms to bo observed in acnte iritis, some of which are peculiar to itself, and others common to other forms of ophthalmia. The latter are pho- tophobia, profuse lachrymation, deep seated circumorbital pain, generally aggravated at night ; and the severity of all these symptoms is dependent upon the extent of the inflammation. The characteristic symptoms of iritis, are, the vascular pink zone surrounding the cornea, on the surface of the Stiierotica, dimness of sight, discoloration of the iris, con- traction, immobility, and irregularity of ihe pupil ; deposi- tion of coagulable lymph on the capsule of the lens, effusion of pus or lymph into the chambers of the eye, particularly the anterior chamber, tubercles or pustules on the anterior surface of the iris ; and sometimes there is even abscess in its substance. In the Dublin Quarterly Journal of Medical Science, No. 10, page 485, Mr. Wilde, after speaking of injuries of the cornea, says :— » We have lately had, in St. Mark's Hospital two cases of injury of the cornea from splinters of stones, which presented, on admission, all the symptoms above described. Upon the pus clearing off, so as to permit the lower segment of the iris to be examined, it was found to present the rare appearance of abscess in the substance of its tissues. An open ulcer, from which pus was discharging, was plainly visible upon i.ie iris ; and one of these cases, that of a man aged 35, presents, now that all the inflammatory action has subsided, the peculiar puckered, yellowish white cicatrix of the iris, which is repre- sented in the accompanying illustration. The injury inflict- ed upon the cornea, in this case occurred towards the upner k i 332 PATHOLOQY portion, where a small leucoma, with attachment of r por- tion of the pupilliiry mar^nn of the iris, still remains. The general haziness of the cornea is clearing off daily ; there is some vision remaining, and the form of the eye is perfectly natural. The iris could not possibly have received an injury where the cicatrix is situated." I do not give the above quotation as a proof of abscess of the iris, for I conceive no proof exists ; I have had more than one of such cases where there wasai; open ulcer on the front of the iris, but never supposed it to be the result of an abscess; on the contrary, I always considered it to arise from injury. It is very well for Mr, Wilde to say that in his case the iris could not possibly be injured, but we must consider the state the eye was in when he saw it, the ante- rior chamber filled with pus, and a sloughing ulcer of the cornea penetrating into the anterior chamber ; this last is evi- dent from the fact that a portion of the iris remains strangu- lated in the cicatrized ulcer of the cornea. Mr. Wilde does not say he saw the size of the stone that caused the wound in the cornea, and it is possible it may have been an inch long, and if so it could wound the iris at any point ; or, granting that it was not thus wounded, it may have hap- pened by some handy man, long efore Mr. Wilde saw the case, poking a small probe into the chambers of the eye, through the wound in the cornea, to look for an imagi- nary foreign body that he expected to find there ; at least such is not a very unusual occurrence in Canada. I give the quotation as a proof of how very rare it is for an abscess to form in the substance of the cornea, as the result of inflammation, when one with a so deservedly large practice in ophthalmic surgery as Mr. Wilde, remarks such a doubtful case as the one quoted. The symptoms that I have given of iritis, vary in inten- sity according to the severity of the inflammation, and are best marked when the inflammation has not spread to any 911 OF THE EYE. 333 of the other textures of the eye. The pink zone in iritis is about u line from the margin of the cornea, a white circle intervening between tlie zone and the cornea; this is caused by the vessels which form the zone perforating the sclerotica about one line from the edge of the cornea"and then passing to the iris. They are the anterior ciliary a rte- ries, which, although few in number while passing over the slerotica, before piercing that tunic, divide Into numerous branches, and these becoming distended form the pink zone, the difference between which and the pink zone formed in inflammation of the sclen-tica, being, that the former Is about a line from the cornea, having a white line interven- ing, while in the latter the zone is upon the margin of the cornea. That dimness of vision shoidd occur in an early stage of the Inflammation, is easily accounted for— by the fact that the pupil becomes contracted, and also by the Inflam- mation spreading so rapidly to the membrane of the aque- ous humour. That the pupil should become contracted and Inraoveable Is easily accounted for, when it is remembered that anything which Irritates the ophthalmic branch of the fifth pair of nerves, whether Inflammation or otherwise, will cause the pupil to contract, through the action of the third pair. I would not have the reader supiiose that in every case of inflammation of the iris, the pupil is altoge- ther immoveaWe, but in the mildest cases its action becomes very slow, and In very severe cases it is perfectly immovea- ble, and even sometimes will not be Influenced by the action of belladonna. There are two causes, either of which may cause irregularity in the shape of the pupil ; one is, that the fibres of one part of It may be paralysed, while the rest of the fibres are in rather a healthy state ; and the other cause, which is the most general, is that part of the iris may become adherent to the capsule of the lens while the rest of It remains free, and this Is not surprising w hen we remember that the serous membrane which covers the I • 1 334 PATHOLOGY Iris also covers the anterior capsule of tho lens, and all pathologists arc awaro of how speedily inllaniniatiou of serous membranes terminates in adhesion. If the whole of the pupillary edge of ilio iris is adherent to the capsule of the lens, there will be a contracted and lixcd pupil. The change which takes place in the color of the IrU will depend upon what its natural color is. A blue iris, when inllamed becomes (jreeniah^ and a dark colored iris reddish.— '■'■ This"' (says Mr. Mackenzie) " is the result of increased vascularity or effusion of lymph into its subsi mce, or on its posterior surface." Mr. Walker says it occurs from a deposit of albuminous matter on the anterior sur- face of the iris, which impairs the transparency of the mem- brane of the aqueous humonr which covers it. " Accord- ingly," (says he,) " the light colored iris, when seen through this partially opaque or turbid membrane, appears of a greenish tint, whilst the dark colored iris becomes of a red- dish color ; more rarely it happens that the discoloration Is caused by a deposition into the proper texture of tho iris." I certainly consider that Mr. Walker's reasoning is the best, at the same time it may bo caused in the way stated by Mr. Mackenzie. The color of the iris, however, is of no practical importance further than as a symptom of iritis. The pustules or tubercles that form on the iris are situated on its anterior surface, and about the size of a pin's head, and are generally absorbed ; sometimes, however, they burst, and pour out matter into the anterior chamber of the eye, forming a hypopium ; but in this disease the hypopiura is more generally formed by an effusion into the anterior chamber, of a fluid, resembling pus in color, but which is a morbid secretion of the membrane of the aqueous humour. When adhesion between the iris and capsule of the lens takes place, lymph is generally deposited upon the capsule of the lens, and it will be seen to run in bands across the pupil, unitinf^ the pupillary edge of the iris tcGther. OP THE ETE. 835 When this takes place, recovery is very iloubtliil, Indeed the case is mneh more lilcely to terminate in tlie lormatiun of a false membrane over the pupil, or in closing the pupil altogether. All these reasons are sufTiclcnt to account for the dimness of vision which takes place in iritis, hut there is another cause which occiu-s in the early stage of the disease, viz:— a diminution of the ♦r.Misparcncy of the humours, which givci to the pupil • appearance. Oauaes.—Thc causes of acute iritis, an G.ir as I have had an opportunity of observing, >n; Mmilar o those which produce inflammation in any of tht . Uu'r ;.,nics, nor have I found it more in gouty or rlieu.;...tic persons than in others, but I have found it more frequently ia women iliaa in men. Injuries of the cornea are a very frequent cause of iritis, and there is no worse form of acute iritis than what is termed the sympathetic, that is the sound eye sympathizing with the injured one, and in turn becominff inflamed, ° Cmsequcnces.—ThG best termination of iritis is that eff'ect- ed by resolution. The unfavorable results are, synecha posterior,— adhesion of the iris to the capsule of the lens, with or without opaque lens, and closed pupil from deposi- tion of lymph,— catorot'to lymphatica, or false cataract, closed pupil by the pupillary edge of the iris becoming uni- ted, which is called artresta tridis compkta ; or there may be artresia {ridi's incompleta, which is when the lymph depo- sited expands, or separates, sufl-erin- the light to pass through a small aperture. One (thougii an unusual) result, 13 for the iris to be pushed forward and become adherent to the cornea, to which the term .vjnecha anterior is applied. If there is ulceration of the iris, it will, if not all destroyed, become puckered up and shrunken. Another result is what is termed cotaracta pigmentosa; this is caused by the pupil dilating, after the inflammation has subsided, and there has -een synecha posteri;;r, and luaviiig the pigment on ' '19 i il ''\l\ 336 PATHOLOGY the capsule of the lens, it (the pigment or uvea) becoming detached from the posterior surftxce of the iris. In consequence of this hvst result, Mr. Dixon, one of the sur- geons of the London Ophthalmic Hospital, condemns the use of belladonna in acute iritis, conceiving that it has no power to dilate the pupil while the iris is inflamed, and that it is likely to cause the above result, if applied after the Inflammation ceases.* In this idea I cannot agree, for four reasons,— first, because there are very few cases of iritis so severe that the pupil will not dilate more or less by the use of belladonna ; second, because there is no case where, if properly used, it will not assist to keep the pupil from closing ; third, because it is even better it should be the cause of breaking up these adhesions between the iris and capsule of the lens, than to suffer them to remain and become permanent, even though cataracta pigmentosa should be the result; and fourth, that this consequence may be the result of iritis if belladonna was not used at all. Trentmcnt.— If the patient is healthy, strong, and robust, much benefit is likely to arise from a general bleeding, but generally speaking poor patients cannot bear such debilita- ting treatment. Whether the patient is bled or not the alimentary canal should be got into proper order by the administration of a dose of purgative medicine. As soon as this effect ha^: been produced, the quicker the system is got under the influence of mercury the better. If the patient is a fit subject for bleeding, the mercury may be pushed to salivation, and the effect kept up for a few days ; but if he is of a bad cop-,titution, the mercury should not be pushed to such an extreme, but stopped when the breath becomes tainted. The best way to administer mercury is small doses of calomel, combined with opium or hyoscyamus, repeated v./y frequently, say on e grain of calomel every * Lancet, March 4 anil 18, 1848. ~ OF THE EYE. ggljjt three or four hours. If the patient is of a bad constitution I would recommend a combination of quinine with the calo- mel. As soon as the mercury has been pushed sufBciently far, the quinine may be continued, and if it is found not to agree, the ioduretted iodide of potassium mixture may be substituted in its stead. If, notwithstanding these remedies, the disease still continues, and the inflammation becomes modified by scrofula,— iodine, hydriodate of pot- ass, sarsaparilla, change of air, nutritious diet, &c., will be found serviceable, and I have frequently met with cases which, after having withstood every treatment, yielded ' the calomel and quinine administered a second time, with the same precaution as at the first. If the inflammation becomes modified in persons of a gouty or rheumatic habit the remedy of all others to be most depended upon is hydrio- date of potass, in eight, ten and even fifteen grain doses. The thing next of importance in the treatment of acute" iritis, and indeed in every form of the disease, is to try and keep the pupil if possible under the influence of belladonna. The oest way of accomplishing this is to drop on the conjunc- tiva every day, the solution of atropine:* but the general way is to smear the eye-brows and lids with the extract of belladonna, the extract being first brought down to the consistence of cream, or oil, by mixing it in a little water The atropine is the best preparation, but it is so expensive that few practitioners could afi'ord to use it except with wealthy patients. When using the extract of belladonna I always apply it round the back and front of the ears, and find it has just as good an effect as if applied round the orbit. My object in applying it to this part, is, that I may be able to apply the veratria round the orbit, which I do once every day. To derive any benefit from the use of belladonna it should be kept constantly moist. w I I 'liil 888 PATHOLOGY Blisters anil other counter-irritants, on the temples, nape of the neck, and behind the ears, have been recom- mended; I have always found that they aggravated the disease. During the treatment of acute iritis, perfect quietness of mind and body should be observed ; the eyes of the patient shoul'i not be exposed to the glare of the sun or artificial ligl:i, but by no means phould his room be darkened. I v;ould not recommend his being confined to bed, but rather to his room, at the same time permitting his friends to visit him, and if the inflammation becomes modified, he should not be even confined to his room, but allowed to go about the house, and even out of doors if the weather be fine. During the very acute stage mild antiphlogistic diet is necessary, but such should not be continued long, for very soon it will be necessary to give light nutritious diet, such as broths, &c. ; should the conjunctiva become engaged in the inflammation, the eight or ten grain solution of the nitrate of silver should be dropped upon it once or twice a day. Chronic Iritis. — When acute inflammation of the iris subsides, and partakes of the chronic form, many of the severe symptoms already described, disappear, and others become less marked ; still the morbid process, though of a slow and inactive character, gradually goes on till vision is destroyed. The pain sometimes disappears, or at least the patient complains very little of it, or indeed of anything else except dimness of vision ; the vascularity of the sclero- tica becomes very inconsiderable, although that of the iris itself may inci ise; the vessels can be sometimes seen on the capsule of the lens. If in the acute stage the pupil is contracted, irrcgula.- and motionless, it is doubly f o in the chronic form, but intolerance of light is seldom complained of. It is when iritis is in the chronic stage that we find synecha anterior more generally produced ; and this is OP THE EYE. 339 caused by the aqueous humour becoming absorbed, and not renewed, m consequence of the morbid state of its membrane- consequently the iris and lens having no support, fail for' ward against the cornea, and the anterior chamber is obli- terated. The loss of the natural color of the iris is another symptom which continues in the chronic ige Chronic inflammation of the iris may take place without acute inflammation ever having existed; wnen such is the case the symptoms at first are not well marked. Its pro- gress IS very slow, and it is seldom found to spread to any oi the other tunics of the eye, although generally speaking from the very beginning there is dimness of the cornea The pain IS very slight, and it is rarely accompanied with pho- tophobia, lachrymation, or intolerance of light. What the patient most complains of is loss of vision. The vascular pink zone is found round the cornea, the iris loses its natural color, and the pupil becomes fixed ; all these symn- ioms may continue for twelve or fourteen days before there .s any sign of lymph being deposited. After this, om bands of ymph may be seen stretching from the pu^i Z margm of the iris to the capsule of the lens; finally 7e ;!npsule becomes opaque from the effused lymph. After this the whole eye-ball may become atrophied, or the aque- ous humour becoming absorbed, and the lens and iris beiuff pushed f.,rw.rd, the anterior chamber is obliterated, and the ins Decomes adherent to the cornea. Causej.-Wth the exception of scrofula it is very hard to say / .lat peculiarity of constitution predisposes the Iris to that pecuhar inflammation termed chronic. If, however the practitioner finds that the patient had suff^ered from' gout or rheumatism, he is justified in considering either of them as a predisposing cause. I have remarked that .um- bers of the poor emigrants who were afflicted with fever in the summer of 1847, became aff-ected with a chronic form of intis in the winter following, and th^ m^hrhv of *^ . 1 340 PATHOLOGY were in females. To this form of iritis tlie term post-febrile might be justiy given, but I conceive it would be only multiplying terms without any practical use, as in rec'Uy it is nothing more or less than chronic iritis * The exciting causes are similar to those which produce acute iritis. In- jury of the co/nea is very liitely to produce it in strumous children. Treatment.— An emetic and gentle ;iperient may be first administered, after which quinine and calomel should be give., until the gums are slightly affected. This latter medicine should be given with great caution, not in fre- quently repeated doses as in acute .*;. , but about one grain every twelve hours for a few days, and after that once a day will be often enough to take it. As soon as the gums 4»re affected the calomel should be relinquished and the quinine continued. If the patient is a child it will be better to substitute the hydrargirum cum creta for the calomil. This is also one of those forms of iritis in which the greatest benefit is found from the administration • The following cases will illustrate the benefit to be deriyed from quinine combined with calomel in these cases of iritis : Case 1«<.— December, 27th, )a47 lannah Grady, ag.. 22, house servant, had her right eye affected for ten un; •= ; had the fever in the fall of the year She complained of dimness of sight and {. -at circumorbital pain. On exami- nation, I found she had well marked iritis with hypopium, I smeared her eye-brow with belladonna, and gave her calomel and opium every six hours till her mouth was affected. There was no check to the inflammation ; I then cave her a quinine mixture, and ordered her one table spoonful every eight hours. There were ten grains of quinine in the eight 02. mixture. /Jtor taking two bottles of the mixture her eye was perfectly well. Case 2nd.— January 21st, 184S, John McCallagh, aged 22, laborer, bad inflammation of his e^e six weeks ; had fever in the month of September • never had syphilitic disease; I found that he had iritis of the left eye, and that he complained greatly of the circumorbital pain. I gave him one of the following powders every eight hours ; IJ Sulph. quinine gr. i. Submur. hydr. gr. i. Pulv. opii. gr. ^ M As soon as his gums became soft the inflammation abated, after which I gave him an eight oz. mixture of quinine, to take one table spoonful th f - times a day jwhen the mixture was finished he was perfectly well. •ng, OP THE EYE. 841 of the hydriodate of potass. Light but nutritious diet, and exercise ui the open air, are very necessary towards the accomphshment of a cure. Belladonna and veratria should be used, as is recom- mended in acute iritis. I should not recommend blisters or any counter-irritants. If the conjunctiva be engaged in the inflammation, a solution of the nitrate of silver should be dropped upon it daily. Syphilitic .ntis.-1hh is a secondary syphilitic affection, which rapidly extends its destructive influence to the whole eye-ball, so much so that it might be called syphilitic oph- thalmia. The inflammation first attacks the iris, although from the very beginning the redness of the sclerotica is very remarkable. Dimness of vision is much greater than in any other description of iritis, and in a very short time from the commencement of the attack, opacities of the membrane of the aqueous humour and capsule of the lens are to be observed. The first stage of the inflammation has no sooner appeared than with the greatest rapidity it runs into the second, when puriform matter and lymph are depo- sited, and adhesion takes place. It is therefore in the second stage, when we examine the eye, that we more particularly find the chief characteristic symptoms of this form of inflammation. But in a disease that runs its des- tructive course so rapidly it is necessary that it should be diagnosed in its first stage, therefore in every form of iritis the practitioner should enquire into the history of the case : he should examine and see if there are any symptoms In the throat, or on the skin or the bones, that would she'- a syphilitic taint In the system ; in fact he should make every effort to know if the person ever had syphilis, and if so, when he had it, and whether he was cured by mercury pushed to salivation. It is true, oases will occur to which the practitioner will never get any clue, but generally speak- ing, he will find syphilitic iritis accompanied with som- \ -f.!'. \\% ' f i ' f 342 PATHOLOOY characteristic symptoms, imcli as ulcers In thf throat v blotches upon the skin. .Some authors say that it is accom- panied with a particular description of eruption, but I have seen it with every descrintjon of syvihriic eruption, and much more frequently unatc< uspanied if any eruj)tion at all. If the practitioner is baffled in the'f5rst su^g of ;he inflammation, he should watch dusely for liie sennd whet, the symptoms that l.ave already been enumerate'! wiO more than prAliaLJy afford him a clue. Mr. iM ckenxie speaks of a rusty color of the iris near to Its puplll^iry edge, and pustules or tubercles on the sur- face of the ..I'; I have never been able to discov r the rusty appears r.c- he spe^iks of, and as for pustules or tuber- cles, thty are often found where syphilis never had an exis- tence. The characteristic signs given by Beer are h'm> dar pupil and condylomata sprouting from the iris. Irregular pupil may be found in any form of iritis, and pustules or tubercles may be mistaken for condvlomata. The following remarks are by Dr. Jacob :-« In the first stage of the dist ease, when the change in .» structure and appearances ^^ owing to mere increase of vascularity, it is, I believe, impos- sible to pronounce an opinion as to the character of the dis- ease, from inspection of the eye ; but in what I consider the second stage, the period of adhesion, effusion, and loss of transparency, I think a satisfactory diagnosis may generally be made, especially when the inflammation has been per- mitted to go on for some time unchecked. The opacity of the membrane of the aqueous humour takes place more fre- quently, and is more remarkable ; the effusion of lymph or purulent matter into or upon the iris is more usual and characteristic ; and the adhesions of the pupil to the Jens are more rapid and extensive in formation. The opacity of the membrane of the aqueous humour is indeed aim. <^ exclusively found in syphilitic iritis. It occurs in that fr of inflammation of th'^ eye which is in a great do-ree ,, , OP THE EYE. 343 fined to the chamber of the aqueous humour, and which is generally observed in delicate females of a feeble frame or scrofulous constitution, but seldom, if ever, in the simple Idiopathic inflammation of vigorous and healthy men " With reference to the opacity of the aqueous humour, he says :-" I believe that the aqueous humour is seldom if ever, rendered opaque by effusion of purulent or other mat- er ,„to It; but, on the contrary, when purulent matter is secreted 1 does not become diffused or mixed with the natural fluid but falls down, presenting the peculiar appear- ance called hypopium. That it appears very like a mSddy or clouded state of the aqueous humour I admit, and this is rendered still more deceptive by the circumstance that the opacity seldom occupies the whole of the membrane of the aqueous humour, lining the back of the cornea, but is con- fined to Its lower half or two thirds, leaving the upper part transparent, as if the opaque matter had subsided towards the bottom It is, however, to be observed that the mottled or speckled appearance is not seen during the inflammatory stage; ,t IS one of the effects or consequences which remain long after the inflammation has subsided. The opacity IS at first a diffused, uniform, muddy or clouded patch, resembling, a? has been seen, effusion into the aque- ous humour. ^ "Syphilitic inflammation of the eye, although unaccom- panied by any cutaneous eruption, sore throat, or other secondary symptoms, may generally be recognized from the greater amount of disease affecting the iris. That the yellow depositions of coagulable lymph or purulent mat- ter, already described, may sometimes occur in other forms of inflammation, cannot be denied, but that they occur far more frequently in the syphilitic form, is equally certai . Whether we cal them globules of lymph or abscesses, they are found in their most perfect and characteristic shape and appearance in this species of inflammation ; so much so that 344 PATHOLOGY III when present, I hesitate not to predict at first sight that on enquiry the existence of syphilitic disease will be estab- lished. •' These depositions have already been described when treating of the consequences of iuaaramation in its simple and uncomplicated form ; it only remains to add, that the dull-red, or light-brown irregular ring, surrounding the pupil, is perhaps found almost exclusively in the syphilitic species. The greenish yellow stain, on the other hand, is as often, if not oftener, observed in idiopathic inflammation after injury."* Mr. Walker, speaking of syphilitic iritis, says:— "I have already stated that syphilitic disease often extends to the iris, and gives rise to acute inflammation of its texture. This is a very frequent occurrence, so much so that when we find iritis among a certain class of individuals, we im- mediately inquire if there are any other symptoms of syphilis, either primary or secondary. Iritis is most com- monly met with among the secondary or constitutional symptoms of lues, such as ulceration of the throat, and eruptive disease of the dcin. It is well that you should be conversant with this fact, so as to be aware of the frequent combination of syphilis with iritis; but I do not know that It will lead to any practical result, since the treatment of intis, however excited, must always be conducted on the principles I have laid down, nor are there any diagnostic symptoms which could enable a practitioner to say by merely examining an eye thus aff-ected, that such a case is syphilUic or otherwise. It was formerly thought that the existence of tubercles and the displacement of the pupil upwards, were decisive of t'-e syphilitic origin of the dis- ease. Such a notion, however, is now completely explo- ded. You will find in several of our modern works very elaborate articles on the subject of syphilitic, rheum atic, ♦British American Journal, volume 2. pages 99—1 25—1 52. OP THE EYE. 345 arlhrific, and strumous iritis. The condition of tho system |"d.catcd by these different epithets, renders the Vef e ! .aps, somewhat more disposed to be affected by di^ ase han m a person of a healthy constitution ; but that such comhtions materially or perceptibly modify the characters of ophthalmia generally, or of iritis in particular, is, to my admtlT"'^^'L"' ^^^^'^''^hed ; moreover, the trjatmeni admit of no further modification, so far as the eye is con- cerned, than that I have already pointed out, and which relates more to the intensity and duration of the disease tnan to the exciting cause."* The reader must at once perceive the perplexing and contradictory opinions that have been given in reference to he local symptoms of syphilitic iritis ; many others could be quoted, but none of them arc so satisfactory as to leave no doubt upon the mind of the practitioner that such symptoms are confin,.d to syphilitic iritis. For my part, although I have found this torm of the disease more rapid in its progress than anyotherlorm, yet if there were not some constitutional symp- toms present to assist me in my diagnosis, or the patient's own confession that at some period of time he had had vene- real disease, 1 would be averse todeciding that thecase before me was one of syphilitic iritis, from local symptoms alone. This disease ,s rarely found in children, yet it does some- imes occur and then it is generally found accompanied by small irntable ulcers on the tongue and palate, the whole body IS emaciated, and the skin of a pallid ding^ color; un- fortunately, the inflammation does not generally at ract much attention in children till sight is irreparably !«"[ The consequences already enumerated, as the results the'resltf ""Z'""".^?^'' '"*'«' ^^e equally liable to be the esult of syphilitic iritis, such as artresia iridis, irregular S rV'h'?>.';r 7 ^"'^ «f •^^^tractHe power In the iris, opa- c^^fMhJhejens^ capsule, synechia anterior o; pL 'London Lancet, isiv. .ume for 1841, page 46. ' ® t- ;l 346 l-AihOLrjGY tenor, il,sorn:n.Hzed retina and consequent amaurosln, pro- jection of tln^ cornea or sclerotica, or the globe of th.. eye becoming shrunkeu and contracted, &c. !♦<. general ter- ininat.on in children, when not cnr .], I, ai»o.ganized retina and paralysed iris. Trea'ment~WHh some few exceptions, every thing that has boon said m reference to the treatment of acute iritis, is equ,.I,y applicable to the form termed syphilitic. Blodd- let ng, as a general rule, is seldom, if ever, required, indeed .0 the majority of people who suffer from secondary syphilis )) eeding is worse than useless. If mercury is useful in other forms of iritis, which is doubted by none, it is doubly so in the syphilitic form ; indeed, there is no medi- cme that can be administered in any disease to which the human frame is liable, that v ill produce such decided speedy, and good offects ; nevertheless, cases occur where it IS not only a useless but an injurious remedy j for example .ases where ihe patient has been already salivated, and debility produced, ^vithout checking the inflammation; inder such circumstances the best thing that can be done is to alter the treatment, discontinue the mercury, and dve either quinine or the ioduretted iodide of potassium, which is one of the best medicines that can h given under these circumstances. Goc nutrit] us diet uould be dven and even, sometimes, if the patient is very weak, a little wine will produce a good etfect ; however, it must be given with great caution. If the we.ther be fine the patient .hould have exercise in the open air, but under any circumstances he should not be confined to his room, » •; allowed to go about the house It is In such c- ,es ttiat turpentine Is found of so much use ; this remed, r .- nhilitic iritis was first recommended by Mr. Hugh ( mic 1 of Dublin In the year 1829, he published an e.nay on the subject, and since that time he has been abused by some, and applauded by others ; I am inclined to rank myself among the latter OF THE EYE. 347 disease : but I mimf nf ♦».« i^>try oilier form of the ^ , oui 1 must at the same t me ( onf(w^ ♦»,,.♦ :♦ k been so where mercury faiJed or Z,J ' ^ ^^' mercury was not adrnifsib 'l LT 2 "* '"""l ''"^' where turpentine had „o effe t i ecki 1 ho'l" ' T' and from the mnmnn« *i ''"^'^'^'"^ "'<"»^'a»imatlon, snhstilule wh™ rr„™ I'™™"™ lu meroury, but as a I think I have found ,.;,!* '"■'""''™ "''"'■• mercury some have .aTd Z,k Ff " "'"P'" °'' 'I'" <""«"»: ="«..;..wl,r:a,'ttS.i'""''""''"^-^- ™rr.ti tZa'^ss * '"■ '"^ °"'»""»''-' he neglected A, » ? , ' *"- "■"" ™ "» "^unt qnininT tte btt but I 1.'"'%"''"" '°"'" "« '»«-'«■'. effect, troTioZolLJ^Z '"""">' '"'•'"' «"' •>=« «omach w" Id bear '" "' ""»« "' ""= P''"™'^ i*mraSr::f;7'o"a;!;:,e°:;ir°" '-•"- -"»-"'•'. heeu con.ta„tly alludrd to r T 'TT ''""""" '■"' this membrane beW, "' "''" ■""'" "«'«'' "'a' Mamed;s::sLL:rp:;;;:tr;ht;i' ?^^^^^ ;':r;:;r3:traX;~^^^^ «.e anterior cap,„re » he en 'Cntb, •"""''' "" 848 PATHOLOGY i humour, the iliseas, in called uquo-ciipsulitis. This Infliuu- matioii may be either acute or chronic in its character ; that 18 to say, it may be cither rapid or slow in its itrogress, and the symptoms may be (iither severe or moditiod. It is very rare to And it existing alone, as the iiiHammation generally spreads to either the cornea or the iris, or to both ; when it spreads to the I'onner all the symptoms of corncitis will be present, and when to the latter, all the symptoms of iritis. Symptoms. — The symptoms of this disease consist in a doll muddy condition of the aqueous humour, instead of the transparent color it presents in the healthy state; as it advances the rauddiness becomes more distinct, so that sometimes the pupil and iris become quite indistinct. The Immoura also increase in quantity, so as to cause the cornea to become prominent, and the membrane itself becomes dotted with opaque spots. If the inflammation is acute, these symptoms will generally be found accompanied with inflammation of the conjunctiva or sclerotica, the cornea or iris being more liable to partake of the inflam- mation if it be chronic ; if the inflammation continue long unchecked, lymph will be eff'used, and either form of synecha may be the result ; or a coating of lymph may form over the membrane itself, which in time may become organized. The inflammation may extend to the retina, which may disorganize that tunic, and cause total loss of sight. The pain complained of is generally in the forehead with a feeling of fulness of the eye ; there is not much intolerance of light, but it is sometimes attended with an increase of tears. The causes of this disease are similar to those already enu- merated as producing inflammation in other parts of the eye, viz : — over exertion of the eyes, injuries, cold, &c. Treatment. — Hemembering that the part inflamed is a serous membrane, if it be in the acute form, the best treat- ment is bleeding and general antiphlogistic treatment, pro- OF THK EYE. 849 vided tlio patient is strong luul of a I.ealtliv consfitnlion alter which small aiul repeated doses of calomel and opium' should he given, until the gums become slightly touched when (h(! calomel may be discontinii."d, and some tonic, such as quinine, substituted. The patient should not be confined to bed nor should the starving system be adopted, still the general diet should be light and nutritious, and not so strong as that used when in a state of health. If he be a poor debilitated person, bleeding should be resorted to with great caution, and I doubt much but that general bleedin- would bo injurious. The calomel also should not be pushed HO far, and from the first it had better be combined with quinine. The same remarks hold good if the case is one ot chronic or modified inllammation, when much benefit is likely to bo derived from the internal use of turpentine or the iodurettcd iodide of potassium ; good effects may also arise Irom the applicatiou of stimulants to the conjunctiva Whether the variety is acute or chronic the iris should be kept under the InOuence of belladonna; and in the chro- nic stage, or in the acute when lymph is deposited, benefit will be found from the use of veratria to the eye-brows and eye-lids, and fumigating the conjunctiva once a day with the fumes of hydrocyanic acid ; this treatment excites the action of the absorbents, by restoring the healthy action of the ophthalmic branch of the fifth pair of nerves. Mr Wardrop recommended and spoke highly of the good results following evacuation of the aqueous humour In cases of aquo-capsulitis. The authority is good, and if I found any necessity for it I should not hesitate to follow his advice. Inflammation of the Lens and Caf.mle., jyrodudng Cataract In the Lancet for March, 1841, there h . lecture on this sub- ject, by Mr. Walker, in which he makes use of the follow mg language :_" I shall not occupy your time by enterinff upon a detailed account of UntitU and capauliti,, because i 4 1 %' Hi If, rv ' it 350 PATHOLOGY these conditions are merely the result of extension of inflammatory action of the iris or some of the internal tex- tures of the globe. " Morbid changes of the crystalline humour or of its capsule, however, originating, are always followed by one strl', ,g alteration in its appearance, viz: — a loss of trans- parency, the technical name of which is cataract. " Opacity of the crystalline lens, or cataract, is no doubt occasionally the result of increased action or inflammation ; more commonly, however, it seems to depend on a diminu- tion or loss of vitality, the vessels supplying the lens being weakened or impaired in their action, or in some instances they may be even cut off or ruptured, as may be supposed to be the case when cataract supervenes upon blows or other injuries inflicted upon the eye. Doubtless it is from diminished vitality that the morbid condition so frequently arises in elderly persons. A similar state of opacity is likewise frequently noticed around the margin of the cornea at a somewhat advanced period of life, — the condition of which I formerly spoke as constituting the appearance termed arous senilis, and which, according to Dr. Ammon, is always accompanied by a corresponding opacity of the circumference of the crystalline." Now I cannot agree with Mr. Walker that inflammation of the lens and its capsule, is solely the result of extension of Inflammatory action of other textures ; I grant that such is very frequently the case, but reasoning from analogy, and \^hen we remember that these parts aro as well sup- plied with vessels, nerves, &c., as other parts, I conceive that the lens and its capsule may be tlie primary seat of the inflammation. Nor do I at all agree with Mr. Walker, when he says that the result of every morbid change that takes place in these parts, must of necessity be followed by cataract, unless he would call that opacity a cataract which disappears on the subsidence of inflammatory action ; there ' m OP THE KYE. 351 ndeed h.s .dea would be correct ; but It does not appear that he means any such thing. I conceive every case of cataract, whether capsular or lenticular, oven th^se cases which occur i^n old age, to be the result of inflammatory action, with the exception of those which occur suddenly Whether produced by blows or otherwise. There can be no doubt but that in some instances there is diminished vitality of the part yet this very state must be considered as 'the result of chronic inflammation ; but if cataract were alone dependent upon diminished vitality, we should first have opacity of the iiyaloid membrane and vitreous humour, and of the membrane of the aqueous humour, for their vital organization is much less than that of the lens and its cap- sule But a question worthy of consideration is, why do the lens and its capsule generally remain opaque, and even very often increase in opacity, after the inflammatory action has been subdued? I attribute this to the power of the absorbents having been diminished by the severity of the previous inflammation But it may be argued that pain is one of the symptoms of inflammation, and that in the forma- tion of cataract there is none. It is very true that one of the symptoms of inflammation is pain, but it need not neces- sarily be present; as a proof of which inflammation of the iieart and other parts is an example. Inflammation of the lens or its capsule, whether spo.ita- neous or traumatic, may be either chronic or acute, but they more generally partake of the chronic form The mflammation may commence in these parts, and extend to .ther parts of the eye, or it may not spread at all ; or, as has been already seen, it may commence in other parts of the eye and spread to the lens and its capsule. If inflam- mation of the lens or its capsule is not subdued in the early stage, frequently they will continue opaque even after the mflammation is subdued. This opacity is termed catara^C. i !t\ 352 PATHOLOay Symptoms. — The symptoms of inflammation of the lens or its capsule, while in the first stage, are very obscure indeed, and this, in my opinion, is one of tlie causes of so many cases of cataract, for I have no doubt, that if, in the first stage, the symptoms were as visible as they are in inflammation of other parts of the eye, the inflammation would be more frequently subdued than it is ; bui unfortunately we seldom see cases in the first stage, except traumatic cases, and if we do meet with them, we do not generally pay sufficient attention to them to diagnose what the case is that we have to treat. In order to a proper examination of the eye, par- ticularly if we suspect inflammation of the lens or its cap- sule, we should first get the pupil well dilated, by dropping on the conjunctiva the aqueous solution of atropine ; then examine the eye in a good light with the assistance of a double convex lens. If the inflammation is in the anterior capsule of the lens, small blood vessels will be seen to cross its surface, sometimes presenting a varicose or knotty appearance. If the posterior capsule is the seat of the inflammation the appearances of the blood vessels are very similar, but something more obscure, and larger towards the centre than at the edge ; the membrane presents a muddy whey-colored appearance, and the pupil, when not under the influence of the atropine, does not contract so much as when it is the anterior capsule that is inflamed. If the inflammation is in the lens, there are no vessels seen towards the centre, unless the patient is very young, but they form a small red zone round the edge of the lens, behind the anterior capsule. The pupil is generally con- tracted. In lenticular inflammation there will be a general dimness of vision ; in capsular, dark strokes and spots will be complained of before the sight ; and in both cases objects will often appear not only double, and treble, but I have seen cases where every object appeared to the patient sexlupled, even when one eye was shut. OF THE EYE. 353 The ijiflanimation inav oxtcmi f..n«, ti 'ens, or A-o.n the lens to't e '1 mJ^T ? ■'"' capsule is the seif nf fv, , -a P^"?" ^^''^n the anterior fin 1 u ; .• ^^^^ inflammation, we more frenerallv hnd It extondmg to the retina than if it wore ZT J ' capsule or the lens itself that was nLld wh h i" 'r accounted for, when it is remeu.be 51^0 fh' "7^ renSe;th:^t~:;j^i^rr^^ bined with amaurosis than iny other Z n " ' ''"^■ iris and pupil are more liable to uffer'l .^7"'- ^u' seat of the inflammation, whieh can aMh " '^' by the anatomical fact thl.t ^e lenTreti^^ir::^^^^^^^^ ''' nerves from the ciliary, by means of fhr.V- '""'^ and posterior edge of the iris A , t ''^""^ ^''''''^' the inflammation nanv a" n. ! ^''" '^''''^y «*«'«'^ !ts primary seat, iTn^Lb ed^ iTs^ tf;"^^-^^'^^ 'n opacity, or cataract, and even ZV.'T "™""'*' after the inflammation has be su ducT: I'd 2 ""^" likely to occur in tbp fmnr., *• .l . ' ""^ '^ ™ore those cases wherth:fl '^'" '" ''''^ spontaneous. In injury. ''' '^' ">fla„,mation is the result of 'an very many eases'Tr: '^^^l^^'^^^C^Z T'' ''"^ small objects, by artiflJiil Ji„i,. "™'^>"'e "'e ejos on n.enl over Or s,l " fe tf i?;" ^~"^"'°' ""'P'^r- at furnace, glaUow"; I """' ""^ ""P'"^"" r«n(«,i«<,_If the cause be a wonn.l r,f .!,» ens, .here is general,, .pe„ki„; ;;" i, L' Xh?"" prevent „g ,|,e fc,,,,,,,-,,, „f ^^^^^^^ ™ ^^ any cha„ce be removed l,y a„ operation, for gcnerLlvL ,„" ."' :;::ev::v^::ri:ra:rvr'^'-^*™- ^:|i <•' I'm 1,1 i'tt ;l « 354 PATHOLOGY attempt at an operation for ten or twelve months after, when the capsule may be torn up with a cataract needle. Although, however, there is but little chance of preventing the formation of cataract, yet the inflammation that exists at the time, should be subdued by the ordinary means necessary in inflammation of any of the internal parts of the eye, produced by an injury ; but the practitioner should take good care not to injure the patient's constitution, and render him debilitated by antiphlogistic treatment and mercury, in the hope of clearing the opacity. If the case be seen in the first stage of the inflammation, whether the cause be spontaneous or from an injury, the treatment must be antiphlogistic, but it should never be pushed too far. I generally begin with an emetic and purgative, followed up by cream of tartar drink, containing minute doses of tartarised antimony. I resort to local instead of general bleeding, keep the pupil under the influence of belladonna, and direct that the eyes have perfect rest, and be not exposed to strong light. If the disease run into the second stage, and the vascu- larity disappears, leaving the parts opaque (cataract in the incipient stage) the treatment must be altered at once, and recourse had to alteratives and tonics, such as calomel and quinine combined, or nitric acid, mixed in molasses so as to enable the patient's stomach to bear it in large doses. Benefit will also be derived from the internal use of the ioduretted iodide of potassium. The local remedies are, keeping the pupil dilated by means of atropine, or bella- donna; fumigating the conjunctiva once every day with hydrocyanic acid, brushing the eye-lids and eye-brows with the solution of veratria, insulating the patient and drawing electric sparks from round the orbit and from the eye-lids, and keeping up a counter-irritation behind the ears by applying to these parts the tincture of iodine. It is just as nei'cssary that the patient should avoid strong light, and .«»te»«aaki-M4&»,Mii' OP THE ETE. 355 S05 cotaract, but Lave Z f„ l "'"' "' '""P'™' such sight a, enabled themT , ""'"■ "^ "'""o. The (hree foZi ,t ct^ ,f ? " ■"°''""' "■^«' P™«' operation^ The hw cL S 7'""" '""" ™"'™' disease had existed forVper 7//™ /rn'- "' "■" n.a»y yea^; i"„ the m^:"!:l^'' °^''7 "'" ''»°" f«r fo. n,e „„ the 2I.t ! ^ "S'V" ''""'r'' ^™' disease of her eyes Sii. .,, , ;, ' ° '°"™" ">« f"' years her sight had been „?„"""' "''°'' """"" '"' 'ho dimness had ^pi*; „!~SL'^"7."'""' '"" "'" ■» ll.al at that time%h[c„ IdCli;! t ''' '^ °'°°"'"' another, except by their speed " ,1 ""^P*"-*"" from very bad, and she wa „, Intlv "",8™""' '•^""h ™, family physician. "^ ""*' ""= '»« of her ..:a?"carrat7b''<:;T;:s's!7' t """ "^'""'-'»'- to be ripe for oneraL? h', f ""'"""°'' '" """ '«« as ;'.e W.h't ey: TXZ'.ll Z^Z 'Z f^t '" for operation, and thereforp ,Ui.r • i "' ^"'^ect <'^ treatment; and a,S d ^ ZT'': ""'"' expect myself, much benefit a th re 1^ w^'"' ""'' faction of seeing I.er as Ind .7n i '"'^^ ^'''^ ^^«3" "or l>ra>-er-bo,5. ^^ier t eroTal'?'/"^ ^^^ ^'^^^ during which time I s.vv L^ ^'"' ^'"^ '"'^""^^^ f™.>.atedherr;s'S':;XXo^™riSr"' ^ -J jf^^urc atropine a£ the time. the donna, :" , 'I ^ali* 856 PATHOLOGY Diirinp my treatment her pliysician was giving her tonics. This lady is now dead ; were slie living I know I should have full leave to mention her name. Case 2nd. — The patient in this case was a lady well known to nearly every person of respectability in the Province of Canada, who has kindly written me a letter with permis- sion to make use of it : it will accordingly be found below. January \%th, 1.847, I was called upon by Mrs. M of > (C. W.); she stated her age to be 57, " that she could just disrover large objects undefined, when moved between her right eye and the light, but that she did not mind about it as she had been blind of it for a long time ; that she more particularly wished to consult me about her left eye, which had been getting so dim, for some time back, that at that tiu»e she could not read with it, nor indeed maike much use of it, and that every object shedid see was multiplied live or six fold ; the moon, or a lamp, for exam- ple." On examining her eyes I found she had capsulo- leniicular cataract of both eyes ; ripe for operation in the right. She did not like the idea of an operation, nor did I {M-ess it till other remedies should fail ; I told her that I did not expect to be able to do much for the right eye, and that she might be satisfied if she had good sight in the left, nevertheless, that I would give both eyes the same treat- ment ; she attended me daily for nearly a month, when she left me with the sight of her left eye so perfectly restored, that she could read and write with ease. In the June follow- ing this lady paid me a visit as she was passing through Montreal, when 1 saw such a change in her right eye for the better, that I urged her to return to me again for a short time. In a week, or ten days following, I received the foilowing letter from her : , C. W., June 28, 1848. My Dear Sik,— On leaving Montreal, I almost promised you Ui return shortly, and place myself under your care for OP THE EYE. a few (lays longer, but I find it will 357 e for - not be practicii .-■^ present, and should the sight in my right eye continue .npro.e as .t has done, I don't know thatit will be nece" sary. I can mark ,ts daily improvement, and in doing so always think of you with gratitude and regard, bearing n ruib ,: ;/ 11 '"''"'"" ' accidentally shut my left eye by rubbu.g It, and to my surprise found that I savv the pen in n,y an very distinctly ; this is indeed an improtl f" roLv!^ A 1 "l^ ^"'^'"'"^ ^'■^''**'"«"* ^'"«h I received rom lou. And with every kind wish for you and yours believe mc to remain, sincerely your obliged, ^ ' nomram'lr^'''' I ' ^'"^^ '^ Montfe'ar'a!I;o. Z eZ o77T/"'V''! ^•^^•^-'^-venth ar'ticlesof tnc treaty of Ghent, aged 78, was led by his daughter to my surgery on the 24th of February, 1848. fif stated hat he , a ,een blind of his right 'e'ye since ^ br t ^ 1789 and d.d not expect I could do anything for it bu hat the s,ght of his left eye had been always god up o the past three months, when it became a little cloudy which loudmess gradually increased, up to ten days previous ..s coming to me, on which morning (the 14th of fZ rv t-rht' v:lf' f''"^ '' -' ^« '^"^ that -n^ o.i/-l«ght He stated that he had applied to two well kuown medical men, who professed to know som ^h nro be c;:neThr ^ '''^ ''' '''' ---' ^^" ^^^"^ -^^ J^a^nLlV'^'^ru '""' '' ''' capsuMenticular ataract of the leil eye, fully ripe for operation : and a cica- nx ,n t,he centre .f the right cornea, so surroun ed by 1^1. aj^orend^Mh^^^ ,p.,q„^^ causing iTto • Meaning " Treated." ~ 1(1 ' I; ■i 1 1 f I*. 358 PATHOLOGY appear as though the sclerotica extended over the front of the eye ; not one portion of the iris was observable throagh se f, after having daily attended me for three weeks. After attending rae for three months he was able to read and vmte, and ,s now able, so far as sight is required, to read and wnte at all hours during day light; I prohibited him iTnir ?5 7 ''f""^ ^y •''•^■'^^'^' ''^'^t; some time past he told me^hat on the previous evening he had seen a partL- the age of 19. I then examined his eyes, and found scarcely a vestige of cataract remaining in the left eye: and the nght cornea so clear; that the whole of the iris and pupil were visible even the cicatrix was much smaller, indeed not more than half its original size. The treatment In this case was exactly alike for both with the hydrocyanic acid, and his eye-brows, lids and temples brushed with the solution of veratria; sparks of electricity were drawn from round the orbit about three ^W^Z r ' '"** <>^casionalIy I dropped on the conjunc ^va the two grain solution of atropine. For the two first weeks he took every morning a wine-glass full of the Infu- sion of gentian, containing a small quantity of the sulphate of magnesia, and sulphuric acid. Inflammatim of the Hyaloid Memhrane.~The following statement is made by Mr. Mackenzie In his work on dis- ease of the eye :-« The morbid states in which the vitreous humour IS occasionally found, such as synthesis or dissolu- tion, dropsical increase, atrophy, unnatural viscidity, change ot color, loss of transparency and ossification, lead us to regard the hyaloid membrane as susceptible of lnflammat:on. A still more convincing proof is, that the vitreous humour is sometimes met with, on dissection, Infiltrated with puru- lent matter." *^ OP THE EYE. 359 ^oner^lv -'vtT'^ 'V'^^"'' ^^'' ^^^^^enzlc's conclusions generally yet he perhaps goes too far in attributing to pus .n to the vitreous humour; I am, at all events, certain that where pus ,s effused into the vitreous humour di or gamzation of other textures of the eye, as .vel as o th" hyaloid membrane, will be discovered •on of he hyaloid membrane can be diagnosed, excent those which are found in glaucoma, a disease whTch wl lu.: ittf ""'^I'^^'r'^ ''' -->^«' «f that membrl whether ,t begins m ,t and spreads to other parts, or whe- ther ,t commences in these parts and extends to that mem- brano I shall therefore treat of inflammation of the hyaloid membrane under the term glau^ma. Glaucoma, or inflammation of the hyaloid membrane my be either acute or chronic ; but more generally so^ atara " .T-' '' '^ ' ''"'^^« «"- ^founded with cataract, which ,s not so much to be wondered at, when we remember the close connection there is betwe n 1 " hyaloid membrane and the posterior capsule of the len ' ;« extt i 1r " " '] ""'^ ''"P^^^''^'^ '^'"'^ -^--tL' to exist m this membrane without the posterior capsule of the lens participating in it. When the practitioner exa- attention ,s a slight opacity of the vitreous humour, wluch he sees through the transparent lens, and he can It on perceive that this opacity is deeper seated than the lens CO ta" witi r.^'""" ''' opacity comes in close; contact with the lens, making the diagnosis between cataract and glaucoma the more diflicult One very remarkable circumstance to be observed in tttZT'.r "^^^-^t'^" «f the hyaloid membran , i" color, which becomes more marked as the disease ,f ih f '.A' idvanc! pa 360 PATHOLOGY rromh first attack of the inflammation, the 8i<,ht is misty, and fo the most part (ii,„i„i.hes ^dually till vision is altogether lost. Althon^h there is a. doubt but that Hau- coma can ex.st without the retina becoming diseased yet so freauently s it found diseased in glauc'oma, that 'm VVaker calls glaucoma, a variety of amaurosis. My opinion .s that ,t mayex,st without the retina being dLrdered because I have seen patients with glaucomatous eyes, that Without vision being destroyed, nor were there any amaurol tic symp oms present. Reasoning from analogy, I think we have a right to expect that the inflammation may be check! wh. e I IS confined to the hyaloid membrane and vitreous humour, leaving these parts more or less opaque, the retina remainm- perfectly sound. As the sight Juviinishes, in glaucoma, the pupil contracts ut when s.,h, H completely gone the pupil £les dflS and the i • j .w'y ,ed. This latter eflect appears to me to be caused hyil.. surrounding parts being pressed upon particularly the ciliary nerves, by the incretsed quantity of vitreous lumiour, for that there is an increase of this hu- mour ,s qmte evident from the fact of the eye-ball becoming large and hard to the touch. ' ^ fiprT^n" /''' r*'""* '"'"P'"""' °^ •""scjB-volitantes, and fiery .pectra of various shapes, before his eyes, with pain hX eV^f ' ''' "^^"" "^^ »^^ --^'^a* -ot only le vP, t;"'\?'?° '' ^"^^'•' ^"^ ^'^« *'>« third and fifth nei ves. Mr. Mackenzie says, that green cataract is always a compamed by glaucoma. Beer considers the sub/ecis of glaucoma and cataract viridis, together in the same chap er believe hat green cataract cannot exist without thetre- sence of glaucoma. ^^ This disease is generally very slow in its progress; indeed It often takes years before it is matured, but when once U begins to advance more rapidly, it soon runs its full course. OP THE EYE. set 'vfcon .hi, di,oa,o i, „ i, tfeir """; "^"y'VU'Mfy »«'« in, after which it is „„, 3 ,' ^""'"y "' "'<' ' .11 W; Mr. Maokfnzifr;; ' ■ J«»"-'le«h; '-ever this rcspecl, for he not 0^/1! T '""" '''"■»'■«'' '•> friends who'sent him pel^r"' "'•'"' ""' '"" "''" regional frieml, „re va I i!T "''"""'"'°" ' '"''' P'»- ttey are " ,e„ a„d far ;:*„':?"''■ """ "'" ■»"'•' ^ »' ti-ereiTj:-;',;!::;^,; ireT T" '» "°"""™. f- have aeled i„ „, friendl ''^ "'""' '" '^''"""'»' "!•" ;«t as they had it1„"ti ;Z: X* T' ™ '" »' thanks are due. P"vver, and to whom my best The following extract is from Mr \t.oV • , the eye :_« i had long felt anxioru '. ^^'^'^«"^'« « ^ork on tion the changes which the pv". ''''''*"'■'' '^^^ dlssec being favored'some L a j;;" '"^^" ^'" ^'^»^«™^> and I carefully examined Tern T 1 ''"' '^'^ '" ^'^'^ «tate, f'-om subjects pretty far "dvan^T •'''!:.?" '^ '^'"^ ^^^^en -e the particulars whth Ub etdl t '''^ '^"^'^'"^ of cases :— "oserved m the greater number " 1st Tho I *• reddish:brownX-;ecStTor^ ^^""^'^'^-^' - sistence firm • and '•!, V"^"^ ^^^^rds its centre : its con- In some cZXCeJ^rZ^'^''''' ^ "W • central part of ^heToItL? ''f'^''^'^^^^ color of^he -•derablyto Irn^J^tZZZ 7b " '"^ '' ^- drier than natural. '•"'P^'^ency. This part was also PeIw!\Iltletr:S ' «"'^ «*«*« perfectly membrane. ' ^^"^ ^'"°^' "« trace of hyaloid i'> J % IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I ^1^ IIM 12.2 1^ m 10 Hill 2.0 Hi Ki U ttUb 11:25 1 1.4 — 6" i^ 1.6 y^ Sd^ces Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716)872-4503 :1>^ V ^ <,\ •«««« a vein, &c --but it ' ^^' '^''"' '""''' ^"^'' as tying by lesi'ons ;;f the e;e sXsT*""^ 'T' '^ '' P^''-' ^^ eye, such as those produced by operations, description of ophthaLl! ', r '^''"P^""^' "^ ^^^^-y but the most prSnT sVl. '" ^"'' '"^^' '^ *•>« ^««4 Pany iritis, aZTZslmyT ''' '^'''' '^''' «^«««' tis, and th^seTympCf ;;t"'r' "' ^'^"J""^'*-'" of the attack and the auseonh.;"^ '" *^^ ^^^^"fy ophthalmitis is generaUv L J ! '"'^^'"'"^^'^n- Phlebitic are similar in S f ms vvhZ 'I^'.^^'^'^^^'^P'^'^^ idiopathic, only varyiZ In t I ^^^'^'^''' *'''''"'"^*'^> or or if it be mod^ed bv a ZrlT^''''''^'''^ '' ^^e form, inodified the sym^^^^^^^ '''''^'^'^^- When thus not run its cou^rretTap^d l Th '" '"T-' '^'' ^'^«^^« ^««« nor is suppuration of f hi ^' the vascularity is not so great, althoughTr ria ^of'^ii^f 7 '''''' *« '^ ''^ -»'^ nea are'trrJrm!;: E;:^^ '^L^'r ^^^" themselves into the aol.h'"' '""'^ Anally discharge the margin of the cornea i\T°"''' "' ''''™'"^ ""'^'^ subject of one was aTanJ^rthr; '"" '^"^^^ ^''^ both cases the tubercuirted'mn« ,'"''•"' ^ ™^" 5 i'* rior chamber, it"^^' lu^ l^^^^^^^^^^^ -% yellow, and apparen;!^.:Ltllt:nS:::rS^: 364 PATHOLOGY According to the account of both patients, these tumours, though existing for years, had not increased in size. Sight was gone in both cases. When the disease is not modified by scrofula the iris changes its color, tlie pupil is contracted, the lenticular capsule becomes opaque, the aqueous humour is muddy, and sometimes tinged with blood. The patient complains of great pulsatory burning pain at the bottom of the eye, extending from thence to the temple and forehead, and a tense feeling in the eye-ball, as if it would burst. Preceding this stage, and before vision is lost from disorganization of the retina, fiery spectra before the eye are complained of, with a great intolerance of light. From the first stage the con- junctiva is swollen, and forms a chemosls of rather an amber color. When the inflammation has advanced to the above stage, suppuration sets in at the bottom of the eye and orbit, and if the patient lives, it is poured out into the posterior chamber of the eye, when it pushes the iris forward against the cornea. At this period the patient's sufferings are v?"" great, and, if the case is left to nature, the only chance patient has of life is, by the spontaneous evacuation of ii .. purulent matter from the bursting of the eye, which generally takes place through the cornea, but sometimes through the sclerotica, when the latter, the matter becomes lodged under the conjunctiva. But it often happens thai before the spon- taneous evacuation of the matter, the patient's sufferings are terminated by death, which generally takes place during a fit of convulsions. When rigors, delirium, and convulsions supervene, the case generally terminates fatally. When once disorganiza- tion of the eye-ball takes place the most favorable termina- tion that can be expected, is, to have the shape of the eye preserved; as to vision, it is lost for ever. OP THE EYE. 365 Oames.-l have already mentioned that phlebitis and ^njunes are the chief causes of ophthalmitis, t cm im f om.rs after severe forms of fever, such as scarlet and typlms dief trtT~^ 1 ?' '""'^ '''^' '^ ""'« J'«<^««« the reme- dies to be depended upon are both general and local J nf heath general bleeding should at once be Lorted t aS a good purgative and nauseant, such as salts and senna w h a smal quantity of tartarised antimony in it. AfteJ everj three or four hours, until the gums becoine soro • It w,:i then be found necessary to give the inffpn.., proparajion of iodine, or nitric a'cid invars ^ ,'•!„- tme will sometimes be found useful • nn «» ""« '" "•» fresh and talte gentle exerc.se. But this, the usual plan of treat- Z lou'eTttT '""■r" "°' ""^ '"'""" '"™» wTlhou abL „ A„ -'T'' ''^.*''""»''"« 'he constitution wunout aba .ng the inHammalion,-! mean where there is uch a constitution to be dealt .4h as the sc „ o„ '" """"• '"""" """- «■« i"n..n,na.i„„ is n,odili7by a 866 PATHOLOGY scrofulous constitution. The treatment in such cases is so well and ably explained by Dr. Jacob, that I shall quote his words :— " In providing for the treatment of an attack of inflammation of the eye-ball in a truly scrofulous sub- ject, the practitioner has to consider carefully the probable effect of the remedies he usually employs in ordinary cases, when applied to this form of disease. When alluding to the treatment of simple, uncomplicated, or idiopathic inflam- mation of the eye-ball, I suggested the necessity of recon- sidering the opinions generally entertained, respecting the beneficial influence of depletion, in treating of Inflammation modified by a scrofulous diathesis, or even by that languid or defective condition of tho nutritive functions, which is often assumed to be scrofulous or perhaps equivalent to It. I have here to suggest a similar or even greater degree of caution. A patient presenting all the constitutional marks of scrofula, but otherwise in vigorous health, may be, and often is, benefited by local or even sometimes by general bleeding, but such a subject may also suffer from it, if it has not the effect of arresting the inflammatory action. The sudden abstraction of blood, by weakening the heart's action, and diminishing the activity of the capillary circu- lation, will often cause local inflammation to abate, or even to cease altogether ; bu: if it has not this effect, it often contributes to produce that state of the system which leads to effusion or deposition of serum, pus or lymph, or even of the peculiar material called tubercular ; atid more frequent- ly in scrofulous than in healthy subjects. In such subjects also, bleeding appears to have less effect in causing the inflammation to abate or cease, than in those not so affected ; and this I think especially to be observed when bleeding is resorted to after the inflammation has existed for some time, and has been thoroughly established. Bleeding should therefore, if resorted to at all in this form of inflammation of the eye, be resorted to at the earliest period, and with OP THE EYE. 867 the view of sudJenly weakening the heart's n.r thereby diminishing the activitv nf f^ ... *'''°"' ^"^' than for the V^rpoLf s.^^^;^^^^!;^^^ -ther ^he salutary and ordinary Ainctionfo t ^iu L 1"" ^^ The local abstraction of blood bv ]oJh "'^"'^^'"^ organs, effect on the disease what t ll tl n '"P^'"^' ^' '^'^ prejudicial influence on the nSr^ n ^'^ '''''''''' '««« ing, and may therefore be ado, , " ^." ^'""'"'^ ^^''^' .consequences'; but in'^t Lr t 'ITS re " "'' ^^ '"^^ 'ng to my experience, to be rel ei 1 . '?' '''''''^' Proces^rrrlrth^^^^^^^^^^ -pending the quantity of food of proper Zitvf, ' '' ^^' "«"«' action also requires Lon'idTrS; whTu "''™'"^^^'^ apphc] in scrofulous suh;pr.f« «, ' '* ^""es to be be recollected th peso r InrcL?""'"'^- '' '^'^^^ a renewal of the blood cieuSn-'nl-""' '' '''' ''"'''"' is obvious that such ren wa t/;" the.r vessels ; and it administration of food caplble of^ffl , '''^ ^^^ ^^ *he sufficient supply of the inS- I '^'"^ '"''' '''^od. A is also requiK m^iSf hl^r^^^^^ '^ ^"^*^- % -d Without such he'^Cate c^t'^^^^^^^^ «^«< action cannot be controllori nr ^J'stem, inflammatory to .he extent, of eS *1 „S^'"^^^ '""" P™eedi„l «o". Acting on these prt I 7hf !!!? ,?' "^aniza- not, in scrofuious subjects at pi»!. • 7 P""^'"'™" should of .ijne the use of Siotd rn'rutielT "^ ''"«''' supply the incessant expenditure „„"„,™' '""""^ '» tion and excretion I rt! „ ' ™°»" ''J' »ecre- qnantity or ,„ Ity the die 1 M °k '° '">'*" «'">- in ammal and vegetable n,atcr aTs ne 1 - t71"!'"r " preserve health, and the snbstitu. ion 7,ho« "? '" 'm ' "' -».». >o, such as are eon.„„nl, cai.edl. ,V„ C .^^ 1' th • i r«iJ n 868 PATHOLOGY permitted. The peculiar character of Inflammation in scrofulous suhjccts, is, its not yielding in a short time, or in a distinct way, eitlier spontaneously or to remedies, but rather gradually diminishing in intensity, or becoming less active ; in other words not terminating so often in what is called resolution, but becoming chronic ; we should, there- fore, be prepared to encounter a protracted state of the disease, and to provide for its consequences by sustaining the strength and health of the patient. With this view animal food should not be interdicted, as it generally is from a prevalent belief that it indnces a predisposition to inflammation, or when it takes place exasperates it. Ani- mal food should not be given, especially at the commence- ment, in such quantity as to risk even a temporary increase in the quantity of the circulating fluids, and thereby to Induce increased action of the heart, and corresponding activity of the capillary currents; in other words the patient should not be allowed to make what is called a hearty meal, but he should have as much nutritious food as will secure the supply of the necessary quantity of blood, of good quality, to his system. Sudden and extensive change of diet should be avoided for another reason. The stomach and alimentary canal may have their ordinary functions disturbed or interrupted by the discontinuance of the usual digestible food, and the substitution of new and less agreeable aliments, and experience has fully proved that nothing contributes more to the destructive progress of Inflammatory action than such disturbance. This, however, Is a subject upon which I cannot venture to enlarge here, because it involves the whole question of diet and nutrition In relation to scrofulous disease generally; but I am in- duced to dwell so far upon it, because I so often see the evil efl"ects of undue depletion, and defective nutrition, in scrofulous inflammation of the eye, and observe so fre- quently the reliance placed on medicinal remedies In its OF THE EYE. 369 treatment, regardless of this m..t • arresting its progress, and r,w;r'^^ n.eans of destructive. It shou d bo Z' ^ , , ''^"^^^''^nces Jess t'o»f are applicable to tb treat^ " r ul ''"''' '''^««^^«- mation of tbe eye-ball, a t o ' b "h ™'' '^'"«^'"- the present occasion, b caul f i T ''''''"^ ^''^'n ''or disease the "ecessit; of^ ^^ J I" ^ «?- '"'""^ '-•» ^^ ent, and nutritive functLn be" L '^'^''''''' '^'^'^ practitioner should not coio ^att ™?^« "^^«"'- The ;n providing for the improve!, ^ h " '' ^'^^ ''^'<'"«, tut.on b, means not merei; ^di ."^ ''' P!^"-^'^ constil a>r, frequently changed iL ^'. ^'^^P'ration of pure amount Of animal heat' ad "'"'"'' "' ^"^ "«^««^" should not be neglected irtgSrV- ""^^'"^ "^'^^' close, crouched, and uncleanly dwpM; '! ""* '"'^ '" ^^e attention to respiration of pur^^^'r^''^ '''^^ Poor, that ^ng rooms, and nurseries of affl/.'"'^'^' ^^^ «'««?" require as much care, badl^ conr.r. , ^'"""' ^'•^1"««tly are, for the attainment of his «' e ' '^ '' """^ ^'"'^'"^ frequently fi„d them with tin 7 ' ''"'^ incumbered as we pets, and unnecesraV 1^7 ':!' '1 ^"'•^--' -- wntten on the ventilation orepin.anTr' ""'''' ^« the contrivances which mi^ht be ' jf "^f ^'"^"t^^ and on defects of construction in ou ho ses S '" "'"''' '^' Circulation of pure air impossible ' "' '''''^'' ^ ^ce ^^e c^^dTo^ Of tt j:::r I ^^'^^ "^^ -« ^'--^ '•- cottages in the country wou J rpn'^^' ''^"^' '^'- ^^ ^heir «Pace for their suggestbn /^T' '° '•^«^' '"^niount of here than direct "' tioV^'t^"'"^-' '"^ "« --« subject, and leave it to his j d^m It'^Lr'"'"'' '' '^' apply a remedy. The maintenancP ,/ ^''""nities to of heat in the system, especLlTv " ' ' ''""^ ^'"«"nt attention also, difflcul as' often IT"' '^"'^"^' ^^'^"-e^ ^-ce Of the direction Of t^^^-:-^i--e- 370 PATHOLOGY the doors and windows to the fire-place. A temporary screen, with the necessary clothing and bed covering, and in winter a fire of sufficient strength, will enable the attendant to eflTect this object. The exclusion of light, or immuring the patient in total darkness, is generally consi- dered an essential part of the treatment in all inflamma- tions of the eye, yet I am convinced that the practice is founded on erroneous views. It appears to be assumed that light must necessarily cause pain, and consequently irrita- tion, if admitted into an inflamed eye, but this is a mistake. Light, it is true, often does produce this effect, especially in the advanced stages of the disease, and in peculiar forms of it, but as often do we find no inconvenience experienced by its presence. I therefore do not exclude light by closing the shutters or drawing the curtains, but merely as a pre- caution let down the sun-blind, or I direct the patient to sit with his back to the window or candles, as long as no complaint is made from exposure ; being convinced that in the majority of cases distressing intolerance of light is induced by rendering the eye more sensitive to it by the use of shades and curtains. These observations respecting diet and general management are more applicable to what is called after treatment, than to the first attempts to arrest inflammation, but I have made them here because I so often see the evil consequences of a disregard of such means, followed by the worst consequences. The rule, from the very commencement, should be to avoid as much as possible making the patient an invalid, and in all cases where the practitioner can venture to do so, he should treat the patient without confinement to bed or bed-room, and even, if the weather be fine, allow exercise out of doors in shaded situations. The principles which I thus suggest to be applied in the treatment of scrofulous inflammation of the eye, have been advocated by writers on disease of this nature, both ancient and modern, and are therefore not OP THE BYE. 371 atlvanccd as original Mr p • .. . ^'^ ^ " While treating ofthJothlrr' '^ '''''''^'' oj the eye-ball, I enter af/u^h llT.H^'.'''''^'^^^-" .•••^specting the value of the L? ^^^ '°'« '"^"'"e.s '/« relief, that it is unnecessarv ?' """".'^'^^ P''«P«««d for J«tan. Antimonials, reTcZ .-17""'^^ '''"" "«^ in -nehona, sarsaparilla glS ; ?' '"r""«' '^«"> I conclude, be made as avaS ,. ? '"'''"'=»'"' '"ay ^fons which circumstancs je' n?-''"^'^^^^^^^ •diopathic, syphilitic, or rhunfr'.'" '''"''■"'«"« ^^ in however, to suggest some m'^^ ^'''•^^- '^ '« "^^essary adapt them to tt treat^enTo tsT ''/""« ^^-^«> '« ^vell marked acute attack If • -r '"" ''^ ^'«««se. I„ a T-ball, occurring in a se J^^^^^^^^^^ Z '"^-'"'"ation of the ^^-en under simiL 1 m '^^^^ the practitioner should no l:r;::^^" ^'^"«''-' hut a constitution which will not umL 7 u ''"' *" '^"a' >V''th *-he effects of this reme y, a 'JZlu' 'T "'"^ ''"P""'*^ onej and also, that in su^h a Ttal of "f'^''^ '' ^^^''^y ficml effects of a full and frL 'if ?""""" ^''« ^^"^ apparent or decisive aslTsolT/'r'"''^ «••« not so The medicine should be more siowt "^ '^' ^^^^«™' ioi have I ever I strongly .leT;aul/r,.Zf r'"]'^''"™'''™"' oansed byneufalgiaof the;^ ,Lth™r„Sr''' of nerves, accompanied by inflammation r, f* '""■ case, however, of scleroliir. JT .u ' 'ave had one pain and intalttn ""e^"''''"''"' ™^ "" '»«««= "f months, till the disease wZ..r » ^' '"' "^""^ "^ "'™ case, as there was ml „Tle ^ t '^ """"'' ■■"' "™ '" «"» the lonies, we I" d not 1' h-""""'"" '" "'"''""'""' meaning of ,he wort bew "?'!;? '° ""= '™ '"""' a-* ophthalmia. B fire U ^Thfr T^ " '■"""»""■»' ■alivated, blistereTanr t": 'I : rin''rhe''"n '.-eck,.alUo„„p„.pese. Igavrh":'! X' 1 r 376 I'ATIIOLOQY OF THE EYE. grain doses, from which hcderived no benefit; I then gave him tiic iodurottcd iodide of potassium, and after continu- ing the use of it for tiuee or four wecits his eye got per- fectly well. Syinpatlietic Ophthalmia.-— yf\m\ traumatic inlhimraation is produced in any part of tlio eye by an injury, and tlie other eye becomes inthimed through sympathy, this second- ary affection is called sympathetic ophthalmia, and it is an extraordinary fact that it is generally the most severe form of inflammation. Lacerated and punctured wounds of a severe nature, arc those injuries which generally produce sympathetic Inllanunation of the opposite eye to that injured, but it is astonishing what a slight wound or injury will sometimes cause it. 1 have seen it produced by the blow of a snow-ball. Persons whose constitution has been injured by drunken- ness and debauchery, arc most liable to this form of inflam- maiion. The usual period at which sympathetic inflamma- tion comes on, is, from three to five weeks after the injury has been inflicted ; Mr. Mackenzie gives a case that occurred three months after. Treatment.—li the treatment should be prompt and decisive in ordinary cases of inflammation of the eye, it should be doubly so in the sympathetic. It is in all res- pects the same, depending of course upon the part that is inflamed. Mr. Wardrop and Mr. Mackenzie hint at the necessity of evacuating all the humours of the eye that has been injured, and suffering the ball to collapse, as a means of saving the other eye ; this treatment was suggest- ed by Mr, Wardrop, from his seeing Farriers practice it in similar cases in horses, with the desired eff'ect. CflAPTEU XIX. •■""1 perhaps there is „„, 1 T "' l'""'lo"t oplu|,„tai„ «o«..er than this very Zct '^^ ""'' "'' ^^l' '■'>><" Willi rouffl, irri,»„I,r „ .' " S™""-'' oi- 'e-'s de-rrce very small, aid in 0(1,7/;. . ^'"'"''' "'' """elimes P'-'^ Lead.' it Ip " Td'l 7 "■'" "« "' '"■■«' - » "» "«gh surfaee if „1„ fj .f™^' ""' "'»'. »■>'" as "■•ane, which caC a '1 rSVr''^ "' "'»' "'™- vaaeulo-nebulous s.a. of rcortl «7 "' T'™' f""' "PPer pan, and soon after ZZT,n "^'' '"'«'"' ™ "» As these granulalionll "^f ' "^ "' '"f""- % eonstilution, fZ7SC.T r" r?""' °' "" "■">»»'- changed by the ZittZ^- ""''''' "^ ^''« ^'^^^^^ ri-'i 4 11^1 r K 878 PATHOLOGY ophthalmology. I have tried them all with the same result, perfect failure. I have asked many medical men ia Montreal, and elsewhere, whether they had ever seen a case of granular conjunctiva cured, and invariably the answer has been no; but several ofthem,with many medical students, can now testify, that they have seen many cases cured by me ; and I do not think I am guilty of exaggeration in say- ing, that within the last four years, I have cured upwards of two hundred of such cases. My treatment is both constitutional and local. Believing, as I do, that the granulations form in consequence of the diminished power of the absorbents, and that this is pro- duced by the disordered state of the ophthalmic branch of the fifth pair of nerves, my object is to restore these parts to their healthy action, and thus get the granulations absorb- ed, and not destroyed, us is the usual practice. To accomplish this, the local application that I use is the acetate of lead, in the following manner:— When I first see the case I evert the lids, and then wipe the granulations quite dry with a soft sponge, after which I dust them over with the acetate of lead, it being previously pulverised in the finest possible manner.* I keep the lids thus everted with the lead on them for four or five minutes, then let a little water pass over them, after which I restore the lids to their natural position. If much irritation is produced I remove it, by brushing the parts over with a little olive oil. Every day after the first, till the eyes are perfectly well, I drop on the eye a large drop of the saturated solution of the acetate of lead, and order the patient to smear the edges of the lids, every night, with a small portion of the red, or Jannin's ophthalmic, ointment. If the case is not a bad one, I do not use the acetate of lead in powder, but depend altogether upon the saturated solution, which cures the disease equally * I put the fine powder into a phinl, then cover the mouth of the phial with a piece of fine uuslin. This bottle I use as an ordinary pepper-caster. OF THE EYE. 379 '■» to (he other raodeaof Lp„ ', f I'™' ''''J«'i»n Umt there consequences. The m J. ,7 '""'"' "V ^M'' evil rated »!„«„„ „f u ,.„7* ^^^""f ». '^ '» make a ,atu- tion. P"" «'". "nd then to Alter the solu- PartT/'llrerMiui.'ir''.'':'; "*/»'' ™""'J the upper «"" if the patient a'/jflr';.'"'"''™ »' -™ria, ^po»"f"i Of the *w^;t:tr;i:r::- jr:t;"-«"» ?■ Sulph. quinine, gr. viii. Tart. ant. gr. i. Acid, sulph. aromatic, gut. x Aquae fonuna. ?viii. M I never confine my natienMn -f exercise in the open ai th^' ^T^' '"•" ''^^ P'enty him to use good, wholesoLlSV?"'" '' ^»«' «"d order and even to^ak^ a g^^roM^o' r"'' '°'™'' ^"^ ^'^^'^^^ This treatment I h ""^ "^'"^ »* dinner, can safei;:l7i"VaveT;-f opted for four years, and I conjunctiva irf that tLtlrilT T '''''' ^r.n.lar sorneinstances where"; co^ict^^^^^^^^ the use of escharotics, such as tl^P 1 v , /" ^''*''"^«^ ^y everlasting sulphate of copper whio; "'/''''^ ^"^ '^^ this disease. ^^ '' '^'''''^ '« "sed so generally in -I:rnrt1^^^^-"^ ^-^--^^ ^-^ have heen -ffieienttosay Ih la ;rer:t',-' '^ ''''''' '^ '" copoeia that could be tried I^r^ '^"'"' '" ^''^ Pharma- has been tried, and in I^t "'''''' '^^^">^ o"- constitutionally "cSS^L;;::;i:^t^;^"'egranulat^^^ «n,go,l or disordered shi?! , ', ''''^ '■■™' «»"> » *- Tl^e di,ea»c now ,Se,I !, ■ ''7""' «'»"''• i«/iam,nalion. Many Juse .T", "' '' """" '"' »™^'^ -lUuneli™ assnmi,,;,,;::;, , , t" mT""- ''"^ "'° >t IS from the use of escljarolir. Jl'i .: *'"*™2i» tWnlts fre k in an i„„,„,j ,,ate Wl,rn '""""'""" "''™ «'« "■? canse I insider be immldit ""^ '"^ "'« »"t- "Pon a disordered .tate Jh,! J.^'f '" ''" ""P™-'""! "ftl. pair of nerve, i a tal v ,,t"'*?, """'" "' "'« aiirosi, i, prod„eed byparalvrlf ,■ """ ''''™ "»- accompanied with a mere "r 1 V "'"'"'' '' ''» "'"y^ ' va ; and I l,.,e alw^rreL rL i '. t "^ "'° """J'""^" "•e conjunetiva i, predacedT „„ '"■° ""'' '""= «' ; »" l.as been medMcd;?^ "".'"'"''',"'"!,'''' '*■»"'»- case I would call lacbrymal xeret "'"""" ' ''"^k a T^^":;;r:;r^r-'"".epa.ie„. f:»XSdi-f?s^^^^^^^^^^ "■« eye, and the ,igl't i,™;' ^^^f "V' "' '""" "■-« '" Pamed with ,„me decree of ei^If • ^"""''''"J' a«om- -e dwarti* and irreg d r To':!''"'' "" "^-'-kes "•acW, and the mncous n embnlT, " '" '""■"^» ~"- ™™ea presents a dnil appeartce „» , """' *•>■• Tbe fri'JiJflh^disease ceSeT'tl e "'l"'* '"""'"^ !■ II if m r*'i'f'i r f 1 F'ffl '1 li'fl 1 a 1 1^1 #Hi 382 PATHOLOGY |o move, niul tlio cornea, or its conjunctival covering becomes opaque, and blindness will bo the final result. Treatment.— Wlmthcr the disease be curable or not, the patient's sufferings can be at least alleviated by keeping the conjunctiva moist with some saponaceous lotion, like that recommended by Walthre, in lachrymal xeroma. It is composed of a few drops of aqua potassa; to two ounces of tepid water. With this lotion the eye is to be bathed occasionally during the day, for a minute or more. The only treatment I have ever found any benefit from m this disease, is thejdaily use of the veratriaand electricity In the way so frequently described in this work ; soothing applications, to moisten the conjunctiva, with ; quinine inter- nally, and every other means likely to excite the action of the ophthalmic branch of the fifth pair of nerves, such as air, exercise, good food, and warm clothing. Abscess of the Cornea.— This is always the result of in- flammation ; it differs from all other abscesses in not hav- ing a sac, being simply a deposit of pus or sero-purulent matter between the layers of the cornea. It was formerly supposed that in whatever part of the cornea this deposit was, it gravitated until it fell to the bottom, or lower edge, of the cornea, and there presented a white semi-circu- lar opacity like the mark at the root of the finger nail, therefore the name of om/x or imguis was applied to it' However, it is quite evident that the deposit does not thus gravitate from the part in which it is first formed ; I have myself seen many cases of it, and I never saw such an occur- rence, and when the anatomy of the cornea is considered it will at once shew how the weight of the matter could not thus separate the layers of the cornea. It is true that the abscess may form at the lower edge of the cornea. These facts were first shown by the late Mr. Tyrrell, and since supported by Mr. Lawrence, nevertheless many authors still adhere lo the old idea. OP THE KYE. 383 "•»rdly leaving an ul"7„fl„°!'' " ""^ '"'"<■ »«- piniii. ''• •'"" '"™ " spurious hypo- .1..' :n™ir :;;Tur:t T"",fr ■■- -•^'''---^ tl.0 inferior edge of't 1 , T^ u'" """'' "» »' " "Vx or unguis give Z M "/ '"'"'"'"•' ''I"' «»" "p'iX™?" ::,"irei,::':f*;:'' '-"" «■» i>*"t s.a„d, the .a,ne edge „r ,,,0 1 i° "' .T^"" " ™"'«. -Wle Ihc palient lurn Lis 117,™ ' ''°"™"'a' <"• '"vel. If «<'«red as .„„ ma. r gTa.i 1*.:'':,°' '."« >W-un, i/ moUon produees no ehafg™ I J" "a ' """" ''"^'' •- every mean, i„ 1 fpl° V" '"■''"""™" """"" K <» "■« 1epo.i.. If the is T„l':i™""° "•» """'P"™ of treatment reeommendod n eo™Ui T fn °"'' "" "'"■" "f a" thing, no slimulaHnglo a, fnl'','" "*''=•'' "•« nsed, as they always do l,L ti. " ' ''''™' *»"''' he adopt, i, to give eai'mel a Zinil^,:'"" u """""«»' ' ose,, nn.il ,he ,y.,en, ,, ,„g2. ;2 J"" -" -Peated keep the sy„e„ i„ „,,, „„«„ fj/"'f^ f .^^ 'he mcrenry ; "' ~ntin„e '"^ exercise, and a free diet «f 1, . . "'e Palient air, food. '"°'' °f •""'' animal and vegetable During the above treatment, I teen ,!.„ of the orbit, and behind the ear „S^ ■?""■ P"" t"re of iodine, not a, a counter irri,'^ 1 """" ">" «"'- the iodine excite, the ac "on IfT \ °l"''' *"" '«"»» that with the above leatmenl the IT^""- " ' """. Idi,con,inue the quinine arsubSuuTe."'?"' """'"'»<' of potassium in Us ,^^^1 ™''*l""te the loduretted iodide T 1 IkIj I 384 PATIIOLOQY Hypopum.-^ ,,s tern, Is give,, when pu«, lymph, mucus, or scrum or any „l ti.ese con.bine.l, is collocto.l In tl.c cimml bcrs of the oyo : whether it is in one or both chambers, it is always the result of inflanunatlon, and is of two varieties VIZ :-<.«. ami sinmous. A true hypopium is formed by the' ma tor bc.ng secreted from some internal part of the eye. such as the n,cmbrane of the aqueous hun.our, the hyaloid men.brane, or even the retina. A f^Use hypopi.im is formed by an abscess of either the cornea or iris, bursting into the anterior chamber of the eye. In the farmer the nmt .ecreted often fills up both chambers of the eye, hiding t^L •ns and pup, completely from observation. I,', the latter the antenor chamber is rarely, if ever, filled with the matter, and It can be seen running down from the abscess whether such abscess ,s .n the iris or cornea. When the patient is standing upnght, if the anterior chamber Is not filled he superior edge of the hypopium is horizontal or level, an the infermr edge .ssemi-circular; when the patient turns it" "? ''^''' "'" "'^"^'- ^''"^•t^^tes over to tha th 'mat7 rn'''.'^''"''"^"' ^'" «^« l^ecomefdled with the ma ter, there is great pain and feeling of tension in the eye-ball, and f the matter continues to utrease the corne beconjes prominent, and finally bursting, permits the Iris to drop forward, when staphyloma will be the result lreatment.--Th^ great object to be attained is the absorption o the matter, and this I conceive best accom' P .shed, by the treatment already recommended for absces. ot the cornea. If, however, the chambers become AIM and here IS danger of the cornea giving way, the surgeon should not wait for such a result, but at once evacuate the matter by making an opening in the inferior part of the cornea, which opening must be sufficiently large to permit the matter, to escape without any force being used. So much has been said when treating of the difTercnt forms of 'C*': OF THE EVE. 985 by It, lor so „r r ' r "^" r'-«y« acco,„pa„lI, superficial, deep, an,I tra le VV "■"" '""'•^' ^'■^=~ extensive than when i? ' T, 1 " !' "''«'" ''^ "'«'•« "leor is sn,ailer,a„:rof a un e hat'' T^ . ^"^ ^^^ ulcer i. so called iron, its clea n ss al^ 'th. .V""?'''"^^"* 's in observinir it • i,,jp„,, j/ '/ '""^ '''« difficulty there whereas the Stl.e;s e ' X^r'^ "^^ '" P-«'e, cornea; it appears as if i were an ^rr!?^ ^''''' '' '^' off with a sharp instru JenZ Wh ^an^ '^^^^^ '''"'' edge of the cornea it is usuallv? . "'"'"' '^^ ^^^ narrow, and is geneL ,/ o^VbTthrr"' '^"^ ""^ P"«tnle; it is not very ^0! .m , "''""^ °'" ^ penetrates into the chan^berTt^^^^^^^^^^^ '^ "-^'-- surface of theUea aid ITt ?T ""'P'''^ «^«^ '^^ its superficial layer 'a.^d fill. .^^^^ ''''" ''''' ^''^''Y staphyloma b/destCL th?' .T'"''' '" ^" '"^"•'-ble ulcer Is frequent yZfsuU of af T""* ^''^ ^««P bursting externally thlTr * . ''''' "^ ^^^ «0"'ea from it,\ its peneLit irL'^T.*' '^ "PP^^''-'J«d eye, generally foHowed 5! V" "^^ this will be the JoT ntun'te fl "', "" .'"^' «"^ centre of the cornea • scald rn . "''"■ '« '" ^be and sometin^es into er^nce f^ a ''"'"" '^'^'-^^ation, of the cornea. The pair"Ts sfd 'b^r"^'"^ '''''' "'^«" of the ophthalmic b'ranc \ t^e fifth tvT™^ '""^'^^^ exposed to the tears. ^ ^^ "®''''«« being z t % ' m I 1 '^ l^ ' ' s'J 9f I' .1 i ifiS 380 PAfP^LOOY I h f N. w.nff romarks „„ the transparent ulcer are made by Mr W. .1,. :-» Tl... trannparont ulror of tl.o rornea l.as been 1..,.^. kn..v.n an.l .loHcrihcI ; in some instances, how- ever, wc are unable to .leteet it when wo exan.ine the .•ornea m front, and oidy hcconio aware of its existence bv observing it in profile, or making the patient roll the eyo about. Ihere .s however, a nyn.pton. attending this form of ulcer, w.th which we have been long acquainted, and which has not, that we are aware of, been heretofore de- Hcribed ; it is the dark shadow thrown upon the surface of the HIS by this ulcer, be it ever so transparent or so small, particularly when the patient stands oppo:;ite the light At [irst view of this shadow, which is generally a dark circu- lar si)ot, through whicli the natural color aud slrlje of the ins can be seen, it appears like an ordinary congenital mark, but from this it can be distingui.^l.t.d, by turning the head or eye from side to side, when it will be seen to shift its place on the surface of the membrane."* The best termination there can be of an ulcer of the cornea is for it to heal, and as in every ulcer there is loss ol substance, the coiiscquence must be a cicatrix (leucoma) which will leave more or less of an opacity for life Treatmcnt.~.mich has been said on this subject in the articles on conjunctivitis and corneitis. If the ulcer conti nues to increase, and does not present a healing appearance, the local application most to be depepded upon i« i!e mtrate of silver, the strength of which will depend upon tlie state ofthe ul cer; if it is a superlicial or transparent o* .., In the British Ainoncan Journal of MBdicnl an,! pi,. .; i o • thr ..L . ■ . ■.. ... irroXriiJ:'-''''' "^ '"^ """'•'^^""g '"l^'O". and explain & ^ OF THE EYE. .387 generally .spoakin;^, it will ,|„ to .Iron on it Kv.' , en Mr. n .o!„fio„, wInVI. should ' I J dT " '''•' "'" J-'ec,, and likely ^^;ol^^^ «ye, or if it l,asHl,-p.uiv H "" '•''«'"'>ers of the 7"' ^ ' .0,; ;;:'h'i: :„;r:;sM"™ '""'""' "f silver; and this is host and ... . " 1""''' "''"•ate wottin, the point o a fl" ' I'l -'"^ "^'^"•"l''''«».cd by "■en applying it to a pni't;' •;";"' '" "«*°^ «"^ P<"-"t of the brush sho, Id t ; c 1 / '. •' "'''"' "''^ and immediately with.lravv " '" '" ""' *"^" *''« "''^e'', covered with a u hi l^i Bv , ''''' "'" ^« -°" -'ver in this .„„„„er S is ' " '' 7' "''* "'^"^'^ ^^ the eye if the patient sholl s dde 1 IT .f."-""^ ""nutes after the application of th Ll "r /' '" " '"^"^ •« H'uch pain, it may be relieved bv "''''*' "'«'"« ".n over the eye. )^hen I ^ ' I'l'llf •^, "'"'.« --"^ •" I'e n,orninff the ten or oiihtVra^ r''' '' ""'"^ applied at night; in fact an ul er of '^'"" ^''""'^ ''^ of being aluay coated wiUth. .° '"'"'" '^ ""^ '^«"««- gives the patient rel of u, TT '' ''''''^ ''' " l>;o"ueed by the tears Vunirove-'t "'^"'"^ P^'" '« the ulcer, so when the ni rate "f . ''•' '"^'^^ '^ the.pain that, for tho time d bee 3- " ,""" '^'^' ••»ga.n. When once the healinrnnr ''^'' ''^"''"^ "itrnte <>f silver should not be sed' n '' '''"'"'"^'"' *''« " cer improves, the strength of h ol ti'"'"' ''' '' ''' ally diminished. When the nLr h ' '"'"^ ''^ ff'-^d"" vessels will be seon c" run tf T' '' ^''^^' ''' ^^^ ''ed '-''-ays a good sy ,0 Toulh ' '^"^ ^-<^ it, which is '•onsidered it a aui of llt.T^' '" ^'^^'^"'"'^ ''ave f- - to take hold of thLfve r^^^^^^^^ .Tr' ''"' ^^^ ^ <''em across. A most -rronn .. -^ '^"''*'®J'« and cut "nation kept up the X Z I. ' "".' ^'^'^^ "*« '"««•»■ -'"chkeepsl,pt,,eS2 t^'"^fM^'^*''^'''-• ''"^"• *^'"fe the nitrate of :;,.Hi' wj •P. ■l! 1 '' t'~'^ 388 PATHOLOGY w silver i8 thus being used, much benefit will be derived from brushing the upper eye-lid and round the upper part of the orbit with the solution of veratria. During the above treatment the patient should take qmnme, w.th very m.nute doses of tartar emetic; he should have a.r and exercise, and be allowed a free wholesome shaded but not closed up with a bandage, as is , o often [he case. The eyes should have rest till they are perfectly well. For the treatment that should be adopted when the ulcer penetrates into the chamber of the eye, and is fol lowed by a prolapsus of the iris, I must refer the reader to" my remarks upon prolapsus of the iris. I would here however, quote a few valuable remarks made by Mr Wilde on he treatrnent of prolapsed iris :-"We still believe the bes thmg hat can be done in penetrating ulcers of he centre of the cornea is to touch the rupture with a weak solution the n Urate of silver, applied with a fine cameT hau- pencil but if the iris has protruded it is better toTm U this); then to drop into the eye a strong aqueous solutfon atropine; to close the lids carefully with a bit of i „? glass plaster, extending from the forehead to the cheek • to apply the extract of belladonna plentifully in the usual' manner all round the external parts, to lessen c nge" ion and inflammation by local depletion, such as cupS o^ leeching, &c.,andto relieve whatever other urgent symptoms maybe present, to confine the patient to bed or the recumben posture ; to enjoin extreme rest, and not to meddle wth the eye for forty-eight hours at least."* The reader must at once perceive that Mr. Wilde speaks of prolapsus through the centre of the cornea, therefore i must be borne in mind, that if the perforation is in the edge of the cornea, the use of atropine and belladonna will onlv favor a p rolapsus of the iris. ^ * Dublin Q'^'^'ri^ri^^^^^^^^^l^n^edi^^ *iaSto)ta»ia<-„ m OP THE EYE. oscular n J 1! T'T ^'i^'^P'^ 389 ■ea. vascular and non-v so 7^7' • «^, ^'''^ ^''^ease, the the pannus of the com "^ T?'' ^^' ^'''«^"'«'- *« be -ehave ^^^UM ZTjj^^^^^^^ yet they then go on to descrf Hp f hi 'i ^ ^ ^ '' ""^ ^''^^ Pannus 5 'ous state of the corneT'and t"'^' ''™' '* ' vasculcn'ebu. granular conjunct h^' tL Tn '^ '' ""^^'' *^« ^'""^'e «« "Though the vasclnph, """^ ^""^ ^'^ ^ords:- eribed, \ owing „"!''?"' '''^' "' ^''^ ^'^'^ "^ ^^e- *••«" of the eySZsfZT'r '' '''' granular condi- «ntirely to thlfcale luf ]' T"'^"^ ^« ^«^"he U result of the san e nflamma " T. ^'"''^ ^" •'""^^'-te trophy of the pap nf of the nT' Tl' '''' ''''' ^" ''^P^- There is no doubt hnf ll f ?""'"' 'Conjunctiva." -«eh to do in ptd e Lg t ? ff ^-"T '"'^"™«"°'^ '^- 'ar conjunctiva keep IJ'^'^f'^'^^'""^ ^"^ that the granu- taln, from the fact that thA 'T"''' '^' ^'''''' '« ^^r- of the granulations T?e T ^'"'t "^^^ ^'^^ ^«»-val -Harwaybythektll r; 'U: T'""' "' ^ or entropion, and the rnrp V T ^s, from trichiasis the cause. '"'' ^*^P^"''« "PO" the removal of communicated to theMedicoChinl'I'f ''"""' ''^''^ '''' by Dr. Hamilton, on tl c ^o ''f 'f ''^''^^'"''"'•^''' by the inoculation o tl.L'J/'f^ -f« of pannus' Stont of Vienna. In th s arUH ,^'?"«^'*«^-, by Dr. of pannus is an increas , 1 , ! 'k- f " ''^" '^'' '^ -^-«" affecting the sclerotic and eolTn? '''"" (hypertrophy) '•"to two varieties viz _ p! '"T "^^'^«- It is divided .(^i .■l I m ,; .ijj •• 1.1 ! i ! vn r '!' OT 390 PATHOLOGY state of tI,P .nn- *. "^ continued inflammatory irom view TLe symptoms of Iho second variety are-after levelopmen. the me.aLrph„r vers He t „ f^"'' °' ^•n, to Us entire snrface'a broZrr d cIl anTZ' p o:fded°I7L*™?^"T ''""' '^« ^'-- "- proceeaea thus far, neither the iris nor vessels nnn h. d.stmg„r,hed, and the cornea appears to be n „lved ,„a wHhTl vli „; r ''"''?""'"■'' '"''"■"■ '"'comes covered witn a growth of red granulations, so called almost in»n s.Me bnl easily bleeding, which aje so nam ronT, la thev" sometoes appear conflnent, encroaching npT h c„mea until they totally cover if Thoir ;„ from the evP hln r .' "''"'*'' separates the lids iroratne eye-ball, sometimes everting them. raedull.r!" ""'^ ' "'?'' '^'"""^ '"'^^^ be mistaken for medullary sarcoma, and the more so as the separation o the brown crusts which form on the surface, frequentlv occasions considerable hemorrhage. Experie , hoTver proves that in this affection of the conjunctiva, he corne [ often participates but little, and in the greater nut of Tf*. depth remains quite transparent." ^ ^' In treating this disease by the inoculation of blenorrhoe. we are directed to be sure that the general health is^oH^' OF THE EYE. Jeast that it 391 i''l.''"!rf°^'»"'''!'»'''-»bjoct treatment o..v,um imr no from a r.,o:tt^\^'^J:^:Z '\ ''""' ""''"'' applied at lirsl lesi (hi T ""'""'' '" "»' '<> te tW„,ia) aheJidVo 1* V rVr'°"' *.''™'™' °'>''- « oven to six week" If t ,'"'•"'''' "'™'''"e '""eo'- far, it is ,0 bcToite b"' kT T "'.'■'"'™' '» «°'°° bntweareinforrdth,! !* u™' """PMoSi^'e mean, ; simple t'eJlTs«T:!Z^',?'f''''; " °"'^ «1"-os is also stated tha whlLth 7'^ "''"""' ™''^ ™'0'-- H inoculate one, and the result tnu 7 *''^ " ""' "»'» were inoculated whil? f i ° "" """" '^ 'f ''»"' V' "0 danger „ the 11 eV""^' '■' "f""'''' «'"o « applioatln of ttviroS dtrSVe'^^' "™ "" muc "traro;:rz' it "" '"'""■^■^■''""'' -""> f«' .bout whic7s IcUs sa 7ir:i'° "" '""' ""' "''""-' nebula, at least the fir,. „' .*'"« "■^ ""^ ™scular nevers'ecntbe condJr™ ,., J';,""" """"'«'' ' "''"' ■■» .bo fl.t forn, La "r-de^;:' " ""''^ '''""" """ " By the terra nebula I understinr] a nU a cornea, generally extensive aTdl,^^^^ '' ''' at its centre and less so towards U ed ' I ' "'T' a thin serous effusion between hlaveTs* of /' """''"^ ^^ between the cornei -infl u. ^ ^ "'^ ''^'""ea, or always the rcsul of i 1 ''T^'^^y^^ covering. It' .•« vaseulurn bul "Vf ^"^"^^'^'^ and differs only fron. larity of the t L L ?' """'"""' ""'^ ^"^'^^-■ -aLer,wi:i::;Zwr::r:::^r^^--^^ vemence that the patient «"fr,.... r„„T '^.'''- ^''« "'^o"" cornea, ■ " I that he sees objects as if through m a mist. ,! 392 PATHOLOGY Treatment.— The treatment of vascular nebula is to re- move whatever may be the cause, whether granular lids or otherwise, which will remove the vascularity of the cornea, and perhaps its nebulous state also ; if not, however, it will leave the case simple nebula. The best treatment that I know to produce the absorption of non-vaacular nebula, is fumigating the eye, or eyes, once every day with hydrocyanic acid, then dropping on the eye the SIX or eight grain solution of nitrate of silver ; after which the eye-lids and eye-brows should be brushed with the solution of veratria, and the same parts occasionally electrified, by insulating the patient in the ordinary way and drawing sparks from the parts. During this local treatment, quinine and minute doses of tartarised antimony should be given internally; alterative doses of mercury would sometimes be found necessary, and some preparation of lodme. Indeed I have found the ioduretted iodide of potassium of the greatest benefit in producing absorption of all opacities of the cornea. The patient should be allowed to live his usual way and take plenty of air and exercise. ' Albugo.—This is a white speck in, or on the cornea, with well defined edges, generally of a circular form, dense in the centre, and of a pearly color. It is formed by an exudation of coagulable lymph, sometimes situated superficially and at other times deep in the substance of the cornea. The remote cause is inflammation, but the direct cause, is, when a phlyctenula, pustule, or abscess, is removed by absorption • and nature, making an effort to heal and unite the parts that have been separated by the matter, deposits lymph in its place. Recent albugo is generally of a milky white, but as it grows old it becomes the color of pearl. Red vessels are sometimes seen running into the albugo ; when such is the ease it is called vascular albugo, which is generally super- ficial, and occurs in those of a scrofulous diathesis. This OF THE EYE. 393 t^^:::. "'* '°°'»""» '->«*. "•» ».i- rare,,, , ed by diffused lyZb,7 ,"'™ '' ^°"™">' '""»""''- puckered Crance' "' " '"«"""" '•™™ """•«» 'J' »» thalmic ointment Jannn ;,'"'";"."" '""' °'' *''« ^P'^" may be used But I tv ; eUher diluted or otherwise, answer lilt. " ^"""^ '^' "'^^^^^ «f «i'ver to from r?oit 7r ''V- ^'"^"^ ^-^^ ^« — ^ have npvpr triJi • • ^ patient better v s on. I ca efully dl sTcted off Tr P?'*"" **^ ^''^ 'P^'^'y ''« y ais8.cted off. This completes the operation. Cold ^ 'h^ * i' r 4 394 PATHOLOGY away. ^h/;:::;:ri"ir :::;;;'•' f- ^'-^^ ^■''«^- cartilaginous whifpno^/ ' ' ''' '"""'"'"a loses its partly Lr o,U ' 0. of'V"'"'''"' ""^'"^•- ^"'^ ^'^-^or, excision is performed whfoi '"'*"'^- <^«'np'ete nent, about 'ths^zo^e' Tr' " ^'^'^'^ ^"'^ P^^™'" • pupil, so that the' Itilu I. rlf 1^^^ ^/^ f ' hook, and removed as before wi hm.f" f ^ ^^ ""^ chamber, the cdo-es .in!. T ^^'"'"^ *'"^ '"''^rior tures; and Dieffe^b; ' • '^ ^''^ ^^ "''^ ""^ ^"■ the cornea is opaque hlTZ\ ° '"''"'' ""'^'^"^^^ «'" knife, cuts a^y aVthH ''"'"'''^'^^^«'-«"«'"ff'''« knots to i^perti e , :rs "' '"^;"^'^ ^'^' *'^« says 1,8 did this in n. ' ' ''^"''""^ ^'"m»ur- He Malgagnrpe fo ' th ''''« !"f««««fu"y. We saw M with%Lct'tr \?^^^^^^^^^ r '-'''' ''' he had performed th same operTtion'^f "''"" ^'''''" whose corhea was so perfe 1 eCL "' ''"'' """'"'"' to determine upon which eye ttadCad^'V'"''^^ since we performed it «../.«! "Perated. Six months •nent has esu ted t ^117^' ' ^""^^ ^'''' ''"P''-'^- opacity strips ff wit , hJ T T"' ^"^^'"" **^ ^«- The toucheswith'tlieedj fthei? r 'V' "^"^ ^ ^^^ «-' ;;on worthy of n.ofe%^Ue:u ' JLut^^s ^^^^^^^^ this country " ^^ y^^ received in ..lb OF TfrE EYK. 395 fo™, a„aa, nei::? irsirr °;r-.T'-',:;r necessary to oweratP i.nnn », lu '' ^"°"''' ^e elevale ,„e,„ „,„ Z t LrC,,' ,rr°" ™"" remove llicm. R„. ,vi,„ ', "'° '°™P'> »"'> 0. t„o e„4„u, j' t~'„ X r„r "trr.r cicatrix „T2' »r„eTa„d t,?r'' "",' ' >"'^''^'' '» «"« »pacUy wa, f« S^r , 'trwil' VT'™™'-''"""^ whereas every case that I L '^^ '')"'''»cyinie acid, local, as well as CO, s'^ ^T "^ "''' ' """' "">'' ieuco'ma „„ y e„ ; :: '™""™" »»'' "- «^"=» of "mailer by the vl, 1- "'°,,"l«"y ™» rendered absorbed. l!,„rsw7 ?, """"""''"' "" '^'«"'™ ^"'"8 trratrZ r h ' '*"'"■ "">" hesitation, that if the .«ay be, (jzx Z7Z:'^::r ^'""""^ "-^^ years,) as the average numb r „red , T'"', ""' of the eye. And I Lli„l .7 , , °"^ """"■ """case ;a£aec„m.ii!h\s:r;:rtirt^^^^^^^^ ,'i -m ...j/'a 398 PATHOLOGV '" ""^ British and ForeLn Af! J ''' "'''^^^^ ««''^> that ^0. 8, New Series tl.o ?f ^^'^^^''^o-Chirurgical Review pretty stronpJvon (h 'uP'"'' "^ last year '"^^ „''"'"'"'* "/'^^CW^ which in such casp^,; T'°"8 therapeutickl „ ''"'"■""'« teem annu- confined to isolated .'' "'"^ ^^ ^^ infallible S,. f^"""' *''« efficacfe" o • ^asea of the ^e'l 7?:;;--^^ ''^.Pr««ition"ei°Vo^,^- "°''^-- nad an opacity of /ho „^ ^*'^' and who simnlf, i "° "°' treat dis- condition of the oarl '"■"^'•' '^'"'"ut statin" ! '"^ f '^'"'^ 'hat the patient various panaceas'^ frjr"' ^ ^^'^ "o de^re than ^ '"l"' "'^ Patholog ca f surgeo^n to an oph.halm'"-''^ ?"'' ««" '« pru sic a^r'^n'° enumerate^' ter remedy for thrrtm ? '",^"«"tion nowexto L^ ,•; ^"^ ^''^n «ve find to examini -h^ caLs S h' f "^"' ^^"'^o^a al7„ J^,P«"es of the Z dehision of curinrnf. ' ''^ ''as recorded with .-L "'"' '*'« are incJinerl --«. by theT^J^rSLr "''•«.' ^P--'--^" aSy^^^^^^^^^^ TurnS so however, in British 'a^ ^ "'"'^' '"'« Passed awav in .if' "'^ ^''^" amau- 'h'ther the hydr^v»n,v. ^'"'^"''a- Dr. Howard nf m ^'^ country. Not n«ure, or^the'"use'7S"r-' 4 "^' «°n'ti u, L^Te 7^""^ «"4«b e 'vhat was the cause of th„ ''""."'«"««. «-e must haveTt "J-'^lP'^'y ^^om of %hat ^as the o;;"3rof'°the '"''"•"''""«• ^^^n^uTt'Tav^Tt H-t'"'-^' ^^'^''t^'^f -fessioZ;^? :L '"^1?- fairiy slat^dtvlr!^! ■"•« f" he cornea or not. ifn^lT"' T- '^^^^^'^'^ "-er^M^s adL°' ""? '"•'«'«nce surgeon, the profession m * '^ '""S^« «>-e fairJv Mat^^ k u" "'^ '^e iris to been Performl,lyi7,™",!'i;,7've with eauti^ the curet^/''^°PbtbaImic a« occurred with one'of I)r ^ "S^'.?^' '''^ though the L/?"''' '° ^^^^ nativp r.,.,. „.„.., «" o' ^'r. lIowarHV .. u./. s" me patient mnv i, ^^«behe„Vhlh\d^;:': ^r;(.f"- vo,u°„f;A;trA^^^^ -««". the hei^fiJt ^Ka>^"^ " -'"^^il'or ^^4 OP THE EVE. 897 wliicli lias been |)ar(iciiliirlv,„ ^^ »'.o,o o,a,-,n, ho!evt otS;t1 '^ "^ * '» "'-- en ""imled. The 'mod. o r 1 ' ""•°''""''°» '■« " a »clul,o„ of p„„,i„ ^ .J 2 Z • l"'""""ly Jippcl lino of tlic sclerotic at .1,, "''"°". "■"Iiin half , ";' needles .0 rcmai , in Lfl: '"'"': '""" ""-""ns The needles are inlreduced so«lI ' ° '," "^ "■'"'"« ammaled cornea, .en,eli™cs a^f r " ^ "' '''"• »» the "nd ,n other cases to the le„, 1?' \ t "1"™"'">"nionr, feporter means o.^pkt.hlZluIZ^^'' "" '"»""' 'ke « Mrawing the needles reZt 0" an, 7 """"^'- Upon -eU^ ...e ordinary mean, in "nh" s'*™™""" " '» <« "owevcr.tlut thene^Llorthu ' "',"' "• " " P"-*" «ays he has succeeded iLufovt '"'~-^^'- ^'okalski central portion, with aknTZ^T''^y'^'^'''<>rn.ahyTtl ;o -move an ink-stail' He' epXr' ^^^^^ '^ 4 ^ '^es, removing very ,itt,e eaZ.t ''''''^*'''" '^--^' nflammatory action, and he neve 'r. "\"'' ^« '""'^"^'e "ear ,ts circumference, for he is of o ''''' '^' '"^'"^''^"e portion bears mechan cal Jeln m„T'?" ^''^^ '^' '^"ntra cumferentiaLf . flerr Ga t of vt "''" "'•-•" *''« «'> - recommended, and also pra is I?"'' ''"'' ^^^^''^ «^o, off the external iamina^ of an olc ' '^'''''''" '' «'^«^'nff £'i ? 11 ' f ii^ P"H 398 I'ATIIOLOOY I have never tried acupuncture, but I ».ink it much more feasible than eitlier abrasion or shaving, Ibr I do not see how an opacity can be removed except by absorption. The six first of the following cases, are those which I published in the British American Journal of Medical Science, and which have been referred to in the preceding page. The three additional c ises are vascular nebula with granular lids. In the cases given under " Cataract" there IS also (in the third) an interesting ease of opacity of the cornea. Case Ist.—AUmfjo.-Mary Ilanigan, ajt. 30, wife of a labourer, had sore eyes for three years ; for a year had merely distinguished the light, and the outline of large objects, and had not been able to go alone through the streets. She had an albugo on the right eye vi m < *i 400 I'ATHOLOOY sisted In daily funiiVutions vvltli the hydrocyanic acid —a drop of ten grain solntion of nitnito of silver, and often insulatni- him, drawing electric sparks from the eye and surrounding orbit. Case GiL—Nehuln.—S. M. a;t. 13, called on mo on May 2nd, 184G, complained of dimness of vision of ri.'ht nye which had existed since he had had the measles in''infancy' Had been treated unsuccessfully in New York by several oculists. The whole cornea was obscured by nebula • was perfectly cured in six weeks. Treatment-daily fumlga- tiona with hydrocyanic acid, and the application of the ten grain solution of nitrate of silver. During the treatment I gave him the iodnretted iodide of potassium. ' Case 7th.— Vascular Nebula.— April 29th, 1847 Pierre Bregon, aged 4.5, a laborer, whose eyes had been diseased for five years, applied to me on the above date. On examina- tion, I found ho had vascular nebula of both cornea;, with granular lids. I discharged him cured after two months Treatment.— The first day I touched the whole of the palpebral conjunctiva with the powdered acetate of lead and after the third .lay I dropped on the eye every morning the saturated solution of the acetate of lead. The patient bathed his eyes night and morning with Mackenzie's sooth- ing lotion. Ca,se 8th.— Vascular Nebula.— November 7th 1847 Thaddeus Mc , aged 28, store-man. Eyes diseased as long as he could remember, but much worse for the last five years ; had been with many doctors, but received no benefit. On examination, I found he had vascular nebula of both cornea', with granular lids. He is now perfectly well. The treatment same as preceding. Case 9th.— Vascular Nebula.— J aly 15th, 1848. David Collins, aged 33, stone mason, residing at Augusta, State of Georgia, stated that his left eye was nearly blind for many years, that he had applied to many doctors for it, but had 1. 1 OV THR KYK. 401 -^c^ved „o benefit,. M.Id not no. HOC „.orotl.a,.M.t witfi It. On cxiuninat on, I fonnd li.. I....I .. . ^ on..«w,.o,econ.ea,and^..a„;;;;;;'^:j'^^^^^^ attended n.c every day for six weeks af/or u Z- discharged l.in. perfectly cnre.h ' ''"'' "'"*' ' The treatment tlie same as in «l.n , .1 . 'l«yroiii.J (l,„ urmcr part of llw ,M > """" "' iiUU.T, a,„l i, „«,e„llv l J „ !■ " .'""'"""'aUon . •' — 'v^uii ui umuinniation p:K.ralIy accompanied by some other of the eve. snch na ,.o<..„,..* ^.. .. ' ^"^ cornea, staj,l,vl„„,a i, «„ . . '' "'"""J' "^ "'» 'K a.,a ,1.0 ...ea.„,o„. f„,. aSll ;„"'""" "^ '"■™- ocai«,u „r .,e;„pn, '^i ^x Se':„"r :",!r l.u...our ,l,e tcel,„ical (e,,,, ,„r „|,M, if .;;;1;"" °"''"' pff^:rr:e^:^st*--- h .1 1 1 I ^ 'J I in it 402 PATHOLOGY the orbit in the ordinary way, and dropping the aqueous solution of atropine upon the conjunctiva. These means should be steadily persevered in for a long time, even after the inflammation has abated, but when they fail, the only resource remaining is a surgical opera- tion, by which an opening, or artificial pupil, is made in the iris.* Artijuyial Pupil. — An artificial pupil is formed by one of three different operations, which have been a long time practised by ophthalmic surgeons, and which have not admitted of much improvement since, although attempted to be modified by some modern surgeons, who as a general rule have only complicated the operations by recommend- ing a variety of useless instruments, difficult to obtain, and 1 I I ore so to use. The three operations for artificial pupil are incision, exci- sion, and separation. The first is called corotomia, and consists in making a cut through the iris, either horizontally or perpendicularly, in the hope that the wound will gape and remain open by the cut fibres contracting. This • The following case of the absorption of lymph that had been deposited in the pupil, and on the capsule of the Ions, will shew how much may be done in such cases without the use of the knife. Case. — May 6th, 1848, Jane Dunholra, aged 8, of the Township of Kingsley, (C. E.), was brought to me by her father on the above date. Her left eye had been destroyed by a wound from a pair of scissors, and she could only observe the outline of bodies passing hf twecn her right eye and the light. She had long suffered from chronic inflammation of this eje. I found her to be a child of a strumous habit, and on examining her left eye I saw that the pupil was very small, fixed, and filled up with lymph, form- ing a regular false membrane. This child attended me daily for nbnut two months, after which time she left me, able to read moderate sized print, and to run about and enjoy herself without any danger. The pupil actM, and there was only one small band of lymph remaining. The treatment in thiscasewasfumigatingtheej'eevery day with hydrocyanic acid, brushing the eye- lid, &c , with the solution of veratria, smearing round the orbit with belladonna, and taking the quinine and tartarised antimony int<'rnally. I used electricity occasionally. And after using the quinine for sometime, ' iihstituted for it the iodurettod iodide of potassium. OP THE EYE. 403 tl";": ms '"^r'"-^''^ Cheselden so far back as tne > ca. 1728. The manner in which he performed it was by introducing a small one-edged knife through the te n,,or. .ueot,, sclerotica behind the iris; he th\„ pu J chamber of the eye, then turned the cutting ed^e of thp kn.fe to the anterior surface of the iris and'with rel u pressing the knife at the same time against th r L bv •s mot.on he made a horizontal incision across wo! birds ^n;.ion produced b, the o;:Mi;:;f^^ The second mode of operating, or excision, is called c.r^^m,a, and consists in removing a piece frm the ris form an artificial pupil. ,t was first pLrmed by W „ /el, who accomplished the operation by puncturing the cornea w.th a cataract knife at its temporal side a^if f! e extraction of cataract ; when the poL of t L1 had entered the anterior chamber of the eye, he carried U on ttu he pushed it through the same shle' of th li "l brought the handle of the knife back towards the tin lie push.ng the point towards the nasal side of the ir s v're he agam pierced U till the point entered the anterio ch.m ber; he then pushed the knife through the nasal s So the" cornea, and continued his incision as if for the ex a tion of cataract till the knife formed a semi-circulu Cof th/ "Pper part of the iris, which was of cour bet' it of the cornea could be formed. After getting th s ar with I^e flan 71'-" ""' T '^' ""'"'' "'""' ^^'""^"^ '- cut off me nap ot the ins and removed it. The third mode of operating, .^^am^.o«, is called coro- 'W., and consists in separating the iris from thecil^r; Deiieve hcarna was «hp fire* that r-- .' - . I TTa., ,in: „rgi tnat pt-normea this doalyasi J"i?a % m i»! i:'5 •- '■11,11 ¥' "i *< ' 404 PATHOLOGY m operation, and it was suggestod to him by seeing thia effect result from blows on the eye. He pierced tbe temporal side of the sclerotica with a straight needle, then pushed it forward behind the iris till its point came to its nasal side, where he pierced it ; he then pressed the point of the needle downwards and 'for- wards, towards the centre of the iris, till he detached it at its nasal side from the ciliary ligament, and thus formed an artificial pupil of a triangular shape, its base at the ciliary ligament, and its apex the centre of the iris. He afterwards recommended the bent needle as the best to operate with. These are the three operations as they were first perform- ed for the formation of artificial pupil, each operation being called for, from obliteration being the result of inflammation produced by couching for cataract. They have since been effected in different modes, still they are virtually the same, and though surgeons are con- stantly publishing some, so called, new operation or other for artificial pupil, when we come to read the account we find there is nothing of the sort. If they would only term it a new mode of performing the operation of excision, or incision, or separation, it would be somewhat nearer the fact. For example we read of the term indmdm's, and sup- pose it to be a new operation from the term, when in reality it is a compound of excision and separation, that is, cutting off the piece of iris that has been detached by separa- tion ; or instead of excising the piece, it has been recom- mended to strangulate it in the wound of the cornea. There is another operation for artificial pupil, but as it is worse than useless I will merely name it; it is called sderectomia, and consists in making an artificial pupil in the tunica sclerotica. The operations of corotomm, corectomia, and corodilyasis, are all of equal merit in their places ; one being fit In one ji jL ■.Mi,micmmi OP THE EYE. 405 case and in another not so, of the three varieties, however incision IS to be preferred vvlieie it answers tlie purpose, and excision is certainly preferable to separation. But where incision cannot be performed, excision can, and where neither of these arc admissible, separation should be resorted to. As has been already said, these operations were first performed in consequence of the pupil being closed, and as the result of inflammation produced by couching for catar- act ; but other causes have since been met with which call for one or other of these operations, and they are accordingly performed in different ways. In all cases that require the operation for artificial pupil, here ,s one rule that always holds good, which is, if there be no opacity of the cornea nor any other objection, the pupil should be always formed in the centre of the iris nearer to its nasal than its temporal side. ' Before minutely describing the several operations it will be first necessary to consider the cases that call for the for- mation of an artificial pupil, and those where such an attempt would be not only useless but dangerous. Firstly The formation of an artificial pupil should never be essayed when the person has one good eye ; for there is always danger of inflammation following, which the sound eye may partake of, and the result may be loss of both • and even should inflammation not follow, the axis of vision will not be perfect, consequently the patient seeing objects differently with one eye from what he docs with the other nothing could be gained by the operation. Secondlj/. The formation of an artificial pupil should never be attempted so long as there is the slightest symp- torn of inflammation remaining in the iris, for an attack of acute inflammation would be sure to follow. Thirdhj. The operation should never be performed so long as the patient enjoys tolerably fair vision. Fourtlifi/. Granular conjunctiva, and vascular nebula are decided objections to the operation. i.i, ",(H i I I I ii f ili]. r 'h •I ., ■'^rl^ iliiiii; 406 PATHOLOGY Fifithly. There should be no operation when the whole of the cornea is so opaque, from a cicatrix, that it does not admit any light. Sixthly. When previous to the obliteration of the pupil, the surgeon is aware that amaurosis exists, or if at the time the appearance of the eye is such as to satisfy him that there is amaurosis, (a conclusion he may safely come to if the patient is not able to discover any light, if there is a varicose condition of the superficial vessels of the eye-ball, attenuation of the sclerotica, the eye-ball having either increased or diminished in size, or its having become either hard and firm, or soft and doughy to the touch,)-if under such circumstances the surgeon operates, he will only dis- appoint both himself and his patient. Seventhly. If the anterior chamberof the eye be compJetely obliterated, and the whole of the anterior surface of the iris adherent to the cornea, success in such a case would be very doubtful indeed. EtghtMy. The result is also very doubtful where there is partial staphyloma, but if there is complete staphyloma, it is useless to attempt the operation. Ninthly. An operation for artificial pupil should never be attempted, except when the portion of cornea opposite where the pupil is to be made, is clear and transparent. borne authors recommend that an operation should not be performed if the constitution is deteriorated by scrofula syphilis, rheumatism, or gout. But if there be no other important disease of the eye present but simple obli- teration of the pupil, the constitution must indeed be in a every bad condition to prevent me from giving my patient the benefit of an operation ; perhaps the only exception which I should feel inclined to make would be in regard to a patient who was scrofulous and under the age of puberty The following are the cases in which the surgeon is called upon to form an artificial pupil : ■^^SA££itSiiSMM^&^^S&u, OF THE EYE. ^f Firstly. When none of the objections already enumerated exist, and there is closing of the pupil from a deposition of lymph, it does not matter whether there be adhesion to the capsule of the lens or not, or whether the lens or its capsule be opaque or clear; the case is one for operation. Secondly. The patient should get the benefit of an opera- tion, if none of the objections already enumerated exist, and the closing of the pupil is purely the result of iritis, the inflammation not having attacked other parts of the eye. Thirdly. If the obliteration be the result of a prolapsus of the iris, caused either by a wound or ulcer of the cornea, the case is also one for operation. Fourthly. When the pupil is perfect, but concealed by an incurable opacity of the centre of the cornea, which prevents all light from reaching the pupil, an artificial pupil niay be made behind that portion of the cornea which remains clear. Having resolved to operate, there are some cautions to be observed; 1st,— Not to wound the clear part of the cornea; when any part of it is opaque as it would thereby be rendered opaque by the cicatrix that would follow ; 2nd,— Not to take it for granted that there is opacity of the lens or its capsule, for operating as though the lens were perfect, would not forbid our continuing the operation and removing ihe lens if it were found affected. I have already said that the choice of operation will depend upon the circumstances of the case, and I will illus- trate this point by a few examples wliich will be a guide to the reader. If the pupil be obliterated in consequence of a prolapsed iris drawing in its fibres, the artificial pupil is best formed by making an incision through a part of the iris and across the fibres, for as soon as the incision is made the wound gapes, and always remains so in consequence of the drag that is kept on it by tue part adherent to the cornea. >;i I,', "I m J . »'.i I' 1, 1 1 I - ■ -a j-3 408 PATHOLOar by letting the middle fll«-f« 1' ".'"" "^^PH^ed .be .owef lid, re™* ":?«!': '■•™^' ""'* -»''-«» OP THE EYE. 409 the ■aua the a,„eri„r tmber i„ ed™ •"T" 1""' °"° '"'" "^ anl preyed agatet 1 hl^,l. J'?°" '""■■"■* ""= ™ a horizontal in 11 tTt.'T °""™™'' "'""' ™«« iri». This i, he Is. 2„l , "f °" "■" """^ »f 'he i"g cero Ji X„ Te^ ■•:"!' ? ""' "^ "^ P"''"™- obmemdonofthepnpi, """°" '"™ """' »™Pl« i"-» IJ^^fhrrflr;*^ '™' "'""P- Of "■« "pon i, successfnl r by "1 °hi„l T'"' '''""' "P"""''' through the upper Ml of r^ " ""' *''P'«' ''"'•f« anleriicharabTofle v' be'r h"'" "/''""' "■« 'he knife towards I ee'nr'e of «™ "•""""" P"'""" downwards and a m.lc Svar, illT.' " Tf ' " the centre of llm iri, Wh!„ ,1 7' " P™"" ""•»"«h cut, they contra tej 1'^,™!?,° '"''"*"'' "•"•'»""« "■»» forced an arifiS p "n" ^ '. " ^^P'"? ™""« cornea portion o; tte" ^ropl ^ TtV^ ""'' '" '"" strangulated portion of S '^"' """"'"'"S «>» He lirst, with te catartt L f '"',"'"' ""' '"^"•°"><'"'' .oten-or^ha.ber^CgT.h' ' iTo rrr'lf '"'° '■■' near to its edffe Whon ♦!,„ r }. ^'^® «' the cornea was to be fol owedTextactr n:?' "f"''" ""P" extent of the wonnd^:* 1™ „ " ^'if """^ '"e -ce of the cornea, but made it J t'n° £, ' i7:ht I ' J !,'" f 410 PATIIOLOQY was no cataract to be extracted. The scissors he used, to complete the operation, were very small, with one blade sharp and the other one probe-pointed. When the two blades were. brought together, their united size was not larger han a common sized probe. After having made the open- ing through the cornea, he flnished the operation with these scissors, by introducing them through the wound of the cornea with the t at sides looking forwards and backwards, when the blades had reached near the centre of the iris he gently turned them till the sharp point came next the' 'iris, and with It pierced this membrane near to its tempora side ; he then pushed the blades forward towards the nasal side of the eye, the sharp pointed blade being behind and the b unt po nted blade before the iris ; when L points cam sufficiently near the nasal edge of the iris, he suddenly dosed the b ades and thereby made a transverse wound in he centre of the iris. If the lens was to be extracted, he after piercng the iris in the first instance, pushed on the sharp point of the scissors till he penetrated the capsule of the lens, and then cut both it and the iris with one stroke of the scissors. M. Maunior, finding that the wound In the ins did not gape sufficiently, after making the first cut urned down the points of the scissors by raising the handles an'' made another incision from the temporal side of the first cut thus forming a triangular piece of the Iris the apex of which was at the temporal and the base at the nasal side of the iris. He found that the little apex curled up and left a good pupil. I consider that of all these modes of operating by Incision preference ought to be given to those of Beer or Alexan- der but I would not operate at all by Incision except in such a case as Beer operated in, viz .-obliteration of the pupil from prolapsus of the Iris. ISkocision, or C.r.c' " 'P^t^eous pro- -Win Witt Tbe't :„"',",' '^"°'-." ■""" "« »'- PosiHon it will b L'„d JaV T'""' "' ""°™' iria hooksidc-wavsin I'.h '''•"'"°:' '^ '» P« "•<■ «»»" centre of the iriflZ ht "7";'' "" "' ''°'"' ^'l'"' "-« i*, and .a I ™'l, r»f .hi. , rV" ""?' '""* "■' "trough .he woLdiateori't.™"" """ " S«""^ finished as if ihe iri, Zj T' J"" "P""""" '" "> be .bat .he h„„/„tv:.rr Ltrdiirti''" •°"''^^^''p' l-oMs is excised with a pi r „ sti r sT"" '"""" " prefer (akins hold nf «,. • • • '"">'°"- Some surgeons .•ns.ead o ,L hoik ' , "I' .T''! " '"'•■"' P"" »' f-^ps s.rume„t of the !; ' '!""'' ":" ''»* "'« ">"« oertain i„- coraea should ;™dtT^'^''''•■ *'»*»='» '"" ''-™p„ra,sid:rr.r-Lrt;;te'if^^^^^ f 412 rATHOLOGY 8houI,I, f possible, be made nearer to tbo nasal tban the temporal s.de; secondly, if after making the artificial pu„il a cataraet manifested itself. 1 conid nior^ easily cnh^rge h wound m the cornea for the purpose of extractL. ^ When cataraet exists Mr. Gibson says that it should be fir^ broken up, and the artificial pupil effected after tl irritation produced by the operation has subsided Sejjaratwu, or Corodtalysts.-'n^^ manner in which Scarpa recommended that this operation should be performed, ha been a ready detailed It has long since been given up n. it wi^b ' '"""" 'r''^"" '' '^ """ ^"- '^ V --"bin': ion n Vh '•'''•'7"'/: ^y strangulating the separated por- tion m the wound of the cornea. When, under the drcumstances Jready mentioned the surgeon determines on forming an artificial pupil n'th part of the cornea through which he is to introdu e the small iris hook with its flat sides looking forwards and „' f r;';f ^' '"? "^ *'•« ^'^^ <^omes opposite the clear part of the cornea, he is to turn its points towards the iris and seizing hold of that membrane is to detach it from the ahary hgament, by withdrawing the hook and bringing w.th It the detached portion of iris through the wound n the cornea when he has his choice of either leaving i" strangulated, or cutting the piece off with a pair of sharp difficulty found m strangulating the portion, and very fre- quently (particularly if the wound in' the cirnea Is Targe) as soon as the hook is removed the piece recedes ^^ In the formation of an artificial pupil, accidents are some- times liab e to occur in the hands of tiie most skilful ope- rator, such as m incision, teanng a part of the iris from the ihary ligament, or wounding the capsule of the lens, which, .f clear would be very unfortunate. The first accident may OF THE EYK 413 a happen .n oxcs.on, particularly if tl.c patient should at, or t e operator's hand be unsteady when the port n us to bo cxe.aed is drawn through the wound in the Separation is the most painful of these operations, and it « frequent y ,olh>wed by an elfusion of blood in the aque umour, winch accident may also take place in any f t^ other modes of operating. This blood, however, though at he t.me annoying, is of but little consequence, a it is .fn rally absorbed in thirty six or forty hours. Too large a pu il .nay be formed and as it has no power of contrafti.fg' lik the natural pup.l, it will allow too much light to fall upon the ret, na: . ,en this occurs it can only be counteracted by some mechanh^al means, such as wearing goggles the .lass ofvvK.h should be replaced by a plocPof^a 'l ving sma hole m it. A pupil may be made so small as not to a m.t sufficient light through it, this also would be an u pleasant result as it might call for a second operation Another accident that may occur in any of these operat ns* -s for some of the vitreous humour to escape thro gh the wound in the cornea. ^ ^ After-Treafment.~As soon as the operation is over, the edges of the wound in the cornea should be brought 'og her, and the eye-lids kept closed by means of strips of ismglass plaster stretched from the forehead to the malar bone ; a wet piece of lint may then be laid on hreye and the patient sent to bed, where he is to remain ITalt as possible for thirty-six hours, partaking verrspari gri food and that of the lightest nature. °At theLd of this Ume the eye may be examined, when if all goes on we 1 th wound ,n the cornea will be found healed. If inflammat on should supervene, the treafnent must be the sam aMM recommended in iritis. The patient must not be kept too ong m darkness, but light must be admitted very cau! t.ou.ly at first, and the eyes gradually brought o bear 'l-l I r ,jf ■ '4 / '(■^^B '' l^H ttl^^^l '^^H ( r -^-«^^^^H V » ,9 ' 'A^^^^^^l L ^S 414 rATIIOKMiY Stronger I.^^ht. U (here Im, been catarnct requiring tho removal of (he lens, ,l.e patient will I.e ol.li.ell to wear «:onvcx glasses; this, however, he shouM not do for one year at least alter the operation, and not even then if there IS any inllannnation of the eye. [f the lens has not heen rcniove.1 and is perfeetly transparent, aeeording as the patient's sight is short or long, it will bo necessary for him to wear either concave or convex glasses. Treatment erf (Unmet hy OpeZtion.-'V\x^ treatment of cataract or inflammation of the lens and its capsule with- out operation, is treated of in Chapter XVIII, page '.349 The first division that is made of cataract, is inti) tlue and Himrious. By the first is meant opacity of the lens or Its capsule, or both, producing a dimness of vision By the second is meant opacity of the parts external to the capsule of the lens, such as opacity of the membrane of the aqucons humour, lymph deposited in the pupil, &e The latter class have been treated of und.r their difTerent heads True cataract may be divided, with reference to the cause which produces it, into traumatic and idiopatliic,_and with reference to its consistence, into hard and soif this last division is of tho greatest practical importance ' The next division is in reference to the part that is opaque • when it is the capsule, it is called capsular cataract, when' he lens, lenticular ataract, and when b< th capsule and lens are implicated, this double affection is termed capsulo- lenticular cataract; where the posterior part of the capsule only 18 at fault, it is denominated posterior capsular catar- act; and when it is the anterior capsule that is opaque it Is known as anterior capsular cataract. Another form is ^hat IS termed secondary capsular cataract, which is caused by the capsule remaining, and being at the time, or bccominc; opaque, after the lens has been removed by absorption or' extraction. ' These are the only divisions of cataract that I can see any benefit in adhering to. OF THE EJE. 415 Some aiifhors liave civcri \f()ivM,rn;.,,, * "" mcroase in the quaMtity of tl.o li.p^.r , ' ' '"'^ very much douht tho existence of s,.cl. . ^iZ^iT ^ grantin. tl.U tins tI„M becomes opaq. ; fr , l '''",' would consider it in the sam., Ii,rl. , ""'",'y'> ^""'^e, ' tl'scasc is combined with the cat iru-t Zl*. r ■" A>unded upon their color, c^lr^H ; '&"' ^Z'Z "r cataract more or less vision is enjoy d, Ides it L? , cated with some other disease sn. h .«„ ''''"P''- opacity of the cornea, ^^TL^Zn^^T'"'' T^"^"*^ ;lepends upon the par't nffecte . Th ^ :;:;. '7"^' If, lor example, the case li ..in i • ^ "^ *^"''**''«- wm be ,. Jvi^ion .:: :, „ „ ; : ;; ;:;,r:','';r ™ ar; and if it l,e |„,„i„,|,„. ,|,„e wiluT , vjdl « .f .t wre cither anterior or ,,„„eri„r can, hr Z ,1 dred yea,. ; but it i, ,n„re generally fonnd Lt " 1 !"" offifty and seventy than at anyothcrperiodoflifc ft a '*?' you„„e«„s , generally very rapid in itsprogr^ ^ " timea forming ,„ a few days, and frequently in a con Irr weeks ; ,t is generally eapsnlar, but llwa/s "oft, 7eLr capsular, or lentienlar, traumatic, or idiopathic. ' ' The cataract of old age Is slow in its progress often t.l, ever, ,t forms very suddenly. It is generally of the eapsuZ i: ■ ''i 416 PATHOLOGY m en icular form, and its consistence always hard, whether it be traumatic or idiopathic, unless the old person has had a traumatic cataract from youth, in which case it is found to remain soft even to old age. As a general rule, in old age both eyes are alTected, whereas in youth only one eye is the subject the disease. There are, however, many excep- tions to this rule. "^ In ail cases of cataract, the pupil, which is naturally black and shining, loses its color and becomes of a dusky gray, or amber, and sometimes a whey color. If the case IS one of the posterior capsular variety, the opacity is tolerably deep in the eye; if lenticular it is nearer the pupil; and if the case is anterior capsular it is nearly in contact with the pupil ; but should the case be capsulo- lenticular, then it will appear as if it were nearly ir the pupil Itself. '' If there is no other morbid affection of the eye but catar- act, the pupil will always obey the stimulus of light for which reason a person who has cataract can always' see much better on a dark than a bright day, the former allow- ing the pupil to dilate, the latter causing it to contract. When the pupil is contracted the light falls upon the most opaque part of the lens, viz :-its centre ; but where the pupil ,s well dilated, the light falls upon the whole of the lens, and is transmitted through its most transparent por- tions. Inamaurosis the stronger the light the better the patient sees, provided such light does not give pain If cataract is combined with synechia posterior, either the pupil will not contract or dilate, or only a part of it will do 80, thus causing irregularity in its shape. If it is comnli cated with palsy of the iris, the pupil rests immovabJe • when such IS the case it is frequently combined with para- lysis, or some disorganized state of the retina, in which case the patient cannot discover any light, and any operation would therefore be useless. OP THE EYE. 417 shining „,etamc appearan e ?„ ^^^ ^^"'^''^^^ «^ * '.^raatodes the opacUy (at Lit fn fC'"T '"'^ ^"°^»« ?'sease where there would be anVrliffi .r'^^ '''^' '^ '^' '« deeper situated than it is i„ ^ j^'?^ undiagnosing,) seen when the eyeTs Ll- ^"■^'*' ^"^ '* ^^^not be cat^act even whT n^t Snc:; ^^^''^' ^^ ''^ ^ - voIItares7Lr;?^:trr"^ Won.s,suchas nausc. fungus h^.atodr£ t;;^,^'"^ ^^^"^^ -^ never the result, of^atarrCLT^^^^^^ ^'^'^ «- not be much impaired for years nor fh ^'""'"'"^ '"a^^ than at first; whilst in catara't vL ' '^"'"^ ^^ ^''^^'er rapidly as the opacity gradual Z" ^^"^''^'^^^ ^edines eye-ballin glaucoma, XprLHr^^ '^'^^ firmer than when in a healthv I/. , ^^' ^"^er, feels feels quite natural. ^ '*^*'' ^^'^^^ ^n cataract it Were it not that I know it tn h. rence for practitioners to raistakr .r^ *" ^y^ry-day occur- «bouId hardly think it ^rtrwhirr"''' '^^ ^^'^^^^^^ vations, for it appears to m tha^ 1 u- ""''' ^^''' ^^ser- •gnorance or stupidity c:mV^%tln^ -'' ''^^''^^ «rror, yet I have known men whrh T *" '"^" «"^^ «n their professional ability all th "" ''""" °P'"'«° o^ incurably blind of amaurt^tl^^^^^^^^^ ^« ^-^"'e what they supposed to he' ^ZcTr^ " '^''''' ^«^ authors have met with similar Prirn. • many other BB eye:— » Ml J '^1 418 PATHOLOGY " Having dilated the pupil of the suspected eye by means of the extract of belladonna, the state of the crystalline lens should be examined catoptrically, according to the method recommended by Professor Sanson. The observer and the patient should be placed in moderate day-light; the patient's back is to be turned towards the window ; he should be seated so that the observer may look rather down into the eye than upwards ; and a candle is to be used which burns steadily, and does not blaze much. When a lighted can- dle is moved before a healthy eye, at the distance of a few inches, three reflected images of it are seen, viz : — an erect one from the cornea, a second erect one from the anterior surface of the crystalline, and a third, an inverted one, from its posterior surface. The second or deep erect image, which is produced by the anterior surface of the crystalline, is not nearly so sharp as the inverted image formed by the posterior surface. "The anterior surface of the crystalline, being the segment of a larger sphere than the posterior, and being convex externally while the other is concave ; the deep erect image is larger than the inverted one, and appears behind it. The deep erect image even appears larger than the image from the cornea, being magnified by the aqueous humour through which we see it. The inverted image is very minute ; we require to move the candle in order to see it. If the candle is moved to the rightj the inverted image is seen to shift to the left ; if the candle is raised, the inverted image is seen to descend ; and vice versa. " In cataract and glaucoma, the superficial erect image which is formed by the cornea suffers no change. Cataract, even at an early stage, obliterates the inverted image, and renders the deep erect one very indistinct. Glaucoma only when much advanced, obliterates the inverted image, while in all its stages, it renders the deep erect « iie more evident than it is in the healthy eye. Dr. Staberoh has remarked OF THE EYE. 419 hat m estimating the changes which are ohserved to occur in the appearances of the images reflected from the eve • Its several diseased states, it is necessary to take' in o account two sources of these changes, viz^-h state of he surfaces which form the images,;nd that of he medL' through which we see them. mar til It J";'""''"' l™"™'"'' «to»ma, or «.hatwe may call tbe lirst degree of the disease, both the dpm «„. ;»asca„dthe inverted one are diatin'et. The deep e" J' Wi I .;:, advance of glaucoma the inverted imatr, deJe of"r'" 'T'-' ^'^'* ^« 'nay call the second aegree ot glaucoma, the inverted imap-e is nr^ffv ^s r . when found near the edge of the TyJ 1, e' Tit f tt rjghteye which is the subject of examinatn, and observer moves the candle towards the right sfde of hi patient the inverted image will be seen behL I e Lfa edge oh. pupil . but if the candle be brough WMn f nt of the eye the inverted image, as it moves acrols t " pup.1, is seen to become less and less distinct, and „ some cases IS altogether extinguished, till on the candle approacT .ng the patient's left side, the inverted image re«^^^ behind the temporal edge of the pupil, being Igain formed by the circumferential portion of the posterior capsule No such appearance as this is seen in lenLula ca ate" a dt ease which always affects the superficial laminifl ,t n such a way as to prevent the formation of the inverted image by any part of the posterior surface of the crystamne body. The extinction of the inverted image, when! e to ^ '"^^^ •' ^^^^^^ ^^° PUP'I of an eye affected \>' i'-'^f 4?'^ PATHOLOGY with glaucoma of the second degree, is owing to a loss of transparency in the kernel of the lens, which suffers, as I have already mentioned, a peculiar degeneration, charac- terized by dryness of substance and a reddish-brown color. " (3.) In complete lenticular glaucoma, or glaucoma of the third degree, the inverted image is no longer visible even t the edge of the lens. " (4.) The deep erect image is better seen in the second and third degree of glaucoma than in the healthy eye. It is large and evident, but its outline is not sharp ; so that it often appears like a diffused blaze. The fact that it is more distinct than in the healthy eye, is to be attributed to the reddish-brown kernel of the lens acting as a foil to the image. " (5.) In the incipient lenticular cataract, the inverted image, though changed neither in color nor in size, is indis- tinct, and its outline as if washed off. It is extinguished long before the cataract is fully developed ; a fact of the greatest importance in the diagnosis which we arc now considering. Jc capsulo-lenticular cataract the inverted image fades much sooner than in mere lenticular cataract, and even the capsule on the superficial substance of the lens, seems to be alone opaque, the inverted image disap- pears much sooner than we should expect from the appa- rently moderate degree of opacity. " (6.) In lenticular cataract, there is merely a general reflection, but no distinct image, from the anterior surface of the crystalline body. " (7.) If the lens is not it its place, but has been absorbed in consequence of an injmy, being removed by an operation, or fallen down into a dissolved vitreous humour, neither inverted nor deep erect image is formed. "In the diagnosis of incipient cataract and incipient amaurosis the catoptrical test is perfectly decisive, for in amau- rosis uncombined with glaucoma the three images are OP THE EYE. 421 always d.st.nct, while in even the early stage of cataract, the inverted image is obscure. The diagnosis of incipienJ cataract and incipient glaucoma requires the catoptrical test to be familiar to the observer, else he may not be able to distinguish, that when the candle is held in the axis of the eye, the inverted image is indistinct in both diseases, but whenever it is moved to one side it becomes distinct in glaucoma and remains obscure in cataract." The diagnostic symptoms between hard and soft cataract are of much more practical importance than the diagnostic symptoms between capsular and lenticular. Cataract is generally found hard in old age ; firm in those of middle age; and soft ,n youth. A hard cataract, is generally of a dark gray or amber color and the centre only of the lens is very opaque Ifthecaseisoneofhardcapsulo-lenticularcataract m an old person its color is generally of a pearly white, and here is very little vision. When the cataract is soft it is of a light gray, approaching to white, and the whole of the lens IS opaque ; generally speaking, the softer the cataract the lighter IS us color. The lens may be, and often is, opu.ue without the capsule participating in the disease : bat it is very seldom that the capsule becomes opaque without a similar condition of the lens being present ; this, however, does sometimes occur. When the case is one of pearl- colored capsulo-lenticular cataract, the fringed border of the ins IS very visible ; when it is Icaticular only, and the opacity is confined to the centre of the lens, a dark colored ring ,s observed, caused by the shadow of the iris falling upon It Capsular cataract is generally streaked or speck- led, and If It be the anterior hemisphere that is opaque, the opacity w. be convex; while if it is the posterior hemis- pnere it will be concave. Id the article on amaurosis the diagnostic symptoms be- tween It and cataract will be again alluded to. Before the surgeon makes up his mind to operate he should be careful I, Ml {.il t I '> ' : !' ( i ■i V'' S\ 422 PATHOLOGY as far as possible, to satisfy himself that the cape is one likely to be attended with success. If the patient's general constitution is good, and there is no other affection of the eyes present, the su' i^eon is justified in operating. I say eyes, because many authors differ in opinion, as to whether, If there Is only cataract of one eye while the other remains perfectly healthy, any ope- ration should be performed or not ; some have considered that when there is cataract of one eye the performance of an operation upon it prevents the formation of cataract in the other eye ; my experience does not lead me to such a conclu- sion, but I have very frequently seen sympathetic inflamma- tion set in, in the sound eye, and often terminate with the loss of that organ ; and if the operation be ever so successful there is an inequality between the vision of both eyes; these, however, are not sufficient objections, if there are no others, to make the surgeon hesitate to operate upon one eye when it alone is affected with cataract, and the objections are even less if the cataract be traumatic. Those appearances of the eye which are mentioned as adverse to the operation for artificial pupil, are equally so to that required for cataract. When none of those objections exist, and the pupil is seen to move briskly according to the light cast upon it, the patient seeing such objects as the fingers held up before the eyesj it is a most favorable case for operation : but even should the pupil act while the patient is incapable of dis- covering any light whatever, the case will be more than doubtful, as it is probable such a state is owing to some affection of the retina ; for it must be remembered that the pupil acts independently of the retina, through the medium of the ophthalmic branch of the fifth pair of nerves, which, as I have already proved, is sensible to the stimulus of light, independently of the retina. Should the pupil be dilated and fixed, in other words should there be paralysis of the iris, OF THE EYE. 423 and the patient unable to see the light, the case is hopeless, and no benefit will be derived from an operation. If the pupil be immoveable in consequence of synechia posterior, It IS no valid objection to an operation, although the case is not to be considered so favorable. Neither is artresia indis an objection to the operation for cataract, for it can be performed after the formation of an artificial pupil. One question to be considered is, at what period of the disease ought the operation to be performed ? It has been always recommended not to operate until the cataract was ripe, or in other words until the parts become perfectly opaque. So long as the patient enjoys tolerably fair vision, I would not operate, but would try to produce absorption by those means already enumerated in the treatment for inci- pient cataract in Chapter XVIIL, page 349, under the head of inflammation of ^he lens and its capsule ; but where these means fail, and the patient ceases to discover objects around him, even when he has his back to the light, the operation may be performed. When cataract is the result of injury the operation should be undergone when all traces of inflam- mation have disappeared from the eye. If the case is one of congenital cataract, operation must not be delayed on any account; it should at farthest be undergone before teething sets in, for by delay, the capsule which is at first soft, becomes tough; the eyes also acquire that rolling appearance of moving about, from not having any distinct perception of objects ; which state is very likly to continue even after the cataract has been removed ; delay may also cause the retina to become amaurotic for the want of its natural stimulus, light. The state of the weather is not sufficiently attended to by surgeons generally; some operate at all seasons, which IS certainly wrong ;-perhaps the Germans are over cautious m this particular, but they certunly err on the safe side. They will not operate when there is any threatening change li i h 424 PATHOLOGY in the weather, such as thunder storms, &c. The most pro- pitious seasons in Canada, for operating, depending of course upon the weather, are the months of April, May, June, September, and October; sometimes the end of June is too warm and the end of October, too cold. The surgeon should always select a period when the temperature pre- serves a medium range ; damp weather is decidedly objec- tionable. Another question to be considered, is, should both eyes be operated upon at the same time ? Authors vary in opi- nion upon this point. I am of opinion that they should, if the operation is division ; and if no violent symptoms set in after displacing the cataract in one eye, the surgeon may proceed to displace it in the other; but if, on the contrary, violent symptoms set in after displacing the first, it is better to postpone operating on the other. If the patient is strong and healthy, extraction may be performed on both eyes, one after the other, at the same sitting ; but as a general rule it is better to wait till all danger of inflammation has sub- sided, after extracting the lens from the first eye. Before considering the choice of operation it will be necessary to describe how many modes of operating there are. There are three operations for cataract ; different modes of performing eac.i ; and one operation equally as good as the other under particular circumstances. The first operation ever performed for cataract was dis- placement, of which there are two modes, viz:— recUnatvm and depression. By depression is meant pressing the cata- ract with a needle below the level of the inferior edge of the pupil, into the vitreous humour, and thus making way for the light to each the retina. Reclination is a modifi- cation of depression, and consists in turning the lens back- wards and downwards into the vitreous humour, and thereby clearing the pupil. OP THE EYE. 490 The second operation is extraction, by which term is meant extracting or removing the cataract altogetiier out of he eye The third mode of operating is divisim, which is break or tear up the cataract with a needle and then leave the pieces to be absorbed. ^ As to which of these modes of operating is to be chosen m preference to the other, depends altogether upon the sort ot cataract that is to be operated upon, and the general state of the eye and system. It is much to be regretted that men who from their professional standing ought to know better, can be found to write and speak such ridicu- lous nonsense on this subject. Some men will unhesita- tmgly declare that the best operation for cataract in every case, without distinction, is division. Another considers reclmation is the one most to be depended upon ; and a third goes so far as to conclude that any surgeon who does not operate by extraction, in all cases indiscriminately, rejects the operation because he is unable to perform it. If the case is one of hard cataract, the rest of the eye perfectly sound, and the constitution good, the best opera- tioii IS extraction. The same rule holds good in firm catar- act, nevertheless, if the operator prefer displacing It, it is perfectly safe to do so, and is certainly the easiest mode of operating ; when I adopt the latter mode, I prefer reclina- tion to depression. If (he case is one of soft cataract, most decidedly the best operation is division. If it is secondary capsular cataract, after the lens has been removed, division may succeed, but extraction is the surest method. It is important to consider the accidents that may occur in operating. There are accidents which may happen in the hands of the most skilful operator, but they arise in most cases, from the unskilfulness of the operator. It is positively astonishing how little some persons seem to value the sight of their fellow men ; for very frequently, without well knowing what they >..(! I I!, •1 V ' ■i 426 PATHOLOGY arc abont they will insert a knife or needle into this most Jlehcate of organs, cutting and carving as if they were amns- >ng themselves with the eye of a dead ox. I cannot help making these remarks, when so many unfortunate people presen themse ves to me with their eyes in such a state as to preclude a I hopes of doing anything for them. It is not an unusual th.na: for a person to be led to me, who, upon DocToT' " '"fs" ' ''' '^ "''""^' "P- ™V eye, and Doctor operated upon me, promising to make me see, but I have never had any sight since, and I saw a little before he cut my eye." On examining the eye perhaps I find the ,r,8 rent in pieces by the needle of the operator, or the vitreous humour all torn up ; or if the case be one of extraction I perhaps discover that the whole of the vitreous humour has been extracted, along with the lens: it is but fair to say hov ver, that this last accident may occur with the most skilful operator, if the vitreous humour be soft or the assistant be unhandy and self-confident. AnotheJ accident proper to extraction is wounding the iris while making the section of the cornea; it may be punctured when the knife first enters the anterior chamber, or it may be wounded when attempting to counter puncture the ZTl .1 . ""■■' ^'"''■''"^ ^^""^«d by the iris fall- ing before the knife when it is traversing the anterior chamber of the eye, when, if the section if eontirulra piece of the iris will be removed, which will form a false or increase the size of the natural, pupil, a circumstance that would be rather unpleasant; this accident is caused by the pressure of the aqueous humour upon the iris; therefor'e the operator before making the counter puncture should let some of the aqueous humour drain off. Another accident that may, but should not occur, is the laceration of the iris wi h the needle in attempting to open the capsule. It not unfrequently happens that the iris is protruded through the wound in the cornea after the lens has been extracted j to OF THE EYE. 497 guard against this accident an effective opening should be made m the cornea, since the prolapsus is caused by for- cing the lens through a small opening. When this accident Happens, the prolapsed portion of iris should at once be restored to its natural position, bcf..ro any attempt is made to bring the edges of the wound in the cornea together 1 he same cause which produces prolapsus of the iris is also likely to occasion a loss of the vitreous humour. In the act of extracting the lens it may be found brittle and may break into pieces; in such a case, the operator should remove the largest portions of it with the scoop and Ic, ve the rest to be removed by the absorbents, getting as much of it as possi- ble, however, into the anterior chamber of the eye. When the lens is first touched it may drop back into a soft VI reous humour; then the great probability is that much interference to extract it will be followed by evacuation of the vitreous humours. After extracting the lens, the cornea may fa 1 m against the Iris, its anterior part becoming concave instead of convex; here the scoop should bo introduced into the anterior chamber, and the cornea pushed outwards, with It, to its proper position, which it will retain permanently as soon as the aqueous humour is re-secreted. On tryinff to adjust the edges of the wounded cornea, the flap may turn in and prevent the wound from healing; it must be everted with the scoop or small probe, before the lids are closed for the purpose of letting the wound unite. Undue inflammation of the cornea may set in, and on the surgeon examining the eye upon the fourth or fifth day, he may find tha the cicatrix has given way, and a portion of the iris protruded; when such is the case, there will be but little use in trying to restore the iris to its natural position ; it must, therefore, be either cut off or touched with a pencil of the nitrate of silver. When corneitis sets in, the usual means for allaying the inflammation must be made use of borne authors state that union of the cornea cannnf fat« ■i ': '■I I,' 1 I I -+- 428 PATnOLOOY ■« .'■ Im pla e for the want of sunicientFy active innammatlon, and that th,s my bo oanso,] in old and enfeebled person by d fie.eney of tone. Although I have never seei it, I ave no doubt but that such an event is possible: g no al y p akmg, however, the consequence n.ost to be . reTdcd Z";??' ,"';"■" "'"^^""^^ '---tes in suppura- kelV to f 'f "'!'"" "^ "'" 'y'-^'^^-^ t'"- 5 ' 'Host likely to follow when instruments have to be i froduced frequently into the eye through the flap in the con la Is to the untoward circumstances likely to occur whe,^c;trac ^;in.trj^n^;-,t^^^^ from the choroid, to such an extent as to hide the catrc'? from View, atrophy of the eye from a profuse loss orthe In bo h cases the loss of the vitreous humour wa gr a ' ThereTeT ''" V ''''' ^^'"^^"P'^*« amaurosfsT' aft'te;^e^r:fX^^^^^^^^^^^^^ ^"^^"? ^^ attempted t, rough the ttThich I ^^^rnrth: ng way it becomes impossible to put the cSlarL "out o sight, and 80 place it as to prevent its ascending L it or ginal position, and should it be adherent to the ir s to detach U from that membrane, without lacerating i^u be found nearly impracticable. When it is pfr fomed rough the sclerotica, which Is the proper way, a ^ or ignoran operator may, on pushing the need e in the posterior chamber, pierce the iris, and separate it from the ahary hgament, which will be followed by a flow of bio d into the aqueous humour, and the formation of a false pupi; to avoid this, if the needle pierces the iris should at once be withdrawn, and the operation postponed OP THE EYE. 429 If there are adhesions, the iris may be wounded in sona rat..., then, or it .nay be wounded in passing thT„S "Kwards and anterior to the capsule. Any of these ! U or accdents are generally followed by t.-a.Latic i i i «ornefn.es happens that the cilia, v proeesses are wounded or the .r.dal ar c'ry divided, wi ,. ti.o . n .die, which accKlent H sure to be fo lowed .by hen .rrhap^e; ..o blood, h^- ver of en escapes through the wo.nc, (hougl. it some itnes gels nto the aqueous humour, con-pK^oly ob..urlng the a afa from the s.ght of the operator, a. . sometimes^equ g to b removed through an opening in the cornea, al lough generally speaking, it is absorbed in a reasonable t me if tt^rdtSd"^^^^^^"^""^-^^"^-^-^"^ The operator by not directing the needle in the proper d rect.on may pass it into the lens, which will prevent h bemg able to displace it. He must then turn the needle a few t.me3 upon Us own axis so as to loosen it In the lens and afterwards withdraw it by degrees, till he frees it a U^ gether. In displacing the lens it may be pushed through thepup.1 into he anterior chamber of the eye; such fn a cedent can only be remedied by at once operUng the cor- nea and extracting it. The lens, although properly dl placed may ascend at any time to Its original pition Beer has known this to occur after a lapse of thirty yea s Tn consequence of a fall on the head ; It rarely occurs how ever, after the first fortnight. Its reappearance g'ne X caused by softening of the vitreous humour, and If theTenI .8 no found to become absorbed, the operation must be repeated. To prevent this accident, Mr. Morgan, Tgeon U ^ 7-1% n"''' P^'P"''*^ ^ "'^P'*'^ of treatment, which ^&^lf " ' " ' *^' *"'''' '^ " ^^'^i^^^^'o"^ of bZ The operator, when attempting to displace the lens, may find ,t so soft that the needle will go through it: when such 11 §# ;1; 480 PATHOLOGY 18 the case he had better change his original intention and divide It leaving it to be removed by absorption. The ac- cident of least consequence, that can result from the opera- tion of displacement, is effusion of blood under the sclerotic conjunctiva where the needle has penetrated : this blood is jy soon absorbed,, a fungous excrescence sometimes s 100 s from the wound, but it can be removed by occasion- a ly touching It with the nitrate of silver. Violent vomiting often occurs dunng and after displacing cataract, which is generally caused by some injury to the ciliary nerves, or retina. The worst consequences that are likely to occur from the operation of displacement, are dissolution of the vitreous humour, or amaurosis, from the lens pressing upon the retina: when this last takes place, the lens should be at once raised passed into the chamber, and extracted: there .8 no remedy that I know of, for the first. A very unusual but at the same time possible occurrence, as the result of displacement, is severe internal ophthalmia The following are the accidents which m'ay occur during and after the operation of division: any of those which occur in displacement may equally take place in division • tliere are also accidents peculiar to this mode of operating' The operator may find the cataract so hard that it cannft' be divided ; if so if he be operating through the sclerotica) he should change his intention and displace the cataract The nucleus may be so hard, as not to become absorbed, after its surface has undergone that , rocess, but drop into the anterior chamber of the eye and there act as a foreign body • this must be remedied by extraction. Another result may be that after the lens has been absorbed, the capsule not beinff sufficiently torn up, its wounds may unite, and produce secondary capsular cataract,-or if the capsule be not well torn up. Its wounds may become healed, even before the lens IS absorbed. OF THE EYE. 481 When division is performed through the cornea, the need e, instead of going through it, may shp in between Its layers, which will compel the surgeon to witli- draw the needle and begin the operation again. If he nl? ;f "'* "f"J«™f'^' ^'>«t ^ t'^Pen-ng towards the point there will be a loss of the aqueous humour causing the iris to advance towards the cornea, and the cornea to collapse in a greater or less degree; this accident would make it very difficult for the surgeon to finish the operation. ^ There is more pain in operating through the cornea than through he sclerotica, consequently, as soon as the cornea 13 pierced, the pupil will sometimes contract so much that It will be difficult to get the needle through it, to finish the operation. " Conjunctivitis, corneitis, or aquo-capsulitis, or all of these afi"ections, may be produced by operating through the The result of division differs very much from that of the other two .operations, for in this we have to trust verv much to nature, indeed much more than in either of the other two modes of operating; for in these all we want from nature is to heal the wounds that have been made • whilst in the operation of division we require her to absorb he cataract that has been broken up, which process ought to be accomplished in the course of five or six weeks that 13 if the cataract is soft, or even firm; but should it be a hard cataract it will sometimes be even twelve months in the absorption, whereas the soft cataract of a child will be absorbed in as many days. That the absorbents may act quickly. It will be necessary to allav all inflammation fo as long as there is inflammation of the eye, there will be no absorption of the broken cataract. It often happens that the operation of division requires to be repeated not only a second but a third and even a fourth time, for as oftpn.o im :1 !tll :!' .If!. 1 nf t 432 PATHOLOGY absorpt,on ceases, and any part of the cataract remains it must eaga.n performed, that is if the absorbents cannot' hi «xc ted to action, which I have very frequently sucTeeded in domg by fumigating the eye with hydrocyanic acid and brushmg round the orbit with the soluti^i ofTetlZ - 'yX tV/r ' ' '"* "^" '•"''^^'' «^ inflammation 1; JWany authors, among whom Is Mr. Makenzie, doubt if he capsule ,s ever absorbed; I cannot help b Hev ng From what has been said of accidents, and other evil d fficult It IS to decide upon the superiority of any one them over another, and how the choice of o^peration mu" depend upon circumstances. Division is certainly the mo Simple and less harm is likely to follow wh „ pe fori^ed by one unaccustomed to operate. It is also certain ha persons o an irritable and delicate constU ion w," bear the operation of division with impunity; while they might be altogether unable to bear either extr^ctio^or dis- placement but particularly the former. As to the com na- rat.ve merits of dmsion through the sclerotica, or coJaT not very easy to decide; certainly a greater number of id dents may occur when the operati^n i. performed through the sc erotica, but on the other hand tiere are two great advantagesj-firstb^, if the operator should be wrong i n h diagnosis anu find a firm where he only expected a so cataract, he can more readily change his first Mention and displace it; and secondly. If he finds It to be a hard cataract he can push it forward. Into the anterior chamber and ex rad it. Dr. Jacob prefers dividing through the co'rnea and often as I have seen him operate In that way, I never once knew an accident .o occur with him, nor any bad ?!gj|g ggi'; ^ r^y? ^' 'r ?i»'ywig!j OP THE EYE. the eve itself. Preparation, and m some cases either i„th„„°y„a!wi„V'' ■*""''' ''""='' ""«'«'. under the influence of Irafv r ,!' J .'*'*' ^^^° Tyrrell, and Dr. Hay., of PhiMelphir ' "'""' "■•• Jel/al'iM^ r™L'l!^-«"» »'««" ^e .he ,!i.l m i'i ^'1 J 11 f' the side next to the eye to be cc iM,}i' ope- W 4« 434 PArHOLOGY rated upon should be always turned a little towards the window. The general position for the patient is, to sit upon a chair with his head supported by the chest of an assistant, who at the same time keeps him from moving his head by supporting his chin with one hand, while with the index and middle fingers of the other hand, he supports the upper eye-lid, lettingt he fingers sufficiently far under the edge of the orbit to prevent the eye-ball from roiling upwards. Some surgeons cause the patient to lie on his back, and certainly it is the best way if the operation to be performed is division through .'-r - ,iea -, and also in the case of children, who in addition «hould be rolled up in a sheet to keep them steady. When I operate upon an adult, T place him in s.n operating chair sitting in a some- what reclining position, with his head thrown a little backwards; he is then strapped tight in the chair so that there is no possibii.ty of his stirring ; this also gives the assis- tant the use of both his hands, and he has not to support the patient's head against his chest, which, with persona Inclined to be restive, is sometimes not so easy a matter. When I have a sfc i assistant I prefer his using his fingers to support the iid to using any speculum j with irritable patients, however, where there is great spasmodic contraction of the orbicularis muscle a speculum becomes necessary ; the best kind, of those now in use, is Pellicr's, which is a piece of bent silver wire; it is to be found in every case of eye instruments. While one eye is being operated upon, the other should be blindfolded with a hand- kerchief. Extraction.— The instruments that are required for this operation, are a knife, scoop, a needle with a bent point and cutting edges, which is generally in the same handle with the scoop ; probe-pointed scissors may be required, they should, however, be always at the surgeon'- ' id.' The knife generally used is Beer's cornea knif,:, . ' 'ade of OF THE EYE. 4m -first, making the section of ihZT ^® P"'°^»' the ca;s«Ie of the lens and tt?' ' .''''"^' ^P^"'"^ cj'e-ball. He then lakes Wd ofZ l ".° P™=»°" "?»" tbe .ha. h „o„,d hold a pen, a,!5 bZ;' H^™ 7„7'^ wards with it he pierces the cornea a rteloaf 7"" about the ^Vth of an inch from the sclerotinl T , "*'" ** .Vth of an Inch above the lowe half of h '^'"' '^« of the cornea. When the nlTnf .i \ . ' '^"cumference rior chamber, iutllati!^^^^^^^^^ ^'^ -^e- the temple, so as to bring the Lt I'^^^^^^^ fectly parallel with the surface of the Vif , 1 ' ^''' directed towards the point of exilon he n' "J -J ' ^''"'' cornea, which should be exa tly pposi Tfi . '' *^« and at the same distance fron^ S'^^^^^^^ ''^T' cautiously pusL the knife forwar t'wa Js' ^ (keepmg his eye on the noint nf ihal-r \ P°'°*' hee^. Of the ed^, and tL^lt o ;^Z' rltT; making tlie counter pumm. which „„,; ,1,: "' """» p.e.e.. under hu co'».»„d '.h :'te''ra;'':,irdr i :i '■'I i.'''..V Mii 11 486 PATHOLOGY finger that has been resting upon the caruruula : im raasi then com^ilete the section of the cornea by pushing the 1 nife on in the same directioUj till it cuts ttself out, kcf'ping the handle back so as not to bring the itoid against the rose. Before the section is completed some of the aoueous humour should be allowed to escape. When tiu) kniie has thuf; cut itselfout, forming a flap of the upper part of Uie corisea, the 0|i« Tiitor and assistant should reinove U\q lingers ixmi alto ■ the li^ss ta close, the patient being directed to keep quiet. Thw Tae first p;irt of the operation is over. It is ■^ekaoM'ledged by all surgeons that have ever perfonne;} ♦Jiis nice operation, that the main difficulty is in inakiijg the counter puncture ; now, the only thing to be attained in this part is to form half, or ,'.s much of the cornea as the operator pleases, into a flap. I have invented a knife for this purpose which forms the flap without making a counter puncture, and renders the opera- tion much more simple.* Tne following is a description ♦ The wood cut is not put in true perspective, owing to the difficulty of chuwing the blade of the kuife properly by strict adherence to the rule. Fig 1. A. The handle about four inches long. B. The arm carrying the blade— J's of an inch. C. The triangular blade, D. D. The extreme width of the blade. E. E. The extreme depth of the cutting part. F. F. The guard which prevents penetration to too great ■ Q. The sT'w which secures the.guard, and permits iU • ,>viu to allow '' ; Made to be sharpened. Fig2. C. The • if the blade of the exact dimensio< OP THE EYE. 437 of its appearance and size •— Tf {« Af o #,„ i i the Janaie similar to iC.JjVi.t ^^^^^^^^^^ B he curve from the handle to the blade, to g ve '"1' for the fingers of the assistant in holding up the upper eye to the globe of the eye; C. the blade rather convex on the ieariy el: f;,;t ' ''''• "^ '''''''' width, fnd being dfamet r'of 1 '"^ "''"'l^ '"^""'^ '' ^'^^'^' perpend cular V n? ^„r ' '"'"''' *^^' " ^^^^ *« th« knife to pre- nten eV rr '"'' !'' ^"'""^ ^'^^"^^ ^-'her than s iart of 2V "^•'"'''- ^'"^ '^ ^"'^ '^^' ''"ifc the upper part of the cornea is p.erced at about Xth of an inch from ndlhetnTth T'^1" ''' P-JendiculL it^ " ana the handle then brought backwards and upwards it mbn„, the back of the blade parallel with the' anfeS dolwafdtiiriLn -r*'" ""* ^'^^^ P"^^ *•>« '^-^^ aownwards till its point comes near the bottom of the ante- nor chamber of the eye, at which time its guard wU be a^ s transverse diameter, or nearly so, and the upp^half of i;r;:ri! \i '"'"^^ ''"*r '^- ^^^^'^^ may be perfect, the surgeon should be cautious to watch he point of the knife so as to keep it exactly he Tr' chamhP ",!:'™'*'' "'"^ ^^"^'"^ " ^•»^*>"g'^ the anterior chamber; be must also be sure that its back is pari le some of ,^ '' ^"/ P""'"'^"^ '' ^'^'S so, he should le^ wThlf "'1 "^"««"« '^"•"O"'- e«eape. After the knife L withdrawn he operator and assistant should let go the Id and the patient must remain as quiet as possible^ ' 1 believe that many advantages arise from making ih^ flap with this knife ; in the first place there Ts no oun^^^ puncture of the cornea, nor is there any danger of he ir s falhng before the edge of the knife anJ ther^ becoming >i '■ 488 PATHOLoay wounded ; and again the operation can be performed with the right hand on both eyes, which is a great object with many ; I am free to confess that to me it is of importance, for I cannot operate with the left hand with the same cer- iainty as with the right. To perform the second part of this operation, the surgeon should support the upper eye-lid with the thumb of his left hand, and holding the needle in his right band direct the patient to look down. The needle having its convexity down- wards should in this way be introduced into the anterior ehamber of the eye, through the section in the cornea, until k comes opposite the pupil, when its point is to be turned towards the capsule of the lens, which is to be torn up with it, by drawing the needle across it in three or four different directions. The needle should then be withdrawn and the lids closed as before, which completes the second period of the operatloa. The third part is performed by gently rubbing the lids with the fingers, over the eye-ball, producing slight pres- sure upon it ; * then when the lid is raised the lens will be seen to extend the pupil, and pass through it into the pute- rior chamber, and from thence out through the section in the cornea : it is sometimes necessary, however, to remove it out of the anterior chamber with the scoop, which should be introduced the same way as the needle till it is got under the lens, then with it the lens is to be raised up gently till it passes out through the opening in the cornea, when the operator should receive it upon his finger nail and see if it be perfectly whole, and if he find it so the operation is finished. The patient must then close his eyes again and remain quiet for a few minutes, during which time the chair may be turned so as to bring his back to the light. As the patient will expect it, he may be then told to open bis eye-lids gently, and try if he can see anything, some object, such as a watch, being at the same time held about tv. Ay * I btve however found it sometimes necessary to make much pressure. OF THE EYE. Which .ho operator sh„„M .entlMTZli; ^ ^ answt i?r^ r^ ^^' 'P'"'*""'' '^^^ ^^^^^^t'^'^ ^» equally answer ,f the section is to be made in the lower part of the ornea excepting that if the knife nsed is that of Beer U edge should be turned downwards when making the sec ion ey: Xtrdiff'^^^"^""^*^^^^ knife in his eft hand ; if, however, be is not so expert with his left as his right hand, he may 'stand behind he pat^^t withrhrw'."","PP" "' ""^ ^'^ '«" hand Crate with the right ; m which case he must trust to the assistant not only to depress the lower lid but also to fix the eye! In performing this operation some make a section of on y the fourth of the circumference of the cornea thers half the circumference; I prefer the latter, as saving both Ume and trouble it being much easier to 'extract th'e let counprn "'T ^''!'''J'^' ^"rgeons, after making the counter puncture m the cornea, withdraw the knife and think h^r" ""' * ^"^" pair of curved scissorsTi bnk the plan a .■ ■ : one; it is, however, sometimes necL 2 tll'-^ ."'P r* «^^' ^°d ^'«o if the operator sees nl { T T^ the section the knife would come out inroagh the sclerotica. :i!l I 440 PATHOLOOir J/ie,^Treatment.~EyeTy thing which might induce in- flaumhUion must be avoided. The patient must be kept quietly in bed, if possible in . ' , of moderate tem- perature, and for the two l.rsi days he must be <;autiou8 even in turning in the bed : his mind must be kept at ease as ^vell as his body ; and his food be simple and antiphlogistic On the third day the strips of plaster may be removed, and the eye examined, when if the wound be found healed, the aye must be again closed and the plasters repeated. The patient may then be raised up quietly in the bed and allow- ed to remain so during the day. On the seventh day th*- eye may be again examined, when if all is found right the patient may keep it open, but covered with a shade. The antiphlogistic plan of treatmer. must he continued up to the tenth day, when if all has gone on well up to that time he may be allowed to walk about llie room, and after the lapse o: fifteen days he may go where he pleases. If during the after-troatmest the bowels become confined, they had better be relieved by means of an enema. Modvficatvm of Extraction.— Before describing the various modifications there are fDr extraction I would remark that I know of none so good as the m de just described, with this addition, th when lae cap !e is opaque it should be extracted as v,c.l as the lens, which can be easily done with a small hook or forceps after the lens has been removed : or, if the eye hf > a;..>ady undergone too much handling, the operator may wait until it has perfectly recovered from the effects of the operation, and then eith r tear up the capsul'^ with the needle, as in seconda;, capsular cataract, or extract it by making an oi' .g in the cornea the second time. I would prefer tea , it p with the needle, but if at all possible I would c act it in the first instance; and I conceive the best instrument to accomplish th... is a pair of spring forceps with very fine blades and tooth points I perceive that for this purpose a very ingenious forceps has been invented by L. A. Desmarres of PftHa « ^Itm.u OF THE EYE. of Which is in his very valuable work Tra.'a ri' • Pratique des Maladies d.s Yen., pige G49 *^"' '' Mr. Walker recommended the section of the cornea to bo made with a spear-shaped knife, his object beTnt ! ensure a large section of that tunic Mr r In ^ n^ended that the cataract shonldTrextll^ted t'h .S:i" sclerotica, the opening to be made in the upper part o Z eye-ball the knife to be introduc . about theTentrof an i„ h beh nd the cornea, and the incision to be of sufficient si or the cataract to pass through it. To , emovrZ ca act h. recommended that a sharp pointed probe be passed nto the wound and made to penetrate the lens, whi h e u d be then l.fted out of ti.e ey,. This operat on a be „ rem: : of- th?i ' '''T ''f' ^^ '-'"-"ts for u" removal of the iens, such as hooks, forcep., &c. I think there are few surgeons of the present day who wolld operate in this manner; I would not myself!^ Mr Scot --or surgeon to the London Royal Ophthalmic " Hospi-' with V h he says there is greater security to the jris than ...h Beer's, and not liable to the same objec- tions m any respect. The following extract will show the objects he proposes in the construction of the instrnlnl .}Ji' I . ' ^' '*' '"®''''"* '^"g^l^ ^« traverse com- P etely the anterior chamber, and divide the nasal margi. 01 the cornea. "'S"* nninf '/^^''\" '^*" [""'^'^ '" ''''^^^ ''"^ thickness from point to heel, enough only to prevent the escape of the aqueous humour, in its transit across the anterior chamber bu hat ,t. width shall have no reference to the dimension^ of the section that Is to bo made, as that circumstance conceive has occasioned all the difficulty of it- introduc tion and the chief danger of the operation. '3. That it shall be of surh a shape and figure that when introduced in the middle of the temporal margin of «is PATHOLOGY Um^'i the cornea, and carried across the anterior chamber, it shall read.ly puncture the nasal .side of that membra ej and when placed m this situation, the cutting ed-^e shall be so ar beyond the pupillary margin of the iris, aSd o p ied 80 large a portion of its anterior surface, as will prevent its escape beneath the edge of the knife to endanger i division in making the section of the cornea. i.i^' '^^^\'^^'''' *''« "^'^t'^" of the cornea is thus about to be made, he edge of the knife shall be opposed only to the margm ol the section on either side, and not to an exten- Beer' s k„if:""''' "'' '"'^^""^' '' '^ ^"« ^^ '" -'"^ He describes his knife in the following M-ords — ^ The back of the knife describes a sixth part of the circumference of a circle, the radius of which fs tn lines The chord of the are formed by the back of the knife, so The knif?b„! • " " ^T '" ^'^'^ '''•°™ P°'"» *« heel. The knife has its convex edge sharp and cutting, and its concave edge the reverse."* ' In the Medical Gazette, for October, 1848, page 37, there are two plates given of Mr. Mackenzie's mivefble needle- knife, with a description, and an article from him on its use I consider the knife a veiy complicated instru- ment, and one hat is much more difficult to operate with than Beer's knife, I will, however, give Mr. MackenS tZ Tf'rC V'' '^°™ Palluci'sioveable nee e k fe that I took the hint to have the one made with which I operated npon Wylie. I omitted the groove along the ower edge of the needle, as I thought that was likfly a^low the aqueous humour to escape ; but In other respecti, ^ere is no essential difference between the two instrument The "eedlejgrtnrnade_b^^ broader, so ♦ Provmoial Medloal Journal, August 10, 1849. ^ OP THE EYE. 449 tortam co„8.,f..rable portion ..f the seclion ;-longcr that the kn fe Pelluc.'s knife was convex on the edge ; I made ye H ra.ght, exactly like Beer's knife, that it might tra V rse the cornea with the least possible resistance." Then foHows a description of the knife, when he continuesr: to at a!h h ^"■' '"'"' '^ '^' ^^^""'"ff^« ^hich appear to attac themselves to such a moveable needle-knife: with ; n ','. ""u '"''"■ **" *'"^''^"« »»>« anterior chamber with a needle than a knife. tion !f IL'' ""'•' '"''''■ ^' ^'''^'''' ^^' connter-punctura- t.on of the cornea accurately with a needle than a knife; and how much depends upon counter-puncturating wel depend .„ a great measure on exact counter-puncturation. evacuated fn'/' "t "^ '^' "'^''^'^"^ '>"'»«»'• ^eing evacuated m traversing the cornea with a needle than with ihl'^'i^^^ ''"'"®* ^^'"^ transfixed by the needle part of ect'sTelT'"*' ''; '"''^ ""'''' ^'«"^ * •^'-t- -ith pe- tti oft"''' '"'^ certainty, and completes a regular sec- tion of the cornea, at a definite distance from its edge. The chief disadvantage attending the use of a movea- least in Wyl e s c^se, I have experienced on some subsequent occasions, is, that the pressure necessary for moving on the knife to make the sectioii, i. a,)! to be accompanied with slin! onf f'.r''"T* -^ '^"' ''''^^'' '' "^^'^ «« that it slips out of the nasal side of the cornea and allows the aqueous humour to escape. This danger may be partly TTit /.. ?? '^' '"'''■"™^"* exceedingly well finfsi; ed so that he knife moves sweetly along the needle, and jet IS not at a!! loose or unsteady. It is difficult to adapt 444 PATHOLOGY lH«e arrest unolth! IT' ""'' '"""« ""^ ""« ="" the nwHr. h • ' '''^"'^ ''™<'> ""^ """"I surface of beh nfl ,l,!.7 "'""""' °f '"''»"' ""'-siJ'li of an inch ba^kS ini,, >^'' "" °'" "'''«" "-^ "»«''l» a little uacKwaras, lill u has penetrated about the fifth ot .„ : i d" 1 by rep awlZl "' "^ '"'' *" ■"-' "^ u uy repeated vertical movements of the needle Thi. operator must then rotate the needle so as tc make it's con cave surface look up, then raise the handle sTas to bZ he concave surface of the needle under ihoiZZj^Z the lens ; the handle must then be brought backwards ani depressed so as to bring the point of the n dlelto tL postcnor chamber of tUe eye, Shere-it can be se!:. thlgt OP THE EYK. 445 just raise the handle upwardsl ? h. ^^' ""^"T' *°^ and almie outward,, i„t„ .,« vitl'^tmt; TS again rising. Clu eX-°'.re 11'"';°'"' Iho point of tte needle to Ibe Zn in »h- u . • '"^ ""' •he needle different ti.e, :rjrdg:r;;;Lr^^^ bewi,,a.„ni?,e;:r:u:rrdtni: »an,e po».t,on he did when piercing the tnnic, J^i to! S:'" "^ °''""'™ "' ^'""-«-' '^™Xhe "e! The reader will have perceived that the operation of d»p acemenldivlde themselve, into fonr period,, WzT-Fir,t the mtroduction of the needle through the tulc. into S 4 i'j ,' : y 446 PATHOLOGY vitreous humour. Second, the dividing of the posterior capsule of the lens. Third, the breaking up of the anterior hemisphere of the capsule ; And fourth, the displacement of the lens. He must also have perceived that there is but one instrument used, viz :— a needle, the point of which is curved and flat with cutting edges. There are some minute directions given, which it is necessary to explain. The object of having the ring and little finger supported by the cheek bone is to guard against the needle entering too suddenly, and probably too deeply, into the eye. The needle is to pierce the tunics with its concave surface downwards, to avoid wounding either of the branches of the iridal artery with its cutting edges, which it would bo very likely to do if it was entered with its cutting edges upwards and downwards. It is to be entered a little below the equator of the eye, that the tunics may act as a ful- crum for the needle, so that when the handle is brought to the horizontal position, the point of the needle with the cataract, will be sufficiently below the pupil, not to require any direct pressure on the point of the needle to push the cataract down. If the needle is entered too far back from the cornea it is likely to wound the retina, if too near the cornea it will wound the ciliary processes. The reason for directing it in the first instance towards the vitreous hu- mour, is to prevent it from sticking into the lens. After- Treatment.— The eye-lids must be kept closed for three days with strips of isinglass plaster, and a linen com- press pirmed to either a roller or night-cap. The patient had better remain in bed for the first twenty-four hours after which he may sit up, but must keep very quiet. ' The eyes may be opened on the third day, but shaded and the light admitted into the room must be moderate! The patient may look about him so as to see large objects* but he must not examine minute objects, or make such use of his eyes as will cause them to become painful. During "^'"T'-'y^lllfli OP THE EYE. Modificatims of Dwplacement.-Vvoxn what h.« », already «aid of displacemeut through the con a f tr f''" surgeon will be inclined to perform it n th..' f "" newly f„r„a .„ereU„„ e.l eclSa „ , , ! ""'", "f '^ perform U,e operation from k^.l^l \, ", ,",1 '" ascended after being displaced. lie 4 J "vo ' ■ '™' of which he was successful. ° ° ""°'' "' ""^ DimAn tlrmgh the Sderalicu.-yfha.l division i. 1 already been explained. There is onlv „„! ■ , '"' .ecessary for operating through ^ e I^t,™ a'd IT" the same needle wifh wh;«h .i- i '"""^'*> »"" "lat 13 The operation t ^ll" ^htTcLltt'lltr.- .n;o six periods. The «rst, enferi ^ht "e* . L" f The second pcr^ fstrhri ^irS iltf '?="'• clamber of the eye, with Us convex „lei;ok„T'''"r the cornea ; this is done exactly in ZT ^ '""* operation f^dispiacemo^rrtl'trUlrhi",";' e^'s Ththirt: "f "^"'"^ '"^ '»''-■- - 2 ft lens. ^ne third period commences by turnin«yfh/r..- * !.![ needle to the capsule of the lens, an'd a f s": 1" ' ' .np,eees,in the same way a,, if dispiaeem'e lit oT low this third period runs into the fourth wht.!, ? , con ,nue this tearing process with the pi. /.he j 't 'I the lens and capsule are cut in pieces. The liflh ,,erW of .? operation is for the operator to' push, with the S"„nt 448 PATHOLOGY needle, as many pieces as possible of the broken lens into the anterior chamber of the eye, there to be exposed to the influence of the aqueous humour. The sixth period is to clear the pupil well of the capsule, with the point of the needle, after which it may be withdrawn from the eye in the same position as it entered, which completes the opera- tion. If at a future time absorption ceases, it will be necessary to operate again, in the same way, tearing up whatever portion of the cataract remains. If the cataract is fluid, it will pour out into the aqueous humour as soon as the capsule is torn ; if it is soft the needle passes through it very easily ; if friable, it breaks into pieces ; but it is sometimes so hard that it cannot be divided. After- Treatment.— The after treatment is the same as that already recommended, after the operation of displace- ment, in addition to which it will be necessary for some time to keep the pupil under the influence of belladonna, for the purpose of preventing the iris from becoming irrita- ted by the broken pieces of the lens rubbing against it. After all danger of inflammation is over, rubbing the lids over the eye-ball, with the fingers, assists in promoting absorption. It is necessary to shade the eyes until the cataract is fully absorbed. Bivtston through the Cornea.— 'There is no needle so well adapted to perform division through the cornea as that known by the name of Jacob's cataract needle ; its blade is so small that the wound it makes in the cornea leaves no mark ; while at the same time it is very strong and of fine temper, so that it is capable of tearing the lens and its capsule into pieces without any danger of its breaking. It is also of such a regular shape as to prevent the possibility of any of the aqueous humour escaping. This needle is made by curving the point of a sewing needle (No. 7) with a pair of plyers, or in any way that is found most conve- OP THE EYE. 449 nient, the needFe beine- cold at f),„ *• /. . of fifty needles scaredy one „av hi T" ? ^"'''"^ " ' «"» but when once the nlZrC rJulr^^ the cnrve. The curved nnin. r A ''''^''^' P'^^^'^'^e each side, on a Sne hone h' V ^' ^""^""^ "^^ «« into a cedar handle leav n'. ti' Tf ^"^ ''^^" ^" ^« P« iong. The handle Inave^hl '^'. ""'^ ^^'' '^'^ '"«'» cataract needles general '""'' "^*' '^ *''^« '" the lick may be h d t tl 1^ Y ?^ '^''''^'^^ ^«'««d; pupn,shon,d^ewen^;;a::Lli::a^^^^ Jens. To perform the first ''h? ''' ''\' '''''^"^ *»•« needle, gently, between he twflr I''" ''°"!' ^^^^*"« the right band and having the eye k! if /'. '"? ^™^ ^^ lid depressed with the indfx and "S. fi ""^ '^' ^''''' hand, he must bring its poL neaT fb ^^''' '^ '^' '«^* the tenth of an inch from it „r '''"'"' ^"^ *hoat the point of the needtsVh?\1*^ '^' '"''''^^^'^ with its flat surface tlwars'u'e^rH"""'^*^ position the operator is to sJ.ke t Z^e^^ZiL " *'' and then push it through that tunic into thl ? '°™''' berofthe eye- this jf ' V *^^ ^"^•^"«'" eham- ihr, * I ^ * " sometimes very difficult f.w}n„ * the toughness of the cornea • if *i ™*^""' ^^^^S to does not continue tonushTh!' J 'P"""*"*' ^•'^«^«'-. cornea, he .1 find it sL in h T -''f'^ ^'^^^"^'^ ^^e obb-ge 'him to withi ': vtz: T/:2 ^""^ ^" operation again. ' *"'* commence the When the needle has enterpf! ♦Ko „.,* • first period of He operatTo ^^0™ «,7r """"""• ""' the eye completol/underhU Sot r ™'°™ ''» &:' point DD 4M PATHOLOGY needle is Ihen to be brought to the capsule of the lens, wiich must be torn up by repeated scratches with it ; this completes the second period of the operation; and the third is to continue this tearing process with the point of the needle until the whole of the lens is broken up, to accomplish which the needle must be used much more freely than is required for tearing up the capsule ; much cau- tion is requisite the prevent the needle from touching the iris. When the lens is torn up, the operator may withdraw the needle, which requires to be turned different times upon its own axis, to free it Irom its hold in the cor- nea. Aftei^ Treatment. — The after treatment is the same as wbea divi»ion is performed through the sclerotica, the most important poiat being to keep the pupil well dilated. The operation may require to be performed more than once, bat DO rule can be laid down as to the time that must be allowed to elapse after the first operation ; it should not, however, be attempted while any inflammation exists, nor so long as absorption is going on, producing a change in Uie eataan«sordinai7 por. «ee a; well as ^ did aU^^^^^^ ^ 'T' ^'^^^ ^« '^^^^ "«* employed. He will so on rfh- ?' '^^'''* *»« fi^at a« his power of "f^ecr^'Lrr^^^^^^^^^ finding none which will enaWe h 1 ^" '^ '°^' '" With those which he fi Jt emp^^^^^^ *Xth^ if 'I '^ '^ onr patient does not begin totZtta,^, L "'^'L^^'''' '^ completely recovered fl the^opSo 1 ^"T^V'" '^^ ^^« as much as possible, babitaat^d Use f « If.; k^' '^' ''*^' crystalline lens, If L ftiPn 1 i V *^^ ^^'^"^^e of the the. for a whii; L^ :^:X:^:^ ^ - tmue to improve, and his first gla se w m n "?'' f '" '^^^ be an old man, serve him a» hifi r J P'^^'^bly, if he 30 or 40, he ^ill not relf It f ' '^ ^' '' * ™*° «^ or 60. He will be !L.T V '^'"'^' *•*«"» «" ^^ be 50 ••n which he hal^l^tp^-;;^ f -*. '^-^ of worfc person be a female, to seS ' Tl .f *'''"^' o""' '^ ^^^ of a cataract glass s thaTwht^,! V'^'' '^^ "^^^ *««t of the eye, itlable^ t^^^n'SXTo'^ ^™"^ that distance at which he coulT.Tu \j^^ ^''J^^*« «* «»« tta, e„.b,e bi™ t„T«zr,r.' *: A' «--•' .1: 452 PATHOLOGY furnished with glasses of shorter focus than those he had at first selected, so that the image of the objects may be formed exactly on the retina. Cataract glasses ought not to bring the object too near, else the patient will be apt to mistake the distance at which it is placed from him, and in trying to grasp it in his hand will fail short of it. When this is the case glasses of a longer focus should be selected. It is said that those who have been short sighted previously to the formation of cataract, can after a successful operation lay aside their concave glasses, without having occasion for any convex ones ; and that some require even concave glasses after the operation for cataract, but less concave of course than those which they formerly used. But such statements are probably incorrect. Having operated by extraction, on a man all his life short-sighted,, I found for the vision of distinct objects he required the usual glasses of four and a half inches focus. If a patient from whose eye a cataract has been successfully removed, has been origin- ally a little short-sighted, but never used a concave glass, on supplying him with a concave glass after the operation, he will sometimes mention that he sees objects much more beautifully than they ever appeared to him before. In fact he had never seen objects with the distinctness and brilliancy with which they appear to an ordinary eye or to a myopic eye armed with a concave glass." Staphyloma. — There are different terms applied to this state of the eye, depending upon the shape it presents. Thus, it is called spherical staphyloma when the cornea retains its natural form, but is more prominent than it is in the healthy state of the eye. It is called conical staphyloma when the cornea in its centre tapers off to a point, forming a tumour ; and staphyloma racemosum, when the cornea pre- sents several irregular projections. Staphyloma of the cornea may be either partial or total, or in other words either a part or the whole of the cornea OP THE EYE. m Every de,crinlionr, '..11 ,' '"" " ™""")' «'inet- contact „,-n ,h, back o?,!,/":!; ""' " " '" "™ '» ia 'St r-: r:itr.T " ^-r'^ -"^^ '- there i, „„ inca-e in ThT s?, „ ^'""T ."""'r'^' ""^ .be eye: 5.u the ^ph^!:;: -r/a ^ ," X mmX' of the cornea ; it then becomes stretched Zkl ^ .«fan.«estxcilrsTitt;;rtr son arrives at maturif v a =♦ u i "®" *"® P®"" derable amou^oTt ,2 • "'°,"»S> "»« lh»s a consi- .1.0 staph;:::' hti r irtS^t™?^ ■"'°- '"''"» »' again can be covcrel hv .f .-j I '"J"™*; »"•"» do^ except to improve the'appearancertl'^^ .clerotica so tTfet thel° ' .7=""'" »»" "™'*»S "■» eorne» „„." .1 :,. ' ""^ ''"""'? m^>r through it. The r-e. ... ,t, ,hape, and ,s at lirst ihicJ. and tongh, ^p* PATHOLOGY but as the disease advances, the pressure on the cornea ejcites interstitial absorption, so that it becomes thin, and sometimes so transparent that the patient can discover objects; this raises his hopes, but is an indication to the surgeon that the cornea is about to give way. When this accident occurs, the cornea sinks for a few days, but its former shape and appearance soon re-appear. This de- scription of staphyloma is generally the result of long con- tinued inflammation of the different textures of the eye which destroys the absorbent power, at least of those absor- ,bents which remove the superabundant aqueous humour, leaving the secretive power perfect. I should remark that although the natural cornea is often affected as described above, vff /-^nerally speaking it is Urst destroyed by abscess, and rf^'JHv; by a paeudo-comea, which finally becomes Tha iQkkr^-iag statement, made by Mr. Mackenzie, shows what the im suffers in this form of staphyloma :— " There is a circumstance regarding spherical staphyloma which merits attenUon, namely, that when the tumour attains a large size, the Lis unable to expand to the same degree as the pseudo-cornea, and its texture much more frail, sepa- rates from the choroid, and becomes torn into shreds, so that when we examine the internal surface of a staphyloma after death, or after it has been removed by an opera- tion, we find the iris which adheres to the pseudo-cornea, broken and reticulated ; whereas the internal surface of a staphyloma which has not reached a great size exhibits the iris still entire." Treatment.— For total spherical staphyloma there is no cure, that is, there is no possibility of restoring vision ; All that can be done is to remove the unsightly appearance and irritation ; and the best mode of accomplishing this is by the operation recommended by Beer; other modes of treatment have been recommended, such as incisions, "S^. iMiiiiiliaMMif OF THE KTB. 4165 setons, escharotlcs, pressure tannin^, x. v. . that was about to be ext^ac d wm , ""''' '''''''' not only should the a StTnt Inn' .h "''""°"' '^'' should also denress tZZ ^^ . *''' "PP" "'^ '"^t he both band free t!^ n''; '' "'« «P"^tor must have or a h-gature X mL?T" ™"'' *^'" P^^« '^ ^^^^^^ the sta'phylolals ea 17^^'^' '''^^^^ ligature in his Ipft I...„h T I ! ^'^'"^ ^'^'^ hook or his contr He t en t J' « *\' '^' ''""^^''^'y ""^^^^ e«t lhr„„gh the inferior drSeleeT.r "^ '"'T ' which Ihe eye-lid. d,„„ .t onerbe 1„ i^*"! '"7°^ »«f .void, if p„„ible, tho di.ch.rge of fhelL »„.',""* .m.»r, and .hey „„.. he kepf inlL";^!";; ZZ :°:ef r f""'^" ?^ ^*.-.« ixti ^: IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I ^ m ^ tiS. IL25 i 1.4 2.5 2.2 20 |m 1.6 Photographic Sdences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 6 406 PATHOLOGY been preserved, the surgeon will find formed a flat semi- transparent pseudo-cornea, of a gray appearance ; and the eye-ball of rather a square shape. This pseudo-cornea becomes, in course of time, completely opaque and firm, of a bluish or brownish color. If after the operation inflammation sets in, which is not very likely, it must be subdued by the ordinary means. Conical Staphyloma. — This deformity of the eye is gen- erally the result of a large penetrating ulcer of the cornea ; it rarely reaches to so great a size as the spherical, in conse- quence of both chambers of the eye being obliterated, and there being no collection of the aqueous humour. The lens presses with the iris against the cornea, and these are again pressed upon by the vitreous humour, which is gene- rally in a dissolved state. The sclerotic and choroid coats never become involved in conical staphyloma ; and when the tumour is once formed, time does not increase its size. It is more rare than spherical, and not being so large is not so unsightly, and is never accompanied with the same degree of irritation. Treatment. — The treatment is exactly similar to that re- commended for spherical staphyloma, except that but a small portion of the cornea is all that is required to be removed ; and as the lens lies in such close contact with the cornea it is nearly impossible to avoid removing it along with the portion of cornea and iris that forms the tumour, and the operator may congratulate himself if there is not a loss of some of the vitreous humour also. In operating for conical, as for spherical staphyloma, the surgeon should never go deeper than the base of the tumour, and in every case, should avoid wounding the sclerotica, as to do so would be likely to produce very severe inflammation, and probably convulsions, particularly if the patient be a child. The after treatment is also the same as that recommended for spherical staphyloma. If the case terminates well, it leaves a very well formed eye. OF THE EYE. 457 Staphyloma Eacemosum.—Tliia state of the eye is the result of several parts of the cornea becoming perforated by ulceration, and the iris prolapsed through those diflFerent holes. The aqueous humour being lost there is no protru- sion of the cornea ; on the contrary, the cornea is generally flat, with raised lumps on it of a black shining color, which lumps are the protruded portions of iris, covered over by pseudo-cornea, which is semi-transparent. Treatment.— U the whole cornea is in this state, vision can never be restored, but if any part of the cornea is clear, and a part of the anterior chamber remains, there may be a chance of restoring some degree of vision by making an artificial pupil in that part of the iris behind the clear por- tion of cornea. If the protruded portions of iris be so large as to produce irritation, they may be snipped off with a pair of scissors, and the parts afterwards touched with the nitrate of silver ; if they are small, touching them occasion- ally with the nitrate of silver will be quite sufficient. Staphyloma Sclerotica,— Thh is occasionally met with when there is a similar condition of the cornea; but it is also met with, and not very unfrequentl/, without any such combination. It is generally the result of long continued inflammation, but it may be caused by a rupture of the fibrous coat of the eye, from wound or otherwise. When it is the result of inflammation the sclerotica be- comes attenuated by the process of absorption, and it assumes a dark olue tint, from the choroid coat appearing through it. This thinning of the sclerotica may be either general or partial: when general the whole eye-ball is enlarged, and all the white of it presents the bluish appear- ance just mentioned. When the thinning is only partial, one point of the sclerotica gives way, generally the anterior! (although it may be the lateral or posterior part,) and a tumour is formed within its concavity, which tumour pro- jecting from the general surface pives rigo in q .r«.„ 4^ PATHOLOGY considerable irritation. The contents of this tumour are the choroid coat, and very frequently some of the humours of the eye; its size varying from that of a pea to a nut. When staphyloma sclerotica is the result of a wound of that membrane, it is of course partial, and its situation depends upon the part wounded. It may be caused by the choroid protruding through the wound at the time the injury was received; or the wound may not unite well, and the cicatrix may give way after it has been for some time healed. IVeaiment.—The treatment in this disease will depend upon the amount of Irritation. In a case of general staphy- loma, with irritation, the patient being able to close the eye-lids, I would not operate, as the staphylomatous eye, generally speaking, after some time, becomes in some degree atrophied. Should the tumour be so large on the eye, as to produce great irritation, when all the other treatment fails to reduce it, recourse must be had to excision. I have, how- ever, succeeded in reducing the eye very considerably, by oc- casionally tapping it and evacuating a portion of the ous humour. The vitreous humour does not re-form so r" as the aqueous, and by stimulating and exciting the aciion of the absorbents, a balance of power is kept up between the secretions and the absorbents, as is the case iu a healthy eye. I find the best instrument to tap the eye with, is Beer*8 cataract knife ; with this the sclerotic and choroid coats may be punctured at about the eighth of an inch from the cornea, and a little above the transverse diameter of the eye ; if the puncture is made in a depending part of the eye, the wound will not readily heal. After a sufficient quantity of the humour is evacuated the lids may be closed and kept so for forty-eight hours, after which the puncture will be found healed. If this treatment does not produce the desired effect recourse must be had to excision. OF THE EYE. 459 If the case to be operated upoii is general staphyloma sole- rotica, the surgeon may operate in the same way as for staphyloma of the cornea, removing as much of the cornea as IS possible without wounding the sclerotica; this is gen- erally followed by an escape of the humours, and the eye becoming perfectly flaccid; the eye-lids should then be closed m the manner already recommended in the treatment for corneal staphyloma. If much irritation or pain follows, a poultice will give relief. On examining the eye in eight or ten days after the operation, it will be found sunken, and a iine cicatrix formed where the wound was made Should the case be one of only partial staphyloma, a ligature may be passed through the tumour, which will cause an escape of some of the humours, and render the tumour flaccid; then the operator may snip it off with a pair of scissors. The after treatment is the same as for general ptapbyloma of the cornea. Synchesis, or Dissolutum of the Vitreous Humour.— In treating of inflammation of the internal textures of the eye and of cataract, dissolution of the vitreous humour was con ' 8 antly spoken of. Such a disorganized state of the humour is always the result of inflammation; it is incurable, and gen- erally terminates in, or is accompanied by, amaurosis, and very frequently by cataract. We are generally ignorant of the vitreous humour being in this state, till we discover it when operating for cataract, or after death. The eye-ball sometimes, has a soft boggy feel, but just as often it feels hard, so that neither state would answer as a diao-nostic symptom. " Atrophy of the J^e.~This disease is exactly the opposite to staphyloma; it is always the result of inflammation, but generally in those of a strumous diathesis. The eye be- comes small, and the cornea flat and dwarfish. I have seen cases where the atrophied eye, compared with the other looked very like a sixpence when placed by the side of a 460 PATHOLOGY shilling. The pupil in this disease becomes contracted, looking like a pin hole. This state of the eye is usually found accompanied with either amaurosis or cataract. If the former, the retina is more or less disorganized, and if it is the latter, operating will, as a general rule, be found useless. I have said it was always the result of inflamma- tion ; but it is sometimes congenital, which is a malforma- tion. Varicosity oftU Internal and External Vessels of the Eye.— When there is a varicose conditionof the vesselsof theeye,itis generally a symptom of something very bad, such as glaucoma or amaurosis ; and this condition is always the result of inflammation. If the internal vessels are enlarged very little can be done to remove them. I have, however, found some benefit from the daily application of stimulants to the eye, and when the external vessels only are enlarged I have found decided benefit from this treatment, combined with the infusion of Colombo with nitric acid taken internally, or some preparation of iodine. I have also found some benefit from occasionally dry-cupping the nape of the neck. Amiurosis.—l have placed amaurosis with those diseases which are the result of inflammation ; not because it cannot be produced from other causes, but because the general cause is inflammation. By the term amaurosis is meant an obscurity of vision in a greater or less degree, depending upon some morbid condition of one or all of the nervous parts of the eye. The term gutta serem has been applied to the disease from the erroneous supposition that the enlarged black pupil, that so frequently accompanies this disease, was a drop of black fluid. Causes.—The remote causes of amaurosis are numerous • the immediate are dependent upon some morbid state of either the brain, optic nerve, retina, ophthalmic branch of the fifth pair of nerves, or a general disordered state of the OF THE EYE. 461 whole nervons system. When amaurosis is altogether dependent upon the brain, it is generally owing 7 me state which causes pressure upon the optic-thalm! ^ corpora quadrigemina, or those pits in i.Zldi ri^c tion with the origin of the optic nerve; or any of thpt parts may be disorganised. When the cU i onge t, U ^may be owing to some defect in the formatiwlbe The pressure spoken of may be caused by tumors surh as enlargement of the pineal gland, morbid growth in he membranes or bones of the base of 'the skullf or an absces forming m the brain. Fracture of the skull, w Uh deprt In or effusion of blood, from blows, may be the cause? or eS 8^n of serum as in hydrocephalus. Aneurism of any of he cerebral arteries congestion of the cerebral blood ves- se s, &c. Any of these causes may produce pressure 1 the way I have mentioned, and the result be amaurosil There are many predisposing causes which may prodnce these changes in the brain. Scrofula, the geneial IdT- posing cause for tumors, abscess and morbid growl^„ the brain or on the base of the skull. Blows will cause dpres. sion of bone or effusion of blood. Effusion of serumTay have many remote causes which produce the inflammation preceding. such, as intestinal irritation from wounds, diar" rhoea dysentery, hemorrhage from any part of the body &c. &c. ; uterine disturbance is another cause There are many causes to produce congestion, such as difficult respiration, sudden suppresssion of perspiration 8uppressK,n of menses, suppression of bleeding piles -in' fact suddenly stopping any discharge that the system has been long accustomed to. Liver and heart diseases are a general cause of congestion. Violent exercise, such as blowing long on wind instruments, acts sometimes as a cause Violent emotions of the mind, or the agency of narcotic poisons, will also produce congestion. It would Hi ' . I I, 4es PATHOLOGY ill M be going beyond the limits of this work to mention all the causes wliich produce cerebral derangement, the result of which miglit be amaurosis. When amaurosis is dependent upon the optic nerve, that nerve may bo inflamed, disorganised, or congested in any part of Its course, or it may be pressed upon and paralysed. Any cause which would produce inflammation, disorgani- sation, or congestion of the brain, might produce a similar state of the optic nerve. Pressure on it may be caused by tumours m its neurelemia,or tumours of any sort in the back of the orbit ; it may also be pressed upon by congestion of Its blood-vessels, or aneurism of the central artery of the retina. When amaurosis is dependent upon any morbid state of the retina, this tunic is either congested, inflamed, paralysed, or disorganised: the congestion maybe either from increased arterial action, or diminished or obstructed venous. There are many causes to produce paralysis of the retina, such as pressure upon It from either the internal or external parts, such as thickening of the hyaloid membrane and increase of the vitreous humour, t amours in the orbit, blows on the eye-ball, &e. Partial paralysis may be thi result of a continued loss of the fluids of the body. Any cauae that will produce congestion of the brain or opUc nerve, may produce the same effect upon the retina. For the causes which produce inflammation and disorganization of the retina, see « Retinitis,'* page 321. If amaurosis is solely dependent upon some disordered state of the ophthalmic branch of the fifth pair of nerves, or upon a disordered state of the thirtl, the result is paralysis of the iris in a greater or less degree, and if both of these nerves are paralysed there will be complete paralysis of the ins. When both these nerves are disordered it is generallv owing to some disordered state of the lenticular ganglion but either or both may be disordered without the lenticular ganglion being affected. The causes which produce disor- OF THB EYE. eaaizalion, paralysi,, „ i„ita,i„„ „, ,, »»n,er„„s; the,. ™„y be di,orga„izeJ at ,1 , oTrV '" many caases, and llier m»r L „. i 7. ^'"' '™"' upon 11.6,1, in any pa uflh.^™ "^ ?^""' ''"" I"''""" ophthalmic b,a In '« rv, :*;' ° 'r °"' »' "•» prodnce, i.H.a.i„„ „f .l"l„ll^Xnh:Cr: ^, to say the least of it, reasonable. When tLt nt of h physiology of these nerves and the phySolv o L ^ ' I endeavoured to prove that the oph£ T^^^^^^^^^^^ fifth pan- of nerves was sensible ti the stimuius of It SIS of the fifth 18 not the direct cause of amaurosis hZil * It lays the foundation for the disease in thl JoMnlv- ** ner :--when the ophthalmic brancrof'^ f^ ^S^^^^^ th^^ins becomes in a similar state, andis conseque'ntTyS ted and hxed, giving no protection to the retina so fW greater field of this nervous tunic is exZZZlu ^ * las of light, than there is in he nrrarsLl of fh' '"""." i, -s )i •I I 464 PATHOLOGY blood vessels, or even paralyse it. But it may be argued that partial blinuness succeeds palsy of the iris, sooner than those changes can take place in the retina ; true, but this is owing to the retina being, as it were, confused from the quantity of light, and the rays being scattered which before were collected by the pupil ; in fact there is not a perfect picture of objects formed on the retina. I am led to these conclusions, from the fact that patients with paralysis of the iris, (the retina being in a healthy state ) can see objects very well, and can even write, and tell what o'clock it Is by a watch, when wearing a pair of spectacles, the glasses of which are covered with black paint, excepting only a small spot in the axis of vision about the size of a pin's head, not a ray of light being admitted to the eye, except those which come through what may be called this artificial pupil ; and as soon as these glasses are removed they are not able to find their way although they see enough of light. But it may also be said, and with truth, that total blindness often occurs with paralysis of the iris ; it will be found, however, in such a case, that whatever has caused paralysis of the iris has produced a similar effect upon the retina. When a general disordered state of the whole nervous system is the cause of amaurosis, the brain, optic nerve, retina, ophthalmic branch of the fifth, and third pair of nerves, all suffer in a greater or less degree. Debility is the immediate cause of such an effect, and may be produced by haemorrhage, such as epistaxis, dysentery, bleeding piles, menorrhagie, &c. ; other causes are venereal indul- gence, masturbation, &c., and again, gonorrhoea, leucorrhoea, diarrhoea, diabetes, oxyluria, or nursing ; any of these may act as causes. It is the same sort of blindness that is tem- porarily experienced when a person is about to faint. General Symptoms of Amaurosis.— AmdiXXTom may be either partial or complete, when the former, some vision remains, when the latter, all vision is lost. OP THE EYE. 465 The first symptoms which the patient complains of are a partial dimness of vision, with wealincss of sight Thi« 13 the first stage of the disease, and is callea amblyopia amaurotica, or amaurotic weal^ness of sight. If the nerson affl-cted be a cleric, he complains that Ler wriulg' oTa wh. e, h.s eyes get tired, the letters on the paper be omo confused, and he writes crookedly; another person canTo read from the same cause : a tradesman finds he cannot do h.s work as usual ; tailors and dre^.-makers complain hat thefr Tes ^^''' "''^'''' ^'""^ ^ ''''" ^''"^ «^«' The next stage, which comes on slowly, cimmences with floating bodies appearing before the eyes, of different shapes size, and color and in whatever direction the pat ent turns his eyes, these bodies start to the other. When thev are of a black appearance they are technically termed muacm vohtantes, when of a bright, visus lucidus. The next stage is that one isolated spot, termed scotoma remains fixed, which, if the disease goes on, continues to increase in size, until finally the whole field of vision is covered with it; but before this takes place objects appea m different shapes and forms, sometimes double, which is called V18U3 duplicatus, and sometimes crooked, w^aich is called .tms disjtguratus, and this is generally accompanied with strabismus : sometimes the patie..: will only see half of an object, and as the disease advance Ue is obliged to place objects in a particular position, or ho will not see them at When the patient is about to become completely blind and when he has actually become so, there is a vacant expression of countenance, with a moping and bewildered stare, and as he moves he seems apprehensive of danger In some cases the eye-ball is completely fixed, in other cwei turning irregularly in every direction. 466 PATIIOLOOY Symptoma when the Cause ia dependant upon the Brain. — If disorganization of the brain bo tlie cause of amaurosis, all the Hymptoms already enumerated will be found to exist, and in addition the patient will complain of pain and dizziness of the head ; his whole system suffers, he sleeps badly, and when he does sleep is startled by frightful dreams. The fiery spectra constantly appearing before his eyes add much to his distress. Very constantly there will be paralysis of some of the muscles of the face, particularly the levator palpebraj, producing ptosis ; and there is generally a dilated and fixed pupil. In all cases, whether it be from tumours in the base of the brain, chronic inflammation, effusion, &c., the symptoms progress slowly and insidiously, except when there is depression from fracture of the skull, or sud- den congestion, in which cases the symptoms present them- selves at once : but should the congestion be gradual from chronic inflammation, the loss of vijsion will be gradual also. Prognosis. — The prognosis in amaurosis, will depend upon the stage of the disease and the cause which produced it, but it must be always unfavorable if it is depending upon any disordered state of the brain. Treatment. — The treatment adopted must depend upon the cause of the disease. If there be disorganization of the brain, or tumours of any part of it, or aneurism of any of its vessels, the patient's sufferings may be allayed, but there is no chance of restoring vision when lost from such a cause. If the cause be depression of the brain from fracture of the skull, the depressed piece of bone must be raised. If the case is one of congestion, the surgeon should seek for the cause which produced such a state of the brain, and let his attention be directed towards its removal ; he may pos- sibly find it to be the suppression of some natural or habit- ual discharge, or he may find a chronic inflammation of some part of the brain. If the congestion is great, and the OP THE BTB. patient's prevfoaa health has been good, benefit may bo derived from general bleeding; generally Bneakinn-L ever, the patient will not bear t^ Lo ml oo"!! tL" sys em, but nevertheless bleeding, both genera andToca, w.t general ant.phlogistie treatment, mult be had rec urso 10, If the congestion is sudden from any violent exercise vic^ent emotion of the mind, sudden congestion of the ve; lungs, &c In any such ease the greatest benefit Z be derived from the slow but continued administra on o «.erc„ry internally, and counter-irritation to the nap 'f tl^' neck If the case is chronic, the liver the remote cause and the patient of a delicate constitution, much may be' done by the intenml use of nitric acid, and occasToTallv passing a stream of electricity through 'the reg o . of "he |ver I must, however, refer the reader to other uthorl fnd State of the Opttc iVm^e.-There is no doubt that if (he optie nerve was either disorganized or pressed 1 L general symptoms already enumerated would be present' bu I know of no particular symptom, that would shew thai the amaurosis was completely dependant upon the optic nev and not upon the retina, unless the brain' is also affected S„toms, When a Disordered State of the Retina is tU Cause of Ammtrosis.~ln Chapter XVIII. there is a fuU account given of inflammation of the retina, with its causes and consequences, &c. When amaurosis is the re ult of acute retinitis, the retina, generally speaking, is diW n. .zed and covered over with a layer of lymph, which nrl duces all the general symptoms already enumerad an^ probably paralysis of the iris from the inLmma'ion ha4l spread to the ciliary nerves. If the ins is not altogeXf paralysed, it will, on close examination, be found i^eguUr which IS sometimes caused by adhesion, but more geumHy i ! Ill 468 PATHOLOGY by a paralysed state of a part of the iris. Tlie pupil loses its black shining appearance and appears rather of a muddy color ; the eye-ball is generally fixed and motionless, and varicosity of its vessels is sometimes found existing. It is not an unusual thing for the acute inflam- mation to have reached to the iris, causing the pupil to become closed by a deposit of lymph in it. The history given by the patient in such a case, will be of great assistance to the surgeon in forming his diagnosis. As to a prognosis it is scarcely necessary to say, that where the retina is thus disorganized, and covered over with a layer of lymph, sight is lost for ever. When, after chronic inflammation of the retina has sub- sided, we find no improvement in vision, but on the con- trary complete or partial amaurosis, the retina is either disorganized, paralysed, or its vessels congested: but paralysis in a greater or less degree, is the common result of a nerve of sense becoming inflamed. When congestion of the vessels of the retina is the cause of amaurosis, the general symptoms already enumerated will be found present, and in addition, as a general rule, there will be a greater or less degree of vascularity of the whole eye-ball, particularly if it be an obstructed venous circula- tion, when the face will look blue and cold, and generally there will be a congestion of the whole venous circulation. These symptoms being present or absent, with the cause which produced the congestion and the state of the patient's general health, will be a guide to the surgeon in his diag- nosis, as to whether the cause is one of congestion from increased arterial action, or obstructed or diminished venous. For example, if there be sadden congestion from violent exercise, violent emotions of the mind, sudden suppres- sion of perspiration, or of any natural discharge in a person of a plethoric constitution, and this accompanied with a throbbing of the arteries of the neck : reasoning from OP Tta EYE. 469 analogy, we have a right to conclude that the congestion is arterial : on the contrary, if we find a weak debilitated person, belonging to the lower ranks of life, living in an unhealthy atmosphere, accustomed to work hard and live on bad food, the general constitution injured whether from liquor, debauchery, or otherwise, and having the general symptoms already enumerated, of blue skin, &c., we may safely conclude that the case is one of venous congestion. When amaurosis is the result of narcotic poisons, the case 18 always one of venous congestion ; but when it is the result of retinitis that has been subdued, I think it more than probable that the case is congesti^ -f the arterial capillaries of the retina. In any of these .ases the pupil may be fixed and dilated, or it may act as briskly as ever, but generally it is between these two extremes, that is, the ins acts sluggishly when exposed to a strong light. The color of the pupil afi-ords but little information in forming a diagnosis. Treatment.~ThQ treatment will altogether depend upon the cause of the congestion and the description of amaurosis. If it be arterial, general antiphlogistic treatment must be had recourse to, such as bleeding both local and general, pur- gatives and nauseants, and every effort should be made to excite the action of all the secretions, particularly any natural secretion that may have been suddenly suppressed. It is in such a case as this, that the resolvent powders of Scarpa produce such good effects, although in other cases they pro- duce an equally evil result. These powders are made by mixing one grain of tartarised antimony with one ounce of cream of tartar, then dividing the whole into six powders, one of which he recommended to be taken in the morning, another in four hours after, and a third in the evening ; which treatment was to be continued for eight or ten days in succession : but should the powders produce vomiting, he then discontinued them for one or two days, giving an lip < 470 PATHOLOGY emetic in the interval. When there is arterial congestion of the retina, much benefit will be derived from applying counter-irritation to the nape of the neck, and giving an alterative course of mercury. If the case is one of venous congestion, the treatment will be quite different ; then tonics must be most depended npon, such as quinine and sulphuric acid, or the nitric acid in the infusion of Colombo.* The state of the bowels and liver must be particularly attended to, for which reason much benefit will be derived from an occasional dose of blue- pill. If removal to a dry climate can be accomplished, it will be found of much benefit. If the cause of amaurosis is congestion of the arterial capillaries, the best general treatment is to administer the oil of turpentine as recommended by Mr. Carmichael for iritis. The local treatment from which I have found most bene- fit in all cases of congestion, is fumigating the eye every day witii hydrocyanic acid, brushing round the orbit with the eight grain solution of veratria, passing a stream of electric fluid along the course of the nerves, and dry-cupping the nape of the neck. There is one very important thing to be remembered in the treatment of congestion of the retina, which is, that the case must not be soon abandoned but persevered in even when hope seems gone. Amaurosis from Paralysis of the Retina.— \i inflamma- tion, or a blow on the eye be the cause of either partial or complete paralysis of the retina, the general symptoms already enumerated will be found to exist according to the extent of the disease ; the pupil will be generally sluggish in if action, and only the one eye affected. If it is not from either of these causes the disease will be slow and • If in this, or any other disease of the eyes, head symptoms be present and, at the same time it is necessary to give tonics, the best that can be administered is the oxide of silver which may be made into pills with the extract of gentian. &'Simmm»mmmmm«,i>M^^. -tjjfffug^ mmm ■■ OP THK EYE. 471 insidious in its progress, there will be no increased sensi- bility of the retina, no pain or increased vascularity of the eye, but the retina gradually loses its sensibility, the pupil looks black and acts as in the healthy eye, and generally both eyes are equally affected. Treatment.— U the retina be completely paralysed, it is scarcely necessary to say what little chance there is of its ever recovering : when only partially so, much will depend upon the cause, and whatever the exciting or immediate cause may be, it should, if possible at once be removed ; the patient's mind should be kept as free as possible from all anxiety, and he should be permitted to travel and have change of air; he should take tonics, and live upon nutritious diet. The best local treatment is fumigating the conjunctiva with hydrocyanic acid, electricity, and the use of veratria, in such a case the veratria may be powdered, on a raw surface made on the temple by raising a vesication there with the strong liquor of ammonia. As this treatment, however, would be too severe to continue daily, the eye-lids and round the orbit may be brushed every day with the eight grain solution. If the case is very bad, strychnine may be given internally, combined with quinine ; I generally give one twelfth of a grain of strychnine with one grain of quinine, made in a pill, twice a day. Amaurosis from a General Disordered State of the Whole Nervous System.— When, from a general disordered state of the whole nervous system, the retina becomes either partially or completely insensible, the constitutional symp- toms will be the best guide to a diagnosis. The motor nerves of the eye often in such cases become paralysed, so that luscitas, ptosis, and a sluggish action of the iris, are generally found present. There will be general debility of the whole system, and a weakness of the circulation, and the other nerves of sense as well as the retina, are in a greater or less degree insensible. It is very seldom la I :> if ! 472 PATHOLOGY such a case, that the retina is completely insensible ; on the contrary, the patient often finds his sight temporarily im- proved after partaking of any stimulant. The general symptoms of amaurosis, as already laid down, are found present. This is a disease very frequently found in young persons who have passed the age of puberty, caused too fre- quently by the crime of masturbation, a fact which the surgeon should be acquainted with, although one which he should not think of alluding to in the case of a female. If the remote causes be some periodical discharge, or nursing, the disease may be periodical, but I know of no other descrip- tion of amaurosis that is likely to occur at particular periods, except day, or night-blindness, which is a species of amau- rosis. Treatment. — The treatment must be directed towards the improvement of the general health by every possible means such as change of air, warm clothing, good food, wine, exercise, tonics &c., and above all things to remove the exciting cause. The local treatment consists in fumigating the eye with hydrocyanic acid, and applying the veratria to the eye-lids and round the orbit. Stimulating liniments to the temples and nape of the neck, will also be found service- able. Amaurosis from any Dis&rdered State of the Fifth Pair of Nerves. — It has been already explained in the commence- ment of this chapter, how irritation or paralysis of the ophthalmic branch of the fifth pair of nerves produces amaurosis. The symptoms, in addition to the general ones, are paralysis of the iris, with fixed pupil either more or less dilated or contracted, the patient complains of a dryness of the eye, and not unfrequently we find that the lens be- comes opaque ; the conjunctiva losing its nutritive pro- perties, often becomes ulcerated, and, in some degree, insensible to touch. I have seen patients often, draw their fingers across their eyes without producing the slight- OP THE EYE. 473 est irritation ; and ulceration and sloughing of the cornea take place, without the patient's knowledge so far as feel- ing was concerned. We often find this form of amaurosis accompanied by a most distressing intermittent neuralgia m the orbit and temple, and if the cause be a wound of the frontal nerve, the neuralgia is often accompanied with a spasmodic twitching of the eye-lids. When the liver, stomach, intestinal canal, or uterus, produces irrita- tion of the fifth through the medium of the sympathetic, it IS not unusual to find a similar eflfect produced upon the third, (.urth, or sixth pair of nerves, producing ptosis, and either a fixed state of the eye-ball, or merely a slight motion of it with the cornea turned inwards and upwards. Treatment.— The surgeon's attention must be particu- larly directed to the remote cause of the disease. If the disease is in the incipient stage, some crude indigestible lood in the stomach may be the cause, the removal of which by an emetic will cure the disease. The state of the iris will require particular attention, for it must be borne in mind that while there is a dilated and fixed pupil, the retina will be undergoing some change from the quantity of light upon It, probably either congestion, or paralysis, or a chro- nic inflammation terminating in either of these states. To guard as much as possible against such a consequence, the patient had betterwear a pair of goggles or spectacles, having the glasses painted black with the exception of a small spot in the axis of vision about the size of a pin's head ; this aperture answers for an artificial pupil. If any disordered state of the digestive or uterine organs be found to exist every effort should be made to restore them to their proper action, but should there be no such cause present, then tonics should be given, and I think the best is quinine. Ihe local treatment consists in stimulating the ophthalmic branch of the fifth pair of nerves, and thereby exciting it to action; this I think best accomplished by fumigating the ■hit •Hi V: 474 PATHOLOGY eye with hydrocyanic acid, electricity, and brushing the eye-lids and round the orbit, with the solution of veratria ; this should be done onco every day, and in addition the patient should have a stimulating liniment, to keep up a slight irritation round the orbit, on the temples, and nape of the neck. I would not recommend that the irritation should be carried so far as to produce either pustules or vesication. Sternutatories will also be found useful, and if the conjunctiva and mucous membrane of the nose be found ulcerated, an eight grain solution of the nitrate of silver should be applied to both parts every day. When a wound of the frontal nerve is the cause, Mr. Guthrie recommended making an incision down to the bone in the direction of the wound, so as to divide the nerve. I think the purpose is better answered, by frictions with stimulating liniments combined with the means already mentioned. If there be neuralgic pains, much benefit is derived from an occasional purge of croton oil. The teeth should be carefully examined in such cases, and if any are found carious they should be extracted. When the trunk or origin of the fifth pair of nerves is disorganized, or par- alysed from pressure upon it, there is ancesthm'a of all the parts which it supplies, consequently no difiiculty in dis- covering that it is the cause of amaurosis; the conjunctiva, Schneiderian membrane, side of the tongue, integuments of the eye-lids, and all the parts which are supplied with sensation by this nerve become insensible to touch. This state of things is always followed by ulceration of the cornea. If the nerve be disorganized no cure can be ex- pected ; but if it be pressed upon, the removal of the pres- sure will remove the disease ; this is sometimes, however, impossible to accomplish, as the pressure is very frequently upon It before it leaves the cranium. The following cases of amaurosis will shew what a varifcty of causes there are to produce it, and how the treat- ment must vary accordingly. OF THE EYE. 476 Case Ut.~lh\B was a case arising from injury of the frontal nerve, which produced paralyses of the iris January 17, 1846, Cornelius Hays, aged 36, I'aborer a man of a quarrelsome disposition ; his forehead and e' ! brows were all marked with old cicatrices. He was led to me^ and stated that he had been in the state in whi aw found \L 77.'. ^"' '"'^ ^"* ""''''• 0" examination I memhrt??; ' ^'^T^ ""^ ^^'^^ "'^^^«««» «f the mucous S onof th ' ''"' "'m' ""^' the strongest snuff or rritation of the nose would not produce sneezing; and no from r„? •" '""^ T' "«' ^'^ ''« f-' -y inco'n'venln humours TZ "' '"''' "'" *'" ^«"J""^^'-- ^U the ^wasthensf:L:s;ss::frXnX:;r^ the^tirs'f lr.f '"' r^ ^*^^^'^"'"^' ^""J ^'«^t"eitv over aml^^^^ with stimulating frictions of liniment d onZron •/ '''P* '•^^ conjunctiva moistened, by S'e 2 J t; • '•'' '''"^ '^"'"'"''' ^"^ «ther tonics. tase 2nd.~Tlus was a case of venous congestion of the retma wUh paralyzed iris ; cured after five yfars standi g Tad iplfi^ """"^"ll '" '^' '^''' '^'^^ ' stated that she had been five years blind, and had been under an oculist in New York but received no benefit; she had been bled, blistered, physicked, salivated, &c. ' On examination I found that she could not count my fangers when placed between her and the light: that the pupils were fixed and dilated, that they had a bluish east H m 476 PATHOLOGY and that both eyes converged. Her face, lips, hands and nails, had a bluish cast. After six months this girl was able to leave me and again earn her bread as a servant. The pupils acted well, and all that could be observed was that there still remained a slight convergence of the eyes. The treatment I used was daily brushing the eye-lids and eye-brows with the solution of veratria, fumigating the conjunctiva daily with hydro- cyanic acid, and, occasionally drawing sparks of electricity from round the orbit, and eye-lids. The general treatment was quinine which she took in large quantities. I should have remarked that this girl's catamenia were always regular. Case 3r(f.--This was one of venous congestion of the retina with very good action of the pupil, though not brisk. September 20th, 1848, Ally Meraun, aged 18; never menstruated ; sight so dim for 8 years as to prevent her doing anything but manual labour that did not require much sight ; she said every thing appeared to her as if in a very dense fog. She had applied to many doctors but could gQi no relief. On examination I found that the pupils acted, although sluggishly ; they were rather dilated, the iris was dark brown, the color of the pupil was similar to the color observed in the preceding case ; her lips, face, hands, and nails also presented the same blue appearance. After ten days I discharged this girl, able to thread a fine needle, or read small print ; in fact her sight was per- fectly restored, although there was no appearance of Catamenia. The local treatment in this case was brushing the eye- lids and eye-brows with the solution of veratria. The general treatment was first an emetic, I then gave her a mixture of the sulphate of Bebeerine, ten grains to eight oz. of water, and one grain of tartarised antimony, of this mixture she took one table spoonful three times a day. :* OF THE EYE. 477 Ca^em.-.'This case was one of arterial congestion of the retina. January 7, 1847, Michael II a^ed 28 S.g t of the right eye had been getting dim 'hfilll twelve months; had occasional pain in it, vvith some S pain n. the head; every object he looked'at with I et appeared as though in a fog, with black motes fly ^g b forehim On examination I found that the pupil wa! d dated, and acted very sluggishly; it was perfectly blaTk as was also t e iris. On looking close, with the help o a magn,fy.ng glass and good light, I could observe u silt vascularity round the ciliary ligament. ^ This man's ^ght was perfectly restored in from ten to flf<^en days The treatment was, first an emeti and pur- gative; T then kept up nausea and liquid stools bv a 8du ion of sulphate of magnesia and tartlised nil mended by Carmichael in syphilitic iritis. For theTst week I cupped him three times on the nape of the neck j also made him give his eyes rest. •-"« necK. i Case 5th.-ms is a case of amaurosis from a general disordered state of the whole nervous system. Mi 's^!!!!! aged 18, called on me, in consequence of finding her si.hl become so bad that she was obliged to look vefy los7a small objects to discover them; if she held a book at the ordinary distance from her, the letters appeared as black spots of ink ; large distant objects she saw'Sbi; 1^ no Znin ' ^'^; ^"' ''*'™'"'' ''''' ''S^^^'' but she had no appetite, and her general health was bad ; she was nervous and rather hysterical, very languid, and could not be amused Her skin was purely white, irides brown pupils black, very much dilated, and action very sluggish' In four months she was perfectly well. The treatment' consisted m making her take air and exercise, retire to bed and rise eariy, keep pleasant agreeable company, and par- take of animal food and a glass or two of wine everyday I 4^ m ^|-. Ml It4 I 478 PATHOLOQT and I was most particular in warning her friends not to let her bo alone at any time. I brushed her eyc-browa and eye-lids three times a week with the eight grain solution of veratria, and made her take one table-spoonful of the following mixture three times a day: H Siilph. quinaj. gr, viii. Tart. ant. gr.; Acet. Bulph. aroniat. gut. xx. Aquae font. %\m. Neuralgia of the Fifth Nerve.— Ferh&iiB there is not one nerve in the body more liable to suffer from pain, than that division of the fifth which is distributed to the eye, eye-lids, and circum-orbital region; and although this neuralgia is not always accompanied by, or is the result of inflammation, still while so much on the subject of the fifth I consider I am not misplacing the consideration of this disease. "This disease was formerly called tic douloureuic or painful tic; the former word signii'ying a sudden catching or convulsive motion, sueh as is noticed in the face or other parts of some persons, and is as it were a local chorea, and is such as is observed in horses that convulsively bite the manger. Persons with such catchings experience no pain. But when twitchings occur in neuralgia they are attended by pain, and therefore to their name — Hie'— in this disease the epithet * douloureux ' was added."* At first the pain is only of short duration, and generally occurring at intervals of ten, twelve, and twenty-four hours, and I have known in one case an interval of seven days ; it is a shooting pain, sometimes only circura-orbital, hut often running the course of the branches of the nerve, attacking the side of the nose, the eye-lids, eye-ball deep in the orbit, the cheek and teeth . As the disease continues • CjclopsBdia of Practicul Medicine, yol III, page 381. OP THE EYE. 478 u ouijl ,[ will only give hi,,, any relief. In llieae ipv.™ .ae, the eye will dUeharge a grcl. qnanUty „ 'a,. L ana as soon as the pain ceases, unless there is delirium th r ^;no fl ''?•" 'r^ ^'"'^''^ '''"^"«««d «« Jong as here .s no inflammation, but it is quite the contrary when It .s accompanied by inflammation, and may very eTsiry be m.staken or sclerotitis ; I have myself mel with one case that for a time I consideied to be general ophthalmitis. When It IS accompanied by inflammation the redness of he eye does not disappear on the cessation of the pt but t becomes paler, becoming again florid when the pain 'sets n; and the pain is often brought on before its^ime by hewing, blowing the nose, or even touching the skin o the the attacks of pam, and often remains swollen after thf pain ceases. In addition to these symptoms there will be others present, such as amaurosis, deafness, &c., if the disease ,s produced by organic changes within' the cranium If there ,s one disease of the eye more than another that deserves the name of intermittent ophthalmia, it is where neuralgia of the ophthalmic branch of the fifth pair of nerve! IS accompanied with inflammation. It is very difficult to say what is the proximate cause of neuralgia; pathological anatomy is by no meana satisfac- I f i I PATnOMGT ii|^> The pain may bo sympathcuf, caused by some disor- dered state of the digestive organs, or some irritable state of the uterus. I have found weakly women, when long nursing, suffer from this disouse and recover on weaning the child. Wounds of the frontal nerve will sometimes produce it ; so will a cold blast of air on the eye, and of course any organic change that will produce pressure on the nerve in any part of its course. Treatment. — The surgeon must be guided in his treatment by the patient's general constitution, which generally speak- ing is very delicate, which is quite suflicient cause for the avoidance of antiphlogistic treatment. Some recommend the application of leeches where there is inflammation, but I have neve-- seen much benefit result from their use ; mer- cury I have found to aggravate the disease ; tonics, stimu- lants, anodynes, narcotics, counter-irritation, electricity, warm and cold baths, &c., have nil been recommended. The tonics that have been most used, are the carbonate of iron and the sulphate of quinine. The anodyne narcotics, morphine, stramonium, belladonna, aconita^ &c.; Strych- nia and veratria have also been applied to the parts. Purg- ing with croton oil has been strongly recommended. When I cannot find any immediate cause to remove, such as nursing &c., I first give a purge of croton oil, from half a drop to a drop, I then give a five grain dose of quinine, to be taken a little before the time the attack generally comes on, and an eight ounce mixture containing eight graii of quinine, a table-spoonful of which I? to be taken every cigut hours, after the first five grain dose. This treatment, with brushing the eye-lids and round the orbit every day with the solution of veratria, I generally find performs a cure, whether the case is accompanied with inflammation or no Ot. "< (^-.'osiiL^ in different parts of the jE^c— Pathologi- cai t ;y. ;.y M\j proves, that many parts of the eye become OS su de bo kn ha qui he aci OP THE EYE. 481 ossified as the result of lonir confinno,! inn„ quence, for even shn„I,i Vhl . ""^ '"^ '"»'='• ^onsC" h^ca„do„o«j;t:lx«^^^^^^ a cataract that had ossific deposits in i? "'^'^ w CHAPTER XX. PARTIAL AND GENERAL ENLARGEMENT OF THE EYE.* Hydrophihalmia, or Dropsy of the Eye. — Dropsy of the eye like dropsy in other parts of the body, may arise either from an increased action of the secretions, or a diminished power of the absorbents. I think, generally pneaking, when the eye is the seat of the disease, it is owing to the latter cause, for it has been found that diminishing the power of the secretions does not tend so much to a cure, as increasing the action of the absorbents does. Dropsy of the eye is of three varieties ; the first depending upon the aqueous humour, the second upon the vitreous, and the third upon both those humours. When the case is a preternatural accumulation of the aqueous humour, the cornea becomes dim, the anterior chamber of the eye enlarged, and the iris loses its mobility ; there is a feel- ing of heaviness and tension in the eye-ball but no actual pain. As the disease advances the cornea expands to three or four times its natural size, and its appearance becomes more dim and muddy, owing, however, to the turbid state of the aqueous humour more than to any loss of transparency in the substance of the cornea ; the iris becomes of a dull color, and completely motionless, but the pupil neither becomes dilated nor contracted. As the eye- • The following remarks I take from the Dublin Quarterly Journal of Medical Science, No. lU, page 469. " Megalophthalmos, or preternatural enlargement of the globe. — We are indebted to Mr. Fleming for a case of this description which fell under his notice in one of the temporary fever hospitals. The boy, now seventeen years of age, has brown hair, and dark hazel eyes. The right eye is natural in every respect ; the left is nearly twice the size of the right, and very defec- tive in vision, but perfectly natural and to all appearance healthy in its coats and humours. From all its parts being in proportion to one another, it presents one of the best instances of pure buphthalmia, or congcnitally enlarged eye, which we have yet seen or read of. The pupil is perfectly sensible to light, and the lachrymal appendages normal." HMIIMUg PATHOLOGY OP THE EYE. 433 ball increases in size its motions become impeded the cornea ge s a hard feel, and the anterior part of the sde o^ 'ZoTT ^''"^' ^•"^' ""'^ ^" this te onZ CO nea seldom gives way, but the iris will become ruptu d and absorbed, and finally the eye become atrophied ^ \.s.on at the beginning of the disease becomes presby- opic or far-sighted, but this is soon followed by 1.2^ f"I; .fat the bcgmninj, !<,„ .^^ primary L™t known and the patient', constitnti™ is LTZmZJ, may be entertained of success h„t if ^.K"""'. ™""= "opes its restoration is out of thl ".e'sUon '"" " """ «""» Treatmenl—TlK treatment will depend very much „„„„ he primary cause ; the constitution must be weH attaS to, and .f feund in a weak state tonics must be giv „ de d and the cons.itliion' .ood d^gitrtd^uTnit: 'tS r; hfiTt: ^7'.?' f ™ ""«""» »y»tem°irat d oy the latter. If there be suppression of any periodical d„ charge, ,t must be reproduced by the ordinal mef" .f there be sudden suppression of an eruption, much ben flt' w,l be derived from counter-irritation to therpe of til neck. When the disease continue, without any mi igau™ Beer recommends the evacuation of the aqueous humonr' by opening the inferior part of the cornea w ha lance ! Under such circumstances I do not see why some 0?!^ aqueous humour should not be evacuated, hut I would prefer ns.ngallat cataract needle to a lancet and would raft r 484 PATHOLOGY open the side of the cornea than its lower part, to give the wound a better chance of healing. When there is a preternatural increase of the vitreous humour, the characteristic symptoms of the disease arc, an Increase in the size of the eye-ball with but very little addi- tional increase in the convexity of the cornea ; the anterior chamber of the eye becomes small, and finally obliterated by the iris being pushed forward against the cornea : the sclerotica becomes of a bluish color, the eye-ball becomes hard, impeded in its motions, and finally altogether motion- less ; the iris undergoes no change in color, but the pupil becomes very small. From the commencement of the dis- ease there is pain in the eye, which dally increases until the side of the head, neck, and teeth partake of the pain so as almost to deprive the patient of his senses, and making him constantly call upon the surgeon to puncture his eye. Vision is at first myopic or short-sighted, but it soon dimin- ishes, and is at last totally destroyed. The general health sufi'ers much, and from the beginning the patient is deprived of sleep and appetite. The prognosis in such a case must be very unfavorable, indeed it will be doing much In such a case to save the patient's life. Cause.— The only cause given hy Beer for such a disease, is an unhealthy constitution having in it a scrofulous or syphilitic taint. Treatment.— The most important point is to improve the patient's general health, local treatment being of very little use. The only thing that can be done when the case gets very bad, threatening the patient's life, is the treatment recommended by Beer, viz :— to make a section of the cornea as if about to extract a cataract, and evacuate the aqueous humour, cr>-stal!ine lens, and a part of the vitreous humour ; then allow the eye to collapse, When there Is an increase of both the aqueous and vitre- ous humour, the case is termed general dropsy of the eye. OP THE EYE. 485 -..'^''TT''''" immediate causes are very obsrure excenl when the disease is produced by cither injury or rflarmf t.om Beer considered scrofula a predisposing eais" J'ea,nen,.~ll the treatment rtcommendedT .te pre iniitllrnt''i'^'''''''''"'" ""' "■= "■« «"" of '"tor tuPhk" "J"'")'- <"• " ">ay occur without any very S iseasr-bnf •"""■°^',° "^^ " '"*» -'^''^^ isL n "■ w°°r' r'^ '° '"™°^* ""' '« "" t^i t »; tJio cornea, but it is sometimes situated on the side of ii Authors formerly considered the disease as a hicLninl of he cornea but pathological anatomy has shown h™ kfs a r Lumour "■" ""' '"'" '» "■» '■■-"- »f «■» a,«c- w:=him^ts;ri^^^^^^^^^^^^^^^ they are held laterally .„ the eye. ,f a. .be clS'e™:: i*() "!i»i 486 PATHOLOGY of the disease, the surgeon looks straight into the eye, he sees no change in the shape of the cornea, but if he exam- ines the eye in profile, the cone v/ill be observable shining like a diamond. At first the cone is perfectly transparent, but after the disease has continued for a long time, it becomes opaque. The disease sometimes begins in one eye and after a time appears in the other. Cause.— The caus'e of this disease is very obscure ; it has been met with in every stage of life, but is said to be more frequent in women than in men. Dr. Ammon met with congenital cases of it. Treatment.— The only treatment that has been found to produce any benefit, is giving the eyes rest, prescribing tonics, and attending to the general health ; benefit will also be derived from the application of stimulating liniments round the orbit. Evacuating the aqueous humour, and using pressure upon the cornea have been practised, but with very little benefit. Mr. W. W. Cooper was more successful than others in this treatment, by means of an apparatus that he invented for keeping up long continued pressure upon the eye without producing irritation, at least it produced less irritation than any previous means that had been tried ; it was not, however, so successful as to encourage its use. The apparatus was an air-cushion acted upon by a spring after the manner of a truss.* Sanffuineous Effusion into the Eye. — Blows or wounds of the eye are very frequently followed by an efl'usion of blood into the aqueous humour; but this eflfusion sometimes occurs in very sound eyes without any such causes, and has been known to occur periodically in persons of a weak con- stitution, and sometimes to be brought on by violent exer- cise. The disease is termed apoplexy of the eye ; it is sometimes, but not generally, accompanied by pain, and a degree of inflammation. ♦ Dublin Quarterly Journal of Medical Science, No. 10 page 49 1~ -"^-\ mtimim iii OP THE EYE. 487 sionTuZ!;~] ""T ''^ " '''' '^^^'' spontaneous effu- 8 on of blood into the aqueous humour, but it apoears bv he cases on record, that nature left to herself aE "' nntZff^'^''* ^"'"'"'' '-^'^ ^^Ja«.-It is not a very nnfrequent occurrence, for the eye-ball to become enlarged turn ournn: r'"^." ^^^^^^^^ ^^^^ «^ ". -^s vmnh IZ '^'; r*^ ^' '°'"P''««'* °f '^Jood» organized K;strth' T'"''"' tubercles, or the tumoufs may rio^ ofTp' IT ''' ^'"^^^"^ "'^t ^"h in the inti. or iri wf' ''''^"l'"' *"'"*^"" •" '^' «^'«ro«ca, cornea, P r of thTtV^r' '''^' *""^"" ^«^™ - *b; deepe ?rl .V ^ .' *^'^ *'' sometimes mistaken for fungus eyetall "' '^'''"'"' "^'=-*^« *^«^P*«<^'^ o^ *he CW^.-Injuries and inflammation hare been known to lar V ifT"' "r I" P"'"^'"^ *^-« tumours pa2u! larly ,f the person be of a scrofulous diathesis. JVm^en^-I would first give calomel and quinine until ormrTht''- '"r^^"^"^* ""^^^ ^''^ influence oft former, then g.ve the loduretted iodide of potassium, using a he same time stimulating friction round the orb i'trand counter-jrnta .on to the nape of the neck. If this treat- ment ails to lessen the size ot the tumour, or m tig^^^^^^^^^^ fotJeknt^T' *'^ ^°'^ --dythat'can befe r d to IS the knife, when it will be impossible either to prevent he OSS of much of the humours, or to preserve the shl of the eye, unless the tumour is superficial, and then also shou d always use the knife, although it m'ight be removed by the constant application of the nitrate of silver. The the eye .-« A lady was affected with considerable pain in 1/ ! I 'I ( 488 PATHOLOGY OP THE EYE. one of her eyes, which presented the appearance of a small vesicle pushing into the anterior chamher from under the ciliary margin of the iris behind the lower edge of the cor- nea. The vesicle gradually increased, separating the iris more and more from the choroid, and the pain became severe. I punctured the vesicle, or encysted tumour, with the iris knife, through the cornea. A minute quantity of fluid was discharged from the cyst, which immediately contracted so much that it was no longer visible. The pain was removed ; the wound made in the cyst healed, it filled again with fluid and again appeared in its former situation, but larger than before ; I punctured it a second and a third time, at intervals of six and eight weeks ; after the third puncture it did not fill again. The iris returned to its natural place; the pain ceased entirely; and vision was preserved." I consider the above one of the most interesting cases of the kind on record, and I have no doubt but that it was the aqueous humour getting into the sac that produced inflam- mation, causing it to contract, and its cavity to be finally obliterated. CHAPTER XXI. MALIGNANT AFFECTIONS OF THE EYE-BALL. EXTIRPA- TION OF THE EYE. ADAPTATION OF AN ARTIFICIAL EYE. There are three malignant affections of the eye-ball, viz •- ^rrhus Fungus H^ematodes, and Mehmsis. The first is a to youth ; and the third, to persons of middle age. flif ';7^' great was the similarity between this d^ease and fungus h^matodes, that Scarpa and many others extirpated the eyes of young persons, under the supposition hat ,t was under this disease they were labouring, when in reahty it was fungus. It was Wardrop who by his patho- logical researches, showed the distinction between the two diseases. Females are more liable to this disease than males, and it is at that change of life when women cease to menstruate that it most generally makes its appearance, and is m most cases the result of long continued inflamma- tion of the eye Its chief characteristic symptoms are, that It generally commences as a hard carcinomatous growth approaching to the consistence of cartilage, on the conjunctiva or lachrymal gland, where it may continue for Liin^xr^r ^'^^""^ ''' '''''''"^^ p-«' - It is accompanied with pain in the eye and head, and dimness of sight sets in early, which is soon followed by a total loss of vision ; the cornea becomes opaque and shrun- ken, he sc erotica a dirty color, covered with varicose blood- vessels. As the disease advances the pain becomes of a burning lancinating description, and the slightest touch oi the tumour produces a flow of scalding tears, which causes great irritation ; the subconjunctival cellular tissue next becomes affected, the eye-lids swell, and the eve-ball m ' 490 PATHOLOGY becomes immoveable; the tumour next ulcerates, and the surface of the ulcer discharges an acrid matter: the disease then spreads very rapidly, until one part after ano- ther is destroyed. The pain and irritation increase, the glands of the neck become hard and painful, and fever supervenes, under which the patient sinks rapidly Scirrhus is more liable than fungus to be propagated through the absorbents; it is of a firmer consistence and less sparingly sflpplied with blood-vessels; it rarely grows to so large a size; its progress is generally slower; it becomes more firmly adherent to the surrounding parts- there is very seldom interstitial hemorrhage ; cancer is generally superficial-fungus more generally in the bottom of the eye. B'ognosis.~\i the eye be extirpated in the early stage of the disease, life will be saved by it, but when once the tumour ulcerates and the disease spreads to the surrounding parts, nothing can be done but to try and alleviate the patient's sufferings. Treatment.— ThQ only proper treatment is extirpation of the eye-ball and all the soft parts in the orbit, and this should be done in the early stage of the disease. If the disease IS too far advanced, or the patient is unwilling to submit to an operation, his sufferings may be alleviated by keepinff his bowels regular, living quietly on mild nutritious diet and fumigating the eye with narcotics. It will be also found necessary, particularly In the advanced stage, to rive some preparation of opium. Fungv^ Hamatodea.—Variom names have been given to this disease, viz -.-Medullary sarcoma, encephalotd tumour, soft cancer, spongied mjlammation. When this disease attacks the eye, it always begins in that part of the retina which is pierced by the optic nerve If the surgeon sees the eye in the early stage of the disease, he will observe something in the posterior chamber resem- OF THE EYE. 491 bl ns: a piece of pohshed iron; that the iris has lost it na- tnral color, and the pupil is fixed and dilated. As the disease advances the sljiningbody presents an amber color and as the tumour ,s then advanced forwards, the centra artery of the retina will be seen running over' its surL The disease may remain in this stage for months, or eveo rreilari V nr,hT ""'' "'''''^''' ^'' '"^'^'^''^ ^"^ the oTnhT?h ' ^""""^ '^'^'"•'^ ^' * sufficient symptom to enable the surgeon to diagnose between it and cataract. Up to this time generally speaking, there is not much, if tof^l hiT V ^"^"Tu""""' '^"^ ^'•^"^ *•'« ^^'•y fi'-^t there is Til T ''"^" '^' '"'"'"'^ ^«^'"« t« ^^'^^'^^ towards the ris Its progress is very rapid, generally destroying the whole eye in a few weeks, and the fungous tumour which had occupied the place of the vitreous humour at first wHl now having destroyed the lens, iris, and cornea, fill up the tumour It stretches to double its natural size, the sclerotica becomes of a dark blue or leaden color, and the whleye an i 7u T''^ ^^"'•^' P^^^^"*« ^» irregular appea - ance. Matter then collects between the tumour and the cornea, and the conjunctiva becomes swollen and .dema! tons During this time the patient's suff-erings are very great, the pain m the head and neck producing high fever an sometimes delirium. The tumour may makers way either hrongh the cornea or the sclerotica, but it is more generally through the former; when the cornea ulcerates and bursts a foetid bloody fluid is discharged, and the fungus shoots out. If ,t is the sclerotic coat that gives way the tumour for a time is covered with conjunctiva ; this, how- ever, soon gives way, when the tumour is exposed ; its sur, tace presents an irregular appearance, and is of a dark red i M.. ^1 I 492 PATHOLOQY color being generally covered with coagulated blood. Ihc slightest irritation causes the tumour to bleed pro- iuselyj the surface of the tumour next sloughs, which 18 attended with a sanguineous foetid uischarge, which excoriates any part of the integuments over which it passes After the eye bursts there is some temporary rehef to the patient, but his sufferings soon set in again with renewed vigor, disordering all the functions of the body, till finally he expires either from hectic fever, or loss of blood, or he becomes comatose and dies in convulsions. The patient rarely lives for the tumour to dilate and destroy the bones of the orbit; but it is not unusual for the absor- bent glands under the jaw and about the parotid gland to become contaminated, and for the skin over them to burst, thus producing a sloughy ulcer. Cause.— The exciting cause of this disease is very ob- scure; some have attributed it to blows on the eye, but this I think .8 very doubtful. The subjects of it are go.rally children of a scrofulous diathesis. It rarely if ever occurs in adults. p{agno8is.-l have already given the diagnosis between this disease and cancer, and between malignant and non- mahgnant tumours. If any doubt should exist as to the character of the tumour, Mr. Travers recommended that a section of the eye should bo made, when if the disease was malignant there would be only a small discharge of blood and the eye-ball would remain firm,-but if it was non- malignant, a discharge of discolored matter would take place, when the globe would collapse and a cure be effected. Treatm^t.~BmQ^i has been derived from mercury when given in the early stage of the disease. The follow- ing statement is made by Mr. Lawrence :-« I would not however, represent to you that the state of a patient with fungus haematodes of the eye is absolutely hopeless; by the OP THE EYE. 493 .hi» kind, ,„ w„ich , 1 .'„o": S'z,.rL;r r' »tatc, i„ which the sl„,,e aflcrwar* 1 74d „ / LT'^ became jpatiuc. The eninlnvm^,,, f ° ' ""' '"'" in for maliy'wcck,, ^5 1 ; „ c Ld"'!"''' rr""'" tl.o patient, after remaining ZlZtt^l 'V """ . e bead excited b/dovelep^LT'^ «::,* ^^ ^r;U\rtr:i:er&^^^ .t;virdir.:i:5-:b:vS^^^^^^ gone and ail the soft narfs nf .i,» i : , "J^"-""" "as remaining bnta f goSl,. 1 it h ""'"f """""« have been f„.„d diseLd.Id Ciltll?^ ,?" no a very unusual occurrence to find the sTli- ' theute^^ Th/fiSgtfr ;l::eC^^^^^^ other cases the nerve is snlif in*A *«, ''l^pearance. Iq * i;ubli„ Quarterly j,„,„„ ^^ ,j^^.^^, Scien;;rS;n^:;:7oi: If ill i 1' 494 PATHOLOOY Melanosis of the Eye-haU.~Thh is a disease of very rare occurrence ; it h met with generally la persons of middlo age, and has no tendency to be propagated through the absorbent organs ; the consistence of the tumour is soft, in a thin cellular septa ; its color is nearly black, and it generally attains to a large size ; no blood vessels have been traced in it, and there is never interstitial hemor- rhage ; the rapidity of its growth is variable, and it is not disposed to form adhesions to the surrounding parts ; when it ulcerates its progress is more rapid than before. The only treatment for it is extirpating the eye-ball, and this • Was been found to save life in four cases out of every five. The following statement is made by Mr. Mackenzie :— " In the early stage, the patient complains of imperfect or des- troyed vision, with a sense of fulness and pain in and around the eye, followed by enlargement of the eye-ball attenuation of the sclerotica, so that a mass of black sub^ stance appears sh-ning through it, and a peculiar opaque appearance of the pupil, the cornea or sclerotica gives way and a black fungus protrudes, which increases slowly and in general does not bleed much. If the tumour which pro- trudes from the eye be cut off, the part heals, and by and by the melanosis protrudes afresh. This I have witnessed in two cases. In one case in which Dr. Rainy extirpated the eye- ball at the Glasgow Eye Infirmary, the optic nerve was affected with the melanotic degeneration, but not all the way back to the optic foramen.'» Extirpation of the Eye-ball.~Mm\i has been said by authors on the nicety, &c., of the operation for removin.' the eye-ball ; their remarks, however, in general, seemed to be based on the supposition that the organ was in a perfectly healthy state, and they appear generally to forget that we are never called upon to perform such an operation except when the eye, generally speaking, is one confused mass of disordered substance. When the eye is to be extirpated OP THE EYE. 495 the position Of the patient may he the samn n • . ration for cataract or artificial p J, i;X the horizontal position is tl.o best Tit 1^'''""'""^' -pport the npper an., dcpres: ^X^]Z:Z'T'' the sixe of the tumour this U ,i,m u I ' ' ''' '^^"'» 'i^s rnny be disuuit J at t ei c S T 7'T''' "'« of an incision carried throug tl e f rl h" "X"'^'''"^ and the conjunctiva Th. „ « T '"^'''" "* ''"' ''ds brought together g^ln l^T '• '" ""'"' «'"""'' '^« intention, I soL'r tCo . ^ts" 1^' '^ ^'^^ '''' This incision being made and fhn f" extirpated, we., separated, thf i^S^l^lT^irnr ::?r ^^ "^ needle, pass a ligature through the eye btll '"r"'^ 8ide, he should then take hold of theXt "."''' *" Imnd, and by means o' it draw tl o vVl^ """^ '" ^"' '^^* forwards, then with a bistou "l Kl'^T'^ '"' band, separate the conjunctiva from!, f "/'" ''^^^ and push the bistoPry d rectit 111 ^''°.'"^«"»^' *=a»thus, of the orbit, then tuTninr hL' hantT'^ '"'' ''' '''''^ wards, he with the edl of 1 h^ •lownwards and out- by thi's movement tt eLernarcSr^^ eye-ball from the edge of the owe Id 7' '"^'''''''' "'^ fibres of the inferiof obliqt :„ .'' ^ll^.^t. T'^^ manner he carries the bistoury round tl.P, "™''^'' orbit, separating the eyeJ^ Vom , « ^iTer 1 ^ upper lid, and cutting across the fibr ofThl ^'^ "' "f the origin of all the muscles and ih.Tr ' '^''''^'^ the foramen opticum Th ^l j ' jr/"^%^'«^« *'> which the surgeon should at one ^em "eT^: ( '"^? gland and all the soft parts within the orbU UiU. Vf are diseased *hpv sh , i j ;, " ^' "^® eye-lids ' .hc> should be iirst removed from their i! Hi la I 11 496 PATHOLOGY attachment to the orbit, when the globe can be removed with the h'ds adhering to it. If the lids are not diseased the operator should preserve as much of the palpebral con- junctiva as is possible, to hold in an artificial eye. The bleeding that takes place during and after the ope- ration is, generally speaking, very little, and will stop by exposing the parts to the air, or syringing out the orbit with a little cold water ; it may, however, be necessary to use some pressure, which is done by filling up the orbit with lint, then closing the lids, and covering them with a compress and bandage. The lint should be removed on the second or third day. If there is no bleeding, lint should not be put at all into the orbit after the operation, but the lids should be closed and covered with a compress and bandage. The patient should be kept in bed for ten days afterwards* on low diet, and the state of the bowels should be particu- larly attended to. Adaptation of an Arttf<;mlEi/e.—Tha.t an artificial eye may be the more like the natural eye, there must be a part of the eye-ball and all the palpebral conjunctiva preserved. If the eye-ball is too large to admit of an artificial eye, part of it must be removed, and the wound allowed to heal perfectly before the artificial eye is adapted ; and if there are any adhesions of the eye-lids they also must be removed. If all the soft parts are removed from the orbit, it is very difficult to adapt an artificial eye. That an artificial eye may have a natural appearance, it should resemble as much as possible the natural eye, in the color of the iris, the size of the pupil, the color of the sclerotic conjunctiva, &c.,— the greatest portion of the sclerotica being superior and exter- nal. It is important that the artificial eye should be a perfect fit, neither pressing upon the stump of the eye-ball, nor so convex as to prevent the lids from closing over it ; it should not press upon any part, but should fit exactly ; its edge OF THE EYE. 497 and increase .hoti^^^trSu"' """*' '^''' produces no hrifation Thf ' "° "' " fof" '"» ojerit; he ^us". tben^r ^L t m'u'^Jh' t «? "•"" edge of the artifleial eye passes overT ° '"" lower lid and slipping as^,,,''!"; 'j' ^efessing the lower edge of the^rtilLle " • Tdoin"! «•*.■,"""''• "^ must be cautious not to let ilfall' „„" „ r^„""' ""' P^"""" broljen . he should re.ove'^l'alra l^ ^ 71^;" ^^ re-place it in the morning havinrr ." ^ ° ^,y^'^>' "'««* and .he artifleial eye and i^lmlZft^'Ztl^''', use of an artificial eye is to improve the m^!I;.. ' "'"' if! if' I' I- oa CHAPTER XXII. VAEIOUS STATES OF THE EYE INDEPENDENT OF INFLAM- MATION. Arcu3 Senilts.-Uis term is given to an opaque ring of a dark white color which forms a little within the circum- ference of the cornea; it sometimes, however, surrounds only half of the cornea, presenting a semi-lunar shape. It IS in old persons that it appears, and its appearance is as- cribed to a diminished nutritrion, or marasmus, of the part • It IS no impediment to sight, and of very little practical importance; some have considered that when it was very broad it was an objection to extraction of cataract; as It would be difficult to get the wound in the cornea to unite. Dr Ammon stated that he found on dissection a similar and corresponding opacity round the margin of the lens some of the pathologists of the present day consider it a fatty degeneration of the cornea. ^ M^osis.-This is a preternatural contracted state of the pupil, completely independent of inflammation. The aper- ture IS perfectly regular, but is entirely incapable of dilata- tion so that If myosis is complete the patient is almost perfectly blind, but such a state of the iris is generally accompanied with amaurosis. This state of the pupil differs from that habitually contracted state, which is found in persons who are constantly employed examining minute and shining objects which cause the pupil to contract and are consequently short-sighted, but in such cases the pupil will d. ate more or less by the use of belladonna, or by shading he light from the eyes, while in myosis nothing will dilate the pupil. Myosis is either a spasmodic contrac- tion of the circular fibres of the iris, or a paralysed state of the straight fibres, produced in my opinion by some disor- PATHOLOGY OP THE EYE. 499 important ,aruf lhe?caL''.T" "? """'''" ^" lake of Itehl wI,oIerm„ ? > . ' P""™' »''»«1'' P*'- or course .„at iJ .Le^p^rb^-a./eUeS .1"'° " "' -"-' p»^ftr;;u'i;oV'co:rr™"'""V*^« "="» «' «■» strongest ligh It „„" ! "JJ^"" <'^P»»1 '» the the circular. It ll^, ' ""' '"' » 1'"'J'»>'1 stale of "tale of the bra or! thlt^ V^"'"'"" "^ »"« 'i'^ased tract; I have tried ft tat'cS r* f„ ':jr "T I ^ve_ found good etTects f.„„ ,he Le of ^a't -itud S 3:iJ;rt«„r:r.re;n;ri -srh? "" °° "° case the „„d„,atio„ of the h„»o„rror fe" ^ sl2 ' ho ca e, ,t IS quite evident that the tremulous slaler.L ■ri. .3 dependent upon some dif^anized state of ll,/h n.o«rs; indeed it is ftc„ientl, ,„'„d a oCifj '„' .j'"" W n „p v,,reons humour, and absorption of Ik le„T u sometimes follows an operation for cataract, nli 1,,' 500 PATHOLOGY ^^^:^: r •% -I ■>"••■■- that by division; it is generally, however the ro.uU .r some injury of the eye. Ver, little^enefi his been dTri^^^^^^ from any treatment either local or general I Ifl-.K gentleman however, who had reX^a L bwl t e e^e' which produced tremulous iris and mv^rinl , 7 actual de.,e„c, of a pJlrS:: 'alrratr^^ the pupil doTO to the ciliary edge of tiie 1,17- thit.n ° sriv-! " "^T"^' *""»'"» '-e »" cem „■' t': pupil, and its apex the ciliary edge oi' the iri, t1 u malformation the term ««!» S , '■^ ™„. ..\° ™' « found combtaed with an opacity of the cfpsnl' nh IcnT w th a corresponding fl,,„re in the choroid and ret „a and mth a similar defect in the npper lip and naZ T,! ' malformation haa been fonid to exist tj^ ™° alt^ugh generally speaking it ,;T„V "in'te ZZ' Irtderima or congenital absence of fh^ iJ u . . found. In iJl^,^ ^S'^^rCrMsT nr s/„!h "i"'* ™« accompanied with partial ptosis «l tde ins, in both father and son, shewing that the m«lf™ m.fon was hereditary. Other malformftion, have f '' km,wn, where only a small ring ofiris exisM ronnd th" absent and the corresponding portlfoftb.. V" ™ een.rae.ed and dijd ^yl:^:!^,;;^^:!^. OF THE EYE. 501 believed I,er„:wti^^^^^^^^ appearance was strg? chL. IT' '" '"r''''''- '■'■« part of ,he co,„ea af^ i / * ^':*7 " f 'J- "PP- account of a malformation, of the iriri tl f ff T"« ■n Qnart..,, Kovicw .f Mefa,' Seili^ n'o" ° "t" .ution, who had b \r: withf h°a ;/™'!;'°"' ™"'"- affected wit,, ,,ph„i, Thl tlowtg" fat^enf 1'" ,"" made:— «AcaspmmiiQr*«4K- • ^ siatement is also in the pracUcr ? trbi:' mSr'^^" "^"^^ fact, of the case rela edZ D % f , t- f ^'""''''- ^''^ taken and treated osvdWI^; • v '^'.^' ''""'"^ ''^^'^ '»•«- the surface and b^r of hi'" •''.''" '^"P'' ^^"^'^^ <>" proof of the necesSth/nr? ''t'' itself a sufficient ted with an thrr :r^:s:tt:"^ "^^^-^-•«- evefcr:Lt^7olS'-1^^^ tion is given hyZZT .^^' ^«"o^ing classifica- o given Dy Mr. Mackenzie :—« 1st Tr„i- hormnu, in the cellular substance of the orbit "H Cyaticerca celluhaa, in the cellnlnr Ik? ^"'"l— 2nd, lids, under the conjunctiva and ,"nTh !''"'' '^ ^^' «^«- "3rd M7 • 7. '*""'" ^iie anterior chamber-— 3rd i^tW ^.^^W., under the conjunctiva •-' h Fdarm ocuU humani in the crystalline •-« 5 b /)• /' oauh humani in the crvstalline " ' ' "^'^ recltnde'CrSitr^^^^ »f«>e eK.iti, no irritation • bnl If . T m T '" '""« »* " V">i<^t n ■fii li' I 81 J CHAPTER XXIII. VARIOUS STATES OP THE EYE WHICH MAY OR MAY NOT BE THE RESULT OP INFLAMMATION. Irregular Pefract^cm.~^Nh^n there h irregular refraction from any cause, objects may appear double, triple, or raul- tiphed to various numbers. It may be caused by an irreff- ulanty of either the cornea, crystalline, aq'eoTor vitreous humours, and any of these states of the eye may or may not be the result of inflammation. The treatment 8 to remove the cause if practicable. The . bject of refraction is fully explained in Chapter IV Jns^flif of the Eye to certain color s.-'il,,r^ are many individuals who having perfect sight in every other respect, cannot discover certain colors such as red, green &c. 1 am acquainted with one gentleman who cannot d scover the difference between red and green, except tha he says one is a darker color than the othe , indeed he cannot understand what is meant by green.-Th " sfate of vision n the healthy eye is always 'congenital, but he unhealthy eye is a symptom of amaurosis. There have inTn ^M-7 I "'' propounded, as to the cause of this .nsensibihty to certain colors, but all appear to me to be ifnere theories. Crupsia, or cohred Fm^.-This is a symptom often complained of by persons partly amaurotic' ifrselg luminous appearances of various colors floating before the eyes or settling upon any object the patient looks at. sltoftery"^.*'? " ^""^"^ ^°"^« ^'^-'^^-d state ot the retina. (See Amaurosis). PUtopsia, cr 8hinmg Spectra.~Whm a person com- P auis of flashes of light, luminous circles, baHs of fire" glittering stars, appearing before the eyes whether they PATHOLOGY OP THE EYE. gQS brain or^.taa. ^SeTm,". "'""'""' "»'" "^ '"= -afM5c« VoUtantes.—ty this tprm fi m. . 1,1 , floating before the eyes- is 'Tn .1^ '''^^ ''^''' amaurosis, but unless it i, 1' ^ .^^ ^ '^'"P*''" ^^ beSott'rft ^i'^'-'^—I" 'his dUease .he sight as large doses as the patient can beir Tho , . tr.t.ent is brushing th^ .yAZ^Zj^ Z 1^ he e.ght gram solution of veratria. Generall/ p akin' the surgeon has to take the patient's own word for hS complaint at least so long as he has only nigrblinte fr unless he case is very bad, and of long strand gS IS no morbid appearance in the eye. Some sav thP nnln • contracted, others .hat it is dilated,- I have Z d i ttll! in one case contracted, in another dilated, and in 1 thtd su 2."^?' 'r^""" ^^« ^'-«- comes n qui e suddenly, but generally speaking it is gradual in its nro! gress, s,ght being only slightly in^paired in the early staT but getting worse as the disease advances ; at S eS become indistinct at sunset, and the sight become gradl 504 PATHOLOGY ally more impaired as night advances, until at length it is Ota ly gone but again improves at tile approach of d ! Some persons afflicted with this disease, will observe weak even by daylight, and strong light will produce oain and temporary blindnpy Abrasion,.. 807 •vm... Anntorny of, ", Com,.!,;,^"""^"' 486 t'rupsia, JX„ CrystallinolIuniJur; bcnVriptJ^n of, 28 niysioloffv of,. 78 And ifn CapHulo, In- n . 11- flftinmotion of,. 849 Crvstal hne Lens oiid Capsule n,^., Wslocation of, 242 Dacbyocvstitib. Acute .135 CiittONio 187 Acetate ok lead nECOMMENDKD AS A LOCAL APPLICATION FOR THE CURB or jgg tion of, .777."."""" 2Bq 'n„^ w^i"""'^ treatment of,.. . .'. m OonorrL^al in.- ^'^^SifiS™" «ol Diplopia,....;; ,^l Distichiasis, '"3 Double vision,... ,«» 4iijM »»>« organ'of v(d^: ^i SuDnhed w tl. v„„=„i„ I f^P'P"orft, ,„ Supplied with Vessel.,, Onmn. 4"!' ^^ Absorbent*., 21 Cornea, turned up by Inferior I'umed down by Supe- rior Muscle,. ....... 36 Rys of Light traiismiV- ted by It Y6i A Transparent Mediim' 76 Injuries of, 234 Paietrating Wounds "of, 236 Effusion of Blood into its 'ayers 245 Jtttflammation of, .' ." .' ,' .' [ sOfl Abscess o^ ^^2 , Efy'.ipelatous' OphVhalnua,'. '.'." lit Exostosis of the brbit.. a! *;yc, Composition of the, .7.' ' " " 19 JlVK-BALL, NOT RkTHACTED INTO THE OaBIT, 86 Not Pu.iiiED INTO the Orbit bv the Orbicu- 1.ABI8 Palpebrarum, AS SUPPOSED 4 J Oscillation of,.. 7. iga Injuries of, 284 Non-malignant Tumo'ure of.- 48Y Scirrhus " 4gg Fuii-us Hsematodeso^' 490 IJTOU. 28 78 509 Eyeball, Mo.lullary 8t\rc, Mi'liiMosis of,, . Kxtirpati.iii (If. '■'*■■ ;,",; PA.iie "ma of, 4U0 4\)i Ji'jiiriuHaiidDiBooHed ' Eyo-ia8hoH,D;;,:ri;,ii;.nof,:;;;; ^°» _ I'llVMiuloi'V of do Contusions of,,. Kyu-lidf., Trichiasis of ^^?; «imiM n„,l .Scul'.'ls of.,'" Lucoratud inflam- 169 lU'j 170 170 ^^j;jtropio„,or[„v,r„i„„ HymbIc.p|,ar"„'n"of;;"" A«cl,y|„W,,,,|.uron of;." I I'tlun, or Crab-lico of OaANiri.ATIo.V OK ' 171 173 Incise, I „,|,i Wounds of,. , Phlegmonous niation of, Erysipelatous" infiam. mationof, j^. Oarbunclo, or Antiirai Syphilitic' "uja^ati^n ''^ "'» Hcirrhus and Cancer o»- inflammation of the Mges of, Porrigo Larvaiisof','! Meibomian Glands, Dis case of, Ilordcoluni of, .' .' .* ' Piilyctenula of,.!"" Mill' 177 179 180 18 184 I 184 218 21A 221 222 223 877 '^CETATK "V UkLA.VAT.o.v nw THE H'E Agkncy or tub F.rr„ NauvK, Analomy of'"'"*' Neuralgia of ''''^'*''''"'^y "<■-•■ 46 FiHtula Lach;ymaliH;; '. [ [ '.'mLu^ Modes of Opor- ?,'"«'"'•. 143 tnnes „f the T™ '" 148 interesting Case "^' 160 87 16 224 106 490 F'-.jnj;.iie8oA-ii;;-6;;jj„^ .'« pto«i/of,. . :•:.•;:: " " • ^^ Hu™ours of the i;y;;Re"f;ac"t;ry ^^* Epicanthus of,.. " Z ITv 7',"5 "^ .........,._. „••.. 202 I Hyaloid Membrar.e, Anatomy %e-,ias,K™S^^''--M?^ F^r^%^;Anat^yo; A 377 OuttaSere^™'°'^'=^'''---.^78 HEMAnALOPIA, . . 460 llemiopia,.. "04 I^(>P''*'»lnio8, 01 Short- ening of. 66 202 Ectropium.orErersion Operation of' Catopias- ^°* ^J^"' 2101 Hydrophthid mm Physiology- inflamma- tion of, . . . 29 78 368 488 610 INDEX. Hydrops Sacci Lachrymalk of'^''^ r . %popium, . ' 94 |f"-fi:ementof,. i Paqb Invk: Dr. MocDoMeil's Theory of,. S84j 310, ■'"IS, Anatomy of," fhysiology of," .■.";; Muscularity of Provej;:- • Wes_I.ervesfro„,'t,;e soram OF it;""m;>;;o; ^■ND Sensation due to the Sensible to Light, Im- pendent OF the Eetina, . . 50 I J „;. -;,• ■""=' "> ifeer A WE..IO.V TO THE ''i2X^±-^e, '*'^ A^°*^"'es'i"t"s" Coi'oa E'luysted Tu' Ex^rpationof. 133 s, Ihysiology ' Ko Anatomy ^f;^''"^' ^^^^^i^S, Diseases of 9 I'ljuriesof,. 134 Disease of, ^ ' ^ecretjng. Lachrymal Pai^sases Cnl.: v ' ; ^^2 W IfngoSlJf.ts ''"g'^neou.v . 1 . I32 ^'■ipis Divinus crf"i;:; 202 'alDehr» .«?'■„•;• •.•••• 164 NS, 8 500 2,') 77 25 50 1 50 theNeeve,...: '■**'*' ftoiapsusof,.".";;;;;;;;;; JJ Desmarres Me- ' thod of Reduc- IPJiiriea of,.!"^': 240 Tremulous, "'^^ Afaiformations^f,::::: 2 Coloboma of, ""^ j^^.^ Congenital AbVe„;,;"o",;".";: sS Acut^,.. ■;;;;•" 82i Chronic, ^•'l „ Syphilitic.":::;;; .??? ■n-ERATlTIS, "41 Korestenoma •''09 ^oHavMAL ci^ctlJs". : : f 1^ WiptTo^ocP"'""^ '!! Xte-i"?yof.':::;;;;-- ^s PROCESSES, ^"'"^^ OpticiilDeseripliVn' •/•••• Caps,aeof,Ph^4^j;---- 29 60 65 78 Dislocation' o7Z.''' 241 ^^- and Capsui;: 'i;^— ,,„„ ^^cularG^i;^-X„— ^ of, See Phvsiolnr^^^^'^"^ Nerve nnfT^.T'"^ ^^ Fifth 242 849 18 Js j^:^ ^'^'■v'epage 45, NiTEio Acid ^'=°*'?ular Ganglic Jon Receives x-^™. "crE>r "3 Lsx^- «^- Tumours i„7. "" "^""^^^^'^ I-evatorP;; •;,;,• 'i: Obstnicti.; ^^° tomyot!'r?-^-le.Ana- 45 Obstruction of, Congemtal I-chr,nul Fistula,1^':re? .*:':•: ,^^2 ^-"^yrnal Gland, Anatomy ^f/ Phvsiologyoir" iniia" of, 40 lammation 152 1 Piiysiology Paralysis" Light "^' 199 ^"PPus,. . 63 I-o'ig-sighte'dnJss,".: ^^^ I^;-n,^oo«,i„gof m"k;-:; ,«« Caseof,. ^^4 ' 165 131 147 3 52 125, Chronic En- ii-gementof,. joo "i^ysted Tu- '""'■sin,.... jog stirpafionof, 133 ■1 "ysiology "i,; ; • • 62 Jixcreting, 9 134 •y 168 accreting. 122 Calculi of, 133 '«'«of.-.. 160 "^'onof,.. 151 ^o^^.--.. 132 202 ;••. 164 ™''s,.... 199 28 78 ■ 29 SELS AND CiLiAay ...... 29 o*;-... 60 )nverg- *• 65 yof,.. 18 241 242 nation 849 itomy .... 18 es a 'fve, 45 ...393 ina- ... 4 •■ 40 3 .. 199 .. 63 .. 180 . 69 .. 252 . 164 . 165 Maxileaiit Sin INDEX. Page I 511 T^:^y^':'^:,:]^^^^cH us, Tumours of icn I xt 1 ^ -n I Nerves of the Eye"anH"ni,V ^^^ Anatomy of, ^ ' °''*"*' Melanosis of theirs "''•••- ^«* (^SSa&fth-^- ' ' ' ' ' ^2 Membrana Jacobi^.! *„^4 ^ight-BIindnei ^^ ^^'^''- • 4^8 Meinbrana Kuscliiani ^^ Nystagnius' 608 ''^Z^^'^:^^:^n^o. ^7--^M;-ycV;anatVmy;/,: '^l Physiology' of, JJisease ot;.. 8 62 riiys Inflai Physiology'of, Hammation 62 248 185 Physiology of, iNFEBlOE, ACTS l^ONSENTANEOusiy WITH THE Oebiot- Potassi^-^-'^""^o^i^e-;f-^l ^..''Z... £-fS^tfe-"'""---: " o '^«- Monoblepsis "•'"°'*'^''' 231 (Edema Snh "^^'^^o^Kun Motionstf tL'p;; 168 """' ^"^,-*°?J"nc«val .' 228 MotoresaS:>A-„;„-^3| ,«| I Ophtha.^I^^^^^-^^^ S 35 86 87 Physiology Gives a twig uct,iS;^,rf'::.'.- ?; Tarsi, .'.".■.'■■■ Cataniai, lent^*'""' ""^ ^"^■• Mi-.Guthi^i^'V'i^'.eV ment of,. s^ sr "'>%.- Gonorrd.....*^^^;^ Purulent of Infante, 280 Dr. Jacob's Treatment of, ooa , , Mr.Hamii: ^ ton 8 Treatment of, 297 . Vebatria AsaLocalAppli- . _ Creasoto AsaLocalApDli. '^"""i'lV-.T. 800 TVo.* ^.^smarre's Ireatmentof, sqj Treatment of, gog loduio as a Local Application,. 803 _, ^ Morand's ireatmentof, ggg 512 INDKZ. Ophthalmic of,.. . Ophthalmic Ophthalmia Pustular, 804 Variolosa, soe Erysipelatosa, 308 Compound, 3741 Traumatica 374 Artificial, 374 Intermittent, 874 Sympathetic, 376 Artery, Anatomy •i, 11 iSBANCH OF THE Fifth Neeve, Physioloot of 45 A Nutritive Nerve, 46 Absorbent Nerve of tlie Eye, 46 The Protector Nerve of the Eye Sensitive to the Stimulus of Light, Ophthalmic Nerve, Anatomy of, Physiology of, Ophthalmic Ointment of Jannin jt„„ Ophthalmitis, _' 862 Optics '/_'' go Optic Nerve, Anatomy of, .... . 13 Physiology of,.... 44 Obbicularis Palpebeaeum Mus- cle, Anatomy of, q 41 48 15 45 139 Physiology of, 40 Orbit, Periostosis of. ^^^ Turpentine in, 93 Hyperostosis of, ./ 94 Exostosis of, ' ^5 Osteo Sarcoma of,. .'.."" 90 Deformity of, from Exter- nal Pressure -^qq Tumours in, 108 Orbit, Aneurism from Anastomti.' s'sm jjj Traver's Treat- ment of, 112 Dalrymple's do., 112 Orbital Cellular SemtL,£:"' ^^^'•f. ••• 118 Infiltration of,. 116 . Scirrhusof, 117 Oscillation of the Eyeball, 166 Ossific Deposits in different parts n^^^heE^c ^... 480 Osteo-sarcoma aa PalpebrjB, Anatomy of, . ! ." ' ' " « Periosteum, Physiology of... " 31 Periostitis of the Orbit... «, Periostosis, "' Phlegmon Sub-conjuncVival', .' ." ! 228 s;^lt. ::::::::: iS '''^•''™'^" ophth^ii^i^ Does not keep the Eye feom pkotenmno, assup- _ POSED 4J Orbk, Anatomy of, j Physiology of, ." 80 Bones of, j Foramina of, 2 Contents of, 8 Anatomy of Vessels and Nerves of, n Injuries of, " 79 Contusion of its Edges,. . 79 Fractures of its Edge 80 PuNCTUKiNo Integuments 290 Mr. Hamilton's Treatment of,.. 297 Vebatsia As a Local Application in, 298 Creasote 300 Desmarre's IVeatment of, . 301 Dr. Hocken's ^ ,.«lo.. 803 lodme as a Local Application, 303 Morand's Treat- _, ment of, soi Photopsia, ' Zo TO GIVE EXIT TO Aia NOT I Phthinasis ""'■' wrnrofi^Edg;;.;- e^^p'^rtu.i'Nig^i/Physioiog^ ''' ^r^r*fe-v--:;- «2|pi~ia,-:::;:;::;:::::;:: ,ii Polypus of the Nose, iqO C?mB OF BY Pbessueb and AcETAs Plumbi,... 101 Of the Maxillaiy Sinus, 101 Of Lachrymal Sac, 162 Of the Conjunctiva, 231 General Prognosis of Wounds, g2 Fractures and Injuries of its Walls, 86 Disease of, ....... 86 , Secondary Caries of, .... 88 ... 94 . . . . 06 ... 98 cter- . ... iOO . ... 108 mo- ... Ill 3at- ... 112 do., 112 do.. 112 )is- .. 113 f,. 116 .. 117 .. 166 rta .. 480 . . 98 .. 6 .. 31 ,. 81 . 92 . 228 . 186 . 290 WD£X. Paok 183 27 Sclerotitis, ssx£^^^^-^ - '°' Mr.Hamilton-sTreat- Dr. MiicDoiinelVs Treat- Scotoma...."''^'""'' 816 Ptosis,.. . ^^'J^I^^hiynialia.Ob^truiti!.!; ^^' ^'^^^'^d'banais.-iieWi-- ^'' Punctii^'Au^;^;^ ;•;••• •• ■ gV ^^f Pupil, Anatomy of...... ' CoNTaACTs FEo'si P^n" ■ ■ ■ Action OP BEtLADoW ON Action OK NiTEATE OF SiL-' VEEON, Changks wmoH n UNDEa- ooEs TO Adapp the Eye TO Nkae and REMon Ob. «CT8, Obliteration .^, Artificial,..,.:.., ;;;•• So 75 25 49 60 49 71 ways Advisable, when tliero , ,„ ^w« w one Sound Eye 405 «, „ .^"dJ'« Theory rf do Pustular Ophthalniia . . . gnf ^'^"P' ^''^'«°» "^ the Eye dm^: Recti Muscles. Anatomy of "4 "'^'' U .^ '" ^^''^■""s Closed Dramo bLEBP BY Relaxation of Physiology of,., New Views Con 4 33 C^aWNO THEIa USE ™patl,etic Nerve,' De.^riptiou 184 nil 62 221 41 8H INDEX. Ojnchosis, ^^°^ Sjnecli;-. Anterior, .■.■.■;;; ;;" " Iq? a !.■,• -Posterior, .' * " 40, Syphiiit.c Iritis, o?? ^^^ C^'^rxLAO^, Anatomy j Tears of BlVod, .■.■'.*.' l^ Tendo Oculi Muscle, Aiiitomy Tensor Twsi "Muscie," Anatomy Tunica VagimUs Oculi, Anat/^'"' my of, 4 Pnysio- Ip^of, 81 I Inflam- snation of, uv Mr. Ferrall TurpontineMixtureofCaridchffil, "3 IMosis,- "^ UvBA, Description of, ;.■;. 26 Gives Colob to the Ibm, 177 Tetanus Oculi,. of,. Eye, Tic DodoilrTili;;. l^llYr''^'^'^'''^^(^'.y. '.'.'.'. '.'.]'. ' '" ^os ^ea Palpebrarum, . ." f «„ ^^^kathia, Solution of, .' ' j oi Tnchiflsia ' 1 80 V isiON, Chanoes wmm. ™« v^l ^* Trichiasis, „ Trigemini or Fifth WeVAiikt<;^ my of, 15 Physio- Trochleator, or Fourthfc^' ^' Aiiatomy of 151 n.,^i?~.* — ' "^oo ', Chanqks whioh thk Era LTndkbgobs to Adapt Itsblt toRemotbandneabObjbois, Is Todd's The 812 1 " " ■**' jj^^j^^^ ^^Eye-ball, 48T Tunica cQS^Anato^iyof. *22 PVswlogy ?t.--. '74 IniBneso^.. 848 Tunica Sclerotica, Anatoiliy of. I-IST OF SUBSCRIBERS. 1 1 1 1 1 1 Abbott, Dr. Adamson, Rev. W.'a.' d' r t I Cranby, .. ^"ard, J. R. [^'"- 0. L., Montreal Anderson, John, M. R.'o a V ^^IcEil, " ' " Arcliambault, Dr.. • ^- ^ Lachin'e, Ainoldi, F. C. T.,M.d:;; ?t- HyacintJift. ■ „ . , Montreal Baagley, Francis. M. D Barber, Dr. J. p.,. . . '' Montreal,. . ^ardy, Dr. Louis a, Clarenceville." " i , Betiune, Rev. John D. D L^'l^'e ? ^ethune, John G., M. D "' Montreal,. } aianchet; Jean,M,R.c's'T Berthier, J Boucher, a De la Bn^ere Quebec,'.. i } BosseUe, John ' «*• Hy^inthe * Boutliillier and Turci)!,'..' P*- Sosalio,.. .' } Brookes, Samuel S.,.. . St. Hyacinthe, .' J Brousseau, J. a, . . ! Sherbrooke } Brown, Charles, M. D Beloeil,.. * Brown, L., M. D.. ' Dunham * Brouse, A. M., M' D.' ' Cowansv'iUe" ? «ngham, J. a, M. D Prescotf,.. ^ Butler.J. C.,M.D.,.'.'; PWlipsbuw"'. } p., „ Punl^m,!^'. ' 1 Calder. B. E., M D.,.. t^ameron, Hon.]kL., •• I-achine. Carr.Dr. .T*. Toronto,. . Z* " JJamer, Joseph. M. D ' '^^t Regiment I ^ Challmor, Fras., M. D.;." ,' .' ." I St, Catherin^;, C." W ' Chamberlain, Dr.,. Kingeey, " coMigny,A.p.i,,;;;;; pj-eiighsbui^ft..' Cotton, O.E..M.I).,. St. Cesaire.. Orevier,Dr.J. A Bronze,.. Cummins. John S..... .';;;; St. Hyacfuthe;.' .' ^ n . . . _ Sherbrooke, ' ^ David,A.H.,M.D. 1 Davignon, Dr, M. P. p JJ Amour, Dr. R.H ' Dease, P. W.,M.d' I 1 1 I I I Montreal,..., (Longueuil,,... St. Pie,. De Lisle, B. D, M. D.,.. . ^^^P^hurg,.,. .. } Derbishire,S HeniyvUlef. } DeMaules,L,A,..., Toronto.-., } Dick-nson. E. M:, DentisL; .' gt Hyacmthe, ::;:•••• ' V . (Montreal... '•■*' ^ ■•iamondson. R, M. D „ ., '' BrockviUe,. Fenwick, George E, M. D. IMontreal,,. 516 LIST OF 8€BSCniBER8. Forbes, "WiUiam, M. D JPoster, a, M. D.,. "' Fraser, Wm., M. D French, J., M. D., I, Q. of H;^pi't^;,; ; ; ; • ; S^ep;,'"DrTl'.^'^=-«»-<'y^<'- Gibb, George IX, ivi. i)., " ' " " Gilmor, W.A.R., M.D.,..."! Oodfrey, Robert, M. D.,. Going, Frederick, M. D triffin, F. Guerrin, Dr. Thomas.' .* ." Hall, Archibald, M. D Hall, Dr Hebert, L. G.,....'^.'.'' Hensly, Joseph, ..'.'.' Hingston, Wm-H.,..!' Howard, K P., M. D. St. Bridget,.... Lncole Frost Village^; Do. Montreal,. . Do. ....■ Toronto, . . Laprairie, Montreal, Three Rivers, ...'. Montreal St. Tliomas, C. W., Montr- .u Si. Laurent Jamieson, B. R., Janson, J-, M. D Jolinson, Dr. Thomas,.." Jones, Thomas Walter, M. D.,' Kimber, Dr. T., Montreal St. Thomas, C. W...... Kenryvillc St Athana.se, Montreal, .' Montreal Laflin, Dr. U LaFontaine, Dr. J. D. LaFontaine, ! Laframboise, M,,.. [ .' .' LaRocque, Dr. B.,. " Low, G. W., M. D St. Cesaire Farnluun River St Claire,. Montreal CImmbly, . Clarenceville,. St Edward Chambly St Hyacinthe, L'Acadie, Darlington, C. W.,'. Macdonnell, R. L, M. D. „ , , Macdonell, A.C.,... Montreal, Mair, David,.. , ' Do. Marsden, William," M.D BrockviUe, MacCallum, D., M. D. .. !' ' *»"'^"C'=, McDuir, Timothy, M D Montreal McQueen, Dr.,. ... V'dlage dea Pies. Minkler, E., M. D Brockville, Montagu, John P.' M Granby, Moreau, Dr. P. M.,...'.,. Morrin, Joseph, M. D Moorhead, R. 8. T Mount, Henry, M. R."c.'s." L.,' Nelson, Wolfred. M. D Newell, O., M. D. '.'.■ London,, St Johns, C. K, . . . . . . . Quebec, '/ ' St. Gregoire de Monnojr Montreal Montreal, . Dunham,.. ■"%» No. 0* Copna. LIST OP SDBSCRIBER3. BE8IDENCE St. Hyacinthe, NAME. O'leary. Dr. J., Surgeon,. Poulin Joseph W., M. D Patnck, WilTiaM,..: . . . H St. Mario de Monnoir Peltier, Rev. Mr. .. . Montreal, . "•"""""' • Peltier Hector, M. D., St. Bridget,, Perrault,T. v., ....:';;; MontreS, . . . . R„ . ,. St Valentino,, «°HA.,d;.,... Toronto,...^ ■Liongueuil,. St. Oesaire,. 517 No. OF Rollet, Dr. J. p.,'. Ss;'fc'"»'''«H".««4.'.... M.,„„, Scott, W.E.,M.D.,.::: Kingston I'^^d.Dr. :..; Montreal, omith Hermanns, M. D ^'^er des Prairie's f "ytho Dr. ',,["■ Hamilton, ™^' |'"?rtDr.W. Brockville,. Sutherland, Wm., M. D NapierviUe, „ . . Montreal,... Tetreault, Dr. T. A. T-emey George Boston,: ! ! St. Pie Thyfault , Jos. W. '. ; End of God Sp^ed, vV, _ , . Nap erville '^ ' ' Va^?is.M.R.M.D.,.. ' Vahquet, Dr. Pointe Claire Verity, Fred. S., ; ." Famham,. . . . WI-, , Hemmingford. W utcomb, J. G.. M. D Wight, R. H., M. D ' I Granby, Wolf, James T.,...".',] I St. Johns! C E Workman, Benjamin,.. Quebec, ' Wnght, Wm., itf. D. Montreal,. "' „, Do. '. ■■• *ates, H.,M. D Kingston, N*