:a^> 
 
 '^M.*l¥l 
 
 ; ''•■^^^■:^i3?
 
 / 
 
 a 
 
 %-■.. 
 
 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 ^ 
 
 :^ 
 
 -*^ 
 
 ^■• 
 
 C.:-^^i5r^
 
 
 *f :'v/^^; 
 
 ■'*,
 
 
 r,,. C.^^- 
 
 ^^
 
 A 
 
 SYNOPSIS 
 
 OF THE 
 
 DISEASES OF THE EYE, 
 
 AND THEIR TREATMENT, 
 
 KXC.
 
 G. Woodfall, Printer, Angel Court, Skinner Street, Loudon.
 
 SYNOPSIS 
 
 or THE 
 
 DISEASES OF THE EYE, 
 
 AND THEIR TREATMENT: 
 
 TO WHICH ARE PREFIXED 
 
 A SHORT ANATOMICAL DESCRIPTION 
 
 AND 
 
 A SKETCH OF THE PHYSIOLOGY 
 OF THAT ORGAN. 
 
 BY BENJAMIN TRAVERS, F.R.S. 
 
 SURGEON TO ST. THOMAs's HOSPITAI,. 
 
 THIRD EDITION. 
 
 LONDON: 
 
 A. SiJiRi:,<i-i^ 
 
 PRINTED FOR LONGMAN, HURST, REES, ORME, BROWN, 
 AND GREEN, PATERNOSTER ROW. 
 
 1824.
 
 TO 
 
 JOHN RICHARD FARRE, M.D. 
 
 THE AUTHOR 
 
 DEDICATES 
 
 THIS VOLUME, 
 
 AS A 
 
 MEMORIAL 
 
 OP 
 
 ESTEEM FOR HIS CHARACTER, 
 ADMIRATION OF HIS TALENTS, 
 
 AND 
 
 GRATITUDE FOR HIS FRIENDSHIP.
 
 PREFACE. 
 
 The Volume which I now present to the 
 Public, is the result of a more ample op- 
 portunity of observing the diseases of the 
 important organ of which it treats, than 
 commonly falls to the lot of Hospital Sur- 
 geons. This opportunit}-, originally de- 
 rived from my situation during a period 
 of seven years, as surgeon to the London 
 Infirmary for Diseases of the Eye, has 
 been considerably augmented by private 
 practice in the same branch of the Profes- 
 sion, contingent to that appointment. 
 
 I have always thought that the ad- 
 vantages obtained by the subdivision of 
 professional talent and labor, are infinitely 
 overbalanced by those which arise from 
 the general and undivided application of 
 these instruments of knowledge. No fact
 
 VUl PREFACE. 
 
 more strikingly illustrates the truth of the 
 doctrine, that the confinement of any 
 branch of the Profession to the hands of 
 a few, operates prejudicially to science, 
 than the state of information in this 
 Country, concerning the Diseases of the 
 Eye. Mr. Samuel Cooper has spoken so 
 precisely, as I think, upon this subject, 
 that I cannot do better than quote his 
 words. 
 
 " The disorders of the eye and its appen- 
 dages are far more numerous and diversi- 
 fied than those of any other individual part 
 of the body, and some of the requisite ope- 
 rations for their relief ought to be done 
 with the nicest combination of skill and 
 delicacy. These circumstances, strangely 
 enough, have had the effect of inducing an 
 erroneous supposition, that such cases do 
 not properly enter into the department of 
 ordinary surgery ; but ought to be con- 
 signed to the care of a man, who makes 
 them exclusively the object of his atten- 
 tion, and disregards disease in every other 
 form. The morbid affections of the eye, 
 it is true, like all other surgical cases, 
 must be studied, in order to be understood.
 
 PRE FACE. IX 
 
 They have no peculiarity, however, except 
 what depends upon their number, and the 
 tenderness and functions of the organ af- 
 fected. In their nature they are swayed by 
 the same laws which influence all common 
 diseases, for which the practice of surgery 
 is instituted ; and their treatment is regu- 
 lated by general principles, which prevail 
 throughout the whole of this indispensable 
 art. 
 
 No one, except the thorough surgeon, 
 can make the complete oculist ; by which 
 last term is not meant any body who can 
 merely manage to extract the cataract bet- 
 ter than the generality of surgeons, but a 
 man whose science leads him to recoo^nise 
 the analogy betwixt the diseases of the 
 e3^e and those of other parts, and whose 
 knowledge of the latter, while it qualifies 
 him in a great measure for the treatment 
 of the former, gives him a decided supe- 
 riority over the bare oculist/' 
 
 " On a cru faussement (says the intelli- 
 gent M. Louis, in adverting to the diseases 
 of the eye), que le s^avoir necessaire pour 
 discerner le caractere de qes diverses af-
 
 PREFACE. 
 
 fections contre-naturc, ct pour v remedier, 
 faisoit en quelque sorte un art particulier. 
 Mais quels fruits pourroit porter cette 
 branche, etant separee du tronc ? II est 
 bien prouve, par les faits, que les progr^s 
 de cette partie de la chirurgie ne sont diis 
 qu'aux grands Maitres qui ont pratique 
 Tart dans toute sa plenitude, et dont Tex- 
 perience, relative aux maladies des yeux, 
 a ete eclairee par les,lunii6res que leur 
 avoient donnees les principes qui consti- 
 tuent indivisiblement la science, sans la- 
 quelle on ne pent exercer aucune partie 
 avec connoissance de cause/' — First Lines 
 of the Practice of Surgery, Vol. I. p. 433, 
 4th edit. 
 
 In this country, I believe no one before 
 myself, who designed to practise general 
 surgery, ventured to give more than a cur- 
 sory attention to the diseases of the eye. 
 A fear of being disqualified in public opi- 
 nion, by a reputation acquired in these, 
 for the treatment of other diseases, was a 
 motive, however groundless, sufficient to 
 deter surgeons from the cultivation of a 
 large and legitimate field of observation 
 and practice.
 
 PREFACE. XI 
 
 It was with a public avowal of the sen- 
 timents so well expressed by the writers 
 just quoted, that I accepted the situation 
 of Surgeon to the Eye Infirmary, in the 
 year 1810 ; and from these I have never 
 swerved. 
 
 At the commencement of the following- 
 year, the students of surgery were first in- 
 vited to attend the practice of the Infirm- 
 ary ; an opportunit}^ eagerly embraced, 
 and which many hundreds have since en- 
 joyed. 
 
 Among the gentlemen who with ardor 
 and diligence entered upon this new and 
 interesting study, during my connection 
 with the Infirmary, I have the pleasure of 
 including many of the best educated and 
 most rising men in the Profession ; and, if 
 they will permit me to say so, some of my 
 most estimable friends. 
 
 Upon occasion of electing a second sur- 
 geon to that Establishment in 1814, my 
 friend, Mr Lawrence, became my col- 
 league. I consider it to be no ordinary 
 sanction of my views, that they were thus
 
 Xll PREFACE. 
 
 seconded by the co-operation of a gentle- 
 man, so highly distinguished as the present 
 senior surgeon of the Infirmary. 
 
 But whether my example or my services 
 have been in any degree instrumental in 
 promoting so desirable an object as that of 
 recalling to the notice of the profession 
 at large the neglected subject of these dis- 
 eases, is a matter of no public interest, and 
 which I am content to leave to the candor 
 of the Profession. 
 
 In offering these observations, I entreat 
 it may be understood, that it is far from 
 my meaning to insinuate the slightest dero- 
 gation from the merits of some truly re- 
 spectable Members of the Profession, who 
 confine their attention to this class of dis- 
 eases. We take a different view of the 
 subject ; but no man of ingenuous feelings 
 will arrogate to himself that he alone walks 
 in the right path. 
 
 In this country, the want of a compre- 
 hensive treatise on the diseases of the eye 
 has long been felt and acknowledged. The 
 work of Professor Scarpa was the only
 
 PREFACE. Xlll 
 
 book of reference for Enplish students 
 before the publication of Mr. Saunders's 
 Treatise, which from its intrinsic evidence 
 of a strong and original talent for observa- 
 tion, leaves us to regret as a national cala- 
 mity, the premature termination of his la- 
 bors. Mr. Wardi'op's ingenious Essays 
 on the Morbid Anatomy of the Eye, have 
 since contributed to instruct and gratify 
 the Profession. But the object is yet un- 
 accomplished, and I can only flatter myself 
 with having advanced a step or two nearer 
 to its completion. 
 
 In Germany a merited share of attention 
 has long been devoted to the diseases of 
 the eye. The elaborate work of Professor 
 Beer of Vienna, who has devoted a life to 
 the subject, is said by those of our country- 
 men who read the German language, and 
 are competent to appreciate its merit, to 
 evince a familiarity with these diseases — 
 a comprehensiveness of arrangement — -a 
 depth and minuteness of observation — a 
 promptitude and fidelity of diagnosis — ^un- 
 attained in any other department of Patho- 
 logy. Walther of Landshut, Schmidt of 
 Vienna, Himly and Langenbeck of Got-
 
 XIV PREFACE. 
 
 tingen,and others, have distinguished them- 
 selves in the same field of research. 
 
 I ardently hope that the example of 
 German industry may operate as an incen- 
 tive to our exertions, and should it prove 
 so — without meaning to question the extent 
 or value of their researches in ophthalmo- 
 logy — I may be permitted to express my 
 belief, that they can lay us under no deeper 
 obligation. 
 
 Nations, like individuals, are distin- 
 guished by a peculiar character of mind, 
 to whatever causes attributable, evinced in 
 their respective modes of observing, re- 
 flecting and acting ; and the sentiment of 
 Phaedrus is as strictly applicable to the one 
 as to the other : 
 
 Sua cuique quum sit animi cogitatio 
 Colorque privus * 
 
 I should be sorry to see the sober sense 
 of my countrymen perverted by a taste 
 for fastidious distinctions. Simplicity is the 
 characteristic feature of English Surgery, 
 which is neither more nor less than the 
 
 * Prol. Lib. V.
 
 PKEIACE. XV 
 
 application of the principles of inflamma- 
 tion, as illustrated by the genius of John 
 Hunter. 
 
 I cannot but fear that the condensed 
 and compendious plan of this Volume may 
 occasion disappointment to persons ad- 
 vanced in the study of eye diseases. But 
 I must remind them that it makes no pre- 
 tension to the character of an elaborate 
 systematic treatise, and is designed more 
 particularly for the information of surgeons 
 and students of surgery. It is the result of 
 personal observation, not a compilation 
 from the works of others. Neither is it in 
 any degree critical. I have not time enough 
 at my command to be an historian, nor 
 ambition to be a controversialist. Facts, 
 whether new or old, derive a value of au- 
 thenticity from personal observation, which 
 is not enhanced by the custom of collating 
 materials from other sources. Such a cus- 
 tom is likewise inconsistent with another 
 valuable quality, in practical matters espe- 
 cially — I mean conciseness. 
 
 It was at the suggestion of a friend that 
 I prefixed the sketches of anatomy and
 
 XVI PllEl ACE. 
 
 physiology, for the purpose of bringing 
 the entire subject before the reader in the 
 compass of a volume. In these short pieces, 
 I have aimed at a simple and perspicuous 
 exposition of all that appears essential to 
 a right understanding of the principal dis- 
 eases of the organ. For the more subtle 
 anatomical points, or rather questions, 
 which I have purposely avoided, I refer my 
 reader to the Appendix. 
 
 Against an overweening spirit of anato- 
 mical discovery, the pathologist should be 
 jealously upon his guard, if he would ob- 
 serve honestly and reason accurately on the 
 phenomena of disease. Some ingenious 
 disquisitions have occasionally been given 
 to the Public on the morbid affections of 
 textures, of which the existence is problem- 
 atical. I would by no means speak with 
 disrespect of the pursuit of minute ana- 
 tomy, nor presume to question its utility 
 when conducted after the manner of Har- 
 vey and Ruysch; but I must be allowed to 
 remark that such points as are too subtle 
 to admit of demonstration, are not to be 
 cleared by the helps of analogy and con- 
 jecture, and indeed are never satisfactorily
 
 PREFACE. XVU 
 
 proved but by the anatomy of disease, from 
 which they derive their importance. 
 
 The second part of the work, containing 
 the Pathology, was drawn up and intended 
 for pubHcation in the last Volume of the 
 Surgical Essays, published jointly by Sir 
 Astley Cooper and myself. It is unneces- 
 sary to state the reasons of its postpone- 
 ment; a principal motive was the belief that 
 it would be more useful and acceptable to 
 the junior part of the Profession, as it now 
 stands, connected with the remaining con- 
 tents of this volume. I am induced to 
 mention this circumstance, by way of apo- 
 logy, for what might appear to be occa- 
 sional infringements upon the plan of con- 
 sidering the diseases and their treatment 
 distinctly. To a certain extent the blending 
 of these subjects is unavoidable, but the 
 Pathology having been designed for a sepa- 
 rate and distinct Essay without any direct 
 view to the subject of treatment, the latter 
 is introduced more freely in the way of 
 illustration, than it would otherwise have 
 been ; and, consequently, anticipations and 
 repetitions are more frequent. I think, 
 however, that this fault is mainly in the 
 plan. I should not therefore a priori have 
 
 b
 
 XVlll PREFACE. 
 
 adopted it, but I was unwilling to disturb 
 the arrangement of the piece first written, 
 and to some readers it is probable that the 
 division may not be unacceptable. 
 
 Some highly important topics, in the 
 third division of the volume, my experience, 
 as the reader may conclude, would have 
 enabled me to treat much more in detail, 
 than the plan of this work permitted. It 
 is difficult to speak in so small a compass 
 upon subjects like those of cataract and 
 artificial pupil, either of which is sufficient 
 from its extent and importance, to furnish 
 materials for a distinct volume. I have 
 endeavoured, how successfully I know not, 
 to guard against material omissions, in 
 studying to preserve conciseness. 
 
 As I have made little reference to the 
 writings of others, the omission of the sy- 
 nonyma forming the crabbed vocabulary 
 of Ophthalmologists, ancient and modern, 
 will, I hope, need no apology. The nomen- 
 claturing mania appears to me an evil of 
 increasing magnitude. 
 
 New Broad Street, 
 Oct. 28, 1820.
 
 PREFACE 
 
 TO 
 
 THE SECOND EDITION. 
 
 The reception with which this Work has 
 been honored affords me very sincere gra- 
 tification. Although it presents only, as its 
 title imports, a general and cursory view of 
 the subject, if that view is a correct one, 
 it fulfils the intention with which it was 
 published. A work of minute detail and 
 elaborate research, though more agreeable 
 to a few readers, would probably be less 
 useful to the professional community. 
 
 I have scarcely altered the text of the 
 first edition, but have added a few notes at 
 the end of the volume. I am sorry that I 
 have no better apology to offer for the long 
 interval which has elapsed since the sale of 
 the first edition. 
 
 New Broad Street, 
 Sept. \st, 1821.
 
 PREFACE 
 
 THE THIRD EDITION. 
 
 In a careful review of this Treatise in its 
 passage through the press, I have not seen 
 occasion to make any material alteration. 
 The compendious method in which the sub- 
 ject is treated, which forms probably one 
 of its principal recommendations to prac- 
 tical readers, precludes me from adding 
 the details of a more extended observation 
 — a restraint to which I the more readily 
 conform, from the persuasion that they 
 would tend rather to confirm than to cor- 
 rect the pathological views which the work 
 presents ; and would so considerably in- 
 crease the size, as to change the character, 
 and augment the cost, of the volume.
 
 XXll PREFACE. 
 
 I have the pleasure to acknowledge 
 many liberal and handsome testimonies to 
 its value from individuals of great and de- 
 served eminence in the profession ; and 
 the public confirmation of these, I take the 
 liberty to infer from the rapid sale of the 
 work, which has been out of print for many 
 months — but a circumstance which has af- 
 forded me the sincerest gratification, is the 
 appearance, during the last year, of a spi- 
 rited and faithful translation of it into the 
 Italian language by a physician of Pisa, 
 whose name I would gladly announce had 
 his modesty permitted me to do so. 
 
 To Dr. T. I. Todd, of Nice, I beg thus 
 publicly to express my obligations for his 
 spontaneous recommendation of the origi- 
 nal to the notice of so able and intelligent 
 a translator. To the latter gentleman I 
 offer my congratulations upon the public 
 approval of his translation, evinced, as I 
 am informed, by a very ready sale. 
 
 New Broad Street, 
 April 15, 1824^.
 
 CONTENTS. 
 
 PART I. 
 
 Page 
 Anatomical Description of the Eye and its Appendages 1 
 
 Sketch of the Physiology of the Eye and its Append- 
 ages 45 
 
 PART 11. 
 
 CHAPTER I. 
 PATHOLOGY OF THE MEMBRANES. 
 
 Section I. Conjunctiva 87 
 
 II. Cornea 106 
 
 III. Sclerotica 126 
 
 IV. Choroid and Iris 131 
 
 V. Retina 138 
 
 CHAPTER II. 
 PATHOLOGY OF THE HUMORS. 
 
 Section I. Aqueous Humor 199 
 
 II. Vitreous Humor 202 
 
 III. Crystalline Humor 211 
 
 IV. Diseases affecting the Eyeball 219
 
 XXIV CONTENTS. 
 
 CHAPTER III. 
 PATHOLOGY OF THE APPENDAGES. 
 
 Page 
 
 Section I. Orbitar Appendages 229 
 
 II. Facial Appendages 235 
 
 PART III. 
 
 CHAPTER I. 
 TREATMENT OF THE DISEASES OF THE EYE. 
 
 Section I. Simple Inflammation of the Conjunctiva. 252 
 
 II. Inflammation modified by Struma 262 
 
 III. Acute suppurative Inflammation of the 
 
 Conjunctiva 269 
 
 IV. Secondary Diseases of the Conjunctiva... 277 
 
 CHAPTER II. 
 
 Section I. Diseases of the Cornea 283 
 
 II. Sclerotitis^ Choroiditis, and Iritis 294 
 
 III. Amaurosis 299 
 
 IV. Diseases aflfecting the Eyeball 313 
 
 CHAPTER III. 
 
 Section I. On the Operations for the Cataract 318 
 
 II. Of the Operations for artificial Pupil 341
 
 CONTENTS. XXV 
 
 CHAPTER IV. 
 DISEASES OF THE APPENDAGES. 
 
 Page 
 
 Section I. Diseases of the Eyelids 357 
 
 II. Obstruction of the Lacrymal Passages..,. 366 
 
 APPENDIX 389 
 
 EXPLANATION OF THE PLATES 399 
 
 NOTES 435
 
 ANATOMY AND PHYSIOLOGY 
 
 OF 
 
 THE EYE 
 
 AND ITS APPENDAGES.
 
 PART I. 
 
 ANATOMICAL DESCRIPTION 
 
 OF 
 
 THE EYE 
 
 AND ITS APPENDAGES. 
 
 The orbits are two funnel-shaped cavities situ- Orbits. 
 ated under the arch of the forehead, on either 
 side of the root of the nose. The roof of the or- 
 bit is formed by the frontal and sphenoid bones ; 
 the floor is contributed by the superior maxillary 
 and malar bones ; the malar and sphenoid bones 
 make up the temporal side ; the lacrymal, aeth- 
 moid, sphenoid, and palate bones comj)ose the 
 nasal. The nasal sides are plane, and nearly pa- 
 rallel ; the temporal are considerably divergent, 
 so that the axis of the orbit is an oblique line. 
 A line drawn horizontally across the base of the 
 cavity is also oblique ; the nasal being more ad- 
 vanced than the temporal angle. This configu- 
 ration of the orbits prevents us from command- 
 ing the parietes of both cavities in a front view 
 of the cranium, and greatly extends the field of 
 vision. The globe of the eye is considerably
 
 2 ANATOMICAL DESCRIPTION OF THE EYE 
 
 smaller than the receptacle in whicli it is con- 
 tained, to allow of its free motion on all sides. 
 The capaciousness of the orbit provides for the 
 lodgment of the adipose substance upon which 
 the eyeball is cushioned ; the muscles which 
 move and adapt it to vision in all directions ; 
 the vessels which nourish its membranes and 
 secrete its humors ; the nerves which supply 
 these several parts with energy ; and the gland 
 for preparing the lubricating fluid which is es- 
 sential to its economy. These being situated 
 posterior to that membrane which shuts up the 
 cell of the orbit, may be termed, for the conve- 
 nience of description, the orbitar appendages, 
 in contradistinction to those which the organ 
 presents on its facial aspect, viz. the supercilium 
 or eyebrow, palpebrag or eyelids, and the lacry- 
 mal passages ; which parts, together with the 
 tunica conjunctiva, I shall call the facial append- 
 ages of the globe. 
 
 Their holes 
 and depres- 
 sions. 
 
 The foramina and depressions of the orbit, 
 as of all the bony cavities, form a natural intro- 
 duction to the anatomy of the parts therein con- 
 tained. The nasal and superior sides, for exam- 
 ple, are terminated by the optic hole for the in- 
 troduction into the orbit of the optic nerve. The 
 temporal and superior sides are bounded by an ir- 
 regular slit or fissure, denominated foramen lace- 
 rum orbitale superius ; the temporal and inferior 
 are separated by a similar fissure, termed foramen 
 lacerum orbitale inferius vel spheno-maxillare.
 
 AND ITS APPENDAGES. 
 
 The numerous nerves, the optic nerve excepted, 
 and the principal vein of the eye and its append- 
 ages pass through the foramen lacerum. Two 
 minute foramina left in the suture, connecting 
 the frontal and sethmoid bones, by which a direct 
 vascular and nervous communication is main- 
 tained between the nares and the orbit, are 
 termed foramina orbitalia interna, anterius et 
 posterius. A small hole in the orbitar portion 
 of the malar bone establishes a similar commu- 
 nication with the cheek. A depression in the 
 orbitar plate of the os frontis, next its external 
 angular process, receives the lacrymal gland, 
 which is fastened to it by a particular ligament. 
 A minute pit behind and above the internal an- 
 gular process of the same bone, gives attach- 
 ment to a ligament and cartilaginous trochlea, 
 in which the tendon of a muscle plays in its 
 passage to the globe. A notch or foramen is 
 observed in the orbitar ridge of the os frontis, 
 which permits vessels and nerves to pass from 
 the orbit to the eyebrow, glabella, and forehead. 
 The infra-orbital canal, which opens obliquely 
 at the back of the orbital floor, is continued 
 under it to the cheek, transmits vessels freely 
 communicating with the ophthalmic, and a nerve 
 from which the inferior palpebra derives its chief 
 supply. 
 
 The globe or ball of the eye is not exactly Eyeban 
 spherical, the line forming the visual axis ex- 
 B 2
 
 4 ANATOMICAL DESCRIPTION OF THE EYE 
 
 ceeding its transverse diameter. This line is 
 parallel in the two eyes. 
 
 The figure of the orbit demonstrates that a ^ 
 part only of the ball is contained within it. 
 A needle placed upon the temporal angle of 
 the orbit, and pushed horizontally across the 
 globe, perforates the orbitar plate of the aeth- 
 moid bone, and measures its greatest transverse 
 diameter. 
 
 The difference in the degree of projection of 
 the eye in diiferent individuals is determined by 
 the relative volume of the ball and its socket ; 
 but the figure and the ordinary interspace of the 
 eyelids are subject to variations, which convey 
 a delusive idea of the magnitude of the globe. 
 When a paralysis affects the palpebral muscle of 
 one eye, the organ, compared with its fellow, 
 has the appearance of being diminished in bulk. 
 
 The eye of the female is commonly smaller 
 than that of the male ; and the fissure of the 
 eyelids, which are rounder, broader, and more 
 delicate in texture, is generally less. 
 
 Humors Thc eyeball is composed of the following 
 
 and mem- 
 
 branes. partS I 
 
 1. The vitreous humor, ■> united by their 
 
 2. The crystalline humor, j common tunic. 
 
 }
 
 AND ITS APPENDAGES. 
 
 3. The aqueous humor. 
 
 4. The retina. 
 
 5. The choroid and its appendages, the an- 
 nulus and processus ciliares. 
 
 6. The iris. 
 
 7. The sclerotic. 
 
 8. The cornea. 
 
 The humors give shape to the eyeball, and 
 support to its tunics. 
 
 The crystalline is set in the vitreous humor, 
 and washed in front by the aqueous. 
 
 The retina is the membranous expansion of 
 the optic nerve, upon which the images of ex- 
 ternal objects are painted. 
 
 The choroid is the bed of the vessels of the 
 eye, and the dark screen which confines and 
 condenses the rays of light. Its appendages 
 are auxiliary to this purpose, and to other parts 
 of the economy of vision. 
 
 The iris is the colored membrane in which 
 the aperture termed 'the pupil' is formed. 
 
 The sclerotic is the external opaque investi- 
 ture of the choroid. 
 
 The cornea is the anterior transparent 
 membrane which first converges the rays of 
 light. 
 
 Nearly in the order in which these several 
 parts have been named, I proceed to describe 
 them.
 
 O ANATOMICAL DESCRIPTION OF THE EYE 
 
 Vitreous The VITREOUS HUMOR is the basis upon which 
 
 the larger tunics are expanded, and fills a space 
 somewhat exceeding three quarters of the vo- 
 lume of the globe. Upon its anterior surface 
 it is rather abruptly flattened, and presents a 
 central cup-like depression ; the dimensions of 
 which exactly correspond to the posterior seg- 
 ment of the crystalline humor, which is imbed- 
 ded therein. Its substance is a glairy fluid hea- 
 vier than water, perfectly pellucid, and con- 
 tained within cells formed by processes of its 
 tunic, arranged in horizontal planes. Towards 
 the back and sides of the humor these cells are 
 larger than in the interior, adjacent to the crys- 
 talline fossula; the septa are likewise thicker 
 and stronger towards the circumference of the 
 humor. After a careful section of the frozen 
 humor, its substance may be picked out in 
 solid wedge-like flakes from the interstices of 
 Hyaloid the septa. The continuous covering, though of 
 
 tunic. . 1 r> • p 
 
 great tenuity and perfect transparency, is or 
 much strength, and resists, owing to the sup- 
 port it receives from the numerous septiform 
 productions of its internal surface, a consider- 
 able pressure. When lacerated or wounded, the 
 humor of the corresponding cell or interstice is 
 instantly evacuated ; but if the wound is super- 
 ficial, the humor does not escape in quantity, 
 while supported by the other parts of the globe, 
 or if removed from the globe, while suspended
 
 AND ITS APPENDAGES. 7 
 
 in a fluid. But if in any way compressed after 
 a wound, a dribbling of the humor goes slowly 
 on, until the cells, which communicate with 
 each other, are emptied. 
 
 The tunica hyaloidea is covered by the retina 
 in the whole extent of that membrane, but is 
 connected with it only at the entrance of the 
 optic nerve. The substance of the humor is pe- 
 netrated by a branch of the arteria centralis re- 
 tinge, which contributes a few very delicate ves- 
 sels to its containing membrane. In the foetus 
 they have been displayed ramifying on the cap- 
 sule at the back of the lens. 
 
 The crystalline humor is a double convex Crystalline 
 lens, its breadth about four lines, its thickness 
 about two. The posterior and most convex face 
 of the lens is exactly fitted to the cup in the 
 fore-part of the vitreous humor ; the anterior is 
 opposed to the iris, and the circumference to 
 the canal of Petit. The axis of the lens is that 
 of the pupil, a little to the inner side of the 
 axis of the eye. This humor is of perfect trans- 
 parency in its healthy state. In the foetus and 
 new-born infant, it is spherical, semi-fluid, and 
 has a slightly reddish tint. In the adult, it is 
 gelatinous in consistency, its external lamellae 
 easily broken down between the fingers, but a 
 nucleus of greater firmness is found in the cen- 
 tre, which in some degree resists this pressure.
 
 8 ANATOMICAL DESCRIPTION OF THE EYE 
 
 In advanced age, the lens becomes more close 
 and compact in texture, and the nucleus ac- 
 quires a yellow or topaz color. 
 
 The texture of the lens is lamellated ; the la- 
 mellae concentric and connected by a very deli- 
 cate fibrous tissue. After maceration, the crys- 
 talline breaks into triangular pieces composed of 
 concentric scales, of which the apices meet in 
 the centre. The anterior may sometimes be sepa- 
 rated from the posterior part of the lens, at the 
 line of its circumference, as if it were composed 
 of two segments of spheres of unequal size, ap- 
 plied face to face. The crystalline discovers 
 no vascular organization. 
 
 Canal of Thc tuulc of the vitrcous humor, called tu- 
 
 nica hyaloidea, has also, upon its exterior surface, 
 a process or duplicature, membranula coronae ci- 
 liaris of Zinn, who considered it a distinct tex- 
 ture. It is produced at the distance of a line's 
 breadth from the circumference of the cup which 
 receives the crystalUne humor. At the verge of 
 the cup the duplicatures coalesce, and thus an 
 annular space is included between them, which 
 has been named, after its describer, canalis Pe- 
 titianus. Inflation of the canal shews that it is 
 not of uniform dimensions ; like the intestine 
 colon, it is tacked up into cells or pouches by 
 short transverse septa, whence the name given 
 by Petit, canal gauderonne, or godronne. In
 
 AND ITS APPENDAGES. U 
 
 the grooves corresponding to these septa, the 
 posterior edges of the ciUary processes are in- 
 serted. The intervening looser portions of the 
 membrane correspond to the interstices of the 
 processes ; and the black radiated lines, which 
 appear upon the membrane of the canal, are 
 stains left by the pigment which fills them. Like 
 the corpus ciliare, the canal is broader on the 
 temporal than on the nasal side. 
 
 After the condensation of the lamellae at the Capsule of 
 
 r> 1 ,,. 1 . . the crystal- 
 
 margm or the crystalline, the proper tunic is une. 
 continued over the concave face of the vitreous 
 humor, posterior to the crystalline lens ; and a 
 continuous transparent membrane, produced an- 
 teriorly, passes before the crystalline, so as to 
 retain it in its place. This portion of the mem- 
 brane covering the crystalline is termed capsule 
 of the crystalline, or tunica aranea, and is con- 
 siderably more dense and elastic than the proper 
 tunic of the vitreous humor. Independent of the 
 membranous inclosure now described, the exist- 
 ence of a distinct and proper capsule of the crys- 
 talline is generally assumed ; but its demonstra- 
 tion is not altogether satisfactory. A small 
 quantity of aqueous fluid contained in the cap- 
 sule inclosing the crystalline humor, is called 
 after its discoverer, humor Morgagnii. 
 
 The retina. The optic nerve having per- Retina. 
 forated the sclerotic and choroid coats at the in-
 
 10 ANATOMICAL DESCRIPTION OF THE EYE 
 
 ternal and posterior part of the globe, terminates 
 abruptly in a little white conical eminence or 
 papilla. From the base of this papilla proceeds 
 the very delicate membranous expansion termed 
 * retina'. It encompasses the vitreous humor, the 
 front part only excepted. Its anterior termina- 
 tion is also abruptly defined, and corresponds to 
 that of the choroid tunic which lies exterior to 
 it. It is of exceeding delicacy, and, on dissec- 
 tion, resembles, in semi-transparency and in 
 color, the ground glass of which ornamental 
 lamps are constructed. During life it is of per- 
 fect transparency. • Without caution it cannot 
 be preserved entire m dissection ; and if, when 
 the sclerotic and choroid are divided, the parts 
 of the globe are separated by their weight, by 
 its strict adhesion to the other coats at its origin, 
 it is drawn, off the vitreous tunic in the form 
 of a fine medullary rope, which expands and re- 
 assumes its proper form in water. The arteria 
 centralis, emerging from the axis of the optic 
 nerve, distributes a few delicate branches upon 
 it, which do not in the healthy adult convey 
 red blood. 
 
 Its central A miuutc forameu in the retina is seen on the 
 temporal side of the optic nerve, having a yel- 
 low border, around which the arteria and vena 
 centralis, after a delicate injection, display a vas- 
 cular corona. This appearance first described 
 by Soemmering, " foramen centrale cum limbo
 
 AND ITS APPENDAGES. 11 
 
 luteo," is seen only in the recent state of the eye. 
 Its situation corresponds to the extremity of the 
 visual axis. The membranous surface of the 
 retina is opposed to the tunica hyaloidea, the 
 medullary to the choroid. Its attachment, at its 
 insertion into the ciliary body, is very slight, 
 as it commonly yields at that part, if recent 
 and uninjured, rather than tears by the force 
 exerted to separate it entire. The retina is 
 uniformly expanded over the tunica hyaloidea, 
 but has no demonstrable connexion with that 
 membrane. 
 
 The tunica choroides extends from the cir- Choroid 
 
 tunic. 
 
 cumference of the optic nerve to the margin of 
 the exterior or flattened surface of the vitreous 
 humor; there it terminates, together with the 
 retina, in a greyish colored substance, termed 
 ganglion, orligamentum ciliare, or, better, annu- 
 lus ciliaris, and which is the common centre of 
 union for the interior membranes of the eye. 
 
 The choroid is of a dusky brown color in the 
 adult, reddish in infants, and adhering by an 
 abundant and lax cellular tissue, which may be 
 readily inflated, to the sclerotic coat, and by the 
 numerous ciliary vessels and nerves, which per- 
 forate the latter to take their course upon the 
 choroid. This cellular substance is more plen- 
 tiful in the infant than in the adult, and is most 
 abundant in the track of the principal vessels 
 and nerves. The vessels terminating upon it
 
 12 ANATOMICAL DESCRIPTION OF THE EYE 
 
 Its pig- are extremely numerous, and secrete a dark 
 
 ment. 
 
 pigment, or varnish, which stains the contigu- 
 ous adhering surface of the sclerotic ; it like- 
 wise communicates its stain to the finger, or a 
 piece of white paper, but the texture of the 
 membrane is permanently dark, and is not 
 bleached by maceration. 
 
 The interior surface of the choroid is also co- 
 vered with a black varnish, thicker and deeper 
 colored in the infant than in the adult ; but, 
 having no connexion by texture with the re- 
 tina, its stain is not communicated to this tunic. 
 Around the insertion of the optic nerve, the 
 choroid is destitute of this dye. Residence for 
 some time in alcohol discovers a fine white floc- 
 culent substance coating the interior of the cho- 
 roid, formerly described by Ruysch as a distinct 
 tunic (tunica Ruyschiana), but not regarded 
 in this light by modern anatomists. The pig- 
 ment, there can be no doubt, is secreted into 
 a fine cellulous tissue, flakes of which are de- 
 tached, in some diseased states of the organ, 
 from the ciliary processes and back of the iris, 
 forming to all appearance a real membrana nigra. 
 
 Its nerves The ciliary nerves run in parallel lines, at 
 equal distances, upon the choroid ; and from 
 their size and whiteness are particularly conspi- 
 cuous. The long ciliary arteries appear, one on 
 either side of the globe, in their course to the 
 annulus ciliaris. Beneath these the membrane
 
 AND ITS APPENDAGES. 13 
 
 presents, on its opposite sides, vessels arranged 
 in form of trees with weeping brandies, or of 
 the figure of a jet d*eau ; these, which have 
 been named vasa vorticosa, are veins returning 
 the blood distributed to the ciliary processes, 
 and are collected into three or four distinct 
 venous trunks. The short posterior ciliary ar- 
 teries pass under the ciliary veins, in the inter- 
 vals of the trunks, to the interior of the cho- 
 roid ; and uniting with the anterior at the fore 
 part of the globe, their extremities form a very 
 intricate and beautiful net-work upon its inte- 
 rior surface. The adhesion of the choroid to 
 the sclerotic is most strict, adjacent to the optic 
 nerve behind, and the ciliary ring before, owing 
 to the introduction of the ciliary vessels at these 
 parts. 
 
 The annulus ciliaris is an elastic ring cniarynng. 
 composed of a short and dense pulpy texture, 
 closely adherent to the inner border of the scle- 
 rotic, at the distance of a line and a half from 
 the external circumference of the cornea. It 
 is of greater breadth on the temporal than on 
 the nasal side. The choroid and retina adjoin 
 its greater, the cornea and iris its lesser circum- 
 ference. Anteriorly it adheres firmly to the 
 sclerotic, as before observed, and the ciliary 
 processes are attached to its posterior surface, 
 so that it forms a common centre of union for 
 these tunics. Its color is observed to correspond 
 to that of the iris.
 
 14 ANATOMICAL DESCRIPTION OF THE EYE 
 
 Ciliary The PROCESSUS ciLiAREs. On the internal 
 
 processes, surfacc of the choroid, at the root of the annu- 
 lus ciliaris, the plicae or processus ciliares arise 
 in delicate striae, and, advancing a little anterior 
 to the circumference of the crystalline lens, 
 terminate in a circle of fine grey points at the 
 base of the iris. They appear to be radiated 
 folds of the choroid tunic, from sixty to seventy 
 in number, long and short alternately, and ga- 
 thered at their origin like the plaits of a shirt 
 at the wristband. Viewed collectively through 
 the vitreous humor they have some resemblance 
 to a radiated flower ; a small white circle ap- 
 pears within a large dark one. The white lines 
 represent the edges of the plicae; the black, their 
 interstices coated with pigment. These edges 
 of the plicae are engrooved in the duplicature of 
 the vitreous capsule, which assists in forming 
 the canal of Petit. 
 
 The extremities of the processes projecting 
 from the interior border of the annulus ciliaris 
 interdigitate with the radical fibres of the iris. 
 To obtain a view of them, let the cornea be ac- 
 curately removed at its junction with the scle- 
 rotic, and the iris be torn away, entire, from its 
 ciliary attachment. The points of the process- 
 es will then appear, projecting like the teeth 
 of a comb from behind the annulus ciliaris ; and 
 the ciliary border of the iris, upon floating it in 
 water, will be found to present a corresponding 
 arrangement.
 
 AND ITS APPENDAGES. . 15 
 
 The processes having their edges thus inlaid 
 in the tunica hyaloidea at the margin of the 
 crystaUine fossula, and their points or anterior 
 extremities interlaced with the radical fibres of 
 the iris, form a posterior iris, the aperture of 
 which is exactly occupied by the crystalline 
 lens and its capsule. From their origin to 
 their insertion, they are supported exteriorly by 
 the annulus ciliaris, with which substance they 
 are in fact incorporated. The figure of each 
 plica ciliaris is triangular, the internal obtuse 
 angle being opposed to the circumference of 
 the crystalline lens ; the posterior, elongated, 
 loses itself in the choroid; the anterior is 
 inserted into the iris. The anterior edge is 
 attached to the annulus ciliaris and root of 
 the iris, the posterior to the tunica hyaloidea, 
 and the internal and shortest measures the 
 space between the verge of the crystalline lens 
 and the basis of the iris ; or, in other words, 
 forms the outer boundary of tlie posterior 
 chamber. 
 
 The iris. This is the colored membrane iris, 
 which presents a plane surface traversing the 
 globe horizontally, and dividing the corneal 
 from the sclerotic segment. It is rendered im- 
 perfect as a septum by the pupilla or round 
 hole in its centre. The pupil is not, how- 
 ever, quite central in relation to the iris, the 
 breadth of the iris being always somewhat less 
 on the nasal than on the temporal side. It is
 
 16 ANATOMICAL DESCRIPTION OF THE EYE 
 
 divided into a ciliary and a pupillary portion. 
 Its attachment is, as already observed, by in- 
 denture with the extremities of the plicae cho- 
 roidse, at the inner margin of the annulus ci- 
 liaris, from which it originates. The ciliary 
 portion of the iris is the larger one, and is 
 composed of a delicate fibrous and vascular 
 tissue, in which grey serpentine lines or striae 
 are seen proceeding like radii from the annu- 
 lus ciliaris : from this the smaller pupillary por- 
 tion is distinguished by a darker shade of color, 
 and a gently elevated circular line, most con- 
 spicuous on the posterior surface of the mem- 
 brane. The fibres of this portion have a simi- 
 lar tortuous direction, and are convergent to- 
 wards the pupillar aperture. The pupillary 
 margin is thin and defined, and presents the 
 appearance of a dark circular line when placed 
 upon a white ground, as e. g. the opaque cap- 
 sule of the crystalline lens. The iris diminishes 
 in thickness from its base to the margin of the 
 pupil. Its anterior surface is richly colored of 
 different hues in different individuals. It is 
 thickly coated on its posterior surface by the 
 pigmentum nigrum. 
 
 Its vessels Tlic ciUary vessels, entering the anterior part 
 of the globe, unite with the other detachments, 
 and form arches at the basis of the iris and 
 processes. From the zone thus produced (zona 
 major) the branches run in straight lines upon 
 the iris. In the dilated state of the pupil these
 
 AND ITS APPENDAGES. 17 
 
 radiated vessels are tortuous ; by its contraction 
 they become straight. At the distance of rather 
 less than half its diameter from the pupil, an- 
 other zone is formed by their anastomosis, from 
 which branches are detached to the margin of 
 the pupil. The zona minor gives the appear- 
 ance of the undulating circular line, distinguish- 
 ing the pupillary from the ciliary portion of the 
 membrane. The two long ciliary arteries chiefly 
 contribute to the formation of these zones and 
 the supply of the iris. The short ciliaries, seen 
 upon the interior of the choroid, detach nume- 
 rous fasciculi to each ciliary process, which pur- 
 sue a serpentine course along the fixed edge of 
 the fold, and are inverted to form concentric 
 arches upon its opposite free margin. 
 
 The membrana pupillaris, a delicate mem- Membrane 
 brane occupying the pupil of the foetus, and " '^p"P'- 
 which is supplied by the vessels of the iris, dis- 
 appears before birth. 
 
 Of the proper structure of the corpus ciliare 
 nothing is with certainty known. The notion 
 that it is wholly constituted of vascular and nerv- 
 ous tissue, having no proper fibrous texture for 
 its base, which has also been conceived of the 
 iris, is absurdly contrary to observation and ana- 
 logy. The annulus appears to be a gangliform 
 or bulbous termination of the choroid coat, and 
 the processes resemble plaits or doublings of 
 
 c
 
 nic. 
 
 18 ANATOMICAL DESCRIPTION OF THE EYE 
 
 this membrane laid back to back, to accommo- 
 date it to the area of the posterior chamber. Si- 
 milar uncertainly prevails as to the structure of 
 the iris, the different opinions of its texture 
 being founded rather upon inference from its 
 functions than upon demonstration. If the for- 
 mer species of evidence be regarded, it is in part 
 unquestionably a muscular texture ; the pheno- 
 mena of its action can be best explained upon 
 the supposition that it is both muscular and elas- 
 tic, and that these forces act alternately. 
 
 Sclerotic tu- The TUNICA SCLEROTICA is the external cover- 
 ing of the ball, with the exception of one-fifth 
 part, bearing a proportion to the cornea some- 
 what similar to that which the vitreous bears to 
 the aqueous humor. It is a dense compact fi- 
 brous membrane, of a blueish white color ; its 
 fibres appear reticulated on maceration. It has 
 few nutrient vessels, and no traceable nerves ; 
 its texture is both extensile and elastic. In the 
 foetus and infant it admits of separation into two 
 plates, but these are inseparably connected in the 
 adult. For the entrance of the optic nerve, 
 with the sheath of which it is intimately connect- 
 ed, it is cribrated or perforated with many small 
 holes, by which the fibres of the nerve enter and 
 terminate in the conical protuberance before de- 
 scribed. The choroid and retina adhere firmly 
 to the margin of this cribriform plate. In other 
 parts the connexion between the sclerotic and
 
 AND ITS APPENDAGES* 19 
 
 choroid is by the medium of blood-vessels and 
 cellular tissue. The sclerotic around the en- 
 trance of the nerve, and likewise around the 
 margin of the cornea, has many small oblique 
 passages, of which the apertures on its internal 
 surface are conspicuous, when separated from the 
 choroid, for the entrance and exit of the ciliary 
 vessels and nerves. Adjoining the cornea, the 
 choroid and conjunctival vessels communicate 
 through the foraminula of the sclerotic. On 
 its inner surface it has furrows in right lines, 
 in which the long ciliary vessels and nerves are 
 lodged. The sclerotic is of greatest density 
 in the vicinity of the nerve j it gradually dimi- 
 nishes in thickness towards the middle of the 
 globe, where it is fortified by the tendons of the 
 several muscles. The opening in front of the 
 sclerotic is nearly circular, having its inner edge 
 sloped for the broad insertion of the cornea be- 
 tween its anterior and posterior margins. 
 
 The cornea is of a horny texture, less exten- Comea. 
 sile than the sclerotic, and perfectly transparent. 
 It is, onion-like, composed of concentric la- 
 mellge or pellicles, connected by a delicate cel- 
 lular tissue containing a transparent fluid, in 
 which exhalant and absorbent vessels are abun- 
 dantly distributed. This tissue is more lax or 
 copious between the anterior than between the 
 posterior lamellae. The transparent conjunc- 
 tiva upon the cornea gives a polish and bril- 
 liancy to the surface, which the lamellae of the 
 
 c 2
 
 20 ANATOMICAL DESCRIPTION OF THE EYE 
 
 cornea do not possess, and which is lost at the 
 approach of death, by the transudation of the 
 aqueous humor. They are scabrous from the 
 adhesion of the cellular membrane connecting 
 them, and void of lustre. The cornea is exter- 
 nally rather elliptical than circular, being of 
 greater length in the transverse than the vertical 
 diameter. 
 
 The cornea is of greater thickness than the 
 sclerotic, in infants especially, in whom its pos- 
 terior surface is contiguous to the iris. The in- 
 ternal surface is likewise half a line broader than 
 the outer, the margin being obliquely extended 
 from without inwards, to correspond with the 
 sloped edge of the sclerotic. After maceration 
 it may be detached from the sclerotic, to which 
 it is connected by cellular substance : this sepa- 
 ration is most readily eifected by plunging the 
 macerated eye into boiling water. A fine trans- 
 parent humor is secreted by colorless exhalant 
 vessels in the areolae of the cellular membrane 
 between the lamellae of the cornea. The inter- 
 stitial substance of the cornea receives no co- 
 lored vessels. Numerous lines have been ob- 
 served to form figures of many sides between the 
 plates of the cornea in the eye of the negro, and 
 supposed, from a reddish tinge, to be blood ves- 
 sels. The existence of nerves has never been 
 demonstrated, and it is much to be doubted if it 
 possess any. On its interior surface the cornea 
 is smooth, and washed by the aqueous humor.
 
 AND ITS APPENDAGES. 21 
 
 According to modern anatomists, it is lined by Membrane 
 a tunic proper to the humor, which is reflected aqueous 
 
 r> /^ 1 • • 11 humor. 
 
 from it upon the face or the nis, and advances 
 even to the margin of the pupil. Its tenuity, if 
 it exist, is such as very rarely to allow of its de- 
 monstration, at least in the human eye. The 
 convexity of the cornea is greater than that of 
 the sclerotic, being the segment of a sphere se- 
 ven lines and a half in diameter. 
 
 The aqueous humor. The name of anterior Aqueous 
 
 humor, and 
 
 chamber is given to that space comprised be- chambers of 
 tween the cornea and the iris, ordinarily about 
 one line and a half in depth. The posterior 
 chamber, not exceeding a quarter of a line, is 
 the space between the iris and the crystalline 
 lens. They communicate by the aperture of the 
 pupil, and both are occupied by the aqueous 
 humor. This is a transparent fluid, evaporates on 
 exposure to heat, and is uncoagulable by heat, 
 acids, or alkalies ; it is in quantity about five 
 grains ; in quality, viscous and slightly saline. 
 It gives figure and tension to the cornea, keeps 
 the pupil properly dilated, and supports the 
 parts forming the parietes of both chambers. 
 When discharged by the puncture of the cor- 
 nea, the pupil contracts, and the chambers are 
 obliterated by the collapse of their parietes : it 
 is however reproduced in a few hours. The 
 aqueous humor in foetuses and new born infants 
 is turbid, and sometimes of a reddish tint.
 
 ^2 ANATOMICAL DESCRIPTION OF THE EYE 
 
 Veins of the The clHary veins and vasa vorticosa of tliQ 
 choroid jointly return the blood distributed by 
 the ciliary arteries. 
 
 They perforate in like manner the sclerotic 
 coat, and terminate in the infra-orbital branch 
 and trunk of the ophthalmic vein, which also re- 
 ceives the vena centralis retinae. 
 
 ORBITAR APPENDAGES. 
 
 Periosteum ThE PERIOSTEUM AND ADEPS OF THE ORBIT. 
 
 The dura mater, which is the internal perios- 
 teum of the cranium, lines the orbit, and is con- 
 tinuous at all its openings with the periosteum 
 of the head and face ; hence the extensive sym- 
 pathetic pains in the inflammatory affections of 
 the bones of the face and cranium, and their 
 common membrane. Hence also probably, the 
 suppurative inflammation of the dura mater after 
 extensive fractures and injuries of the orbit. 
 
 The fat, which in health is secreted abund- 
 antly in the orbit, surrounds the optic nerve, and 
 invests the posterior surface and sides of the 
 globe, forming for it a soft bed, and defending 
 the vessels and nerves from compression in its 
 motions. In emaciating diseases its diminution 
 by absorption produces that characteristic sink- 
 ing of the globe in its socket, and loss of con- 
 vexity in the eyelid, which is familiarly expressed 
 by the term " hollow eyed." On the other hand.
 
 AND ITS APPENDAGES, 23 
 
 its secretion in excess, as in morbid obesity, 
 protrudes, compresses, and thus induces con- 
 gestion in the vessels of the eye. 
 
 I proceed to describe the muscles, vessels, 
 and nerves contained in the orbit. 
 
 The muscles are seven in number ; viz. the Muscles. 
 levator palpebras ; the rectus superior, inferior, 
 internus, and externus j obliquus superior and 
 inferior. 
 
 The levator palpebrae has an acute origin from Elevator of 
 
 1 . 1 1 y • .the upper 
 
 the periosteum above the roramen opticum ; its eyeUd. 
 fibres spread in their course, giving it a fan-like 
 shape, and they are inserted by a broad aponeu- 
 rosis in a condensed cellular substance, which 
 connects the upper tarsus to the orbitar ridge, 
 between the conjunctiva and the fibres of the 
 orbicularis palpebrarum. From the nature and 
 extent of its connexion with the eyelid, it re- 
 sults that the partial division of the tarsal liga- 
 ment, or even the removal of the cartilage, does 
 not take away the power of elevating the Ud as 
 the paralysis of this muscle does ; the elevation, 
 however, under these circumstances, is imper- 
 fectly performed. 
 
 The rectus superior lies beneath this muscle, Superior 
 arising from the border of the foramen opticum muscle. 
 and the partition between it and the foramen la- 
 cerum.
 
 Q4f ANATOMICAL DESCRIPTION OF THE EYE 
 
 Internal and The icctus intemus and rectus inferior arise 
 
 inferior. . _ i • i • 
 
 in common irom a ligament which in part sur- 
 rounds the optic foramen, and fills up the fora- 
 men lacerum.. 
 
 External. The rcctus eMemiis arises by two distinct 
 heads : the inferior having a common origin 
 with the last named muscles, from the ligament 
 which occupies the inferior angle of the fora- 
 men lacerum ; the superior from an arch of li- 
 gament crossing the foramen above. It is im- 
 portant to note this bicipital origin of the rectus 
 externus, as some of the nerves of the orbit pass 
 through the interspace between its heads, and 
 others through the top of the foramen. The 
 ligament of the foramen spheno-maxillare forks 
 into three intermuscular slips, which give origin 
 and support to the external, inferior, and inter- 
 nal recti muscles, in the manner of the inter- 
 muscular ligaments of the extremities. The 
 four recti muscles, varying in length and direc- 
 tion as the sides of the orbit to which they are 
 adjacent, pass over the great circumference of 
 the bulb, between which and the cornea they 
 are inserted, at equal distances, by straight ten- 
 dinous fibres, into the substance of the sclerotic 
 coat. 
 
 Superior The supcrior oblique muscle rising from the 
 
 '^"^^' periosteum between, and a little anterior to the 
 
 origins of the superior and internal recti, passes 
 
 its slender rope of tendon through a half ring of
 
 AND ITS APPENDAGES. 25 
 
 cartilage which is affixed by a hgament to the 
 OS frontis, a little above and behind its internal 
 angular process. The trochlea is provided with 
 a sacculus mucosus, and the tendon emerging 
 from it is inclosed in a ligamentous sheath to 
 its insertion in the sclerotic coat, at the poste- 
 rior and upper surface of the globe, beneath the 
 superior rectus muscle. 
 
 The inferior oblique rises from the orbitar inferior 
 plate of the superior maxillary bone, behind the 
 lacrymal fossa, and takes an oblique direction 
 between the globe and rectus inferior, to its pos- 
 terior and outer surface, where it is likewise in- 
 serted into the sclerotic. 
 
 The sing-le actions of the recti are expressed Their ac- 
 
 ^ ^ tions. 
 
 by the terms, levator, depressor, adductor, and 
 abductor. Their co-operation retracts the globe 
 in its socket. The oblique muscles, acting 
 singly, roll or rotate the eye in contrary direc- 
 tions. Theu' co-operation antagonises that of 
 the recti, which power is demonstrated by the 
 course of the superior oblique, the origin of the 
 inferior, and their posterior insertions. 
 
 The arteries of the eye are principally de- Arteries. 
 rived from the ophthalmic artery, which has a 
 short but sharp curve at its origin from the in- 
 ternal carotid, before it enters the orbit. This 
 it does through the foramen opticum, upon the 
 temporal side of the nerve.
 
 ^6 ANATOMICAL DESCRIPTION OF THE EYE 
 
 The arteria centralis retince which runs in the 
 centre of the optic nerve, and the long ciliary 
 arteries which pass upon either side of it, are 
 its first branches ; next the lacrymal artery, 
 which contributes a ciUary branch, a branch to 
 the rectus externus, and another which runs be- 
 neath the globe to the obHquus inferior muscle 
 and reaches the inferior palpebra. The lacry- 
 mal branch then divides into two : one, a branch 
 of communication with the deep temporal branch 
 of the internal maxillary artery at the outer mar- 
 gin of the orbit ; another, which is dispersed in 
 the substance of the lacrymal gland and supe- 
 rior palpebra. 
 
 The trunk of the ophthalmic artery then 
 crosses obliquely beneath the optic nerve, and 
 on the nasal side of the nerve sends branches to 
 the superior oblique and levator palpebrae, rec- 
 tus superior and inferior muscles, and commonly 
 a ciliary artery. The remaining branches of the 
 ophthalmic artery, which is here tortuous, are 
 ihQ frontal, through the supra-orbitar foramen ; 
 one or two to the rectus internus,. the nasal 
 branch which passes by the anterior aethmoid fo- 
 ramen into the nose, and the infra-trochlear 
 branch. The ophthalmic artery at length 
 emerges upon the inner canthus, furnishing the 
 superciliary and palpebral branches, and anasto- 
 moses with the nasal branch of the facial artery 
 from *the external carotid. The muscular 
 branches penetrate between the fibres, and run-
 
 AND ITS APPENDAGES. ^7 
 
 ning in the same direction, appear beneath the 
 conjunctiva on the sclerotic coat. Here they 
 subdivide and ramify upon the conjunctiva; the 
 fascicuH inosculating so as to form a faint cir- 
 culus arteriosus around the cornea, when filled 
 with colored blood. Those of the rectus inter- 
 nus are most numerous. 
 
 The veins. The ophthalmic and nasal Veins. 
 branches of the anterior division of the facial 
 vein, freely communicate at the inner angle of 
 the orbit with the ophtlialmic vein ; and the an- 
 terior and posterior CEtJmioidal or nasal, the la- 
 crymal, all the ciliary veins from the globe, the 
 vena centralis retince, the infra-orhitaly the several 
 muscular, periosteal, and adipose branches, are 
 all collected into this trunk in its passage through 
 the orbit. It takes a serpentine course over the 
 optic nerve, through the foramen lacerum, to 
 terminate in the anterior part of the cavernous 
 sinus of the dura mater. 
 
 The nerves of the orbit, exclusive of the op- Nerves. 
 tic, are the third pair, or motores ; the fourth, or 
 jjathetici ; the first division of the fifth, or trige- 
 mini ; and the sixth, or abducentes. 
 
 The third pair enter the orbit between the 
 heads of the rectus externus muscle, in com- 
 pany with the nasal branch of the fifth and the 
 sixth pair. Its lesser and superior branch rising
 
 ANATOMICAL DESCRIPTION OF THE EYE 
 
 before its entry into the orbit, joins a twig of 
 the fifth pair, to assist in forming the ophthalmic 
 or lenticular ganglion^ and then divides to sup- 
 ply the rectus superior and levator palpebrae 
 muscles. Its larger and inferior branch passes 
 under the optic nerve towards the nasal side of 
 the orbit ; and while covered by that nerve, is 
 divided into a branch to the rectus internus, a 
 short thick stalk to the ophthalmic ganglion^ and 
 a long slender filament to the inferior oblique 
 muscle. 
 
 From the ophthalmic ganglion lying concealed 
 in fat, on the temporal side of the optic nerve, 
 a superior and inferior fasciculus of ciliary nerves 
 arise, and creep along its sides in a serpentine 
 direction to the bulb. 
 
 The fourth pair of nerves, with the lacrymal 
 and frontal branch of the fifth, pass through the 
 upper part of the foramen lacerum. It some- 
 times receives a branch of augmentation from 
 the fifth pair, and always increases in size to- 
 wards its termination in the central fibres of the 
 superior oblique muscle. 
 
 The first or ophthalmic division of the fifth 
 pair gives oflT, 
 
 1st. The supra-orbitar, which is subdivided 
 into the supra and infra trochlear ramuli, and
 
 AND ITS APPENDAGES. 2f9 
 
 the proper frontal nerve ; which last, running in 
 an external and internal branch upon the levator 
 palpebrge, is distributed upon the forehead. 
 
 2dly. The lacrymal nerve, which, taking a di- 
 rection to the outer canthus, splits into an ex- 
 ternal and internal branch. The internal sup- 
 plies with filaments the glomera of the lacrymal 
 gland ; twigs from the external likewise enter 
 the gland, and together they are dispersed upon 
 the superior palpebra. 
 
 8d. The nasal nerve, which gives a branch 
 to unite with the short stalk of the third pair to 
 form the ophthalmic ganglion, and contributes 
 two long ciliary nerves to the globe, then passes 
 obliquely under the superior oblique muscle to 
 the aathmoid foramen, by which it enters the 
 nose, furnishing an infra-trochlear filament to 
 the nasal region of the orbit. 
 
 The sixth pair, having parted with the fila- 
 ments supposed to be the roots of the great sym- 
 pathetic upon the canalis caroticus, enters the 
 orbit with the nasal of the fifth and the third 
 pair, to be spent upon the rectus externus 
 muscle. 
 
 The lacrymal gland is of the conglomerate Lacrj'mai 
 kind, of a flattened oval form, divided by a cleft ^ ^" ' 
 into two lobes, of which the superior and internal 
 is the smaller and thinner, the inferior and exter-
 
 so ANATOMICAL DESCRIPTION OF THE EYE 
 
 iial the large extremity of the gland. Its posi- 
 tion is oblique ; the inferior and internal surface 
 hollowed to suit the convexity of the globe 5 the 
 superior convex to fit the corresponding surface 
 of the orbit to which the gland is attached, by 
 a ligament passing transversely beneath it. It 
 measures, in length, about ten lines j in breadth, 
 five or six. The structure of the gland resem- 
 bles that of the salivary, its lobules connected 
 by a dense cellular tissue, upon which its vessels 
 and nerves subdivide, to supply the granules of 
 which they are composed. The vessels enter 
 the gland at its posterior margin; and from the 
 anterior, its ducts, five or six in number, pass 
 out in straight lines, and pierce the conjunctiva 
 at the orbitar edge of the superior tarsus. 
 
 We have now briefly described the orbitar ap- 
 pendages, or those parts situated behind the tu- 
 nica conjunctiva, and proceed to the 
 
 FACIAL APPENDAGES. 
 
 Eyebrows. ThE SUPERCILIUM, OR EYEBROW. The aTcll of 
 
 the eyebrow corresponds to that of the super- 
 ciliary ridge upon which it is planted. It ex- 
 tends from the tuberosity of the frontal sinus to 
 the external angle of the orbit. It consists of 
 a thick row of strong short hairs, which have a 
 disposition almost erect at the commencement 
 of the brow, and are then arched obliquely out- 
 ward, and gi'adually reduced in number so as to
 
 AND ITS APPENDAGES. 31 
 
 terminate the arch acutely. The few erect hairs 
 correspond to the fibres of the corrugator super- 
 cihi muscle, the crescentic to the fibres of the 
 orbicularis palpebrarum. 
 
 The extent and fulness of the brows vary 
 greatly in different persons. In some, especially 
 persons of dark complexion and black hair, they 
 have little if any interspace at their origin, and 
 are long, prominent, and bushy in the centre of 
 the arch. Among the ancients these were es- 
 teemed points of female beauty. The fibres of 
 the occipito-frontalis, or epicranial muscle, ter- 
 minate beneath the skin of the supercilium, 
 blending with those of the orbicular muscle of 
 the palpebra. The former elevates the brow, 
 wrinkling the integument of the forehead hori- 
 zontally; the latter depresses it, and closes the 
 eyelids, being the sphincter palpebrarum. 
 
 The corrugatores approximate the heads of 
 the supercilia, drawing the integuments over 
 the root of the nose into deep longitudinal 
 rugae : they co-operate with the orbicularis in 
 the act of frowning. The action of the subjacent 
 muscles renders the brow an important feature 
 in regulating the quantity of light, contracting 
 the field of vision, and in assisting the expression 
 of the sterner passions. It would not be a use- 
 less ornament if it were insusceptible of motion, 
 the hair being advantageously placed upon the
 
 32 ANATOMICAL DESCRIPTION OF THE 
 
 projecting ridge of the orbit to entangle and ar^ 
 rest particles, solid and fluid, which might other- 
 wise fall or trickle upon the eye. The habitual 
 depression of the brow is usually a concomitant 
 of a weak or morbid retina ; it is characteristic 
 of strumous inflammation, and is observable in 
 all cases where light is offensive^ and in those 
 central circumscribed opacities of the cornea 
 and lens, in which the dilated state of the pupil 
 is necessary to vision. 
 
 Eydids. The palpebr^, or eyelids, are those semi- 
 
 oval curtains which cover the great aperture of 
 the orbit, and graduate the light falling upon 
 the eye by the degree of their separation, or ex- 
 clude it by their apposition. The skin covering 
 the palpebree is thin, and loosely connected to 
 the subjacent parts by a fine lax cellular texture, 
 which abounds at the orbitar margins of the 
 palpebrffi. The frequent oedema of the eyelids, 
 so disfiguring to the countenance, is owing to 
 the abundance of this tissue void of fat, and 
 subject therefore to serous infiltration. 
 
 The superior is broader than the inferior pal- 
 pebra, covering two-thirds of the surface of the 
 globe by its descent. It is also more moveable, 
 the inferior palpebra being inconsiderably ele- 
 vated to meet it in shutting the eye. The su- 
 perior palpebra, when drawn up, makes a dou- 
 bling or deep crescent-shaped fold in the skin
 
 AND ITS APPENDAGES. 
 
 33 
 
 under the orbitar arch, wliich is effaced when the 
 palpebra falls. Upon the skin of the lower eye- 
 lid narrow and gently curved rugae are seen; 
 these, which are signs of the unequal contracti- 
 lity of the skin and the muscular fibres beneath 
 it, are more strongly marked in persons of ad- 
 vanced years, in whom the muscles have been 
 longer and more vigorously employed, and whose 
 skin is loose or redundant from the absorption of 
 the adeps beneath it. 
 
 When the eyelids are forcibly closed by the con- Orbicular 
 traction of the sphincter fibres of the orbicularis the eyelids. 
 palpebrarum, the tendon of this muscle starts for- 
 ward, and the rugge are extensively radiated from 
 the nasal angle over the skin of the cheek. On re- 
 movingtheskin and the subjacentcellular tissue of 
 the palpebrae, the thinly spread fibres of the orbi- 
 cularis muscle are seen. The tendon with which 
 these fibres are connected is a little round cord, 
 distinctly seen and felt beneath the tegument, 
 implanted in the nasal process of the maxillary 
 bone, in the great transverse diameter of the 
 orbit. The fibres which lie upon the palpebrae 
 are the interior fibres of the muscle, the fissure 
 of the lids being the axis of the oval formed by 
 it. The inferior external fibres, from the round 
 tendon and contiguous parts of the maxillary 
 bone, take an extensive sweep over the orbitar 
 ridge upon the cheek, towards the temple, where 
 they become thin and scattered. The superior, 
 
 D
 
 34 ANATOMICAL DESCRIPTION OF THE EYE 
 
 from the round tendon and contiguous part of 
 the frontal bone, take the direction of the super- 
 cihary arch ; being at their commencement con- 
 nected with tlie fibres of the corrugator, and in 
 their course blended with those of the frontal 
 muscle. The integument of the palpebrae is ad- 
 herent to the tendon of the orbicularis, w^iich 
 has been described as the ligament of the pal- 
 pebral or tarsi; and the angle of union between 
 them is larger in consequence of this adhesion, 
 than the external. The inner canthus, formed 
 wholly of the doubling of the integument, is 
 that notch, or triangular sinus, formed between 
 the tarsi and the tendon of the orbicularis. 
 
 Tarsal car- The TARSI are two clliptical cartilagcs which 
 
 ti lilies. 
 
 give figure and firmness to the palpebrge, and 
 afford a basis for the attachment of their several 
 parts. The superior is broader than the inferior. 
 Their opposite edges are broad and sloped from 
 without inward ; their orbitar edges are thin and 
 continuous with a condensed cellular membrane, 
 which is ligamentous where it is inserted into 
 the orbitar circumference, and especially at the 
 temporal side. Their temporal extremities are 
 angular, the nasal rounded. The former termi- 
 nate the fissure of the palpebrae at the tempo- 
 ral angle; the latter, which are opposed to each 
 other, and brought into contact when the lids 
 are closed, are situated at the distance of two 
 lines from the nasal angle, to which they are
 
 35 
 
 AND ITS APPENDAGES. 
 
 connected by the doublings of integuments form- 
 ins: the borders of the inner canthus. The 
 convex surface of the tarsi is covered by the 
 fibres of the orbicularis and the cellular mem- 
 brane connecting them with the integument; 
 the concave, which is exactly moulded to the 
 face of the globe, is covered by the membrana 
 conjunctiva. 
 
 The cilia, or eyelashes. The exterior bor- Eyelashes, 
 ders of the sloped edges of the tarsi, which are 
 opposed to each other, are furnished with cilia, 
 or eyelashes, disposed in three or four rows : 
 these we may therefore call the ciliary borders 
 of the tarsi. The apertures, in which their 
 bulbs are contained, are seen in the integument 
 when the cilia are extracted: they are more nu- 
 merous and longer upon the centre than the 
 extremities of the tarsal arch, and fewer and 
 shorter on the lower than the upper tarsus. 
 Their direction is curved, those from the upper 
 being arched upwards, from the lower down- ^ 
 wards. The length and fulness of the eyelashes 
 vary in different individuals. They are com- 
 monly of the same color as the eyebrows. 
 
 The meibomian follicles. Upon the inte- Foiiiciesof 
 
 1 in o Meibomius. 
 
 nor border oi the tarsus the mouths oi a row or 
 follicles, seated vertically on the concave sur- 
 face of tlie tarsus, form a slightly eminent line. 
 These follicles, when magnified by a glass, ap- 
 D 2
 
 36 ANATOMICAL DESCRIPTION OF THE EYE 
 
 pear to be small knotted tubes, resembling studs 
 of the smallest pearls, arranged for the most part 
 in parallel lines, and communicating with each 
 other at their origin from the orbitar edges of the 
 tarsi, but terminating by distinct orifices upon 
 their interior borders, which we may distinguish 
 from the ciliary as the meibomian borders of the 
 tarsi. In their length, connexion, and arrange- 
 ment, they present considerable variety. The 
 fluid, which they secrete, may be expressed in 
 a condensed form in diseased states of the folli- 
 cles, or, after death, in the shape of small white 
 worms. It is an unctuous fluid lubricating the 
 tarsal edges, preventing the effects of attrition 
 from their frequent contact, and facilitating 
 their motions over the contiguous surface of the 
 globe. 
 
 '&' 
 
 Lacrymal. ThE PUNCTA LACRYMALIA, SACCULUS, AND 
 
 DUCTUS LACRYMALis. The obliquity of the tar- 
 sal edges, which are opposed to each other, 
 leaves a groove, or sulcus, between the meibo- 
 mian borders and the surface of the globe, when 
 the ciliary borders are in contact. This increases 
 in breadth toward the nasal angles of the tarsi, 
 where the puncta, or orifices of the lacrymal ex- 
 cretories, are placed upon two small conical emi- 
 nences accurately opposed, and terminating the 
 meibomian borders : they are two pinholes form- 
 ed in the cartilaginous substance, and thus pre- 
 served permanently open. Their course is at
 
 AND ITS APPENDAGES. 37 
 
 first perpendicular to the tarsi, in which direction 
 they severally form a short cul de sac j then they 
 are turned at right angles towards the nose, and 
 lie in the doubling of the skin, forming the bor- 
 ders of the inner canthus. They are, if we except 
 their orifices, purely membranous canals leading 
 to the oblong membranous sac situated in the 
 lacrymal fossa ; they terminate side by side, or 
 more frequently, in a common duct, in the up- 
 per and anterior part of this sac, under the ten- 
 don of the orbicularis. 
 
 The position and direction of the lacrymal 
 sac correspond to the fossa formed by the ante- 
 rior concave portion of the os unguis, and the 
 nasal process of the superior maxillary bone, 
 upon which it is seated ; it rises a little higher 
 than the termination of the lacrymal duct or 
 ducts, and the transverse tendon of the orbicu- 
 laris crosses the upper part of it. Below it 
 contracts into a duct, which occupies the canal 
 formed by the nasal process of the maxillary 
 bone, and the spoon-shaped process of the os 
 spongiosum applied to it. The course of this 
 duct is downward, outward, and gently slanting 
 backward ; it opens by an oblique fissure under 
 the convex scroll of the spongy bone, in the side 
 and near the floor of the nostril. A probe, intro- 
 duced from the nostril into the nasal duct, must 
 have a sharp curvature to enter it with facility.
 
 38 ANATOMICAL DESCRIPTION OF THE EYE 
 
 The membrane of the sac and duct is intimately 
 adherent to the bony parietes. The anterior and 
 exposed surface of the sac is defended by a 
 fibrous, or ligamentous expansion, derived from 
 the circumference of the lacrymal fossa. The 
 orbitar is distinguished from the nasal portion of 
 the duct by a fold, or duplicature of its lining 
 membrane, and another similar fold sometimes 
 occurs in the nasal part of the duct. The mem- 
 brane of the lacrymal canals and nasal duct is 
 abundantly furnished with mucous follicles, or 
 lacunae. The fulness of the membrane, where 
 it is reflected from the nasal extremity of the 
 duct, greatly diminishes the diameter of the bony 
 aperture, and gives it a valve-like form. The 
 diameter of the lacrymal and nasal canals exceeds 
 that of their orifices. The puncta absorb the 
 tears, which have been conducted from the la- 
 crymal ducts by the tarsi, and convey them into 
 the sac to pass ofi"by the nasal duct. 
 
 Conjunctive The TUNICA CONJUNCTIVA. The iutcgument 
 of the eyelids is inflected at the edges of the tarsi, 
 and lilies the whole of the concave surfaces of 
 the palpebrae ; is reflected upon the visible face 
 of the globe, enters into the puncta, lines the 
 lacrymal sac, and at the nasal extremity of the 
 duct is continuous with the common mucous 
 membrane of the nostrils, fauces, and alimen- 
 tary canal. 
 
 membrane.
 
 AND ITS APPENDAGES. 39 
 
 The conjunctiva, having lined the interior 
 surfaces of the tarsi, is connected to the Hga- 
 ments of the tarsi and palpebral muscles, and 
 thence reflected upon the globe, so as to form 
 an oblong sac or pouch. Its attachment to the 
 sclerotic is such as to prevent its forming folds 
 in the motions of the globe, to the freedom of 
 which it offers no impediment. As it approaches 
 the cornea, its attachment becomes more strict, 
 and at the margin of that membrane it is inse- 
 parable from it. Its continuity is ascertained 
 by dissection, but its tenuity and transparency 
 are increased, and when held to the light it has 
 a nearer resemblance to a very delicate lamella 
 of the cornea than to the conjunctiva of the 
 sclerotic. After maceration, the separation is 
 more readily effected. 
 
 The character of this membrane is so mate- its continu- 
 rially modified by its several relations with the SateHy 
 integument, the tarsi, the sclerotic, and the '^'^^^*^* 
 cornea, that its continuity alone establishes its 
 identity. The fact of continuity is, however, 
 corroborated by some pathological phenomena, 
 which so often illustrate problematical points in 
 anatomy and physiology. For example, the 
 conjunctiva furnishes the matrix for the adven- 
 titious vessels, which are created to repair 
 breaches of the corneal texture. These vessels, 
 whether formed by the healing process, or open-
 
 40 ANATOMICAL DESCllIPTION OF THE EYE 
 
 ed by long continued diseased action, as in chro- 
 nic ophthalmia, are obviously superficial. The 
 circumstances by which they are produced, are 
 characterised by different appearances, as I shall 
 hereafter point out. Again, when a small portion 
 of the conjunctiva is abraded by an extraneous 
 particle, the scabrous surface of the cornea is 
 exposed, and ulceration of this surface ensues. 
 The deficiency of the conjunctiva is exactly de- 
 picted by the margin of the abrasure, and the 
 contrast of the surfaces. This is very dissimilar 
 to the interstitial ulcer of the cornea. The 
 pterygium, a rare disease, exhibits the continuity 
 jn a very striking manner. It has a full broad 
 base next the canthus, where the conjunctiva 
 lies loose, and is gradually flattened and drawn 
 to a point, so as to have a wedge-like form as it 
 approaches the cornea. But although the depo- 
 sition is beneath the conjunctiva, it does not 
 stop at the cornea, but slowly travels across it. 
 The strictness of the adhesion alters its appear- 
 ance ; the lymph shed between the conjunctiva 
 and cornea, presenting only a progressive dense 
 opacity, instead of the fleshy elevation which it 
 exhibits upon the sclerotic. The continuity of 
 the superjacent texture is demonstrable. 
 
 Upon the tarsi the membrane is closely ad- 
 herent, and although transparent, appears of a 
 pale red tint ; upon the sclerotic and cornea it
 
 AND ITS APPENDAGES. 41 
 
 is colorless. The sclerotic conjunctiva, however 
 destitute of red vessels in the tranquil state of 
 the organ, becomes conspicuously vascular and 
 acquires a deep red color by inflammation, its 
 minutest capillaries appearing to convey red 
 blood, in the vehement acute ophthalmia. Those 
 of the corneal conjunctiva are only to be seen 
 when, by continued distention, the connection 
 is loosened between the conjunctiva and cornea. 
 In this case, the cornea exhibits red vessels 
 freely inosculating from its opposite sides, and 
 anastomosing with each other. The increase in 
 number and extent of these vessels is a gradual 
 process, demonstrable to observation, and the 
 inflammatory action which precedes this state, is 
 ordinarily of considerable duration. The inca- 
 pacity of the vessels of the corneal conjunctiva to 
 receive red blood, seems to depend upon the 
 strictness of its adhesion. 
 
 The VALVULA semilunaris, and CARUNCULA Semi-lunar 
 
 lacrymalis. The conjunctiva is attached to crymaica- 
 the canthi of the eyelids, and, at the internal can- 
 thus, forms a semi-lunar duplicature in shape of 
 a valve. The horns of this crescentic fold are 
 lost in the sinus palpebralis, or angular fold of 
 the conjunctiva. 
 
 -On the fore-part of this valve, a small red 
 glandular body, caruncula lacrymalis, is seen, 
 occupying the hollow of the canlhus. The ca-
 
 ANATOMICAL DESCRIPTION OF THE EYE 
 
 runcula is a granulated substance, of a conical 
 form and a deep red color. The base of the 
 cone is next the orbit, the apex towards the eye. 
 A few fine hairs are scattered over its surface. 
 It is made up of a congeries of minute follicles, 
 secreting that mucus which accumulates during 
 sleep in the form of a gummy matter, at the in- 
 ner corner of the eye ; and appears to perform 
 a similar office to that of the meibomian glands, 
 which are confined to the tarsi. 
 
 From the above description it will be under- 
 stood, that the palpebra, the anterior hemi- 
 sphere of the eyeball, and the lacrymal passages, 
 are every where covered by the reflected in- 
 tegument, modified in its disposition and quali- 
 ties as its economy requires-, which invests the 
 organs of sense, the hollow viscera, and forms 
 the external covering of the body. It is by 
 the continuity of this membrane that the sym- 
 pathy is established between these surfaces, 
 healthy and morbid, remote and contiguous, 
 and that the diseases with which they are 
 affected have for the most part a common 
 character. It remains only that I should point 
 out the origin and disposition of the superficial 
 vessels and nerves, by which the palpebrag are 
 supplied. 
 
 Vessels ami ThE ARTERIES, VEINS, AND NERVES OF THE 
 
 nerves of . . i • /' • i i i 
 
 theeydids. PALPEBRiE. A supcRor aucl interior orauch, de-
 
 AND ITS APPENDAGES. 
 
 43 
 
 rived from the ophthalmic artery, at its egress 
 from the orbit, course along the orbital edges of 
 the tarsi, and form by inosculation at the exter- 
 nal angle, a complete arcus palpebralis. A su- 
 perciliary arch is also formed by the union of 
 tlie superciliary artery, from the ophtlialmic, 
 with the temporal. The nasal branch of the fa- 
 cial artery assists in forming these arches, and 
 freely communicates with the frontal branch of 
 the ophthalmic. The superior coronary, trans- 
 verse flicial, infra-orbital and temporal artery, 
 participate in the supply of the palpebraa. 
 
 The veins, beginning by small radicles from 
 the opposite margins of the tarsi, form an intri- 
 cate plexus beneath the skin of the palpebras, 
 and are collected into the facial, supra-orbital, 
 and deep temporal vein. The arteries pass in 
 the direction of the orbicular fibres, the veins 
 cross them at right angles ; their direction ac- 
 cording to the breadth of the palpebrae. 
 
 The nerves take a direction similar to the 
 veins, the frontal branch of the fifth pair sup- 
 plies the superciliary and superior palpebral 
 branches ; and the infra-orbital, or first branch 
 of the superior maxillary nerve, gives off three 
 principal branches, which turn round the trunk 
 of the facial vein to be dispersed upon the lower 
 eyelid.
 
 44 ANATOMICAL DESCRIPTION, &C. 
 
 For the simple and general view which I have 
 taken of the subject of the foregoing descrip- 
 tion, if any apology be necessary, I know of 
 none more appropriate than that contained in 
 the following paragraph. 
 
 ** The study of anatomy, as it leads to the 
 knowledge of nature and the art of healing, 
 needs not many descriptions nor minute dissec- 
 tions ; what is most worth knowing is soonest 
 learned, and least the subject of dispute ; while, 
 dividing and describing the parts, more than the 
 knowledge of their uses requires, perplexes the 
 learner, and makes the science tedious, dry, and 
 difficult." Cheselden^s Preface to his Anatomy.
 
 SKETCH 
 
 PHYSIOLOGY OF THE EYE, 
 
 AND ITS APPENDAGES. 
 
 It is not my intention to enter into an abstract 
 discourse on the phenomena of vision, a subject 
 more allied to philosophy than medicine ; but 
 the preceding sketch would be incomplete with- 
 out some account of the functions of the organ, 
 and the history of its diseases would want the 
 illustration which a competent knowledge of its 
 oeconomy conveys. 
 
 I I shall suppose the reader acquainted with Preiiminao- 
 
 I ,1 .1. . . . , . . positions. 
 
 the prevailing opinions concerning the origin 
 I and nature of light ; the velocity of its move- 
 '; ment ; the meaning of the terms direct, reflect- 
 ed, and refracted rays ; the equality between 
 the angle of reflection and the angle of inci- 
 dence ; and the facts that refraction is in-
 
 46 PHYSIOLOGY OF THE EYE 
 
 creased according to the relative density of bo- 
 dies, and that the convergence of rays after re- 
 fraction is proportionate to the curvature of the 
 surface through which they pass. Further, the 
 decomposition of light by the prism into seven 
 elementary colors, which differ in their refran- 
 gibility : the reflection of all the rays together 
 producing the appearance of white ; while their 
 partial reflection occasions the various diversi- 
 ties of color, and their total absorption the sen- 
 sation of black, which is in fact but the absence 
 of color. Lastly, the emission of the rays of 
 light from every visible point of the surface of a 
 luminous body, and their divergence thence so 
 as to form a cone, of which the apex corre- 
 sponds to the point from which they emanate, 
 and the base to the surface upon which they 
 impinge. 
 
 Influence of Thc opcratiou of tlic comca upon the rays of 
 textured light is to rcudcr them convergent towards the 
 riys"of"^ retina, by reason of the sphericity of its surface, 
 '"'■ and its greater density compared with the at- 
 
 mospheric medium through v/hich they pass. 
 The rays which fall within an angle of 48°, or i 
 thereabouts, measured on the surface of the cor- 
 nea, pass through it, and are refracted in their I 
 passage Those which are not included within 
 this angle are reflected by the verge of the 
 cornea and the sclerotic coat. The aqueous 
 humour, being of inferior densitv to the cornea.
 
 AND ITS APPENDAGES. 47 
 
 tliminishes in some degree the convergence of 
 the rays which proceed through it, so that the 
 total effect is nearly the same as that which would 
 result from the refractive power of the aqueous 
 liumor alone, if the cornea had not existed. The 
 rays which lie remote from the visual axis, are 
 not transmitted through the pupillar aperture, 
 but are reflected by the iris, and in part ab- 
 sorbed by the pigment coating its posterior sur- 
 face, without which pigment it would be diapha- 
 nous, as in the albino. The superior density of 
 the crystalline co-operates with its curvature to 
 increase the convergence of the rays which are 
 admitted within the pupil ; and by their passage 
 through its posterior surface, this convergence 
 is increased, because they arrive at the vitreous 
 humor, whicli is a medium of inferior density. 
 By the operation of all these causes the rays are 
 collected into foci upon the retina, and that 
 part of the object from which the rays proceed 
 is painted upon this membrane. 
 
 The result, then, it appears, of a series of re- 
 fractions of the rays of light in passing througli 
 the humors of the eye, is their collection into 
 foci upon the retina, so as to form a complete 
 picture of the external scene. 
 
 From tliis account it will be perceived that inversion 
 each pencil will consist of a double cone of rays, 
 
 of the 
 image on 
 the retina.
 
 48 PHYSIOLOGY OF THE EYE 
 
 the axes of which are right lines, their bases 
 meeting in the crystalline and their apices being 
 situated in the object and the retina respect- 
 ively. The rays from the top of the object are 
 deflected to the bottom of the eye, and those 
 from the side of the object to the right of the 
 observer, are deflected to the left side of the 
 eye, and vice versa ; hence the inversion of the 
 picture upon the retina. The following simple 
 experiment, demonstrating this fact, is well 
 known. A portion of the coats being removed 
 from the back of the eye, and their place sup- 
 plied by a piece of oiled or tracing paper, the 
 flame of a candle placed before the cornea is 
 exhibited of diminished size and inverted. We 
 infer that this unage excites the perception of 
 the object, because distinct vision is enjoyed 
 only in such conformations and conditions of the 
 eye, as allow of its being accurately formed and 
 impressed. 
 
 Correction The ncccssary effect of the spherical figure of 
 tion from thc comca is to occasion an unequal refraction 
 fraS/^ of the rays which permeate it, and hence to cre- 
 ate a degree of aberration which would confuse 
 vision. This is corrected in two ways : — first, 
 by the gradually increasing density of the lens 
 from the circumference to the centre, and its 
 consequently refracting with less power those 
 rays which ari'ive at it with a considerable
 
 AND ITS APPENDAGES. 49 
 
 obliquity ; and secondly, by the mobility of the 
 iris, which adapting the size of the pupil to the 
 circumstances of the case, excludes more or less 
 those rays which would produce aberration. 
 
 I have stated that the iris serves to arrest office of 
 those rays which are denied admission through 
 the pupil : they would be unequally refracted by 
 those points of the lens through which, if unin- 
 terrupted, they must pass, or would fall so 
 obliquely on the cornea as to be subjected to 
 too great a refraction. This is its passive func- 
 tion ; but by its power of dilatation and con- 
 traction, in obedience to the stimulus of light 
 upon the retina, it determines the quantity ne- 
 cessary for the purpose of distinct vision. In 
 regulating the quantity of light the iris assists 
 materially in accommodating the eye to different 
 distances : in viewing a distanfobject the pupil 
 dilates, and in viewing a near one it contracts. 
 It is true that viewing the sun occasions a con- 
 traction of the pupil, and the stedfast vision of 
 a near object in deficient light, its dilatation. 
 These are confirmations of the statement that 
 its motions are in obedience to the impression of 
 hght upon the retina, because the direct emana- 
 tion of light from its source in the one case, and 
 the insufficient light in the other, render these 
 objects analogous in this respect to the nearest 
 and the remotest visible objects. But under 
 ordinary circumstances, the illumination of ob- 
 
 E
 
 50 PHYSIOLOGY OF THE EYE 
 
 jects being conformable to the distance, the pu- 
 pil, in viewing a distant object, is dilated so as 
 to admit as many rays of the enfeebled light as 
 is necessary to the distinct perception of the 
 object ; and on the other hand contracts, to ex- 
 clude the superfluous rays, which coming from 
 a near object, would otherwise create confusion. 
 Let a person survey the sun whilst the pupil is 
 fully dilated by belladonna, or under the same 
 circumstances, the flame of a candle, brought 
 near to the eye, and in either case he will find 
 his vision confused to dimness. But the fullest 
 permanent dilatation of the pupil will not injure 
 the clearness of his vision of any other remote 
 object; though that of all near objects will be in 
 a degree confused, and the confusion be in- 
 creased in proportion to the degree of their illu- 
 mination. Where the iris is from any cause mo- 
 tionless, the power of adapting the eye io dis- 
 tances is lost. I conclude, therefore, that the 
 adaptation of the eye to light co-operates with 
 its adaptation to distance. 
 
 power of 
 the lens, 
 
 Corrective By the pcculiar constitution of the crystalline 
 lens, before adverted to, its refractive power is 
 so adjusted to that of the contiguous aqueous 
 and vitreous humors, as to correct the aberra- 
 tions which the figure of the cornea would oc- 
 casion, and to throw the most oblique pencils 
 of rays with sufficient accuracy upon the con- 
 cave face of the retina.
 
 AND ITS APPENDAGES. 51 
 
 Notwithstanding that man, compared with and use of 
 animals, requires the largest quantity of light for 
 vision, the images of objects on his retina are 
 undisturbed by reflection, owing to the absorb- 
 ing quality of the dark pigment ; which being 
 spread over the whole interior of the globe, 
 renders the eye a most perfect camera obscura. 
 Animals, in whom this pigment is a brilliant re- 
 flecting surface, have the advantage of seeing in 
 feebler light, and this power is in proportion to 
 the whiteness of the pigment ; but the accuracy 
 of their vision, it may be presumed, is in the 
 same proportion defective. 
 
 Not only is the clearness of the image undis- Achromatic 
 
 . . . power of 
 
 turbed by superfluous light, but it is also desti- theiens. 
 tute of color, the decomposition of light by ir- 
 regular refraction, being in ordinary vision 
 prevented or corrected by the structure and 
 curvature of the crystalline lens. Light, artifi- 
 cially separated, either by refraction, reflection, 
 or inflection, produces color; but the light which 
 arrives at the eye in its natural combination of 
 elementary rays, undergoes no such decomposi- 
 tion in its passage through the humors. 
 
 The retina is equally expanded over the vi- Field of 
 treous humor, but the field of vision is limited. 
 This is not, however, confined to the axis of 
 vision ; for in certain positions of the eye, ar- 
 E 2
 
 5Q 
 
 PHYSIOLOGY OF THE EYE 
 
 tificially induced, we have a clear perception of 
 an object from wJiicli the rays pass so obliquely 
 as to fall upon the retina not in the axis of 
 vision. It has been long observed, that if an 
 image fall upon a certain spot of the retina, the 
 perception of it is obscured. This spot, about 
 one thirtieth of an inch in diameter, corresponds 
 to the entrance of the optic nerve. 
 
 Magnitude The magnitude of the image formed upon 
 image. thc rctiua, is proportional to the angle which 
 
 the two extremities of the object viewed subtend 
 : with the centre of the eye. Hence, the more 
 
 remote the object the smaller the image. 
 
 Duration of 
 the impres- 
 sion. 
 
 The duration of the impression made upon 
 the retina is in proportion to the strength of the 
 impression ; this is illustrated by the appearance 
 of a fiery circle produced by the rapid revolu- 
 tion of a lighted stick. The principal pheno- 
 mena of ocular spectra admit of an explanation 
 in some degree similar, as for example, the ap- 
 pearance of a luminous halo after looking in- 
 tently at a colored object, remaining even after 
 the eyelids are closed. 
 
 Distance, 
 size, and 
 position of 
 objects. 
 
 The eye possesses no absolute power of de- 
 termining the actual distance, magnitude, and 
 position of objects. Such knowledge is relative, 
 and results from the experience derived from
 
 AND ITS Al'I'ENDAGES. 53 
 
 the combined agency of the senses of sight and 
 touch. 
 
 It remains that I should advert to what may 
 be termed the problems of vision, but as I liave 
 little from my own observation to offer upon 
 these subjects, and as their investigation is in a 
 considerable degree connected with the depart- 
 ment of physical optics, or of metaphysical spe- 
 culation, I shall be excused for touching them 
 lightly. 
 
 The imaffes of obiects are inverted upon tlie inversion of 
 
 ^ "^ _ the image. 
 
 retina, yet we see them, as they are in nature, 
 erect. 
 
 If we look in a concave mirror, objects ap- 
 pear inverted. The image formed upon the 
 retina is in this case erect, and we see the object 
 in the same relative position to the image, as all 
 other objects. Of this fact any one may con- 
 vince himself, by preparing an eye, as before 
 mentioned, and placing beside and a little be- 
 hind the flame of the candle a spoon, the hollow 
 of which reflects it inverted, when he will ob- 
 serve, on the opposite side of the oiled paper, 
 the images of the real and the reflected object, 
 the first inverted, the second erect. 
 
 It has been generally supposed that we actu- Common 
 ally see objects inverted, and that this error of 
 the sight is corrected by experience. Some, on
 
 54 PHYSIOLOGY OF THE EYE 
 
 the contrary, have supposed that the mind ac- 
 quires the perception of objects, not from the 
 picture upon the retina, but from the object it- 
 self, by retracing the direction of the pencils to 
 their points of radiation. Others assert, that a 
 decussation of the fibres of the optic nerve cor- 
 rects the erroneous impression before it is pre- 
 sented to the sensorium. 
 
 Berkley's Thc cclcbrated explanation of Berkley, in so 
 ^°'^' far as it admits of an abridged exposition, is as 
 follows. Visible and tangible ideas occupy dis- 
 tinct provinces, and have originally no affinity 
 to each other. It is only by experience that they 
 become connected. The impressions on the 
 organ of sight suggest by association the ideas 
 of objects acquired by the sense of touch, just in 
 the same way as the word used to denote an ob- 
 ject immediately suggests the idea of that object, 
 to a person who is familiar with the language. 
 The image on the retina is merely the instru- 
 ment, not the object of vision. Its position has 
 originally no influence on the ideas we form of 
 the situation of external objects ; and the sup- 
 posed difficulty in the case of the inverted images 
 arises from confounding ideas derived from the 
 sense of touch with those derived from the sense 
 of sight*. 
 
 * A person born blind and suddenly restored to sight, is 
 the case supposed by Berkley and other writers, and so hap- 
 pily exemplified by Cheselden. Such a person, it is clear, 
 would gain nothing by the aid of sight, until the connection
 
 AND ITS APPENDAGES. $5 
 
 The association of ideas, derived as they are intercourse 
 from the external senses, operates imperceptibly Tenses ne- 
 to an extent that we have no means of ascer- S deve- 
 taining, because the original and absolute nega- "p^""^"^' 
 tion of each sense in succession, so that each 
 should be in turn insulated, is an impossible con- 
 dition, notwithstanding the seemingly possible 
 independence, in a state of society at least, of 
 the animal and vital functions. Touch, in the 
 extended sense of physical feeling, is the basis 
 of all ; sight, hearing, smell, and taste, like the 
 sense of touch itself in its strict and limited im- 
 port, are but modifications of it. That either 
 
 between touch and sight grew up and established itself in 
 his mind. 
 
 " L'objet propre et immediat de la vue n'est autre chose 
 que la lumiere coloree : tout le reste, nous ne le sentons qu'a 
 la longue et par experience. Nous apprenons a voir precise- 
 ment comnie nous apprenons a parler et a lire." — Voltaire. 
 Physique Nervtonientie, Chap. 7. 
 
 Our Shakspeare who ' needed not the spectacles of books to 
 read nature, but looked inwards and found her there/ puts 
 this distinction with admirable force and shrewdness, in the 
 dialogue between Gloster and the fellow who feigned to be 
 cured of his native blindness at St. Alban's shrine. 
 
 Gloster. 
 
 Saunder, sit there, the lying'st knave in Christendom. 
 
 If thou hadst been born blind. 
 
 Thou might'st as well know all our irames, as tlius 
 
 To name the several colours we do wear. 
 
 Sight may distinguish colours : 
 
 But suddenly to nominate them aU^ > 
 
 It is impossible. 
 
 2d Part of King Henry VI. Act 2.
 
 PHYSIOLOGY OF THE EYE 
 
 or all of these therefore should be wanting, is 
 not incompatible with their constitution ; but 
 the sense of contact is so essentially and indivi- 
 sibly incorporate with the organic nervous sys- 
 tem, that its negation would be paramount to 
 acephalous monstrosity. Hence its influence as 
 a substitute and corrector in relation to the rest, 
 when wanting or imperfect, can never be fully 
 appreciated, because it cannot, like them, be 
 subjected to analytical test. But from what we 
 see of the effects of privation of one or more of 
 the external senses, and of their reciprocity in 
 general towards each other in cases of malforma- 
 tion and disease, is it not in the highest degree 
 probable, that their natural intercourse and co- 
 operation are essential to the developement of 
 each respectively ? To illustrate my meaning — 
 If it be possible to suppose a case in which the 
 eye was the only external organ of sense, would 
 the unfortunate possessor have any distinct idea 
 of visible objects ; or, mutatis mutandis, the ear 
 of sounds ? Certainly not. Dumbness is in most 
 cases only a consequence of the absence of hear- 
 ing 5 the organs of speech are perfect: so the 
 loss of visual perception (not of light more than 
 of unharmonized articulation) would result in 
 the case supposed, from the absence of the as- 
 sociated sensations and ideas thence derived. 
 
 Single How it liappcus that impressions made upon 
 
 our two eyes at one and the same time are re- 
 presented single to the sensorium, we know as 
 
 vision.
 
 AND ITS APPENDAGES. 57 
 
 little as why we hear one sound with two ears, 
 and smell one scent with two nostrils. The 
 mind is incapable of receiving two distinct im- 
 pressions at the same instant. The interval is 
 too small to be measurable, but the simple expe- 
 riment of Haller affords unexceptionable evi- 
 dence of the fact, that we employ our eyes se- 
 verally, and not at the same instant, in distinct 
 vision *. 
 
 But we know that if the direction of the two Double 
 eyes .is in conformity, each with the other, ob- 
 jects appear as they are, singly ; and that when 
 a certain divergence or derangement of the vi- 
 sual axes exists, objects appear double. If the 
 image, for example, is thrown upon a point of 
 the retina of one eye, not in correspondence 
 with the spot impressed in the other, this effect 
 is produced. The double image of a candle is 
 seen when gentle pressure is made on the globe 
 of one eye ; and it is either on the horizontal or 
 vertical direction, according as the finger is ap- 
 plied to the side of the cornea, or below it. It 
 is observed that a more considerable inclination 
 of the optical axis is required to produce a dou- 
 ble image in the transverse than in the vertical 
 plane. 
 
 We are not, however, to conclude, that a Double vi- 
 double image is formed only, when the obliquity one eye. 
 
 Elem. Phys. Vol. V. Sec. IV. 9.
 
 58 PHYSIOLOGY OF THE EYE 
 
 of the optic axis is such, as to throw the image 
 beyond the area of the points of correspondence 
 in the .retina. It may happen when but one eye 
 is employed, from a partial compression of the 
 retina, optic nerve, or cerebrum, or some pecu- 
 liarity of figure, or opaque streaks in the humors 
 intercepting the radiant pencils, so as to produce 
 a double refraction. 
 
 Double vi- Neither is double vision a common result of 
 strabismus, strabismus where the distortion of one eye is 
 obvious and permanent ; for in squinting, whe- 
 ther congenital or acquired, the distorted eye is 
 weak in comparison with its fellow, and in the 
 majority of cases the loss of association is the 
 consequence of its weakness. It is, in fact, 
 wholly unemployed in intent vision, which it 
 would only tend to confuse. Wliere double vi- 
 sion occurs, it is seldom if ever a permanent 
 symptom, although the squint becomes con- 
 firmed, or even increases. The disappearance 
 of this symptom might be accounted for by the 
 very probable accommodation of the deranged 
 eyes, and the substitution of new points of cor- 
 respondence in the distorted eye under the in- 
 fluence of habit ; but in every instance of devia- 
 tion, I believe it will be found that the averted 
 eye is unfit, in respect of power, and therefore 
 ceases to associate with its fellow. Even in the 
 cast or leer the affected eye is unemployed in 
 vision. The focal distance of the two eyes is 
 in such cases so much at variance, that confu-
 
 AND ITS APPENDAGES. 59 
 
 sion would necessarily result from their simulta- 
 neous employment, if that were possible. This 
 question is not affected by the arguments which 
 go to prove, that for the purpose of intent vi- 
 sion, one eye only is or can be employed at the 
 same time. The points of correspondence are 
 essential to preserve the unity of vision, because 
 an indistinct or confused perception, or a double 
 image, would be produced in the state of indo- 
 lent vision, when it is admitted that both are 
 employed. The defective eye, it is true, ex- 
 tends the field of sight ; but if the sound eye be 
 closed, the person discovers that he is indebted 
 to it for little more ; and therefore, if it corre- 
 spond in direction with its fellow, he finds an 
 advantage in closing it for the purpose of accu- 
 rate vision ; if it is permanently averted, it is as 
 much unemployed, as if it were closed. Cases 
 have occurred in which the exclusive employ- 
 ment of the averted eye has at length restored 
 its tone and direction. The squinting eye re- 
 covers its position when the sound eye is closed, 
 but relapses when the latter is again opened, be- 
 cause its employment ceases. Cases of squint 
 arising from mechanical causes are of course ex- 
 cepted in this observation, being incapable of 
 even temporary rectification ; but in these the 
 turned eye is idle. 
 
 It must be evident to all persons who consi- Adjustment 
 der the subject, that the rays of light which issue objecuat
 
 60 PHYSIOLOGY OF THE EYE 
 
 iiifferent dis- froin ail object at some distance from the eye, 
 and tliose issuing from a much nearer object, 
 cannot be collected into foci at the same given 
 distance behind the crystalline lens, unless the 
 eye have a power of altering its focal distance. 
 It must do for itself what a convex glass does 
 for those, who by reason of a certain configura- 
 tion cannot see near objects distinctly, or a con- 
 cave glass for those who have no distinct sight 
 of objects beyond a moderate distance. In the 
 first, owing to a defective refracting power, the 
 rays cannot be brought to a focus soon enough ; 
 in the second, owing to too great a refractive 
 power, they are brought into a focus too soon. 
 The picture in the one, without the aid of the 
 glass, would be formed behind the retina, and 
 in the other anterior to it. The point of perfect 
 indolent vision, or the extreme focal distance of 
 the eye, and the range or space through which 
 it has the power of preserving distinct vision 
 nearer to the eye, varies in different individuals^, 
 and very often, as before stated, in the eyes of 
 the same individual. 
 
 Various iiy- I shall contcut mysclf with a very brief men- 
 o leses. ^.^^^ ^^ ^j^^ principal hypotheses to explain the 
 
 adjusting mechanism. To enumerate all with 
 barely intelligible conciseness, would occupy a 
 large portion of this volume; such is the inte- 
 rest which this subject has excited. It has been 
 ascribed to a change of figure in the cornea, to
 
 AND ITS APPENDAGES. 6l 
 
 the variations in the diameter of the pupil, to a 
 change of figure of the globe by the action of its 
 muscles, to a change of figure of the lens by an 
 action proper to itself, to a change of place of 
 the lens by the contraction of the ciliary pro- 
 cesses, and the compression of the vitreous hu- 
 mor at its circumference. 
 
 The first supposes a close aponeurotic expan- 
 sion derived from the tendons of the recti 
 muscles, bracing the anterior segment of the 
 globe; the second assumes the muscularity of 
 the iris, or the extension of its texture, by the 
 sudden injection of its vessels, and vice versa, 
 its abridgement by their contraction ; the third, 
 a power in the muscles of the globe either to 
 shorten or elongate its axis ; the fourth attri- 
 butes muscularity to the crystalline ; and the 
 fifth a similar structure to the ciliary processes. 
 
 I shall not enter into a discussion of the 
 merits of these hypotheses, because no one, I 
 believe, disputes the force of the objections to 
 which they are more or less exposed. 
 
 A healthy state of the retina, of the crystal- Conditions 
 line lens, and of the iris and ciliary apparatus, 
 are conditions indispensable to the perfection of 
 this mechanism. It is impaired in proportion to 
 the debility of the retina in the various forms 
 of amaurosis ; it is suspended during the per- 
 
 requisite.
 
 62 PHYSIOLOGY OF THE EYE 
 
 manent contraction or dilatation of the pupil, 
 and it is lost after the removal of the crystal- 
 line under the most favorable circumstances ; 
 but the failure of any one of these conditions, 
 exclusively, is destructive to it ; as for example, 
 though the retina and crystalline be healthy, if 
 the iris be motionless, or though the retina be 
 sound and the iris active, if the crystalline be 
 absorbed. I know that very different statements 
 have been given to the public, so different in- 
 deed as to be almost the converse of these. I 
 am ready to admit that the results are subject 
 to modifications, as the cases vary, and no two 
 are exactly similar ; but these are the general re- 
 sults of my experience. I have already said that 
 the iris, by regulating the quantity of light, as- 
 sists in the office of adjustment to distance, and 
 that these functions are in a degree consenta- 
 neous. I am disposed to consider adjustment 
 as the result of a change of figure in the lens, 
 such as we may coarsely imitate by gentle pres- 
 sure of the crystalline of the horse or ox, held 
 in a vertical position between the thumb and 
 fore finger. Its form and lamellated texture 
 render it peculiarly susceptible of such a change, 
 and the absence of a connecting medium be- 
 tween its plates, indeed of any vascular organi- 
 zation, prevents the possibility of a nebulous ob- 
 scurity resulting from pressure so applied. A 
 very slight increase of its curvature, we have 
 been informed, on competent authority, would
 
 AND ITS APPENDAGES. 63 
 
 be sufficient to explain the phenomenon of ad- 
 justment, assuming its quiescent state, which its 
 elasticity tends incessantly to restore while sub- 
 jected to compression, as that fitted for perfect 
 indolent vision. 
 
 Notwithstanding the absence of anatomical in? m part 
 
 z» T 1 11 • r> 1 muscukr, 
 
 prooi, 1 cannot but regard the motions of the 
 iris as muscular motions, and the pupillary por- 
 tion an orbicular sphincter, such as environs the 
 several outlets or apertures of the body. To this 
 structure I attribute its uniformity under varying 
 magnitudes — its incapacity of contraction, when 
 having a fixed point, as happens in some mal- 
 formations ; when confined by adhesion at any 
 point of the circle to the capsule of the lens, or 
 when its texture has been the subject of adhesive 
 inflammation — its recovery of a prolapse through 
 a section of the cornea, and resuming its circu- 
 lar figure when overstretched, as in extraction, 
 by a gentle friction of the eyelid — the extreme 
 velocity of its contraction, and the comparative 
 slowness of its relaxation — its ordinary preserva- 
 tion of a mean or middle state, between the spas- 
 modic contraction induced by acute inflamma- 
 tion, and the dilatation we must from ascertained 
 phenomena presume to be induced, by absolute 
 darkness long continued — its inferior power of 
 contraction in children, and the increase of its 
 power by exercise, as in artisans incessantly em- 
 ployed upon minute objects, in whom it is apt
 
 64 PHYSIOLOGY OF THE EYE 
 
 to acquire a rigidity which scarcely admits of di- 
 latation — ^its obedience, in all respects, to the 
 laws which regulate the muscular system — its 
 contractihty in proportion to the strength and 
 perfection of the nerve of sense with which it 
 is associated — its incapacity of perfect contrac- 
 tion when tremulous, and its spastic contrac- 
 tion, even to the resistance of the influence of 
 belladonna, in tetanus — its relaxation when the 
 sphincters are relaxed, as in syncope, asphyxia, 
 apoplexy, or compression of the brain, and after 
 the use of alcohol in excess — its complete dila- 
 tation when under the influence of the sedative 
 poisons, as opium, hyoscyaraus, belladonna, &c. 
 to which its proper nerves are in a peculiar man- 
 ner irritable. 
 
 and partly Thc ciUary portion of the iris I regard as an 
 elastic structure. It is by virtue of its elasticity 
 that the extraordinary dilatation of the pupil, 
 such as we see under the use of belladonna, is 
 produced. Here as in other parts, elasticity is 
 opposed to muscular motion ; hence when the 
 latter is paralysed or from any cause diminished, 
 the former strikingly predominates ; when the 
 nervous supply is intercepted, the pupil gapes 
 widely, the action of elasticity being independ- 
 ent of the sensorium. 
 
 Pupils of ^11 animals which have a moveable iris, 
 
 animals. j^^vc the pupil circular, oblong or elliptical,
 
 AND ITS APPENDAGES. 65 
 
 forms favourable to the arrangement of marginal 
 fibres*. In fish the iris is evidently a prolonga- 
 tion of the choroid without interruption of conti- 
 nuity; it is therefore motionless. I concentrated 
 the sun's rays in the focus of a pocket lens, and 
 threw them upon the pupil of a perch, at the 
 moment of drawing it from the water ; it under- 
 went no change. In other animals it contracted 
 to a line, vertical (cat) or horizontal (adder, toad,) 
 according to the figure of the pupil ; or to a small 
 pin's head aperture, where it was of a circular 
 form, as in the common snake. 
 
 If we look through the vitreous humor ex- Theory of 
 
 T p , , • , . the author. 
 
 posed tor a small space on its posterior aspect, 
 we observe the plicse advancing upon its ante- 
 rior surface beyond the margin of the lens, like 
 a circular fan or screen ; if the lens is pressed 
 evenly backward, the pHcae separate and extend 
 the sacculated circle of Petit, to which their 
 edges are affixed. On remission of the pres- 
 sure the lens springs forward, and the leaves 
 of the fan are closed. The circumferential 
 compression of the globe increases the close- 
 ness of their application. In the dead body, 
 only the most coarse and remote analogies can 
 be obtained to the functions of the living. But 
 I cannot believe so obvious and yet so exquisite 
 
 * It is worthy of notice^ that fish in which the iris is with- 
 out motion, furnish the remarkable exceptions ; viz. the dol- 
 phin, the skate, the cuttle, &c. 
 
 F
 
 66 PHYSIOLOGY OF THE EYE 
 
 a contrivance for changing the site and figure 
 of the apparatus, as this view affords, can be 
 without necessity or occasion. Looking then at 
 the posterior origin of the processes from the 
 choroid, and their attachment externally to the 
 ciliary ring ; their insertion into the vitreous 
 capsule to the edge of the fossula, their en- 
 croachment upon the anterior segment of the 
 crystalline, and their termination by distinct 
 prolongations in the substance of the iris at its 
 great circumference ; assuming the choroid and 
 annulus as fixed points, and the iris and pro- 
 cesses as the moveable parts of the apparatus, 
 it follows that the plicae will be unbraced and 
 partially open in the state of mean dilatation of 
 the pupil, belonging to passive or atonic vision, 
 and in the state of extreme dilatation of the 
 pupil accompanied with blindness to near ob- 
 jects, totally relaxed and floating. On the con- 
 trary, by the steadily contracted state of the pu- 
 pil suited to the nearest extremity of the focal 
 range, they will be closed and braced together ; 
 and, bearing upon the circumference of the crys- 
 talline at every point, will necessarily elongate 
 the axis of the lens. These being the extreme 
 states, so, in proportion, the intermediate de- 
 grees of adaptation will be accounted for. 
 Hence the actions of the pupil, however excit- 
 ed, will extend their influence to the lens, and 
 by this catenation of motions the general con- 
 formity of adjustment to light and adaptation
 
 AND ITS APPENDAGES. ^'J 
 
 to distance are to be explained. And this forms 
 no objection to the hypothesis; because it is only 
 in the voluntary and steadily preserved contrac- 
 tion of the pupil that the latter object is or can 
 be required ; for blindness would as surely en- 
 sue from gazing on the sun, as death from sus- 
 pending the actions of the respiratory muscles, 
 were it in our power to do either ; and there- 
 fore the involuntary has the ascendancy over 
 the voluntary action in both these cases, as it 
 has in all cases of mixed muscles. 
 
 Radiated fibres are described by Zinn and Uveaipro- 
 
 TX11 • ^ ^ • r x*!-*' longations 
 
 Haller as raised on the posterior race or the ins, of the cm- 
 and advancing even to the margin of the pupil, cesses!^' 
 They are distinct from those seen upon its an- 
 terior surface, and regarded as continuations of 
 the ciliary processes. In man no such fibres 
 are distinguishable by the naked eye ; but if the 
 observation, how^ever obtained, be correct, it 
 affords a strong presumption in favour of the 
 power of the iris to change the figure of the lens 
 by the instrumentality of the plicae. The cap- 
 sule, it is true, is fixed by the processes, but this 
 opposes no impediment to the change sup- 
 posed; for the membrane of Petit, to which 
 alone the processes are affixed, is relaxed when 
 they are closed, and extended when they are 
 separated, and thus permits the capsule to 
 yield only in the degree required for the change 
 of figure of the lens ; or, in other words, pre- 
 
 r2
 
 68 PHYSIOLOGY OF THE EYE 
 
 serves its exact adaptation to the face of the 
 lens in its opposite and varying states. This I 
 take to be the use of the membranous circle of 
 Petit, that it gives the processes the complete 
 command of the continuous capsule. 
 
 Some cases of dilated pupil are accompanied 
 by a bulging of the lens. This is not the effect 
 but the cause of the dilatation, for it never fol- 
 • lows the application of belladonna, provided the 
 
 capsule be entire ; but if from any cause the 
 lens be protruded so as to bear down the natural 
 resistance of the processes, the pupil becomes 
 dilated by its pressure. 
 
 Faculty of It would Tcquirc a more intimate acquaint- 
 how far°n- ance than we possess with the economy of the 
 inimais! various classcs of animals, to determine the se- 
 veral degrees in which they enjoy or require 
 the power of adaptation to distances ; but al- 
 though many unquestionably have a great reach 
 of sight, it is highly improbable that any animal 
 approaches to man in minuteness or accuracy of 
 near vision. The curvatures of the cornea and 
 lens, which are inverse to each other, and the 
 corresponding variations in the quantity of the 
 aqueous humor, are obviously appropriated to 
 the different densities of the media in which 
 they habitually dwell. 
 
 The crystalline of man, compared with ani-
 
 AND ITS APPENDAGES. 69 
 
 mals, is of the softest consistence, and occupies 
 the smallest portion of the vokune of the eye- 
 ball. The firmness of the crystalline is always 
 in proportion to its convexity. 
 
 The absence of the processes in fish ; their 
 very slight indication (being close and delicate 
 striae instead of folds) in birds, and such reptiles 
 as possess them ; the absence in all of the mem- 
 brane and circle of Petit, and the insertion of 
 the processes into the capsule of the lens in the 
 latter classes, offer a marked contrast to the ap- 
 pearances observed in man and quadrupeds, in 
 whom they are full and strongly marked, and 
 especially at the salient angle opposite to the 
 crystalline, where they are unadhering and free 
 to move. In fish, as we have said, the pupil is 
 without motion ; in birds and reptiles, as in man 
 and quadrupeds, its motions are vivacious ; in 
 some we are told, voluntary, which, whether it 
 be so or not, must be stated on pure conjecture. 
 The adjusting power in fish and birds has been 
 attributed to other mechanism, on account of 
 certain peculiarities of structure, which seemed, 
 prima facie, to be adapted to that purpose, as 
 the choroid gland in fish, and the pecten in 
 birds; or of such deviations from the human 
 structure as rendered the several hypotheses in- 
 applicable. 
 
 I believe that the motions of the iris in ani- 
 mals are single, and obedient solely to the sti-
 
 70 PHYSIOLOGY OF THE EYE 
 
 mulus of light, and that they have no control 
 over the pupil by volition; a property which per- 
 tains exclusively to the adjusting power, and 
 which is exerted independently of the variations 
 of light. It is probable that they possess it in 
 so far only as it results from the adaptation to 
 light. 
 
 The iris is a mixed muscle ; its motions are 
 regulated in part by the stimulus of light upon 
 the retina, and in part by an effort of the will. 
 
 invoiun- That the motions of the iris which take place 
 
 upon the sudden changes of light are involun- 
 tary, there can be no doubt, for they are ob- 
 served even in sleep, when the will cannot be 
 exerted, and in the earliest infancy. There is 
 another proof that these motions are involun- 
 tary, viz. that they occur in some forms of per- 
 fect amaurosis, I have seen the pupil act 
 briskly, where the person has been totally de- 
 void of the perception of light from bright sun- 
 shine, or the flame of a candle held before the 
 eye. 
 
 The sympathy of the iris with the retina 
 must be ascribable to a communication between 
 the retina and the ciliary nerves which supply 
 the iris. The small lenticular ganglion from 
 which these nerves are derived, lies upon the 
 optic nerve, and is probably the medium of 
 communication.
 
 AND ITS APPENDAGES. 71 
 
 On the other hand, every one may satisfy anavoiun- 
 
 1 . ta^'y motion 
 
 himself of a power which the will is capable of of the ins. 
 exercising over the iris, in viewing alternately 
 near and distant objects ; the state of relaxation 
 or moderately dilated pupil being suited to the 
 remote, and its tonic or relatively contracted 
 state to the near object. It is seldom that this 
 change is sufficient to be obvious to a bystander 
 where the light remains unchanged, because the 
 faculty is seldom exercised in these circum- 
 stances 5 and still more rare for the state of accom- 
 modation to be preserved in defiance of the 
 changes of light, because it is an unnatural ef- 
 fort. I have several times observed, in persons 
 whose eyes were steadily fixed upon an object 
 at some yards' distance, that the approach of a 
 candle towards the eye did not stimulate the 
 pupil to contraction, until it was so placed as 
 that its image should fall upon the most sensible 
 part of the retina, when the pupil instantly con- 
 tracted. So that the voluntary is in subordina- 
 tion to the involuntary power, where they are 
 opposed ; that is, when the stimulus of light op- 
 poses the adaptation of the eye to distance. But 
 by continued application, the mind is capable of 
 acquiring over the motions of the iris an extra- 
 ordinary power, as is well known to be the case 
 with other muscles subjected in any degree to 
 volition. Of this I have seen two or three re- 
 markable instances, but none so striking as that 
 of my ingenious and learned friend Dr. P. M.
 
 7^ PHYSIOLOGY OF THE EYE 
 
 Roget, in whom, I may be permitted to say, 
 profound scientific knowledge is accompanied by 
 a characteristic aversion to ostentatious display. 
 It affords me much pleasure to lay before my 
 reader the peculiarity to which I have alluded 
 in the person of Dr. R. as described by himself, 
 at my request. 
 
 " Bernard Street, Russel Square, 
 Feb. 21, 1820. 
 
 " MY DEAR SIR, 
 
 " I am much pleased with the view you design 
 to take, in your intended work, of the subser- 
 viency of the motions of the iris to the changes 
 which accompany distinct vision at different 
 distances, and of these motions being subordi- 
 nate to the effect of light on the retina ; and 
 the more so as they accord with a circumstance 
 relative to my own eyes which I have often 
 made the subject of experiment, and which you 
 will probably recollect my shewing to you some 
 years ago. 
 
 " When I have stated that I possessed the 
 power of dilating and contracting at pleasure 
 the iris, the fibres of which are usually consi- 
 dered as no more under the dominion of the 
 will than the heart or blood-vessels, my assertion 
 has, in general, excited much astonishment. 
 Such, however, is strictly the fact. I can easily 
 satisfy any person who witnesses the movements
 
 AND ITS APPENDAGES. 73 
 
 I can produce in them, that this power is totally 
 independent of the influence of light ; since I 
 can effectually exert it, although the position of 
 my eye with regard to the window or candle, as 
 well as the direction of the optic axis, continue 
 unchanged. However singular this power may 
 appear, it admits, I conceive, of a very natural 
 explanation. The effort of which I am con- 
 scious, when performing the voluntary contrac- 
 tion of the pupil, is the same as that which ac- 
 companies the adaptation of the eye to the 
 vision of near objects, and is of course product- 
 ive of an increase of its refractive power. This 
 very same power of moving the iris is in fact 
 possessed, in a greater or less degree, by every 
 person who enjoys the faculty of distinct vision 
 at different distances. It is accordingly well 
 known, that if a person after looking at a dis- 
 tant object, transfers his attention to a near 
 object, the pupil always contracts. But this 
 change, it is supposed, can never be effected, 
 unless some real object or image, from which 
 light radiates, be present to direct the sight. 
 I have never, indeed, met with any person be- 
 sides myself, who, while steadily directing his 
 eye to a distant object, and while no other ob- 
 ject intervened, could, by a mere effort of voli- 
 tion exerted on the eye, augment its refractive 
 power so as to adapt it to the vision of near 
 objects. That I have acquired such a power I 
 can ascribe to no other cause, than to my hav-
 
 74* PHYSIOLOGY OP THE EYE 
 
 ing from my childhood, been much in the habit 
 of observing optical phenomena, and of prac- 
 tising various experiments relating to vision, a 
 subject which I early took great delight in cul- 
 tivating. 
 
 " It is still more easy for me, while an object 
 is placed near my eye and distinctly seen, im- 
 mediately to relax the organ so as to fit it for 
 the distinct vision of the most distant objects ; 
 and these changes I can effect in succession 
 with considerable rapidity, each change being 
 accompanied with a corresponding enlargement 
 or diminution of the pupil. The increasing the 
 refractive power of the eye, is always the change 
 that constitutes the effort ; the state of vision 
 adapted to parallel rays being that of com- 
 plete relaxation. The effort which attends 
 this voluntary contraction of the pupil, when 
 there is no object before the eye to call for such 
 a change, is followed by a sense of fatigue ; and 
 if often repeated or too long continued, it be- 
 comes painful, and continues so for some time 
 afterwards. The fatigue is felt almost exclu- 
 sively in the eye to which my attention had 
 been directed during the experiment, although 
 the same change in the refractive power takes 
 place, and I believe to the same extent, in the 
 other eye. It is also remarkable, that when 
 there exists a real object of sight which is 
 looked at, and which requires an equal change
 
 AND ITS APPENDAGES. 75 
 
 in the eye for distinct vision, as in the former 
 case, no sense of fatigue, or hardly any, is ex- 
 perienced. 
 
 *' I need scarcely add, that while I thus alter 
 the refractive power of my eye from that which 
 adapts it to the distance of the objects I look 
 at, those objects appear indistinct, from their 
 images either forming before the rays reach the 
 retina, or tending to form beyond it. 
 
 " I am, 
 
 *' DEAR SIR, 
 
 " very faithfully yours, 
 
 " p. M. ROGET." 
 " B. TRAVERSj ESQ.'* 
 
 In addition to the nerves derived from the ciUary 
 
 1 .. T T ii • • • , nerves from 
 
 lenticular ganglion, the ins receives two or more the nasai. 
 branches from the nasal nerve (5th pair) and 
 its actions may possibly be subjected to the will 
 by virtue of the influence which these nerves 
 convey, for from the same source is derived the 
 nerve which supphes the levator palpebrse, which 
 is purely a voluntai-y muscle.
 
 76 PHYSIOLOGY OF THE EYE 
 
 The limited motion which the pupil has 
 when the retina is for the most part insensible, 
 may be considered as an involuntary or auto- 
 matic motion, similar to that which in a healthy 
 eye affords protection to the retina ; and if, as 
 sometimes happens, the iris contracts in a state 
 of blindness, this likewise must be regarded as 
 its involuntary action, for volition cannot pre- 
 ' cede sensation. It is probable that those mo- 
 tions of the iris, which are in conformity to 
 the impressions of light upon the retina, are 
 purely involuntary ; and that those which are in 
 conformity to the situation of objects, and are 
 therefore directly subservient to vision, are un- 
 der the influence of the will. Hence the de- 
 pendence of the adjusting faculty upon the per- 
 fection of the retina. 
 
 Lenticular The ganglia have been conjectured by an in- 
 
 ganglion. 
 
 genious author to be bars or stops upon voli- 
 tion, and this case of the iris, which he assumed 
 to be purely involuntary, was incorrectly cited 
 in support of the hypothesis. By others gang- 
 lia have been supposed to be small sensories 
 or cerebral receptacles, capable of rendering a 
 supply of nervous energy to their filaments, by 
 which they are in a measure independent of the 
 brain and its appendages. The theory, which 
 I have ventured to suggest, attributes the vo- 
 luntary motions of the iris to nerves uncon- 
 nected with ganglia, the involuntary to those
 
 AND ITS APPENDAGES. 77 
 
 derived from the lenticular ganglion, which I 
 regard as a direct medium of communication 
 between these nerves and the retina. 
 
 The phenomena of ocular spectra, or images ocuiar 
 of luminous objects remaining upon the retina "p^*^"' 
 after the external impression is withdrawn, are 
 highly interesting and curious. Luminous sparks 
 and flashes, halos or variously colored rings, it 
 is well known, are produced at will by friction 
 or pressure of the closed eyelids, and the first 
 are an instant effect of concussions of the brain. 
 The red is that color called up by the rudest 
 artificial pressure ; the violet by the slightest ; 
 and the gentlest impulse is the natural one, in 
 which the light suffers no decomposition. Are 
 these appearances really retinal impressions, or 
 illusory mental phantasms, founded on the feeble 
 and obscure analogy subsisting between mecha- 
 nical pressure and the impression of light ? Al- 
 though blind persons see such appearances, I 
 doubt if they ever present themselves in cases 
 where the retina is disorganised, or after the 
 extirpation of the eyeball, as the mutilated feel 
 their fingers and toes. They seem to me there- 
 fore to establish the essential connexion be- 
 tween the retina and the faculty of perception, 
 or the connexion between the corporeal and 
 mental impressions ; and this is confirmed by 
 what we observe of morbid spectra, which are
 
 78 PHYSIOLOGY OF THE EYE 
 
 symptoms of various disordered states of the 
 retina, of which I shall speak hereafter. 
 
 I have said that the duration of an impres- 
 sion is in proportion to its intensity. The ex- 
 periment of the revolving fire-stick demonstrates 
 that the impressions upon single points of the 
 retina, although successive, become blended or 
 confused by vividness and consequent propor- 
 tionate duration ; for if it were not luminous, 
 the appearance of a continuous circle would 
 
 Direct. scarcely be produced. Spectra are direct or 
 reverse. The first is the impression of a lu- 
 minous object, the shadow of that upon which 
 the eye has for some time dwelt, although with 
 no peculiar degree of intentness, and presenting 
 the outline of the object in color. This either 
 vanishes at once, or it presents a circle of the 
 primary colors, variously associated or suc- 
 cessively exhibited, in the order of their rela- 
 tion. The latter is especially the case after 
 looking at the sun or a very bright light. This 
 is the simple effect of a temporary over-ex- 
 citement of the retina, analagous to the echo 
 of a noise in our ears, by which the auditory 
 
 Reverse, nerve has been over-excited. The reverse spec- 
 trum is produced, when a color, occupying a 
 certain space, has been so intensely impressed 
 (as when for example we make the experiment), 
 as to exhaust the irritability of the retina, and
 
 AND ITS APPENDAGES. 7^ 
 
 render it inexcitable by any and every combina- ■ 
 tion of the rays of light, in which that color is a 
 constituent. Hence the color of the spectrum 
 is that which results from the abstraction of the 
 offensive ray from white light, or the reverse of 
 that of the object. The stimulus most remote 
 from that which has excited the distress, is the 
 only one to which the retina is alive, and in this 
 it finds the relief of contrast. 
 
 In another case the reverse spectrum seems 
 to depend on the excess of susceptibility in the 
 retina, as when the eye has been fixed on a 
 black ground J here the spectrum is white. 
 Hence it is that the ash grey wall, presented to 
 the eye on arriving at the mouth of a cavern, 
 has a silvery brightness. The contrast of white 
 light is alone capable of exciting the retina 
 which has been altogether deprived of its na- 
 tural stimulus. 
 
 Thus we have two states or degrees of ner- Expiana- 
 
 , _ . , " . tion of these 
 
 vous excitement ; the first, simple over-excite- phenome- 
 ment to the extent of continued or renovated 
 impression. The second, excitement to ex- 
 haustion, leaving only a negative sensibility. 
 A third state is that of non-excitement, and 
 consequently accumulated excitability. The 
 two last are directly opposed, being minus and 
 plus states of sensibility, and thus the contem-
 
 so 
 
 PHYSIOLOGY OF THE EYE 
 
 plation of a white surface gives a black spec- 
 trum, as the black gives a white one. 
 
 As they are presented to the healthy eye, 
 spectra need no further explanation. They are 
 to be referred to the preternatural duration or 
 intensity, or to the privation of the natural sti- 
 mulus. They are accordingly produced artifi- 
 cially and at will in all persons. The organ is 
 passive. The hypothesis of spasmodic action in 
 the retina is altogether gratuitous. 
 
 In the *' Anatomical Description," I have 
 unavoidably embodied the chief of what it is 
 needful to say on the economy of the append- 
 ages. A few additional circumstances, how- 
 ever, come properly to be noticed under this 
 head. 
 
 The actions Thc levator palpebrsG being purely a voluntary 
 brai muscles, musclc, the simplc suspensiou of its actiou effccts 
 the closure of the lids, as its contraction opens 
 them in the act of waking. Hence the disposi- 
 tion in the upper lid to fall announces the ap- 
 proach of sleep. In febrile and exhausted states 
 of the system, its impaired energy occasions the
 
 AND ITS APPENDAGES. 81 
 
 drooping expressed by the term * heavy-eyed*, 
 one of the most characteristic symptoms in the 
 physiognomy of disease. A similar state belongs 
 to some morbid affections of vision, of which I 
 shall have occasion to speak hereafter. A vo- 
 luntary closure of the eyelids, as when the eye 
 is from any cause irritable to light, is performed 
 by the orbicularis palpebrarum, which in some 
 casualties and morbid states contracts spasmodi- 
 cally, and the relaxation of this muscle assists 
 the opening of the closed lids. In going to 
 sleep and awaking from it, the lower lid is there- 
 fore passive ; in a voluntary shutting and open- 
 ing of the eye it participates, although inconsi- 
 derably, in both actions. Winking is an alter- 
 nation of the actions of thelevator and orbicularis, 
 and therefore a seasonable relief to the former, 
 and a means of preserving the moist and clear 
 condition of the cornea. It is performed by a 
 very slight contraction of the palpebral portion of 
 the orbicularis. The combination of the action 
 of the corrugator and orbicularis is seen in the 
 strained closure of the lids to resist their sepa- 
 ration by external force, knitting and depress- 
 ing the eyebrows, and throwing the nose and 
 forehead into folds ; and the equipoise of the 
 actions of the orbicularis and levator is evinced 
 in the approximation or screwing of the eyelids, 
 and peering, as is customary in short-sighted 
 persons. When they are both in full action, the
 
 ,8^ PHYSIOLOGY OF THE EYE 
 
 corrugator acts as a moderator to the levator j 
 the orbicularis is the antagonist of the latter. 
 
 Actions of The actions of the straight muscles in va- 
 cies of the rious Combinations, and in succession, explain the 
 ^ ° ^' several intermediate motions to those which they 
 singly perform, and the revolving motions of the 
 ball round its socket. The rotation on its axis 
 inward is performed by the superior oblique, 
 that in the opposite direction by the inferior. 
 The combined actions of the whole preserve 
 the relative position of the eye to the object, in- 
 dependent equally of the motions of the object 
 and the head. The motions of the eyes are in 
 perfect correspondence, and the will cannot 
 place them in opposition. 
 
 Superci- The prominence of the superciliary ridge, as 
 
 3mZ- well as the fulness of the brow, is subject to 
 great variety, and is sometimes an impediment 
 to the facility of operations. On the physiog- 
 nomy I need not say its influence is most marked. 
 The elevation of the eyebrow performed by the 
 occipito-frontalis co-operating with the levator, 
 in staring, and its depression and approximation 
 to the nose by the orbicularis and corrugator in 
 frowning, are habitually employed to a manifest 
 advantage in the opposite states of deficient or 
 feeble, and of superabundant or dazzling light. 
 The eye's * mute eloquence which passes speech,'
 
 AND ITS APPENDAGES, 83 
 
 belongs chiefly to its appendages. An opera 
 dancer would be as effective with a divided tendo 
 achillis, as a tragic actor who had lost the move- 
 able apparel of the orbits. 
 
 The closed eyelids are penetrated by a full Tarsi per- 
 
 1. f ^ . , . , meable to 
 
 ight, so as in ordinary circumstances to occa- ught. 
 
 sion waking, and distress to persons whose eyes 
 are inflamed. The superior tarsus, when drawn 
 up, slides under the arch of the orbit, but re- 
 tains its apposition to the globe, owing to the 
 laxity of its attachment with the integument of 
 the palpebra. 
 
 The origin of some fibres of the orbicularis Muscular 
 
 _ IT • 1-1 compression 
 
 from the ligamentous expansion which supports oftheia- 
 
 , , , 1 . . crymal sac. 
 
 and protects the lacrymaJ sac, gives it a power 
 of compressing the sac in its contraction, and 
 thus assists in the excretion of the tears. This 
 is in part proved by the epiphora which accom- 
 panies a fixed state of the lower palpebra from 
 injuries, and the paralysis of the orbicularis, 
 which states also prevent the due apposition of 
 the puncta. Hence too, people wink often and 
 forcibly, whose eyes are disposed to water, and 
 after shedding tears. 
 
 nctiva 
 a non-se- 
 
 The conjunctiva has been supposed to secrete conju 
 a lubricating fluid, which serves the purpose of creting sur- 
 keeping the cornea clear, and facilitating the 
 motions of the lids. This forms, according to 
 
 G 2
 
 84 PHYSIOLOGY OF THE EYE 
 
 that opinion, the habitual lacrymal discharge, 
 and the secretion of the lacrymal gland is but an 
 occasional one, as when from mental emotion or 
 irritation of the conjunctiva the profuse and pal- 
 pable discharge which we call * tears ' is poured 
 out. I believe the notion rests solely upon the 
 supposed relation of the conjunctiva to the class 
 of mucous membranes. But this need be no 
 fetter upon our conception of the matter, for 
 not only do we see from the varieties of its sur- 
 face that its economy is not throughout the same, 
 but anatomists describe its continuity with the 
 cutis as much as with the membrana narium. 
 Again, the capillaries of mucous membranes 
 carry red blood, which is not the case in the con- 
 junctiva of the globe in health. But there is no 
 evidence of such a secretion ; upon the cornea 
 it is not assumed to exist, yet the difference be- 
 tween the corneal and sclerotic portion is only 
 in the strictness of its adhesion. The folUcles 
 and caruncula are specifically provided for pre- 
 venting the effects of friction, and the incessant 
 although insensible escape of the tears from the 
 lacrymal ducts, unavoidable under the act of 
 winking, in which the upper lid sweeps over and 
 preserves the polish of the cornea, renders such 
 a provision superfluous and therefore improbable. 
 In disease, the sclerotic conjunctiva secretes a 
 mucus which is immediately obvious (the cor- 
 neal surface is excepted because its vessels do 
 not admit red, blood) and this is in conformity
 
 AND ITS APPENDAGES. 85 
 
 with what we see of the mucous membrane pro- 
 perly so called, as of the urethra and intestinal 
 canal, which continually shew that the secretion 
 can be set up by disease upon a whole surface, 
 while in the healthy state this function is con- 
 fined to its follicles and lacunar. 
 
 A young woman who had never shed tears, 
 and was incapable of doing so, had a shrivelled, 
 opaque, and cuticular conjunctiva. 
 
 The puncta lacrymalia absorb the tears, not Excretion 
 
 , of tears. 
 
 by any capillary attraction, but by a vital action 
 as absorbent mouths. They are often spasmo- 
 dically contracted, and afford a resistance to the 
 introduction of Anel's probe, but yield to the 
 point of a pin, so as afterwards readily to admit 
 a probe of much larger dimensions. When over- 
 dilated, they lose for a time their absorbing 
 power, and the epiphora is increased. When 
 they are morbidly patulous and atonic, as some- 
 times happens in age, the epiphora is perma- 
 nent ; and their function is frequently arrested 
 by inflammation of the sac, for we often find 
 the epiphora altogether independent of obstruc- 
 tion. 
 
 The direction of the superior duct varies a 
 little in relation to the sac, according to the de- 
 gree of elevation of the upper lid. By drawing
 
 8^ PHYSIOLOGY OF THE EYE, ETC. 
 
 the lid upwards and towards the nose, it is 
 brought nearly into a line with the axis of the sac. 
 
 The area of the sac and nasal portion of the 
 duct, exceeding that of their orifices, facilitates 
 the passage of the tears ; the slight elevations 
 of the lining membrane and the narrowness and 
 obliquity of the nasal opening probably retard 
 the excretion, which would be inconvenient if 
 constantly taking place.
 
 PART II. 
 
 PATHOLOGY 
 
 MEMBRANES. 
 
 CHAPTER I. 
 
 SECTION I. 
 
 CONJUNCTIVA. 
 
 The vessels of the conjunctiva of the globe are Bioodves- 
 derived from two sources: — 1. The palpebral conjunct 
 arteries and veins ; 2. The ophthalmic muscular 
 branches, and accompanying veins. The first, 
 creeping upon the sclerotic conjunctiva in the 
 sinus palpebrales, and at the angles of the pal- 
 pebrae, have a reticular distribution upon the 
 loose portion of the conjunctiva. The second, 
 after penetrating the tendons of the straight 
 muscles, advance in four distinct fasciculi. These
 
 88 CONJUNCTIVA. 
 
 spreading, as they advance upon the opposite 
 sides of the globe, form numerous lateral anas- 
 tomoses with each other, so as to present a 
 faint circulus arteriosus upon the sclerotic coat*. 
 In a state of congestion a free communication 
 is conspicuous between these two orders of 
 vessels, and their distinctive character is pre- 
 served under very high degrees of inflamma- 
 tion. In a complete section of tlie conjunctiva 
 at a short distance from the cornea, both sets may 
 be divided without injury to the sclerotic. It is 
 by infinitely frequent and minute subdivisions 
 of these vessels that the tissue which unites the 
 conjunctiva to the sclerotic is supplied ; and 
 hence in inflammation, the areolar distribution of 
 these vessels is most conspicuously demonstra- 
 ted where this texture is most abundant. At the 
 verge of the cornea both orders of vessels are 
 rectilinear, and never present the reticular ar^ 
 rangement ; for the looseness of the conjunctiva 
 upon the sclerotic gradually diminishes from the 
 point of its reflection to the verge of the cor- 
 nea, and its adhesion to the cornea is so strict, 
 as to render an artificial separation impracti- 
 cable. This remarkable difference in strictness 
 of adhesion subsisting between the conjunctiva 
 and subjacent textures, suited to their difference 
 of economy, explains some varieties in the mor- 
 bid affections of the conjunctiva covering these 
 parts respectively. 
 
 * See Plate I. fig. 1.
 
 CONJUNCTIVA. 89 
 
 Independent of the accompanying veins of 
 the muscular arterial fasciculi, long and tortuous 
 branches are seen to proceed from the meshes 
 of the conjunctiva, distinguished from the arte- 
 ries by their purple hue, their isolated course, 
 and more superficial seat. Their sharp spiral 
 curves are larger as they .descend towards the 
 base of the visible hemisphere of the globe, 
 where their attachment to the sclerotic is least 
 strict. These are the palpebral veins of the 
 conjunctiva. 
 
 Although in the tonic and tranquil state of Character- 
 the eye, little, if any, red blood is admitted into eUeof Ae 
 the superficial vessels, yet under a very tempo- uvToMhe 
 rary excitement, colored blood has a ready ad- and comea, 
 mission into the vessels of the sclerotic conjunc- flammalion. 
 tiva. Such, however, is the condensation of the 
 connecting texture upon the cornea, as to pre- 
 vent the admission of red blood into its vessels 
 under a very high degree of inflammation, as 
 even where the white ground of the sclerotic is 
 extinguished *. The susceptibility of parts per- 
 meable to red blood to increased vascularity 
 under excitement, is in proportion to the quan- 
 tity of cellular texture entering into their com- 
 position, or connecting them with subjacent 
 parts. Compare, in this view, the membrane of 
 
 * I believe further, that it is inadmissible, except a morbid 
 change has previously taken possession qi this texture. But 
 of this hereafter.
 
 90 CONJUNCTIVA. 
 
 the fauces and the trachea — pleura pulmonaH?* 
 and costahs — periosteum and perichondrium — 
 the lining membrane of veins and arteries. 
 
 Since the easy adm'ssion of red blood into 
 the vessels of the sclerotic conjunctiva discovers 
 a distribution of vessels, not otherwise known, 
 it affords opportunities of observing the acces- 
 sion and progress of inflammation ; and this por- 
 tion of the membrane presents, when inflamed, 
 appearances different from those of the inflamed 
 corneal conjunctiva. But although the colorless 
 circulation of the latter shews the rise and pro- 
 gress of inflammation obscurely, its perfect trans- 
 parency in health makes the results of it more 
 conspicuous. 
 
 Cornea ob- The first cffcct of inflammation upon the 
 Smma- comca is haze or dimness, which depends upon 
 the loaded state of its (serous) vessels. The 
 dimness is immediately removed by the recovery 
 of the circulation, as after the removal of an 
 irritant ; for example, a foreign particle on the 
 cornea ; or after a free evacuation, where the 
 cause is less obvious. Hence transient dimness 
 is merely a condition of congestion. This state, 
 however, continued, produces a deeper and 
 more permanent opacity ; viz. effusion into the 
 connecting texture, and thickening of the con- 
 junctiva upon the cornea. This is the progress 
 of simple ophthalmia in the generic sense of the 
 term. Contrast the epiderhiis in the state of 
 
 tion.
 
 CONJUNCTIVA. 9'1 
 
 blush (congestion) and of incipient vesication 
 (effusion). The peritoneal coat of the liver, the 
 arachnoid and synovial membranes doubtless 
 exhibit, in the distinct stages of congestion and 
 effusion, the transient and permanent opacity. 
 
 The conjunctiva is to the cornea, what the Relation of 
 
 11 T • 1 1 ^^^ conjunc- 
 
 periosteum is to the bone. It nourishes the su- tivatothe 
 perficial lamellge ; wherever it is completely de- 
 tached, the exposed surface of the cornea ulce- 
 rates, and its vessels repair the breach. To pursue 
 the analogy, the interlamellar texture of the cor- 
 nea may represent the medullary membrane ; 
 gangrene therefore does not ensue but from a 
 permanent destruction of both textures, as by 
 blows and explosions, which mechanically dis- 
 organize ; by the action of lime, gunpowder, 
 strong acids, and other chemically destructive 
 agents ; or by the strangulation of the vessels 
 of both textures, as in the excessive chemosis, 
 which destroys on the same principle as the pa- 
 raphymosis, or the strangulated hernia. 
 
 The forms of inflammation of the conjunctiva 
 which I shall now proceed to refer to, I consider 
 as specific variations from the simple acute inflam- 
 mation*, of which the ordinary signs are fami- 
 liar to every practitioner, originating in a healthy 
 subject from an obvious occasional or accidental 
 cause, as an extraneous particle, or a blow not 
 injuring the texture, or a blast of cold air. An 
 
 * See Plate I. Us. 2.
 
 92 CONJUNCTIVA. 
 
 inflammation purely local, uninfluenced by con- 
 stitution, both from the nature of its origin, its 
 recent existence, and the health of the subject 
 in whom it occurs. Such is the simplest exam- 
 ple we can suggest of the morbid disposition 
 natural to this organ, or to any organ ; it is fre- 
 quent, for all are liable to it, if all are not 
 equally exposed : it is in fact an instance of 
 what may be termed, without a misnomer, the 
 inflammation of health. 
 
 inflamma- The inflammation of the conjunctiva, termed 
 conjuncUva, * strumous,* whcrc it has not proceeded to a 
 ^°Suia. change of texture, is not marked by any pro- 
 minent local character. The vascularity is in- 
 considerable. This inflammation sometimes ac- 
 companies pustule of the sclerotic conjunctiva, 
 in which case the vascularity is diflbsed instead 
 of being partial, as in pure pustular inflamma- 
 tion, and the intolerance of light characteristic 
 of the strumous inflammation is present in a 
 greater or less degree. It accompanies also the 
 morbid secretion of the lids when the eyeball 
 becomes affected by the acuteness and duration 
 of that disease, and the pustule on the cornea, 
 especially the variolous pustule. In its simplest 
 form it is almost peculiar to young children, 
 stationary, marked by a very slight redness of the 
 sclerotic conjunctiva, and the greatest possible 
 decree of intolerance. I have known it in more 
 than one instance of such severity and duration 
 as to occasion a distortion of the spine from
 
 CONJUNCTIVA. 93 
 
 the liabitual depression of the head, and ttie 
 obstinate maintenance of an awkward and un- 
 natural posture of the body to screen the eyes 
 from light. 
 
 The disproportionate degree of inflannnation 
 makes it difficult to account for this excessive 
 morbid sensibility. It is purely a disorder of 
 function ; for although it far exceeds that which 
 accompanies the acutest inflammation to which 
 the organ is liable, it never in my experience 
 impairs the faculty of vision. I attribute it to , 
 
 a morbid sympathy of the retina w'ith the se- 
 creting surfaces of the primae viae and the skin, 
 for neither of these organs perform their healthy 
 functions during its existence. The tongue, 
 the index of the former, shews by various signs 
 gastric irritation or disordered digestion, and the 
 cutaneous surface is remarkably dry and harsh^ 
 Accordingly it is cured by diaphoretics, as tar- 
 tar emetic to nausea, James's powder, or calomel 
 combined with opium in small doses ; by the 
 warm bath ; and materially corrected, if not 
 removed, by a preternatural secretion in the vi- 
 cinity, as by an open blister on the nape of the 
 neck. I have often seen an aggravated intoler- 
 ance removed in twelve hours by the application 
 of a blister. 
 
 This state of intolerance bears an analogy to 
 cases of depraved, or rather of painfully acute 
 sensibility in other organs of sense. The senses
 
 94 CONJUNCTIVA. 
 
 of hearing and of smell are in some rare cases 
 rendered morbidly acute, independent of the 
 slightest organic affection, so that the ordinarily 
 agreeable stimuli of these organs in a state of 
 health, viz. an acute sound and a pungent odor, 
 become causes of distress. An amateur of 
 music, when labouring under an occasional dis- 
 order of the auditory passages, compared his 
 sensations during a fine performance of instru- 
 mental music to those of Hogarth's enraged 
 musician; all was jar and discord. Every snu£F- 
 taker knows the effect of a catarrh to spoil his 
 enjoyment. 
 
 The nebula and the pustule of the corneal con- 
 junctiva are the terminations of this inflammation 
 when it affects the texture of the organ, to 
 which may be added the small herpetic ulcers, 
 reddish brown points, giving to the cornea a 
 scabrous appearance. The healing action is al- 
 ways remarkably languid and protracted, as if 
 the state of excessive irritability checked its 
 progress, and prevented its completion. 
 
 Aphthous The conjunctiva of the sclerotic is disposed 
 rnflamma-' ^0 form aphtha2 or pustules at the verge of the 
 cornea, or near to it. In the former situation, 
 where the more lax adhesion becomes abruptly 
 strict, the pustule is elevated or cone-like, and 
 is the termination of a distinct pencil of vessels ; 
 which arrangement sometimes precedes and an- 
 nounces the disposition to pustule. When it is 
 
 lion of the 
 conjunctiva.
 
 CONJUNCTIVA. 95 
 
 situated at a distance of a line or two from the 
 corneal margin, it is broad and flattened. It 
 is a small speck or patch of lympli, and sel- 
 dom advances to suppuration. It is common 
 to see one on either side of the cornea, in the 
 transverse axis of the globe *. Sometimes they 
 appear in detached clusters, or a zone of pus- 
 tules environs the cornea. This resembles the 
 aphtha of the mouth and fauces and intestinal 
 canal. 
 
 The pustules of the corneal conjunctiva which 
 are less frequent, except in children, are general- 
 ly situated near to the margin of the cornea, 
 where one or more pustules of the sclerotic por- 
 tion appear. Like the aphtha of the glans penis 
 and the stricter parts of fine cutaneous texture, 
 the pustule on the cornea usually forms an ulcer. 
 
 The ophthalmia with puriform discharge is a inflamma- 
 disease of the palpebr^e. The secretion is sup- foiiides 
 plied by the meibomian follicles and the con- fo'rmE" 
 junctiva bordering them, and likewise by the *"^'^^' 
 caruncula lacrymalis. 
 
 A puriform discharge is furnished by the crypta? 
 of the tonsils, the lacunge of the urethra, and the 
 mucous glands of the nares, fauces, rectum and 
 vagina, in mild inflammation of these parts. But 
 ill the vehement acute form of inflammation, the 
 
 * See Plate I. fig. 6.
 
 96 
 
 CONJUNCTIVA. 
 
 matter of suppuration is furnished by the tumid 
 and villous surfaces of these membranes. 
 
 Acute sup- 
 purative in- 
 flammation 
 of the con- 
 junctiva. 
 
 The sclerotic conjunctiva m acute suppu- 
 rative ophthalmia presents the following states : 
 1st, Serous effusiou (oedema) which is common 
 to other inflammations, and especially those of 
 a less vigorous kind. 2d, Effusion of lymph 
 (chemosis) peculiar to this form of inflammation, 
 by which it acquires a solid aug mentation of 
 bulk. 3d, Viilosity, or a subsequent prolonga- 
 tion of the extreme vessels in the form of villi, 
 which secrete pus. The strict adhesion of the 
 conjunctiva to the cornea prevents these changes 
 from taking place upon that membrane. Upon 
 the tarsi the conjunctiva thus aifected becomes 
 preternaturally vascular, thickened, and scabrous, 
 or forms fleshy eminences. That the vascular 
 villi of the conjunctiva secrete pus, may be as- 
 certained by the aid of a lens. The pus, when 
 formed, collects in the interstices of the villous 
 texture. We have no evidence, as I have be- 
 fore observed, that the conjunctiva is a secret- 
 ing surface in the healthy state. 
 
 Mild acute A form of disease intermediate to these in 
 JnflSTma^^ cxtcut aud scvcrity, a modification of the sup- 
 tionofthe pm-ative ophthalmia, is the viilosity and pu- 
 riform secretion of the conjunctiva palpebra- 
 lis, as seen upon eversion of the lids, while 
 the membrane upon the globe is simply intu- 
 
 conjunc- 
 tiva.
 
 CONJUNCTIVA. 97 
 
 mescent, giving it a more rounded figure, and mo- 
 derately vascular. This is the mild acute sup- 
 purative ophthalmia, which seldom injures the 
 cornea, but frequently leaves after it the same 
 fungous or granulated state of the conjunctiva 
 palpebralis which so often follows the most 
 acute form. 
 
 The difference then between the inflammation 
 of the meibomian follicles and caruncula (the 
 disease which if neglected terminates in lippi- 
 tudo), and the suppurative inflammation of the 
 conjunctiva, whether of the palpebrse or the 
 globe, is a difference in kind as w^ell as in seat j 
 the one is the conversion of a transparent and 
 bland secretion proper to the organ (meibomian) 
 into a viscid and irritating mucus, puriform in 
 appearance ; the other is the de novo production 
 of a true suppurative surface by inflammation. 
 
 The highly contagious nature of the suppura- suppurative 
 tive ophthalmia, whether in the mild or vehe- communi- 
 ment acute form, is sufficiently proved. For one contact 
 person affected with this disease above three 
 months old, I should think at least twenty are 
 subject to it under that age. The mother is the 
 subject of fluor alb us or gonorrhoea, and the 
 discharge is usually perceived about the third 
 day. In new born infants the disease begins in 
 the conjunctiva palpebralis, and is often con- 
 fined to that portion of the membrane. Where 
 by neglect or improper treatment, it extends to 
 
 H
 
 98 CONJUNCTIVA. 
 
 the conjunctiva of the globe, it often destroys 
 the cornea. I have repeatedly seen the most 
 virulent form of the disease produced by an ac- 
 cidental translation of the matter of gonorrhoea 
 from its source in the same subject, and from 
 one to another, as from the husband to his wife. 
 I have also known it set up by the fluid injected 
 into the eye of a patient, spirting into the eye 
 of the medical attendant, and by the use of a 
 sponge which had been recently employed to 
 cleanse the eyes of an infant affected with the 
 disease. The mild as well as the acute form of 
 the disease, it is well known, runs through ar- 
 mies, schools, and families. There is much rea- 
 son to believe it epidemic as well as contagious, 
 but the former is a point less easy of decision. 
 
 Chemosis. The chcmosis, as must appear by the descrip- 
 tion above given, is an affection widely differing 
 from ecchymosis, with which it has been by 
 some writers confounded. It is after the exist- 
 ence of this morbid condition which is charac- 
 teristic of the suppurative ophthalmia, that the 
 conjunctiva forms fungous excrescences, pendu- 
 lous flaps, or hard callous rolls protruding be- 
 tween the palpebrae and globe, and everting the 
 former (ectropeon), or if not protruding, causing 
 the turning of the lid over against the globe 
 (entropeon). The tarsal portion takes on from 
 the same cause the hard granulated surface, 
 which keeps up incessant irritation of the scle- 
 rotic conjunctiva, and at length renders the cor-
 
 CONJUNCTIVA. 99 
 
 nea opaque. These eminences, sometimes cone- 
 like and sometimes flattened, are not granula- 
 tions in reality, i. e. adventitious glands secret- 
 ing pus. Granulations, I believe, are never 
 formed without breach of texture. 
 
 Preternatural elongations and excrescences of Eionga- 
 tlie conjunctiva, concealed in the hollows of the crescences." 
 palpebrse, are a sequel of the protracted mild 
 suppurative ophthalmia, where the palpebral 
 conjunctiva has been the principal seat of dis- 
 ease. They are similar to those of the mem- 
 brane lining the rectum, and the fine skin at the 
 verge of the anus after inflamed piles, and the 
 pudendum muliebre in acute gonorrhoea. All 
 such membranous growths are, I believe, refer- 
 rible to irritation of inflamed parts by the dis- 
 eased and confined secretion, as the warts in 
 external gonorrhoea. 
 
 A firm fleshy fungus, which sometimes attains simple fun- 
 considerable bulk, so as to project from between fonjuncUva. 
 the eyelids and globe in an orbicular figure, even 
 to the circumference of the orbit, I have extir- 
 pated. Such fungi are exclusively formed of 
 the conjunctiva, and usually originate from in- 
 jury. 
 
 There is a malignant fungus of the conjunc- carcinoma- 
 tiva, for like the mucous membrane of other of the con- 
 parts, this is sometimes the seat of carcinoma ; •'""'' '^^' 
 
 H 2
 
 100 CONJUNCTIVA. 
 
 and excepting the lacrymal gland, I believe no 
 other texture related to the organ of vision is 
 ever primarily so affected. I have removed the 
 contents of the orbit for a painful tubercular 
 fungus, with ulcerated depressions containing 
 an ichorous discharge. The coats and humors 
 of the eye were for the most part absorbed, the 
 lacrymal gland scirrhous. The disease after- 
 wards returned upon the palpebrge, and de- 
 stroyed the patient. I have at this time a simi- 
 lar case under my observation. The fleshy tu- 
 bercles grow from the conjunctiva, both on the 
 cornea and sclerotic, and the inferior palpebra 
 is extensively ulcerated*. It is accompanied 
 by lancinating pains in the supra-orbitar region, 
 and an unhealthy discharge. 
 
 Pannus. The pannus is a chronic thickening and opa- 
 
 city of the conjunctiva of the sclerotic, generally 
 unaccompanied by inflammation. By relaxation 
 of the connecting tissue the membrane becomes 
 redundant in extent, and forms folds or dupli- 
 catures, on one, or on all sides of the cornea, 
 which encroach upon it considerably in the mo- 
 tions of the globe. The elongated uvula is the 
 only analogy that occurs to my mind. This is 
 often unpreceded by inflammation, and the ex- 
 tension is purely membranous. 
 
 Pterygium, The mcmbranous pterygium is a true nebula 
 
 * See Plate II. fig. 1.
 
 CONJUNCTIVA. 101 
 
 of the sclerotic conjunctiva; the fleshy is an membra- 
 
 T 11111 nous and 
 
 adipose or sarcomatous growth beneath the scle- fl.shy. 
 rotic conjunctiva. It extends from either can- 
 thus or sinus palpebrahs, most commonly from 
 behind the caruncula lacrymalis ; and by its in- 
 crease forcibly detaches the conjunctiva from 
 the cornea. In its progress it occasions a per- 
 manent and indelible opacity by the thickening 
 of the conjunctiva, and the deposition of lymph 
 in the interspace of these membranes, in the form 
 of a little tongue-shaped process. The wedge- 
 like figure of the fleshy pteryx, and its gradual 
 extension upon the cornea, afford the best pa- 
 thological demonstration of the continuity of the 
 conjunctiva ; and the spread fan-like figure of 
 the membranous, its semi-transparency as w^ell 
 as its termination in simple nebula of the corneal 
 ■conjunctiva, shews the difference in the nature 
 of the two diseases. Both this and the disease 
 last mentioned, like other morbid growths of the 
 cellular texture or beneath it, are most prevalent 
 in warm climates. 
 
 Adipose, steatomatous, and even cartilaginous Conjuncti- 
 tumors form in the cellular tissue of the scle- onthesck- 
 rotic conjunctiva, and produce the same change 
 when situated in the vicinity of the cornea as 
 the disease last mentioned, viz. a marginal in- 
 terstitial deposition. 
 
 Circumscribed tumors of a dense and firm audcomea.
 
 lO'i CONJUNCTIVA. 
 
 texture are sometimes formed upon the surface 
 of the cornea, and attain a considerable magni- 
 tude ; but such cases are rare. I excised the an- 
 terior hemisphere of the eyeball in an elderly 
 lady, in whom the cornea was concealed by a 
 tumor, of a dark purple color, protruding to 
 such an extent between the eyelids, as to occa- 
 sion great inconvenience and deformity. It had 
 the appearance of being disposed in lobes, some- 
 what resembling a bunch of currants of unequal 
 size. On dissection, the cornea and sclerotic 
 proved to be entire, and the morbid growth, ly- 
 ing upon and adhering to the corneal and a 
 small portion of the sclerotic surface, had ac- 
 quired the lobulated appearance, as if by dege- 
 neration of the covering conjunctiva; for de- 
 licate white bands, the only vestiges of this mem- 
 brane, were seen intersecting the lobules at ir- 
 regular distances, in the form of septa. The 
 substance, on section, was firm, of a dark color, 
 here and there mottled with white, and mea- 
 sured a quarter of an inch in thickness from the 
 external surface of the cornea*. 
 
 Encanthis. The cncauthis is a morbid enlargement of 
 the lacrymal caruncle, in the form of a granular 
 tumor, involving the valvula semilunaris. Some- 
 times the short down growing upon this gland 
 takes on a morbid growth and harshness. The 
 disease is extremely irritating, and occasions 
 * Pktell. fig. 2. andfig. 4.
 
 CONJUNCTIVA. 10^ 
 
 epiphora by a forcible diversion of the lacrymal 
 puncta from each other, and from the surface of 
 the globe. I have never known it assume the 
 malignant character ascribed to it by some wri- 
 ters. 
 
 The elongated valvula semilunaris retains its Elongated 
 crescentic figure even to the margin of the cor- miiunani!" 
 nea, where it has a loose and thin edge. By this 
 and other parts of the conjunctiva, fringes or 
 clusters of soft red caruncles are sometimes pro- 
 duced, resembling those occasionally seen in the 
 site of the carunculae myrtiformes, and about the 
 OS externum vaginse. 
 
 The frena or frenula connecting the conjunc- Frena. 
 tiva palpebrarum and conjunctiva scleroticse, a 
 troublesome, and often irremediable deformity, 
 follows burns and wounds of the conjunctiva 
 tarsi, and the excision of tumors connected with 
 this portion of the membrane. They are mem- 
 branous bands formed by adhesive inflammation 
 of the opposed and contiguous surface (pleura 
 costalis and pulmonalis — peritoneum of the in- 
 testines and parietes). It is not necessary that 
 both surfaces should be wounded, if the position 
 be by a mistake of treatment preserved, as by 
 the application of a bandage. " The opposite 
 uninflamed surface,** as Mr. Hunter observes, 
 " accepts of the union.** I have seen these 
 frena produced by a slit eyelid from a fall, and
 
 104< CONJUNCTIVA. 
 
 trifling as the inconvenience might seem, it so 
 restricted the motions of the globe, and the dis- 
 ease was so materially aggravated by operations 
 ' to reheve it, i. e. by the multiplication of fre- 
 nula, that the patient became disturbed in his 
 intellects, from an exaggerated sense of his mis- 
 fortune. 
 
 Co-adhe- The co-adhesion or concretion of the tarsi by 
 
 ling tarsi. -in- n ^ 
 
 organized adhesion or the conjunctiva tarsorum 
 is rare. I saw a remarkable case of it in a full 
 grown boy, whose eye was found perfect after 
 the division, though he had been thus blind 
 from his infancy. It is similar to the co-adhe- 
 sion of the nymphae or labia pudendi, and the 
 closed anus in new born infants. 
 
 indisposi- The conjunctiva is not prone to ulcerate, 
 conjunctiva whilst the substance of the cornea readily as- 
 inBanima-'^ sumcs that actiou ; hence the frequency of ul- 
 cers not opening externally, and of ulcers pene- 
 trating into the anterior chamber. Its readiness 
 to assume the adhesive inflammation is evinced 
 by the rapid formation of a superficial speck 
 where it has been scratched or abraded, and the 
 assistance it affords in healing open ulcers of the 
 cornea. There is a marked disposition in these 
 cicatrices to ulcerate in subsequent attacks of 
 inflammation, which are in the same degree as 
 in other parts slower to heal than the original 
 texture. The synovial membrane is as much less 
 
 tion.
 
 CONJUNCTIVA. 105 
 
 disposed to ulceration than the cartilage, as the 
 conjunctiva is than the cornea, or the periosteum 
 than the bone, or the peritoneum than the mu- 
 cous coat of the bowel. All these external close 
 membranes accord in their disposition to adhe- 
 sive inflammation. 
 
 The conjunctiva, viewing its compound pa- pathoiogi- 
 thological character, bears in its respective rela- S the con- 
 tions to the sclerotic and the cornea, an affinity to J""^''^^' 
 the two distinct classes of membranes : viz. the 
 mucous upon the sclerotic, and the serous upon 
 the cornea ; hence the frequency of pustule and 
 the tendency to suppurative inflammation of the 
 sclerotic portion, and the indisposition to ulce- 
 rate and proneness to adhesive inflammation of 
 the corneal.
 
 SECTION II. 
 
 CORNEA. 
 
 Ulcers of The comea is disposed to adhesive inflamma- 
 e cornea, ^.'^j-j^ ulceratioD, and sloughing. It rarely sup- 
 purates. The ulcer of the cornea begins, not in 
 abscess, but in a circumscribed deposit of lymph, 
 or in pure ulcerative absorption without pus. 
 In most instances, when of spontaneous origin, 
 it begins in the interlamellar texture. When the 
 conjunctiva has been detached, and the cornea 
 deeply injured, as by a large spiculum, or by an 
 ulcerated pustule of the corneal conjunctiva, the 
 ulcer is filled by an inspissated mucus, or a little 
 dirty white slough which may be picked or 
 washed out, leaving a clear but rough fovea. 
 The ulcerative process is unaccompanied by any 
 appearance of colored vessels, and the adhesive 
 process is, in many instances, conducted by co- 
 
 and their lorlcss vcsscls. That the proper vessels of the 
 
 modes of i i r> • ii • 
 
 heaUng. comea are capable or secretmg adnesive matter, 
 is proved by indelible opacities both with and 
 without breach of its texture, and the healing 
 of interstitial ulcers, without any appearance of 
 a colored vessel. 
 
 The organizing process is, however, in some
 
 CORNEA. 107 
 
 instances, performed by colored vessels. Where 
 interstitial ulcers open externally, or pustules of 
 the conjunctiva terminate in ulcers of the cor- 
 nea, a narrow pencil of vessels is produced from 
 the sclerotic conjunctiva to the breach, which 
 organizes the lymph deposited by the proper 
 vessels of the corneal texture. I have some- 
 times observed, that the fasciculus of red ves- 
 sels produced to complete the healing of an ul- 
 cer, opening externally, instead of coming from 
 the nearest point of the sclerotic, crosses the 
 greater diameter of the cornea. I have never 
 seen such a production of vessels without a nar- 
 row and very delicate substratum of recent 
 lymph in their track ; nor have I observed this 
 peculiar deposit distinct from the production of 
 vessels, prior to their appearance, but the vestige 
 of it is discernible for a short time after the ves- 
 sels have disappeared. In superficial lesions of 
 the cornea, as from the insinuation of a foreign 
 particle, the part is at once restored by adhe- 
 sion, and marked by a superficial speck ; it is 
 only where the ulcerative process has super- 
 vened, and the conjunctiva is at the same time 
 destroyed at the mouth of the fovea, that nature 
 adopts the mode of healing by colored vessels. 
 Their office is, I think, limited to the organiza- 
 tion of lymph deposited by the transparent ves- 
 sels of the interlamellar texture ; because when 
 the ulcerative process is checked, the ulcer pre- 
 sents the signs of the adhesive action, viz. the
 
 108 CORNEA. 
 
 marginal halo of lymph and the contraction and 
 filling up of the fovea, before the vessels of the 
 sclerotic conjunctiva are produced. In this state 
 there is often a pause in the restorative process, 
 when the stimulus of a single injection is fol- 
 lowed by the appearance of the red vessels, the 
 effect of which is speedily manifested by a red- 
 dish brown tint communicated to the deposit, 
 which soon becomes distinctly vascular. In other 
 words, the adhesive process is already com- 
 menced before this phenomenon is observed. I 
 have never seen the conjunctival fasciculus run- 
 ning to a transparent fovea. When the conjunc- 
 tiva is entire, as in the interstitial ulcer, no red 
 vessel appears, nor can be made to appear by 
 stimulant injections, although they certainly 
 quicken the adhesive process in such cases. 
 
 From analogy we are led to conclude that 
 the vessels which secrete are distinct from those 
 which organize the deposit, in open breaches of 
 all textures. An insulated pellicle formed upon 
 the bed of an ulcer never becomes skin, but if 
 it be connected by never so narrow an isthmus 
 with the circumference, its organization is per- 
 fected. After the ligature of an artery, the 
 barrier of lymph is deposited from the vessels 
 opening upon the divided cellular membrane, 
 as is evident from its origination within the fis- 
 sure, but injections shew that it is organized by 
 the vessels of the lining membrane. The same
 
 CORNEA. 109 
 
 fact is still more clearly demonstrated after the 
 division of the sclerotic conjunctiva, for we may- 
 observe a distinct interval to transpire between 
 the deposition of new matter in the breach, and 
 its vascularization by ramuli from the divided 
 trunks. This is in opposition to the opinion of 
 Mr. Hunter, who cites the same example to 
 prove the re-union of divided trunks, or inoscu- 
 lation, an hypothesis which has been totally 
 abandoned, since it has been ascertained that 
 the permanent obliteration of arteries is the in- 
 variable consequence of a solution of their conti- 
 nuity, whether occasioned by wound or ulcera- 
 tion. I believe that in all parts the capillaries 
 terminating upon the newly exposed surface fur- 
 nish the deposit, and that this becomes the ma- 
 trix of new vessels opened from its ramifications, 
 under the extraordinary impulse consequent 
 upon the obstruction of the trunk. 
 
 The appearance of colored vessels upon the Colored 
 
 f, 1 • ^ n 1 vessels upon 
 
 conjunctiva ot the cornea is to be reterred to one the comea. 
 or other of the following states, and may be 
 classed accordingly : — 1st, To the presence of 
 adhesive inflammation excited by a pustular 
 ulcer of the cornea*, as in the instance last de- 
 scribed, and in that of acute interstitial ulcer 
 opening externally, described at page 114. — 2d, 
 To the duration of acute strumous ophthalmia, 
 in which the serous vessels of the cornea are 
 * See Plate I. fig. 3.
 
 110 CORNEA. 
 
 opened to red blood upon its entire circumfe- 
 rence, in the form of radii converging to a centre, 
 to an equal extent of from one to two lines*. In 
 this case the cornea is more or less obscured. — 
 Sd, To a state of chronic inflammation, in which 
 straggling solitary vessels, having a varicose ap- 
 pearance, run to one or more specks, or proceed- 
 ing from opposite sides of the sclerotic conjunc- 
 tiva, course over the opaque cornea and freely 
 anastomose upon itt. This state is a common 
 sequel of the suppurative ophthalmia, whether 
 accompanied or not with the granular conjunc- 
 tiva tarsi, and which I have been accustomed to 
 designate " chronic inflammation with vascular 
 cornea." It is commonly seen in cases of dis- 
 organized globe and spoiled cornea, from what- 
 ever cause. 
 
 The first of these conditions I consider ad- 
 ventitious to the adhesive inflammation excited 
 by the open ulcer of the cornea. It is proved 
 to be so by a temporary deposition of a narrow 
 layer of lymph ; the direct course of vessels along 
 it to the breach; their passage not always by the 
 nearest route, i. e. from the nearest point of 
 the sclerotic ; the entire freedom of the cornea 
 from blood-vessels in other parts ; and the spon- 
 taneous disappearance of the vessels and the 
 lymph track after the healing of the ulcer. It 
 is the most striking and beautiful instance we 
 * See Plate I. fig. 4. t See Plate I. fig. 5.
 
 CJORNEA. Ill 
 
 have of the handicraft of nature, of the produc- 
 tion of vessels in inflammation for a specific pur- 
 pose, and their gradual contraction to oblitera- 
 tion ; the determination ceasing when that pur- 
 pose is accomplished. 
 
 The second and third description of appear- 
 ances I consider to be produced by the conti- 
 nued vis a tergo overcoming the resistance op- 
 posed by the enfeebled tone of the vessels. The 
 second is combined with recent and diffused ne- 
 bula of the cornea, capable of removal by ab- 
 sorption. The third is as often present with ul- 
 cerated specks as with simple opacities, which, 
 whether partial or complete, are seated in the 
 corneal texture, and have usually existed prior 
 to the appearance of the red vessels ; and neither 
 the vessels nor the opacities spontaneously disap- 
 pear. After repeated circular sections of the 
 conjunctiva near the cornea, these vessels un- 
 dergo contraction, especially under the use of 
 styptic applications, as the liq. plumb, acetatis, 
 and solutions of copper, alum, &c. ; that portion 
 of the opaque matter which has been recently de- 
 posited, is at the same time absorbed. This ope- 
 ration seems to act beneficially in two ways; viz. 
 by throwing up a barrier of lymph to impede 
 the direct course of the vessels, and by diverting 
 them to the purpose of its organization. 
 
 When I speak of the * production' of vessels, Production 
 
 of vessels.
 
 112 CORNEA. 
 
 I am not unaware of the ambiguity or impre- 
 ciseness, at least, of the term, which is so dif- 
 ferent in a mathematical and a general sense. 
 It would be wandering widely from the subject 
 of this treatise, to enter into a discussion of the 
 question, whether the phenomenon of organi- 
 zation is to be referred to an elongation of ves- 
 sels by virtue of a force operating upon their 
 elasticity, or an occasional formation of ramus- 
 culi from contiguous branches. To divided 
 vessels, the former supposition cannot apply, as 
 their orifices, as before observed, become per- 
 manently closed. I may observe also, that 
 elongation of vessels implies a looseness of co- 
 hesion in the textures in which they appear, 
 which does not belong to the corneal conjunc- 
 tiva in its healthy state; and the example which 
 I have given in illustration of the formation 
 of vessels, is strikingly opposed, in this respect, 
 to the instance adduced of original vessels ac- 
 quiring increased capacity, and being rendered, 
 by the color of their contents, conspicuous. 
 In the first, the corneal surface is otherwise 
 healthy ; in both the second and third, it is 
 raised, thickened, and more or less disorganiz- 
 ed. 
 
 We are led by analogy to conclude that the ef- 
 fect of vascular congestion from altered or inter- 
 rupted texture is only less in degree than that 
 from complete obstruction in larger vessels j viz.
 
 CORNEA. 113 
 
 the extension and enlargement of collateral 
 branches. Observe the vessels of the sclerotic 
 conjunctiva in organic amaurosis ; of the skin co- 
 vering indurated tumors; and lastly, the commu- 
 nicating branches after the ligature of the trunk 
 in aneurism. Mr. Hunter thought that the vessels 
 might be formed in a patch of lymph independ- 
 ent of the circulation. " I think," says he, "I 
 have been able to inject what I suspected to be 
 the beginning of a vascular formation in a coagu- 
 lum, when it could not derive any vessels from 
 the surrounding parts. By injecting the crural 
 artery of a stump above the knee where there 
 was a small pyramidal coagulum, I have filled 
 this coagulum with my injection as if it had been 
 cellular, but there was no regular structure of 
 vessels." Then, likening extravasation under in- 
 flammation, and the vascularization of the mem- 
 branes of the chick to this appearance of a self- 
 organized coagulum, he adds, *' I conceive that 
 these parts have a power of forming vessels with- 
 in themselves.'* — " But where this coagulum can 
 form an immediate union with the surrounding 
 parts, it either receives vessels first at this sur- 
 face, or forms vessels first at this union, which 
 communicate with those of the surrounding 
 surface"*. 
 
 The infinitely more probable theory of the 
 derivation of vessels from parent branches for 
 
 * Hunter on the Blood, p. 92 et seq.
 
 114 
 
 CORNEA. 
 
 the organization of deposits, is supported by 
 daily observation, and satisfactorily explains the 
 phenomena. 
 
 That vessels are capable of producing their 
 kind is as certain as the reproduction '^of bone, 
 tendon, and other elementary textures. The de- 
 pendence of one order of vessels upon another 
 is shewn by the existence of vasa vasorum ; and 
 it seems to me most probable that the vessels 
 first seen in a patch of lymph are fabricated by 
 the vasa vasorum, blood vessels and absorbents, 
 of the terminal vessels of the wounded surface. 
 
 Acute in- 
 terstitial 
 ulcer of the 
 cornea. 
 
 The acute interstitial ulcer sometimes opens 
 externally, by absorption of the conjunctiva, as 
 well as of that portion of the lamellse superja- 
 cent to it. Its figure and extent are determined 
 by the deposit of adhesive matter. This is fre- 
 quently crescentic, and traverses a part or the 
 whole of the diameter of the cornea. It is most 
 frequently situated near the upper or lower mar- 
 gin of the cornea, but occasionally crosses the 
 centre. Upon close examination, the conjunc- 
 tiva will be found to be absorbed at the part op- 
 posite to the ulcer, and the exposed scabrous sur- 
 face of the cornea renders the motions of the 
 upper lid acutely painful. The deposition of the 
 adhesive track precedes the appearance of red 
 vessels, which are derived to it in one or more 
 fasciculi from the sclerotic conjunctiva, and by
 
 CORNEA. 115 
 
 which its healing is perfected, as in the ulcer 
 opening from the surface, before described. 
 
 The terms onyx and unguis have been indis- Onyx and 
 cnmmately apphed to extensive collections or 
 lymph and pus between the layers of the cornea, 
 and to similar collections situated in the anterior 
 chamber. They are applicable only to the cres- 
 centic interlam-ellar depositions above described. 
 The acute interstitial ulcer in debilitated habits 
 of body, or when it is produced by considerable 
 violence done to the cornea, instead of opening 
 upon either of its surfaces, spreads between its 
 lamellae, and in this case a considerable quan- 
 tity of puriform matter is secreted. If it oc- 
 cupy a large and central portion of the cornea, 
 it usually terminates by slough of the entire 
 membrane. 
 
 When, as more frequently happens, the inter- Hvpopio«. 
 stitial ulcer opens into the anterior chamber, it 
 produces the hypopion, which is a mixed secre- 
 tion of lymph and pus ; the former flaky and in- 
 organizable, and situated exterior to the fluid. 
 The soft lymph pendulous from the mouth of the 
 ulcer is often observed connecting the hypopion 
 with it. I never recollect to have seen the pu- 
 riform hypopion unaccompanied with ulcer pe- 
 netrating the interior lamella of the cornea. In 
 these cases, the integrity of the chamber is pre- 
 served, and the iris has no share in the restoration. 
 I 2
 
 116 
 
 CORNEA. 
 
 Procidentia When the external ulcer opens into the ante- 
 rior chamber, so that the cornea is perforated, the 
 iris falls into the breach and becomes united to 
 it by adhesion. When the opening is small, as 
 from simple ulceration, the iris presents a small 
 black point; if large, as from sloughing, the op- 
 posed portion of the iris is protruded in the form 
 of a little sac ; and when this happens, the adhe- 
 sive process is sometimes set up at once, by its 
 pressure on the margin of the aperture in the 
 cornea, and by the ready disposition of the iris 
 to take on a corresponding action. But the ad- 
 hesive process is not so promptly set up in this 
 case as in the procidentia following a wound, and 
 the prolapsus often increases in size until a sti- 
 mulant is employed. The healing action is 
 marked by a dusky white line at the verge of the 
 opening. The contraction of the chamber and 
 the disfiguration of the pupil are proportioned to 
 the extent of the prolapsus. 
 
 Procidentia In the progrcss of an external ulcer to the in- 
 terior of the cornea, and before it penetrates into 
 the chamber, a remarkable appearance is occa- 
 sionally presented, viz. a transparent vesicle, 
 which fills the aperture, and is supposed to be the 
 membrane of the aqueous humor. I have never 
 seen this state maintained ; the prolapsus iridis 
 follows in a few hours, notwithstanding the use of 
 the lunar caustic and other stimulants. This has 
 led me to question its being a distinct texture, and 
 
 corneae.
 
 CORNEA. 117 
 
 its appearance corresponds accurately to that of 
 the innermost lamella of the cornea, which after 
 losing its support yields to the pressure of the 
 humor, and assumes the vesicular form. The 
 falling-in, or cup-like depression of the continu- 
 ous surface of the cornea, where the circum- 
 scribed interstitial ulcer opens into the anterior 
 chamber, serves to confirm this conjecture. I 
 have never seen the appearance which I have 
 heai'd others describe as demonstrating the ad- 
 hesive inflammation of this tunic, viz. colored 
 vessels arborescent upon a deposit of lymph 
 coating the interior of the cornea. If the ob- 
 servation be accurate, the case is very rare. 
 
 Chronic interstitial ulcers from pure ulcerative Chronic 
 
 , . , • n • • interstitial 
 
 absorption, succeed to acute inflammation, m uker of the 
 which large quantities of blood have been lost, 
 and occur frequently in children imperfectly 
 nourished, or adults much debilitated from vari- 
 ous causes. The cornea is perfectly transparent, 
 but indented, like a bonce when struck upon 
 a marble hearth, or pitted, according as the ulcers 
 are diffused, or circumscribed ; the vision is very 
 slightly affected. Under nutritive diet, effective 
 tonics, and moderate topical stimuli (vin. opii. 
 sulph. zinci) they become hazy ; and this denotes 
 the commencement of the adhesive action. 
 
 Opacities are of three kinds : thebklndL 
 
 1. Thickening of the conjunctiva and effusion
 
 118 CORNEA. 
 
 of adhesive matter between it and the cornea, or 
 between the lamellae of the latter. This is com- 
 monly the product of acute strumous ophthal- 
 mia. The corneal surfice loses its smoothness 
 and polish as well as its transparency, when the 
 conjunctiva is affected ; when the opacity is in 
 the cornea this is not the case. This is that 
 form of opacity which, while recent, admits of 
 removal by excitement of the absorbents more or 
 less completely, and especially by that whicli mer- 
 cury produces, the corneal texture being sound. 
 It is what I have been accustomed to call nebula, 
 and though presenting great varieties of shade, 
 it has a soft, diffused, semi-transparent character. 
 
 2. A slow change of texture without breach, si- 
 milar to that by which the pleura, or choroid, or 
 capsule of the lens is converted into bone. The 
 yellow pearly opacity, resembling the inside of an 
 oyster-shell, is of this kind. It is the result of 
 continued, or frequently relapsing (strumous) 
 rather than violent inflammation, and is deep- 
 seated. In this case the layers of the cornea 
 become opaque, indurated, and condensed, so as 
 not to admit of separation by the knife or mace- 
 ration ; and if such opacities are in any degree 
 relieved, it is by an absorption of the interlamel- 
 lar deposit in their vicinity. 
 
 3. New matter, supplying an absolute loss of 
 substance of the cornea, from ulceration or gan- 
 grene. This differs from the second chiefly in
 
 niia. 
 
 CORNEA. 119 
 
 its figure being more abruptly circumscribed, 
 and bearing more resemblance to a cicatrix. In 
 point of density the second often exceeds it, as 
 when the cicatrix does not penetrate the cornea. 
 Both these species of opacity are white in the 
 recent state, and in general the more conspicu- 
 ously their color is contrasted with this appear- 
 ance, as yellow or brown, the less is the proba- 
 bility of reducing them. 
 
 The peculiar hue and loss of tension, as well Gangrene 
 as lustre, of the dead cornea in acute suppura- b^atihesive 
 tive ophthalmia, has been aptly pictured by Mr. JSeame 
 Saunders, by the terms * cindery, ragged, floe- ^tS''^ 
 culent.' It is important, because I have satis- 
 fied myself that the first change of the cornea 
 in this disease is purely nebulous, produced by 
 the deposition of adhesive matter ; and if the 
 inflammation be arrested even on the verge of 
 gangrene, the cornea is susceptible of restor- 
 ation by absorption. This fact I had lately an 
 opportunity of establishing, in the case of a lady 
 who was rendered blind by acute suppurative 
 inflammation of the conjunctiva : so inevitable 
 to all appearance was the destruction of the 
 cornea, which had sloughed in a deep sulcus at 
 its junction with the sclerotic above, that the 
 most experienced practitioner of my acquaint- 
 ance in this branch of surgery pronounced the 
 case hopeless and irremediable, and took his 
 leave. The highest tonic regimen, bark, wine, 
 and opium, followed close upon a very active and
 
 120 CORNEA. 
 
 ' bold depletion, and the anterior chamber was 
 fortunately and unexpectedly preserved. No 
 sooner was a sign of the arrest of sloughing ul- 
 ceration obtained, than I commenced a mer- 
 curial course ; in three days the system was af- 
 fected ; the recovery of the figure and transpa- 
 rency of the cornea was rapid and complete be- 
 yond all expectation, and an equally perfect 
 state of vision was restored and established. 
 
 The gangrenous opacities of the cornea pro- 
 duced by lime or other substances destroying its 
 texture, are sometimes superficial and defined 
 in extent, and a process resembling exfoliation 
 ensues. More frequently this disorganization 
 is integral and complete. The cornea, disor- 
 ganized by acids, is rendered instantly opaque, 
 shrivelled, and of a yellow color, almost resem- 
 bling a piece of wash leather. 
 
 In general, opacities which have a recent dif- 
 fused semi-transparent character (nebulous) ad- 
 mit of absorption ; not so those in which the 
 interstitial deposition has been abundant and of 
 long standing, and the lamellae are compact- 
 ed, owing to the entire obliteration of the cel- 
 lular texture ; or in which a new portion of cor- 
 nea is formed. 
 
 Cutjcuiar I have seen several cases of the conversion of 
 
 conjunc 
 
 tiva 
 
 cornea. 
 
 ofthe the conjunctiva into a skin, rugous and opaque,
 
 CORNEA. 121 
 
 knitting the lids close to the globe, so as to 
 obliterate the sinus palpebrales. I have called 
 it cuticular conjunctiva. In these cases there 
 is no secretion of tears. I have had occasion 
 to observe the accession and progress of this 
 disease, in early and advanced life, among the 
 sequelae of chronic inflammation of the con- 
 junctiva, and am disposed to consider it de- 
 pending on an obliteration of the ducts of the 
 lacrjmal gland. 
 
 All stimulant substances, not escharotic, ap- Action of 
 plied to remove opacities of the cornea, act in stimuli on 
 the same manner as rubefacients upon the skin; "P^*^"^''' 
 they excite a temporary vascular action, which 
 is followed by a corresponding excitement of 
 the absorbents. I have often seen an opaque 
 portion of the cornea cleared by a puncture 
 with the couching needle. If the point of salu- 
 tary excitement is exceeded, the increased vas- 
 cularity is permanent, and occasions increased 
 deposition. Injections applied to ulcers do not 
 excite the absorbent action in the same ratio, 
 but occasion a permanent increase of the vas- 
 cular action, which is here below the ordinary 
 standard. This instance of the adaptation of 
 the same means to different ends, according to 
 the state of the part, is perhaps the best practical 
 illustralaon of Mr. Hunter's quaint but expressive 
 phrase, " stimulus of necessity.'* 
 
 O paque specks, even cicatrices, are obliterated Ab 
 
 sorption
 
 122 
 
 during 
 growth. 
 
 CORNEA. 
 
 during the period of growth, and, as is observed 
 of cicatrices in other parts of the body, change 
 their relative position remarkably in the years 
 of growth. Thus a conspicuous speck, en- 
 croaching upon the pupil in the infant, be- 
 comes a small and scarce discernible speck in 
 the grown child, situated near the verge of the 
 cornea. In other instances, if originally small, 
 it has disappeared altogether. Like cicatrices 
 of other parts, they are always considerably 
 smaller than the ulcers of which they are the 
 vestiges. 
 
 staphyio- The staphyloma is of two kinds, viz. from 
 kinds. dilatation and from breach. In the first case 
 the corneal lamella have not completely given 
 way, but are only bulged, the membrane having 
 been so far weakened by ulceration as to have 
 lost its due resistance, and the staphyloma 
 consequently affects the whole diameter of the 
 cornea (spheroidal). In the second the staphy- 
 loma is circumscribed, the recent lymph, corre- 
 sponding to the breach, yielding at one or more 
 points to the pressure of the humor (conoidal). 
 
 In the spheroidal staphyloma the effect of 
 pressure is to thicken the remaining lamellge by 
 a deposition of adhesive matter, as in the aneu- 
 rismal and herniary sac ; so that the transverse 
 section of it greatly exceeds in diameter that 
 of the healthy cornea. In the conoidal staphy- 
 loma the recently deposited matter yields to the
 
 CORNEA. 123 
 
 pressure a tergo before its organization is com- 
 plete. Sometimes the two forms are combined, 
 and one or more conoidal protrusions are formed 
 upon a spheroidal staphyloma. When, as in 
 the first case, the corneal texture has not ac- 
 tually given way, the anterior chamber is in 
 most instances preserved, and the iris is free. 
 In the other case the iris is usually complicated 
 with the staphyloma. The remediableness of 
 the deformity occasioned by the disease, by 
 means of an operation, depends upon a suffi- 
 cient portion of the iris being left. The iris 
 is kindly disposed to granulate, as we see in 
 sloughs of the entire cornea from suppurative 
 ophthalmia*. 
 
 Three or four days after the operation for 
 staphyloma, the iris is seen coalescing with the 
 conjunctiva, and throwing up fleshy puUulations, 
 which contracting into a little button-like emi- 
 nence, seal up and permanently secure the crys- 
 talline and vitreous humors ; thus the spherical 
 figure of the globe is preserved to support the 
 lids. But if the section be posterior to the plane 
 of the iris, the vitreous humour escapes and the 
 globe collapses and sinks in the socket. 
 
 * I have seen in siicli cases a permanent staphyloma of the 
 irisj the pupil closed, and the exposed iris retaining its cha- 
 racter, occupying the situation and presenting the figure of 
 the cornea. The case is not common, as the cicatrization of 
 the pupil must precede the fall of the cornea.
 
 cornea. 
 
 124 CORNEA. 
 
 Conical The cornea is occasionally subject to a pro- 
 
 cess of thinning, or an absorption of its inter- 
 lamellar texture, and in consequence, loses its 
 natural tonic resistance to the pressure of the 
 contents of the globe. It usually assumes a 
 conoidal figure, but this is not always the case ; 
 the projection of the cornea is sometimes uni- 
 form, describing the segment of a larger sphere. 
 The apex of the cone corresponding to the 
 centre of the cornea, when this figure is as- 
 sumed, exhibits a degree of tenuity and brillian- 
 cy which gives it the appearance of a pellucid 
 fluid, like a dew-drop suspended. The pa- 
 tient's vision becomes so inconveniently short 
 as to render objects confused at a very mo- 
 derate distance ; the change is sometimes slow, 
 occupying months, and even years ; and on the 
 contrary, I have seen it produced in its greatest 
 extent in the short space of eight weeks : both 
 eyes are generally affected, though not always 
 in the same degree. The disease is unpreceded 
 by inflammation, or any obvious assignable 
 cause ; it is more frequent in women than in 
 men, and in my experience affects the periods 
 of youth and middle life. I have never seen it 
 commencing in infancy or old age. It is as 
 much the disease of the robust as of the weakly 
 constitution and frame of body. If inflammation 
 is excited by stimulants, the apex of the cornea 
 turns opaque ; if left to itself, the cornea does 
 not give way, but remains in the condition de-
 
 125 
 
 CORNEA. 
 
 scribed. No remedy yet proposed has been fol- 
 lowed by a beneficial result ; but a pupillar aper- 
 ture set in a black ring frame, about a quarter 
 of an inch or more in depth, greatly assists the 
 patient by lessening the confusedness of his 
 vision. 
 
 It seems that the presence of adhesive inflam- 
 mation is the chief distinction between the sta- 
 phyloma from dilatation and the conical cornea : 
 the absorption is therefore in the one case the 
 ulcerative, and in the other the interstitial. 
 
 The last stage of healing in external ulcers Finishing 
 of the cornea exhibits beautifully the third kind ulcers. 
 of absorption, viz. the modelling, as described 
 by Mr, Hunter. We see it in the lowering, 
 rounding, and smoothing of the jagged edges of 
 the cup of the ulcer, a compromise in some sort 
 with the full and complete finishing of the ad- 
 hesive process, viz. indelible opacity : and in 
 some cases this state of imperfect restoration is 
 perpetuated to a manifest advantage ; for a 
 transparent indentation occasions little, if any 
 impediment to vision.
 
 SECTION IIL 
 
 SCLEROTICA. 
 
 Vessels of BRANCHES fi'om the Straight vessels of the 
 
 the sclerotic* 
 
 conjunctiva penetrate the sclerotic obliquely to- 
 wards the margin of the cornea, and the long 
 ciliary vessels pass in sulci of this membrane to 
 the plexus ciliaris at the root of the iris. At 
 the interior border of the sclerotic, where the 
 annulus ciliaris is adhering closely to this tunic, 
 the ciliary communicate with the muscular 
 branches, and being in deep-seated inflamma- 
 tion fully injected with red blood, the conden- 
 sation of color gives the well known and re- 
 markable appearance of a vascular zone at the 
 margin of the cornea. Injections do not de- 
 monstrate this anastomosis ; for the communi- 
 cating vessels, like those whicli are continued 
 upon the cornea, are too delicate to admit of 
 artificial injection, and only admit red blood 
 after a strong and steadily supported inflamma- 
 tory action*. When once they have received 
 red blood they very slowly recover their healthy 
 
 * A very successful injection of an eye in the state of 
 acute iritis could alone demonstrate this fact to the entire 
 satisfaction of anatomists.
 
 ifiect. 
 
 SCLEROTICA. 127 
 
 calibre, as is proved by the faint appearance of 
 the zone long after the inflammation has ceased, 
 and the almost instantaneous reproduction of 
 the state of congestion, on forcibly separating 
 the lids. When an inflammation at first affecting 
 only the conjunctiva is allowed to progress, 
 the ciliary vessels partake of the action, and 
 this sign of the extension of it to the interior 
 tunics makes its appearance. But the sclerotic situation 
 from its situation and texture serves as a shield tm-e, their 
 to the finer tunics, from external inflammation 
 as well as from external violence. By the in- 
 terposition of the sclerotic the vascular commu- 
 nication of the choroid and conjunctiva is ren- 
 dered extremely minute and anastomotic ; and 
 for this reason inflammation of the conjunctiva 
 may and often does reach to a considerable 
 height, without any indication of its extending 
 to the parts beneath the sclerotic. An acute 
 and obstinate inflammation of the conjunctiva, 
 not threatening injury to the cornea, as the pus- 
 tular, and that with puriform discharge, does 
 not in any degree affect the choroid and iris. 
 On the other hand, when inflammation has ex- 
 tended to these tunics, the vision is affected in a 
 much greater degree than appearances would 
 often lead us to expect. I only mean to remark 
 that if the transmission of blood to the deeper 
 seated tunics had followed readily to that of the 
 conjunctiva, the consequences of every severe
 
 128 
 
 SCLEROTICA. 
 
 superficial ophthalmia would have been mis- 
 chievous. 
 
 Ordinary 
 inflamma- 
 tion of the 
 sclerotic, 
 secondary. 
 
 When the sclerotic partakes of the inflam- 
 mation of the conjunctiva, for it is only as inter- 
 mediate to the conjunctiva and the other tunics 
 that it is usually affected, the vessels which pur- 
 sue a straight course to the margin of the cornea 
 are strongly distinguished. They have a some- 
 what brighter hue than the areolar vessels upon 
 the loose portion of the conjunctiva. I have 
 exhibited this difference of arrangement of the 
 vessels in the sclerotic and conjunctival inflam- 
 mation, as seen in a singular case of inflamma- 
 tion accompanied with pustules *. This ap- 
 pearance is always observed, as sclerotic inflam- 
 mation is always present, during the morbid 
 changes upon the gornea, viz. interlamellar de- 
 posits of lymph and ulcerations. 
 
 Sclerotitis; I havc occasioually observed in a recent oph- 
 thalmia this turgescence of the straight vessels, 
 unaccompanied by any affection of the cornea or 
 iris, and with so slight a vascularity of the loose . 
 conjunctiva, as to give reason to consider it a 
 primary sclerotitis. The inflammation is more 
 obstinate than acute ; the motions of the ball are 
 painful. By continuance the cornea becomes 
 
 * See Plate I. fig. 6.
 
 SCLEROTICA. 129 
 
 nebulous, and the surface roughened, from effu- 
 sion beneath the conjunctiva. 
 
 The inflammation of the sclerotic sometimes and rheu- 
 
 , . . . . . , matic oph- 
 
 accompanies, and is sometimes vicarious with thaimia. 
 rheumatic inflammation. This is not surprising, 
 as its texture is of the same class with the liga- 
 ments of the joints. The rheumatic ophthalmia 
 presents the zonular arrangement of the vessels, 
 more or less cloudiness of the aqueous humor, 
 and a pupil displaced or drawn a little to one side. 
 It is often seen in company with, or following 
 gonorrhoea, eruptions, or sore throat of a pseudo- 
 syphilitic character; and the pains to which, in my 
 experience, it is generally allied, are those which 
 succeed to the exhibition of mercury*. 
 
 The sclerotic, although a firm texture, pos- 
 sesses in certain persons such a degree of tenuity 
 and consequent transparency, as to convey an 
 obscure tint of the subjacent choroid in the vi- 
 cinity of the cornea. This is most observable 
 in those of light-colored hair and iris, and in 
 persons of lax and weakly habits. It is relatively 
 thinner in such persons. It is evidently slenderer 
 in its texture adjoining the cornea, than else- 
 where. A morbid discoloration of the sclerotic 
 is usually combined with an organic amaurosis, 
 whether congenital or induced by inflammation 
 or its consequences. The sclerotic sometimes staphyloma 
 yields in the spheroidal staphyloma, a disease rotic. 
 
 * See note A. 
 K
 
 130 SCLEROTICA. 
 
 proper to the cornea, so much as greatly to in- 
 crease the conspicuousness and deformity of the 
 disease. This happens in hydropic and other de- 
 generations of the humors. It also frequently be- 
 comes extenuated or bulged near its junction 
 with the cornea, in the amaurosis which follows 
 inflammation of the choroid. This protrusion, 
 larger or smaller, is sometimes circumscribed, 
 and in other instances diffused over a large por- 
 tion of the ball*'. It is often seen encircling 
 the cornea, and presenting a sacculated or 
 pouched appearance. It has a blueish grey tint, 
 and the globe is of course misshapen in propor- 
 tion to its size. An increase in size of the whole 
 globe, or hydrops oculi, is often joined with it. 
 
 Persons who are not aware that it is the result 
 of a chronic process, viz. an interstitial absorp- 
 tion of the sclerotic, sometimes mistake it, from 
 some faint resemblance to the black fungoid tu- 
 mor, for a malignant disease. I have heard it 
 pronounced a fungus hsematodes, and the extir- 
 pation of the organ advised. I think it may not 
 improperly be designated staphyloma scleroticae. 
 
 Staphyloma I liavc mct witli ouc or two instanccs of the 
 choroid. actual protrusion of the choroid at the margin 
 of the cornea, which had the appearance of re- 
 sulting from the separation of the sclerotic ; like 
 the staphyloma iridis from the fall of the cornea, 
 described page 123. 
 
 * See Plate I. fig. 7.
 
 SECTION IV. 
 
 CHOROID AND IRIS. 
 
 The appearance of the vascular zone at the Choroiditis. 
 margin of the cornea, which, taken by itself, is a 
 sign of the inflammation having extended to the 
 sclerotic, — if accompanied with dulness of the 
 humors, a spastic contraction, or a very sluggish 
 and limited motion of the pupil, an impatience 
 of light, and a considerable dimness of vision, — 
 demonstrates that the choroid and iris partici- 
 pate in the inflammation. We ought to consi- 
 der, that the local and vascular relations of the 
 choroid and iris, distinct as they certainly are 
 both in texture and properties, are such as to 
 make it exceedingly improbable that the one 
 should not, in all cases, participate more or less 
 in the inflammation of the other. We are per- 
 mitted to see the primary changes induced by 
 disease in the living organ, upon the iris only, 
 and we have not as yet any precise marks by 
 which we can ascertain the commencement of 
 inflammation in the one or the other texture. 
 It is probable, however, as the iritis presents 
 considerable varieties in its form, its access and 
 progress, relatively to the superficial inflamma- 
 tion, and the kind and degree of pain and dim- 
 
 K 2
 
 132 CHOROID AND IRIS. 
 
 ness which accompany it, that the choroid is the 
 seat of the primary inflammation in those cases, 
 in which the changes upon the iris take place 
 later than the other signs of internal inflamma- 
 tion, viz. the arrangement of the vessels, the 
 pain, and the obscurity of vision. I have often 
 seen cases of this description which I have felt 
 disposed to denominate " Choroiditis." 
 
 Iritis. The indications above mentioned, are still 
 
 further confirmed by the presence of an habi- 
 tual aching pain affecting the globe of the eye, 
 forehead, and region of the orbit, and by cer- 
 tain appearances of inflammation upon the iris, 
 as hair-like red vessels and specks of extrava- 
 sated blood in its substance. Adhesive inflam- 
 mation takes place between the fibres of this 
 muscle ; the pupil loses its thin flowing edge, 
 and becomes thick, stunted, and gibbous. Iritis 
 of moderate acuteness is often unaccompanied 
 by any other appearance of inflammation ; there 
 is no distinct deposit of lymph, and it is rather 
 inferred from the fixedness or slight change of 
 figure of the pupil, than demonstrated. I be- 
 lieve the adhesive matter, in this case, is depo- 
 sited on the posterior surface, formerly called 
 uvea, for in the course of a few days, the opa- 
 city of the capsule of the crystalline, and the 
 co-adhesion with it of the pupillary margin, be- 
 comes evident, provided the inflammation be 
 unchecked. In this form of inflammation the
 
 CHOROID AND IRIS. 133 
 
 pain is often augmented in the evening, or at 
 an early hour of the morning, to such intensity 
 as to compel the patient to rise, and even totally 
 to deprive him of rest. Sometimes the pain af- 
 fects the whole corresponding side of the head. 
 In other instances, it is confined to the eyeball 
 and its immediate vicinity, as the forehead and 
 temple, and bones of the cheek. The sensa- 
 tion is sometimes that of pulsatile pain, mark- 
 ing every injection of the ophthalmic artery, as 
 of the radial artery in a whitloe. A sense of 
 continued pressure or constriction, as from ex- 
 treme distention of the vessels, is the more com- 
 mon character of the patient's sufferings. In 
 the vehement acute iritis, lymph is variously 
 deposited upon the face of the membrane, in 
 small tufts here and there, or large tubercu- 
 lar masses. The pupil, in this case, is usually 
 much misshapen, being rendered angular at 
 those points of the circle at which the deposit 
 has taken place, or is most abundant. Its aper- 
 ture is sometimes partially covered, and some- 
 times completely blocked by a mass of lymph. 
 The pain, in this state, is not always augmented 
 in proportion. It affects more the head than the 
 organ. The vision is nearly if not quite extin- 
 guished. The appearance of a stratum of lymph, 
 coating the face of the iris, with a turbid state 
 of the aqueous humor, belongs to chronic in- 
 flammation, which tends to opacity of the cap- 
 sule of the lens, and constriction of the pupil.
 
 134 CHOROID AND IRIS. 
 
 Primary. A primary inflammation of the iris, as for 
 
 example, from syphilis, or from mercury, is 
 distinguished from the secondary, or that by 
 extension from the conjunctiva, by the more 
 sparing vascularity of the conjunctiva, and con- 
 sequently more distinct and conspicuous appear- 
 ance of the vascular zone*. The attack is more 
 sudden, the pain in the region of the orbit and 
 head, commences with the inflammation, and is 
 more severe; the vision is more quickly and com- 
 pletely bedimmed. The efllision of lymph is en 
 masse, and the disfiguration of the pupil greater. 
 
 Secondar)-. *In thc inflammation of the iris by continuity, 
 the conjunctival vascularity is more conspicuous 
 and difflised, and the cornea is so much cloud- 
 ed, as partially to obscure the view of the iris; 
 the albuminous deposit is wanting, or if any has 
 taken place, it is small in quantity, white, floc- 
 culent, and partially diffused in the aqueous 
 humor, or is deposited at the ciliary margin of 
 the iris, forming a lymphatic hypopion ; the pu- 
 pil is little, if at all, misshapen. The pain in 
 the secondary iritis is usually confined to the 
 ball, and is comparatively inconsiderable. Al- 
 though the vision is much bedimmed, there is 
 greater susceptibility to the painful impression 
 of light. This state I have heard others de- 
 scribe as the adhesive inflammation of the ante- 
 rior chamber. 
 
 * See note B.
 
 CHOROID AND lUIS. 135 
 
 TJie terminations of iritis, if unsubdued, are, Termina- 
 1st, constricted or closed pupil, with opaque iritis." 
 capsule ; 2d, co-adhesion of the iris and cornea, 
 partial or entire, the former assuming the con- 
 vexity of the latter ; 3d, organic amaurosis, fol- 
 lowed by disfiguration of tlie globe, and often 
 by protrusions of the choroid and sclerotic. 
 
 intis. 
 
 Iritis, as I have formerly observed, is very Mercurial 
 frequently in company with, or succeeding to 
 syphilis, and the symptoms called mercurial, as 
 peculiar eruptions, sore throat, and pains of a 
 rheumatic character. Primary iritis is rarely seen 
 unaccompanied or unpreceded by such symp- 
 toms. I have never said or thought that it could 
 not exist independently of these symptoms, and 
 their supposed causes, having seen such instances. 
 But I have since had additional opportunities of 
 confirming the facts before advanced, that where 
 mercury had been used in various ways before 
 the iris was affected, and before the other symp- 
 toms appeared which were referred to its use; — 
 where the primary affection was either altogether 
 questionable, or at most a gonorrhoea, or a su- 
 perficial sore, which healed by a simple topical 
 application — the iritis has yielded to the steadily 
 supported influence of mercury upon the sys- 
 tem, in a manner the most satisfactory ; and that 
 no other remedy with which I am acquainted, 
 was competent to this effect*. 
 
 "^ I think it right to state^, that the salutary eifect of mer-
 
 136 CHOROID AND IRIS. 
 
 Morbid The iris undergoes a change of color as well 
 
 changes of , n • n ' 
 
 the iris. as texture, by a continuance or nifiammation. 
 This is owing to the loss of its transparency, and 
 the interruption given to its proper secretion by 
 the lymph deposited upon its posterior surface. 
 The healthy ii'is is transparent, as may be seen 
 in^the albino, white rabbit, and ferret ; hence 
 the use of the pigmentum nigrum. 
 
 It suffers a loss of mobility from the aggluti- 
 nation of its fibres, and ultimately of its poste- 
 rior surface to the tunica hyaloidea, by which the 
 posterior chamber is annihilated. It is from this 
 morbid condition extending to the plicae ci- 
 liares, that the loss of figure of the globe, or 
 the staphyloma of the sclerotic and choroid, re- 
 sults. A notable thickening and rigidity, a 
 leather-like toughness of the iris, and a varicose 
 state of its vessels, are changes accompanying 
 
 cury in iritis, unassociated with any specific action, was an 
 observation made at tlie same time by Dr. Farre and myself, 
 at the ' London Infirmary for Diseases of the Eye.' It was 
 first given to the public in the second edition of Mr. Saun- 
 ders's work, then in the press. I am quite satisfied that the 
 observation was original, notwithstanding all the attempts of 
 the German scholars to convince us, that at Vienna, and 
 elsewhere, it was a matter " lippis et tonsorihns notum." 
 
 I shall further add, that I am unacquainted with any fact 
 in Medical Surgery which ranks with this in point of import- 
 ance ; whether Ave consider the urgency and frequency of the 
 occasion, or the indispensable necessity, and almost unerring 
 efficacy of the remedy-
 
 CHOROID AND IRIS. ' 137 
 
 the state of chronic closed pupil, after reiterated 
 attacks of inflammation. 
 
 A morbid change sometimes, but rarely wit- 
 nessed, is the conversion of the choroid into a 
 shell of osseous matter. 
 
 I shall have occasion to speak of others under 
 another head.
 
 SECTION V. 
 
 RETINA. 
 
 inflamma- The retina is sometimes, though rarely, the 
 retina. ^ Seat of inflammation ; but it is an error to sup- 
 pose that intolerance of light is a sign of this 
 affection, as is clearly proved in the strumous 
 ophthalmia, in which, although the intolerance 
 is in excess, the retina is uninjured : and, se- 
 condly, because the effect of inflammation upon 
 a nerve of sense is to produce direct palsy, not 
 increased excitability. Inflammation of the pas- 
 sages and auxiliary textures of the organs of 
 sense may render the impression of their na- 
 tural stimuli painful ; but here, as in the case 
 before referred to, and probably in all cases, the 
 increased acuteness of the sense is sympathetic. 
 The organic sensibility, we may conclude, is 
 increased in the sentient, as in other organs, by 
 inflammation. This is probable from the first 
 and predominant symptom of inflamed retina, 
 viz. a sudden attack of vehement dashing pain 
 of the most distracting kind, which is described 
 to extend from the bottom of the eyeball to 
 the occiput, or in the reverse direction, and the 
 supervention, within a few hours, of total blind- 
 ness, with occasional sparks and flashes of vivid
 
 RETINA. 139 
 
 light. The pupil, upon inspection, is gaping 
 and motionless, as in confirmed amaurosis, and 
 the humors are thick and muddy. The ex- 
 ternal signs of inflammation are in the com- 
 mencement disproportionate, and quite insuffi- 
 cient to account for the symptoms. 
 
 In some cases, however, the signs of choroid Accompa- 
 innammatix)n are present with the attack of pam inflamma- 
 and the loss of sight. The pupil is not thrown other tu- 
 open, but it is without motion. In addition to 
 diffused vascularity of the conjunctiva, the 
 straight ciliary vessels are remarkably loaded, 
 so as to give a livid red hue to the sclerotic 
 around the cornea. The pupil becomes in a 
 few days plugged with lymph, or the whole iris 
 bulges forward, changes color, and the crystal- 
 line turns opaque ; or instead of this, the same 
 splendid tapetum-like appearance presents itself 
 which is observed in the commencement of 
 the medullary fungus, upon looking obliquely 
 through the pupil. The pain in this attack is 
 accompanied with a sense of confusion so alarm- 
 ing, that the patient apprehends the loss of 
 his intellects. I once saw the disease marked 
 throughout with so much disturbance of the 
 nervous system, e. g. vigilance, temporary wan- 
 derings, catches of the muscles of the face, start- 
 ings and frightful dreams, in the short intervals 
 of repose from exhaustion, — coupled with a sense 
 of heat, constriction, and tenderness of the whole 
 scalp, — that I was at first disposed to consider the
 
 140 RETINA. 
 
 ophthalmia as secondary, and subordinate to in- 
 flammation of the brain or its membranes. When 
 the internal signs of inflammation are less ob- 
 vious, and the humors and internal tunics under- 
 go a slow but complete disorganization in the pro- 
 gress of the disease, meteoric flashes are frequent 
 even after the inflammation has run its course ; 
 and I have known patients gratified with this ignis 
 fatuus, although conscious that it was no more. 
 I have seldom seen an example of this inflamma- 
 tion, which seemed to aflbrd time for the bene- 
 ficial operation of a remedy. I have in more than 
 one instance given a full trial to the lancet, and 
 the immediate operation of mercury j but though 
 both were carried as far as could be permitted 
 with safety, the vision was lost. In others the 
 external inflammation has been subdued, and 
 the vision has been recovered so far as to enable 
 the person to distinguish surrounding objects 
 with tolerable precision ; but the gaping and mo- 
 tionless pupil, the discolored humors, and the 
 superficial congestion, which remained, aflfbrded 
 little hope of its continuance. One lamentable 
 instance occurred under my observation, of its 
 destroying both eyes in a middle-aged lady with- 
 in the short interval of a fortnight. She express- 
 ed, in the agony of her suffering, a conviction 
 that she must either lose her sight or her senses. 
 
 Amaurosis, Amaurotic affections, as is well known, diflTer 
 
 Stionai infinitely in degree, but they differ also in kind j 
 
 and this affords a more scientific basis of classi-
 
 RETINA. 141 
 
 fication. I divide them into two classes, the or- 
 ganic and the functional. The first compre- 
 hends alterations, however induced, in the tex- 
 ture or position of the retina, optic nerve, or 
 thalamus. The second includes suspension or 
 loss of function of the retina and optic organ, 
 depending upon a change either in the action of 
 the vessels, or in the tone of the sentient appa- 
 ratus. 
 
 As causes of the first, we may enumerate, 
 
 1. Lesion, extravasation of blood, inflamma- 
 tory deposition upon either of its surfaces, and 
 loss of transparency of the retina. 
 
 2. Morbid growths within the eyeball, dropsy, 
 atrophy, and all such disorganizations as directly 
 oppress or derange the texture of the retina. 
 
 5. The state of apoplexy, hydrocephalus, tu- 
 mors or abscesses in or upon the brain, the optic 
 nerve, or its sheath ; and thickening, extenua- 
 tion, absorption, or ossification of the latter. 
 
 As causes of the second, 
 
 1. Temporary determination ; vascular con- 
 gestion or vacuity, as from visceral and cere- 
 bral irritation ; suppressed or deranged, or ex- 
 cessive secretions, as of the liver, kidneys, ute-
 
 142 RETINA. 
 
 rus, mammae, and testes; various forms of injury 
 and disease ; and sudden translations of remote 
 morbid actions. 
 
 2. Paralysis idiopathica, suspension or ex- 
 haustion of sensorial power from various consti- 
 tutional and local causes ; from undue excite- 
 ment or exertion of the visual faculty ; and from 
 the deleterious action of poisons on the nervous 
 system, as lead, mercury, &c. 
 
 From this description it will be understood, 
 that organic, and many forms of functional 
 amaurosis are incurable ; and the functional, by 
 continuance, lapses into the organic disease. 
 Even under the continued suspension of fijnc- 
 tion, much more the duration of a state of ex- 
 citement, the power of the retina, as of other 
 parts, gradually fades, and is at length exhaust- 
 ed. Thus the removal of a cataract from the 
 eye of a person who had been the subject of the 
 disease for thirty years, was unsuccessful in re- 
 storing useful vision. This was a sensorial de- 
 fect, for the eye had every appearance of health, 
 both before and after the operation. 
 
 I am aware of the objections to which this, 
 like most other attempts at a scientific arrange- 
 ment of such subjects, consistent with practical 
 views, is exposed. Thus the comprehending 
 under the same heads the states of temporary
 
 RETINA. 145 
 
 and permanent congestion of the vessels of the 
 retina and brain, and the disordered actions of 
 the vascular and proper texture of the retina, 
 may, prima facie, appear to be examples of in- 
 congruity. But for the purpose of descriptive 
 arrangement, a line of division must be some- 
 where drawn ; and opposed to the gradual and 
 often imperceptible transition from functional 
 to organic disease, this division must appear 
 more or less forced and artificial. I conclude 
 that the difference between the disposition to 
 apoplexy and the state of apoplexy, may be ac- 
 knowledged in the eye as well as in the brain, 
 and that the purely functional irregularities of 
 the former organ as a whole, may be classed with 
 as much propriety as those of the heart or the 
 stomach. 
 
 In treating of the disorders of any sense or 
 function, I deem it an essential character of a 
 scientific arrangement, to include in one view 
 the entire organ, philosophically speaking, sub- 
 servient to that sense or function : hence, the 
 brain and retina should not be considered se- 
 parately, but in conjunction. Secondly, to re- 
 gard the locality and demonstrableness of dis- 
 eased states, as affording the best ground of di- 
 vision ; because the presence or absence of cer- 
 tain external characters affords a stronger dis- 
 tinction between functional and organic dis- 
 orders, than we could hope to obtain from any
 
 144 RETINA. 
 
 analysis of the symptoms characterising the va- 
 rieties of disordered function, in the present state 
 of our knowledge. 
 
 History, The liistory and concomitant appearances or 
 
 rent*^""'^"'^' Hiorbid statcs associated with amaurosis, usually 
 iseases. indicate to which class it belongs : as for exam- 
 ple, diseased changes in the situation or texture 
 of the eyeball, or in the brain. A hemiplegia, or 
 partial paralysis, with other signs of apoplectic 
 or hydrocephalic pressure, whether resulting 
 from an injury of the head or otherwise ; or an 
 acute deep-seated inflammation, whether accom- 
 panied by a visible opacity or not, point out the 
 organic nature of the affection. I have seen 
 such an amaurosis produced by abscess in the 
 cerebral substance, and by the medullary fungus 
 of the cerebrum. On the other hand, I have 
 known the following distinct sources of irritation 
 operating to produce functional amaurosis, viz. 
 wound of the scalp *, caries of the skull, abscess 
 and caries of the antrum maxill are, with excessive 
 oedema of the integuments of the lids and cheek, 
 a large abscess under the masseter and muscles 
 of the cheek, and an abscess at the extremity 
 of a molar tooth, while the crown of the tooth 
 was sound. In all these cases it is to be under- 
 
 * A lesion of the frontal nerve is mentioned among the 
 occasional causes of an amaurosis from Hippocrates down- 
 wards. A striking example is reported by Sabatier. Traite 
 d'Anatomie, Tom. 3, p. 228.
 
 RETINA. 14,^ 
 
 Stood that the eye was sound, and the orbit 
 was untouched by the disease of the parts in 
 the vicinity, to which the amaurosis was clearly 
 attributable. In like manner an excessive use, 
 or rather abuse of the visual faculty, the disor- 
 dered functions of the stomach, liver, uterus, 
 &c. ; sudden and alarming depletion, excessive 
 or obstinately suppressed secretions, difficult den- 
 tition, the presence of worms in the intestinal 
 canal, and the deleterious effects of noxious 
 agents upon the organ or the system, are suffi- 
 ciently obvious causes of the functional amau- 
 rosis. 
 
 The professions, circumstances, and habits of 
 patients throw much light on the origin and 
 nature of amaurotic affections. Such as have a 
 direct influence are, sedentary occupations dis- 
 posing to torpid liver and bowels, combined 
 with the continued exercise of the eye in a de- 
 pending position of the head upon minute ob- 
 jects*; in too strong or insufficient light; upon 
 polished reflecting surfaces t; habitual exposure 
 of the organ to a high degree of heat t; to acrid 
 
 * Needle-workers, writers, draughtsmen. 
 
 t Inspectors of linen and scarlet cloths, and of new bank- 
 notes ; money-counters. It is a curious fact, that several 
 persons so employed at the Bank, at the issue of a new coin- 
 age of silver, were affected with symptoms of amaurosis. Co- 
 lor-manufacturers, burnishers, landscape-painters. 
 
 J Smiths, stokers in iron furnaces and glass-houses, tavern 
 cooks, &c. 
 
 L
 
 146 RETINA. 
 
 fumes and vapours * ; and the customary em- 
 ployment of optical glasses t. Immoderate grief, 
 excessive indulgence in venery, protracted suck- 
 ling, continued diarrhoea, repeated haemorrhages, 
 profuse salivation ; and, on the other hand, ob- 
 stinate amenorrhoea, or constipation of bowels, 
 with determination of blood to the head in a full 
 habit, are ordinary predisposing or constitution- 
 al causes of this disease, as I have had abund- 
 ant opportunities of learning t. 
 
 * A wholesale imanufacturer of blacking became the sub- 
 ject of gutta Serena. He had been a constant superintendant 
 of the process upon a large scale. The mixture of sulphuric 
 acid, with the several ingredients, disengages a pungent and 
 offensive vapor, by which the eyes are very painfully af- 
 fected. 
 
 f Watch-makers and engravers, philosophical instrument- 
 makers, sea officers. , 
 
 X There are strong shades of difference in the cases of 
 these unfortunate persons, as regards the intensity of their 
 feelings under the hopeless privation of sight. The man of 
 pure life has the support of the best philosophy. The lite- 
 rary man has not enjoyed his '^Noctes Atticae' in vain; they 
 have provided him with resources. Even the aged voluptuary 
 rises with some degree of complacency as a ' con viva satur' 
 from the banquet of nature ; and contemplating the varioiis 
 evils of the common lot in the circle of his friends, meets his 
 calamity with somewhat of martyr fortitude. The most pi- 
 tiable is the amaurosis of early life, from excess of sexual in- 
 dulgence, and especially of solitary vice. The following are 
 strong examples : — A country lad, of robust constitution, be- 
 came the alternately favoured paramour of two females, his 
 fellow-servants, under the same roof. He was the subject of 
 o-utta serena in less than a twelvemontli. Another, at an
 
 RETINA. 147 
 
 ' Amaurosis, of whichever class, is either per- 
 fect or imperfect. The first is marked by total 
 insensibility to light ; the second, by defect of 
 vision, infinitely varied in kind and degree. I 
 need scarcely remark, that not only the appear- 
 ances and symptoms vary, but the essential cha- 
 racter of the disease varies in its stages. Thus, 
 an affection, purely functional in its origin, by 
 duration becomes an organic disease. 
 
 ORGANIC AMAUROSIS. 
 
 When the eyeball is the seat of organic amau- signs of 
 rosis, it commonly presents some, or all of the chSgein 
 following appearances : * ^ ^^^^^ ' 
 
 1. A pupil fully or preternaturally dilated, 
 contracting feebly, in the first case, on the sud- 
 den admission of light, and absolutely motionless 
 in the second. This appearance is not peculiar 
 but common to both classes, though by no means 
 invariable in either. 
 
 2. A congestion of the superficial vessels, es- 
 pecially of the long fasciculi of conjunctival 
 veins. 
 
 early period of puberty, suddenly fell into despondency, and 
 shunned society. He never left his chamber but when the shade 
 of night concealed him from observation, and then selected an 
 unfrequented path. It was not discovered until too late, that, 
 in addition to other signs of nervous exhaustion, a palsy of 
 the retina was the consequence of habitual masturbation. 
 
 L 2
 
 148 RETINA. 
 
 3. A peculiar bluish grey tint of the sclerotic 
 coat ; sometimes a degree of bulging or protru- 
 sion on one or more sides of the globe ; or 
 simply a loss of sphericity, its sides appearing 
 flattened. 
 
 4. A diffused turbidity or milkiness, appa- 
 rently of the vitreous humor, strikingly observ- 
 able when contrasted with the jetty brightness 
 of a healthy eye. It is little more than the 
 healthy appearance of the humors in the eye of 
 the horse. This state, which the ancients termed 
 glaucoma, is very often mistaken for incipient 
 cataract j and I have known it called a black 
 cataract, and the operation of extracting the 
 transparent lens performed. It appears deep- 
 seated, diffused, and of uniform density j and in 
 examining some such cases at long intervals, I 
 have not found the appearance vary. The lens 
 remains transparent. There are, however, some 
 cases of a deep-seated opacity so closely resem- 
 bling that of incipient cataract, that it becomes 
 next to impossible to decide the actual state of 
 the lens. I have seen the latter, upon an expe- 
 rimental extraction in such a case, semi-transpa- 
 rent, and of a bright yellowish tint throughout, 
 and the sight of the patient has been consider- 
 ably improved. The vision is in general defect- 
 ive in a much greater degree than the visible 
 opacity explains ; and this, combined with the 
 depth of the opacity, a dilated and sluggish pupil.
 
 RETINA. 149 
 
 and some other symptoms of amaurosis, makes 
 for the opinion that it belongs to the latter 
 c. - -. But where other signs of impaired retina 
 are wanting, and the states of dimness and opa- 
 city correspond, the operation would be war- 
 rantable, although the site of the opacity should 
 be disputable, if it were the express desire of a 
 patient properly in possession of the circum- 
 stances. 
 
 5. Another yet more common appearance is 
 that of a white or greenish yellow spot, appa- 
 rently in the fundus of the eye, a little to one 
 side 0^ the visual axis ; sometimes it has a disc 
 of such breadth and splendor, as to look like 
 the tapetum of sheep, or the colored choroid of 
 fish ; but more commonly it occupies a circum- 
 scribed annular space, and is seen only in a 
 strong light, and in particular directions of it. 
 Although this appearance is commonly asso- 
 ciated with impaired vision, I have now and then 
 seen it in persons who made little, if any com- 
 plaint of their sight. This appearance has been 
 referred to a circumscribed opacity of the retina, 
 and the central spot supposed to correspond to 
 the porus opticus, or axis of the optic nerve. It 
 has also been conjectured to be the macula lutea 
 of Soemmering *. It is probably with more 
 
 * A point of opacity within the reflecting mirror of the 
 eye must, of necessity, create so much delusion, that we can 
 scarcely venture, by inspection, to determine its precise seat.
 
 150 RETINA. 
 
 propriety to be attributed to a deficient secre- 
 tion of the choroid pigment, a preternatural ad- 
 hesion betwixt the choroid and retina, and a 
 discoloration or resplendent appearance of the 
 retina from that cause. I have been led to this 
 opinion from observing it combined with that 
 form of amaurosis in which the vision is con- 
 fused to dimness in the broad light of day, and 
 is tolerably clear and agreeable after sunset j and 
 also with that which is disturbed by the partial 
 illumination of objects. 
 
 I have also been enabled to make the follow- 
 ing observations regarding this appearance. It 
 is neither suddenly induced nor preceded by any 
 signs of inflammation ; there is often a degree of 
 blindness joined with it greater than its extent 
 could account for ; and a recovery of vision, to 
 which I have been witness under such circum- 
 stances, is not accompanied by any perceptible 
 change in the appearance. I am therefore dis- 
 posed to regard its connection with amaurosis, 
 whatever it may be, as a casual coincidence, a 
 change incidental to age, like the arcus senilis 
 of the cornea j for it is by no means a constant 
 
 Even the opacities of the cornea and crystalline capsule are 
 ' liable, in some instances, to be confounded. It is highly- 
 doubtful whether anatomy would determine the point in ques- 
 tion ; except by a nice comparison with the sound organ at a 
 very early period after death, the morbid opacity of the retina 
 would certainly pass undetected.
 
 RETINA. 151 
 
 appearance in that disease, nor is it incompatible 
 with useful vision. 
 
 I have more than once seen a condensed and Opacity of 
 palpable opacity at the fundus of the eye suc- 
 ceeding to inflammation of the choroid, which 
 had destroyed vision ; and this I have consi- 
 dered to be produced by a change in the tex- 
 ture of the retina. What adds to the probabi- 
 lity is, that the crystalline in this case after- 
 wards, as if progressively, becomes opaque ; a 
 common sequel of amaurosis induced by inflam- 
 mation. 
 
 In the amaurosis from inflammation of the Amaurosis 
 choroid or retina, where the diseased action has seated in- 
 entirely subsided, the veins of the conjunctiva 
 are varicose, the iris is discolored, thick, tough, 
 inelastic, and preternaturally vascular ; the sub- 
 stance of the crystalline is more or less absorb- 
 ed, or converted into a fluid and discolored ; 
 the vitreous humor is opaque and of a deep yel- 
 low color. The retina, like the other transpa- 
 rent textures, becomes opaque under inflamma- 
 tion, and it is probable that under these cir- 
 cumstances, adhesive matter is effused upon the 
 interior of the choroid ; this supposition I 
 have never had an opportunity of verifying by 
 dissection, in cases of which the history was 
 known.
 
 152 RETINA. 
 
 From ab- I soHie time ago dissected the eyes of a man 
 th7vkreo°us "^ho had cataracts with amaurosis. The cata- 
 cXpsJ'of ^^c^s ^^^^ been formed ten years prior to his 
 the retina, j^ig^th J oiic of them fell dowii behind the pupil, 
 and he was spontaneously restored to sight, aS 
 by a natural couching. Gradually he lost his 
 sight, the eye still remaining plump, and the 
 pupil clear of any opaque substance. The 
 change which had taken place was an interstitial 
 absorption of the vitreous humor, which was 
 proved by the immediate discharge of an unu- 
 sual quantity of watery humor, on opening the 
 tunics, and tlie appearance of the vitreous cap- 
 sule collapsed into a little opaque bag, and ad- 
 hering to the ciliary body at the inferior margin 
 of the iris. A remnant of the crystalline was in- 
 volved in it, not exceeding in size a large pin's 
 head. The remains of the retina were a mere 
 film or string extending from its attachment, at 
 the back of the globe, to this bag or net of the 
 vitreous capsule. The pupil of the other eye, in 
 which the cataract had retained its place, was 
 closed, and the lens adhered firmly to the iris by 
 its capsule, which was involved with the collaps- 
 ed tunic of the vitreous lying behind it ; for the 
 humor was as completely absorbed in this as in 
 the eye first examined, and the texture of the 
 retina as nearly obliterated. Thus the amau- 
 rosis resulted from collapse of the retina, owing 
 to absorption of the vitreous humor. The fall
 
 KETINA. 153 
 
 of the lens in one eye resulted from the absorp- 
 tion of the vitreous humor, and would have oc- 
 curred from the same cause in the other eye, but 
 for the adhesion previously existing betwixt its 
 capsule and the iris. The eyes preserved their 
 figure by the increased secretion of the aqueous 
 humor, which is always in proportion to the de- 
 fault of the vitreous : and could the retina have 
 retained its position, the vision, which was, for 
 a time, recovered, would probably have been re- 
 tained. 
 
 A young gentleman, the subject of amauro- From cere- 
 sis in his left eye, was affected with symptoms of 
 a diseased action in the brain ; as, deep-seated 
 pain in the fore part of the head on the same 
 side, disposition to sleep, and inability to em- 
 ploy his mind as heretofore. He was repeatedly 
 blooded and blistered without relief. The di- 
 gestive functions were much disordered, and he 
 was put upon a course of alterative medicine. 
 The disease, however, advanced ; the eyelid be- 
 came paralytic, and a slight degree of strabismus 
 was accompanied with occasional double vision. 
 The lethargy and the derangement of the secret- 
 ing organs, and consequent emaciation and de- 
 bility, increased, and his death soon followed. 
 The eye had no unhealthy appearance ; the pu- 
 pil was regular, and moderately active. On 
 examination, a firm lardaceous tumor, of the 
 size of a garden bean, was found compressing the
 
 154 RETINA. 
 
 optic ganglion and nerve at its origin tlience, of 
 the same side. 
 
 Amaurosis I have secn several cases of amaurosis from 
 
 from con- . i i i i i i 
 
 cussion. concussion, as by a blow on the temple, or the 
 eye. Of these some were attended with signs of 
 disorganization — some were superficially inflam- 
 ed — and others presented no external appear- 
 ance of injury. One was the case of a captain 
 of artillery, who was struck by what is called 
 the *wmd of a ball, on the right side of the head. 
 He received no wound, but lost, instantly and 
 irrecoverably, tlie sight of his right eye. 
 
 In another case, a young gentleman received 
 a blow on the eye, by which it was inflamed ; 
 the inflammation was superficial and easily sub- 
 dued, but the vision was so much impaired, that 
 a surgeon was consulted, who observed the pu- 
 pil to be dilated and without motion. The iris 
 recovered its activity by depletion, but useful 
 vision was lost. It is not always the eye on 
 the same side of the head which has received 
 the blow that is aflfected. One remarkable case 
 I shall take the liberty to mention. 
 
 A man who had good vision of the right eye, 
 and was nearly dark from a cataract in the left, 
 received a violent blow on the left temple. From 
 that time he lost totally tlie sight of his right (or 
 perfect) eye, which has now the faded appearance
 
 IlETINA. 155 
 
 of an incurable organic amaurosis, and owing to 
 the rupture of the lens, which was at the time 
 undergoing absorption, recovered sight with his 
 left eye, which he still enjoys. Frequently the 
 amaurosis from concussion is purely functional, 
 and is cured by a full blood-letting, blisters, and 
 purgatives. 
 
 I have observed several forms of congenital Congenital 
 
 one, in which the orsran is 
 
 &' 
 
 organic 
 amaurosis. 
 
 preternaturally small and soft, and even flaccid 
 to the touch, as if from deficiency of the vitreous 
 humor ; the iris tremulous, and not influenced 
 by the belladonna j the globe affected with an 
 incessant tremor, and not subject to the control 
 of the will. I have often seen this motion of the 
 globe uncombined with the tremulous iris in 
 cases where there was little more than a natural 
 feebleness of the retina. 
 
 A second depends on a deficiency of the pig- 
 mentum nigrum ; here the tremulous motion of 
 the globe is present ; strong light produces un- 
 easiness, and vision is dazzled and confused ; the 
 vessels of the choroid give the interior of the 
 eye a deep red tinge, but not the bright scarlet 
 of the albino, or the white rabbit. I have seen 
 several of the children of two families thus af- 
 fected ; they are considerably aided by cylindri- 
 cal shades, such as are used by connoisseurs in 
 pictures j goggles ; glasses covered with black
 
 156 RETINA. 
 
 gauze, and every other contrivance to absorb 
 light J even a coat of black varnish besmeared 
 around the eye. I may observe in general, that 
 an amaurotic disposition, greater or less, exists 
 in all persons whose hair and eye-brows approach 
 to white*. 
 
 A third form of congenital amaurosis is that 
 in which the sclerotica so encroaches upon the 
 cornea, that the latter scarcely exceeds the dia- 
 meter of the pupil, while the volume of the 
 globe appears somewhat greater than natural. 
 Various malformations of the pupil, an extreme 
 diminutiveness, and even a total deficiency of 
 the iris, are not in my experience ordinarily as- 
 sociated with an imperfectly organized retina. 
 
 A fourth kind of congenital amaurosis is un- 
 accompanied by any appearance of organic de- 
 rangement. The eyes move in concert as if 
 attracted by a faint perception of light, in an 
 oblique direction ; but the infant is too certainly 
 blind. A diseased state of the thalami or optic 
 nerves would, I apprehend, be discovered by in- 
 spection of these cases after death. It is proba- 
 
 * Professor Beer states, that dark colored eyes are more in- 
 clined to become amaurotic than those of lighter color. This 
 observation is not at variance with my own, since the above re- 
 mark refers only to white-haired persons, the characteristic of 
 whose amaurosis is photophobia, or intolerance of light, and in 
 whom the disposition depends on a defective pigment.
 
 RETINA. 157 
 
 ble that the opaque retina is sometimes congeni- 
 tal as well as the opaque cornea : of the latter I 
 have seen instances ; others are related by the 
 late Mr. Ware. 
 
 FUNCTIONAL AMAUROSIS. 
 
 The functional amaurosis admits of the follow- 
 ing subdivisions. 
 
 1st. The symptomatic, or that which is only a 
 symptom of some general disease or disorder of 
 the system, as for example, general plethora, 
 general debility, &c. 
 
 2nd. The metastatic, or that produced by the 
 sudden transference of the morbid action from 
 another organ of the body ; as for example, 
 from the skin, the testicle, &c. 
 
 3rd. The proper, or that which immediately 
 depends upon a peculiar condition of the retina j 
 as for example, the visus nebulosus, muscse vo- 
 litantes, &c. 
 
 I proceed to treat of them in succession. 
 
 1. Symptomatic. 
 Like nervous deafness, amaurosis sometimes Amaurosis 
 follows typhus and scarlet fever and the various stitutionai 
 forms of acute constitutional disease. This I generarde- 
 
 bilitv.
 
 158 RETINA. 
 
 have several times met with as a result of in- 
 fantile fevers. It is also sometimes a consequence 
 of chronic wasting diseases, in which organic 
 changes interrupt the nutrition of the system. 
 I have seen a rapid and severe salivation insti- 
 tuted for a remote affection, and where no dis- 
 ease had previously affected the eyes, terminate 
 in gutta serena of both. The same has been ob- 
 served of the sense of hearing. The state of the 
 circulation has a marked influence upon imper- 
 fect amaurosis*. I know patients whose vision 
 
 * The effect of fever upon a nervous deafness^ was strongly 
 evinced in the case of a lady whom I knew. She had been 
 incurably deaf many years, when, during the existence of a 
 puerperal fever, it was remarked, that she had recovered dis- 
 tinct and even acute hearing, which again left her, after the 
 febrile action had subsided. 
 
 I was once consulted by a gentleman who was the subject 
 of this species of deafness to a painful degree. He informed 
 " me that he was in possession of a remedy for the disease, but 
 unfortunately it was available only while in actual use, and too 
 severe to be employed incessantly. His object was to ascer- 
 tain if a less objectionable one were known. It consisted in oc- 
 casional drastic j urging, abstemious diet, and the hard daily 
 exercise of a man training to walk against time, or fight, or ride 
 a race. Under this alterative plan, he had so excited the 
 action of the extreme vessels as to restore the sentient tone of 
 the netve. By adopting it, he had more than once recovered 
 a perfect state of hearing, which remained while he had reso- 
 lution to pursue it. But he thought, as would most others, 
 ' le jeu ne vaut pas la chandelle.' 
 
 While upon this subject, I shall take the liberty of stUl 
 further extending this digression by adding a much more re- 
 markable proof of the influence of vascular action upon the
 
 RETINA. 159 
 
 is benefited in a high degree, and others in whom 
 it is as much deteriorated by the quickened cir- 
 culation following a full meal and a few glasses 
 of wine. The former are persons of spare and 
 meagre habits ; the latter plethoric. 
 
 The influence of mental emotion in producing 
 this disease is most frequently seen in the in- 
 stance of grief. Young widows are peculiarly 
 liable to amaurotic affections ; and cases are re- 
 brain and its more immediate functions, and leave the reader 
 to form his own conclusions. 
 
 " A young M^oman, who was employed as a domestic servant 
 by the father of the relator when he was a boy, became insane, 
 and at length sunk into a state of perfect idiocy. In this con- 
 dition she remained for many years, when she was attacked by 
 a typhus fever ; and my friend having then practised some 
 time, attended her. He was surprised to observe as the fever 
 advanced, a developement of the mental powers. During that 
 period of the fever, when others were delirious, this patient 
 was entirely rational. She recognized in the face of her me- 
 dical attendant, the son of her old master, whom she had known 
 so many years before, and she related many circumstances re- 
 specting his family, and others which had happened to herself 
 in her earlier days. But alas ! it was only the gleam of rea- 
 son. As the fever abated, clouds again enveloped the mind ; 
 she sunk into her former deplorable state, and remained in it 
 until her death, which happened a few years afterwards." / 
 
 Tuke's Description of the Retreat for Insane Persons of 
 the Society of Friends, p. 137. 
 
 A man labouring under recent concussion of the brain, and 
 from this cause comatose, was freely let blood, and afterwards 
 took a full dose of emetic tartar. After vomiting, he became 
 immediately sensible.
 
 160 RETINA. 
 
 lated, in which what the poet calls * a short mad- 
 ness* has been productive of the same unhappy 
 consequence. 
 
 That form of amaurosis common to protract- 
 ed suckling, in which the infant may be said to 
 prey upon its mother ; and that in which the 
 impaired energy of the whole nervous system, 
 occasioned by various states of physical disorder, 
 shews itself especially in this organ, afford fami- 
 liar instances of the amaurosis from constitu- 
 tional debihty. 
 
 Amaurosis Amaurosis depending on vascular congestion 
 thoTiJ'ctn. is marked by some or all of the following symp- 
 gestion. thorns, viz. dilated and sluggish or immoveable 
 pupil, ptosis, or strabismus, and oblique or dou- 
 ble vision of the affected eye ; a preternatural 
 action of the carotids, flushed face, sense of 
 weight, pain, or stricture of the scalp, lethargy, 
 occasional tinnitus aurium, with greatly disor- 
 dered and irritable stomach. The patient fre- 
 quently complains, particularly in straining, 
 stooping, or on first lying down, of seeing lumi- 
 nous sparks or flashes*, and a reflection of one 
 or more of the choroidal vessels, the visible pul- 
 
 * Persons labouring under dyspepsia are often troubled with 
 this symptom on first closing the eye to sleep; and in the pro- 
 gress of amaurosis from nervous exhaustion, it is sometimes 
 accompanied with the sensation of a crackling or snapping 
 noise.
 
 RETINA. I6l 
 
 sation of wliich is a cause of much distress to 
 him. A person thus affected accurately de- 
 scribed to me the zona minor iridis, as distinctly 
 presented to his view. 
 
 A loss of balance in the sanguiferous system, rrom de 
 occasioning an undue determination of blood to o/biooVto 
 the head, often exists, distinct from general pie 
 thora, and is aggravated by loss of blood. The 
 following case is an example : 
 
 A young medical man came to me one morn- 
 ing from the country in extreme anxiety, with 
 an earnest solicitation that I would instantly 
 apply a ligature to his carotid artery. This 
 gentleman, aged 25, was of short stature, and 
 constitutionally healthy. His pupils were large, 
 and his countenance was suffused and bore the 
 appearance of preternatural determination of 
 blood to the head. He had been the subject of 
 two attacks of inflammation ; one in April, the 
 other in October of the same year ; during which 
 he lost upwards of an hundred ounces of blood. 
 He had now a constant heavy pain in the head 
 chiefly over the coronal suture, and in the di- 
 rection of the sinuses, with tinnitus of the left 
 ear. After stooping the giddiness was extreme, 
 and a golden colored spot, edged with black, 
 appeared floating before the eye. He had been 
 troubled with muscse in excess, for a year and a 
 half past; he had now fire sparks flashing before 
 
 M
 
 l6g RETINA. 
 
 the sight, and saw a pulse in the choroid syn- 
 chronous with that of the wrist *. When look- 
 ing at near objects he was not troubled with 
 muscae, but they were always numerous, in pro- 
 portion as the object was remote. He did not 
 complain of much dimness. His complaints 
 were not relieved by topical blood-letting. He 
 recovered gradually but perfectly, under a regu- 
 lated diet, and a course of the blue pill with sa- 
 line aperients. 
 
 Amaurosis Tlic amaurosis, from depletion, is sometimes 
 tion. mistaken for its opposite, viz. that from pletho- 
 
 ric congestion ; this is owing to the coincidence 
 of a dilated and inunoveable pupil, musca?, and 
 a deep-seated pain in the head, with occasional 
 vertigo ; and its occurrence often in a corpu- 
 lent habit. It succeeds somewhat abruptly to 
 uterine floodings, and large and sudden deple- 
 tion for acute diseases. The pain is not con- 
 fined to the region of the orbit, though it affects 
 chiefly, if not exclusively, the same side of the 
 head j it is that peculiar nervous pain to which 
 women are subject after uterine haemorrhage, 
 attended with a sense of defined pressure, as of 
 an iron finger on the brain ; and sometimes a 
 
 * The subjects of chronic iritis, and in whom the pupil is 
 fixed, and the capsule of the lens more or less opaque, are of- 
 ten distressed with this or other signs of undue determination 
 of blood to the head, which is not in any degree relieved by 
 drawing blood.
 
 RETINA. 163 
 
 distressing jarring noise like that of a mill or 
 threshing-floor, or the rattling of the shingles 
 as a heavy wave of the sea recedes. It is per- 
 haps connected with an imperfect injection of 
 the medullary substance. By a cautious use of 
 tonics it is relieved ; by whatever lowers or sti- 
 mulates, whether diet or medicine, it is decidedly 
 aggravated. The vision in this form of amau- 
 rosis is further enfeebled by the loss of as much 
 blood as flows from two or three leech-bites. 
 This is not imaginary ; I have seen distinctly 
 marked cases of it, in which large and copious 
 venesection was still urged as the only resource 
 of art. This I consider to be a fatal mistake. 
 
 As the causes of amaurosis, to whichever class Amaurosis 
 it belongs, present infinite gradations, so do the tic with ir- 
 
 />,. n • • A 11,1 ,• ritable con- 
 
 imperrections ot vision. An unhealthy secretion junctiva. 
 of the meibomian follicles and caruncula lacry- 
 malis, a very inconsiderable obstruction in the 
 excretories of the tears, or a preternatural excit- 
 ability of the conjunctival surface from any 
 cause, will give occasion to such a degree of 
 weakness and dimness, as greatly to interfere 
 with, if not to interrupt, the transaction of busi- 
 ness. The improvement of the vision in strength 
 and clearness, during the use of astringent lotions 
 and stimulant ointments, is continually observed. 
 Persons affected with an irritable state of the 
 conjunctiva from any cause, frequently com- 
 plain, not that their sight is indistinct, but 
 
 M 2
 
 164 
 
 RETINA. 
 
 chest, 
 
 weak ; by which nevertheless they mean, that 
 they cannot maintain distinct vision for any con- 
 siderable time together. The retina appears to 
 be sympathetically affected in these cases. They 
 are often accompanied with muscle, and remark- 
 ably benefited by blisters, as well as by applica- 
 tions, which improve the condition of the con- 
 junctiva and eyelids *. 
 
 FUNCTIONAL AMAUROSIS. 
 
 2. Metastatic. 
 Amaurosis Amaurosis by metastasis is not unfrequent. I 
 sil fVoSIhe have seen it from the state threatening effusion 
 into the chest, from gout in the foot, and swelled 
 testicle ; in all which cases the oppressed organs 
 were suddenly relieved, and the eye as suddenly 
 affected. Thus a person goes to bed with good 
 vision and rises blind. 
 
 A lady, above the middle age, who had long 
 been subject to occasional attacks of pulmonary 
 congestion, after one of unusual severity, threat- 
 ening hydrothorax, was suddenly affected with 
 paralysis of the upper eyelid of the left eye ; the 
 sight was slightly, if at all, impaired. On the 
 following day however she had totally lost the 
 sight of that eye, tlie pupil of which was dilated 
 and motionless. On the morning of the third 
 day, the upper eyelid of the right eye was para- 
 
 * See note C.
 
 RETINA. 165 
 
 lysed, and the vision of that eye was also much 
 impaired. On the fourth day the ptosis on the 
 left side had disappeared, and the eyelid on the 
 right side resumed its position. She was now in 
 a state nearly approaching to complete blind- 
 ness ; both pupils dilated, although the left most 
 so, and nearly, if not quite inactive. The attack 
 was accompanied by a marked simultaneous re- 
 lief from the threatening symptoms of the ori- 
 ginal complaint, and occasional fugitive pains 
 across the front and top of the head. Upon in- 
 specting the eyes opposite the light, the appear- 
 ance described 5, page 149, was conspicuous in 
 both eyes, and led her physicians, who were of 
 the first eminence, to apprehend an incipient 
 opacity in some interior texture. Under the 
 frequent administration of calomel and rhubarb, 
 in moderate doses, and the alternate repeated 
 application of blisters behind the ear, and to the 
 nape of the neck, with abstemious diet, the 
 vision of both eyes was gradually restored. 
 
 testis. 
 
 A man, the subject of hernia humoralis, lost an From the 
 unusual quantity of blood by the bites of leeches 
 applied to the part. The testes were suddenly 
 and greatly reduced, and he complained of un- 
 easy sensations in his head ; to use his own 
 phrase, a pain like opening and shutting *. 
 
 * I once saw an attack of hemiplegia originate under simi- 
 lar circumstances;, viz. a sudden redugtion of enormously en-
 
 ICG RETINA. 
 
 Without any other visible sign of amaurosis than 
 a dilated and sluggish state of the pupils, he de- 
 scribed a dark screen seeming to rise gradually 
 from below upward, and at length totally ob- 
 scuring the sight. He lost blood from the head 
 repeatedly, and underwent a full course of mer- 
 cury without benefit. A state of perfect amau- 
 rosis ensued. 
 
 The gout attacks the eye through the medium 
 of the stomach. Vomiting occurs with pain in 
 that organ, on the subsidence of an inflammation 
 in the extremities, and is succeeded by violent 
 pain in the head. The loss of sight is sudden 
 and permanent. 
 
 From the A gentleman, after an attack of gouty inflam- 
 mation in the foot which suddenlv ceased. Was 
 attacked with pain in the stomach and vomiting ; 
 this in the course of the day subsided, and in 
 the night, a violent pain in the head was suc- 
 ceeded by an almost total loss of sight, which 
 was never afterwards in any degree restored, al- 
 though, by steeping the feet in a hot infusion of 
 mustard, the great toe inflamed so much as en- 
 tirely to relieve the head and stomach. 
 
 liirged testes by leeclies and cold lotions ; and since the first 
 edition of this ■work was published^ I have kno^vn a case of 
 iatal apoplexy succeed to a gangrenous inflammation of the 
 scrotum, from extravasation of the fluid injected for the cure 
 of hydrocelcj Avithin three days from the operation.
 
 RETINA. 167 
 
 To this class belong the cases of amaurosis 
 consequent upon the sudden suspension of the 
 catamenia, and of habitual hemorrhoidal dis- 
 charges ; the rapid healing of large ulcers of 
 long standing, and the sudden retrocession of 
 cutaneous eruptions *. 
 
 FUNCTIONAL AMAUROSIS. 
 
 3. Proper. 
 
 A short case or two will best explain what 1 Amaurosis 
 would call a temporary palsy of the retina from excUemem. 
 over excitement. 
 
 The following account is that of a young 
 gentleman who was ardently engaged in the 
 study of the profession when thus interrupted : 
 
 " Having habituated myself for the preced- 
 ing twelve months to intense study, reading and 
 writing to a very late hour, which had been 
 only interrupted for a few days by a slight in- 
 flammation of my right eye, I quitted London 
 
 to recruit my health in the pure air of . 
 
 This daily improved, but I found a growing 
 imperfection in the vision of my left eye, which 
 advanced, unaccompanied by inflammation, pain, 
 or any other external symptom of disease. It 
 seemed at first a film before the sight, but at 
 length amounted to a total loss of vision. On 
 
 * See note D.
 
 168 RETINA. 
 
 examination, I found the pupil greatly dilated, 
 and learned that the iris had little or no action. 
 By the advice of Mr. T. whom I now consulted, 
 I applied a blister, extending from the centre 
 of the forehead round the eye to the i^oot of 
 the nose. This drew well, and I continued it 
 open for ten days, closing the eye from light 
 during that period. I took at the same time a 
 calomel and opium pill thrice a-day. In the 
 space of a few days my mouth became sore ; 
 the pupil acted, though unequally, and I expe- 
 rienced a gradual recovery of vision. In the 
 course of six weeks, I was enabled to resume 
 my studies, and could perceive no defect of 
 vision. I had gradually reduced the dose of 
 calomel, and now discontinued it, drinking the 
 decoction of sarsaparilla. At the distance of 
 four months from this occurrence, the pupil is 
 regular and active, and the sight unimpaired." 
 
 One of our most eminent and indefatigable 
 artists in landscape was the subject of a super- 
 ficial irritable ophthalmia, accompanied with 
 much dimness and confusion of vision. Thi& 
 continued after the inflammation had subsided 
 under the ordinary treatment. He became se- 
 riously alarmed to find, upon attempting to re- 
 new his occupations, that he was unable to dis- 
 criminate the shades of color from each other, 
 and that in fact he had lost the visual tact, if I 
 might so express myself, essential to his pursuit.
 
 RETINA. 169 
 
 He submitted, by my advice, to a gentle course 
 of mercury, and has since enjoyed his former 
 accuracy of vision. 
 
 Examples of this species of amaurosis fre- 
 quently occur among sea officers and others, 
 suddenly, and without any preceding inflamma- 
 tion. I have repeatedly seen it of sudden acces- 
 sion with no other external sio;n than an inactive 
 pupil. 
 
 "^o* 
 
 A captain in the navy had made much use of 
 his right eye for many years in observations with 
 telescopes and sextants. About a week before 
 he applied to me, he observed a mist before this 
 eye, which increased until is was so dense, that 
 he could neither distinguish the features of his 
 friends, nor the large letters of a title page. 
 The eye was free from inflammation, the pupil 
 large and sluggish ; he had no pain either in the 
 eye or the head. He was bled copiously from 
 the arm and temple, and briskly purged with 
 calomel and jalap at short intervals. Blisters 
 were applied to the temples. He then rubbed in 
 a drachm of the strong mercurial ointment for 
 several nights in succession ; this produced a 
 copious flow of saliva and violent diarrhoea, so 
 that no benefit was obtained. By the calomel* 
 and opium pill taken night and morning his 
 gums were immediately made sore. In three 
 days the mist began to clear, and he was de-
 
 170 RETINA. 
 
 lighted to find that he could tell the hour by his 
 watch. He continued improving so rapidly 
 that, at the expiration of ten days, he could read 
 an ordinary print with perfect facility. The 
 pupil had recovered its natural magnitude and 
 activity. 
 
 In one instance this form of the disease fol- 
 lowed a long exposure to the heat of the sun 
 with such suddenness as to lead the patient to 
 attribute it to a * coup de soleil ;' and in another 
 it was referred to the habit of reading by fire- 
 light. It is seldom that both eyes are aifected, 
 and probable in some cases that the discovery 
 of the amaurosis, and not the disease itself, is 
 of recent occurrence. This point, however, can 
 generally be ascertained. 
 
 Symptoms I uow procccd to mcntiou the leading symp- 
 sis. " toms of amaurosis. A great source of difficulty, 
 in the arrangement of this extensive and com- 
 plicated subject, is the circumstance of many 
 symptoms being common to both classes. I 
 shall appropriate them, as far as I am able, in 
 Pain. my description. Pain affecting the forehead and 
 
 temples is a precursory symptom of amaurosis, 
 diminishing in proportion as the dimness in- 
 creases 5 when the amaurosis is perfect, it usu- 
 ally ceases altogether if the disease has its seat 
 in the eyeball. We must judge by its situation
 
 RETINA. 171 
 
 ami extent, but especially by its association 
 with other symptoms, if the pain be character- 
 istic of organic amaurosis. Pain affecting the 
 parts before mentioned, occasionally inconsider- 
 able, and declining as the dimness increases, is 
 common in some forms of functional amaurosis. . 
 If it be severe, remitting imperfectly, immedi- 
 ately increased by exercise, whether diffused 
 over the entire side of the head, or circum- 
 scribed to a small space of the anterior cerebral 
 lobes, it is usually connected with an organic 
 cerebral change ; but in this case, derangement 
 and torpor of the primae vise, loss of strength 
 and flesh, disposition to stupor, occasional con- 
 fusion of intellect, inaptitude to exertion, and 
 paralysis of one or more muscles, will be con- 
 comitant symptoms. 
 
 I have met with cases of amaurosis clearly 
 depending on cerebral disease or irritation, in 
 which the scalp was universally tender even to 
 soreness. 
 
 There is an intermittent spasmodic pain ac- Spasmodic 
 companying some cases of amaurosis, shooting 
 through the orbit into the head, of the most 
 acute and distressing severity ; it makes a pe- 
 riodic attack at or about the same hour, every 
 night, or every second night, and continues for 
 several hours ; it is accompanied with convul- 
 sive quivering of the muscles of the eye and eye- 
 lids, and profuse lacrymation ; there is nothing 
 
 pain.
 
 RETINA. 
 
 in the appearance of the organ to explain its 
 nature and origin. What has been described 
 as an intermittent ophthalmia, is I think impro- 
 perly so termed — the pain, not the inflamma- 
 tion, is intermitting. The pain of tooth-ache 
 and ear-ache, according to the state of the vas- 
 cular system, is subject to intermissions more 
 or less complete, but the periodic pain to which 
 I refer, is independent of any visible sign of in- 
 flammation. I believe it is a tic douloureux 
 affecting one or more of the orbitar branches of 
 the fifth pair. I have cured it in two cases by 
 arsenic, where opium failed to prevent the parox- 
 ysm*. I have known one instance of a similar 
 affection, without any defect of vision. 
 
 Paralysis of the levator palpebrae is a sign of 
 cerebral pressure, and always accompanied witli 
 some degree of imperfect vision ; this, however, 
 varies considerably. Paralysis of the orbicularis 
 palpebrarum is less frequent. It is generally 
 connected with a paralysis of the muscles on the 
 same side of the face. A palsy of either of these 
 muscles is sometimes attended by a degree of 
 vertigo so considerable as to make the patient 
 in danger of falling, if the eye be uncovered. 
 In these cases near objects appear remote, and 
 
 * Since the publication of the second edition of this work, 
 I have seen and treated several cases of this description, some 
 of them complicated with superficial inflammation, with the 
 same remedy and equal success.
 
 RETINA. 173 
 
 much diminished in size, as if seen through an 
 inverted opera-glass. The vertigo seems to be 
 excited by this illusion, as it happens to most 
 persons in looking from such an eminence as 
 renders objects dwarfish, for it ceases as soon 
 as the affected eye is closed. This symptom is 
 usually removed by depletion. 
 
 In other cases of fallen eyelid the affection of ptosis. 
 vision is so slight as scarcely to occasion incon- 
 venience, so that a person may read oi' write 
 while he supports the lid ; but the pupil is inva- 
 riably over dilated, and I have observed that the 
 pupil does not recover its activity proportionably 
 with the recovery of vision ; on the other hand, 
 I have seen both palpebrge affected with paralysis 
 in succession, each for a day or thereabouts, and 
 in this case the blindness supervened upon the 
 removal of the ptosis. 
 
 Ptosis follows injuries of the head and top of 
 the spine : I have known a permanent ptosis 
 and dilated pupil follow an injury of the cervi- 
 cal vertebra3 after an interval of some months, 
 without any other symptom of palsy. It is re- 
 markable that there was no paralytic affection 
 below the seat of injury. But paralysis from 
 irritation may happen in any direction. In this 
 case vision was in great measure restored by a 
 course of mercury. The use of strong lead 
 washes will produce a ptosis. I lately saw a
 
 174^ RETINA. 
 
 temporary paralysis of the muscles on one side 
 of the face, from frequently touching an ulcer 
 of the fauces with the oxymel aeruginis. 
 
 Loss of as- In proportion as vision fails, the eye affected 
 anddi- with amaurosis loses its fellowship with the 
 sound eye, and this loss of correspondence be- 
 comes a conspicuous character of the disease. 
 It is owing to this loss of correspondence that 
 persons, affected with an imperfect amaurosis 
 of one eye, often mistake the relative position 
 and distance of objects, and frequently see them 
 reflected. 
 
 In perfect amaurosis, or gutta serena, as it is 
 absurdly called, the peculiar inexpressiveness or 
 vacancy of countenance, depending on the non- 
 convergence of the optic axes, is too remark- 
 able to escape an ordinary observer, especially 
 if both organs are affected. The patient has 
 either a fixed unmeaning stare, or a constant 
 rolling motion of his eyes. The loss of asso- 
 ciation in strabismus results from a relative de- 
 bility of one of the straight muscles, and, if both 
 eyes are employed, is generally accompanied 
 with double vision ; but that which I have just 
 described is in no degree depending upon loss 
 of muscular energy, partial or general, direct or 
 indirect ; but on the total failure of sensation, 
 by which the actions of all muscles subject to 
 the will are directed.
 
 RETINA. 175 
 
 Strabismus is either congenital, or from the strabismus. 
 debility of scrofula, like the paralysis of the 
 lower limbs in children ; or from a morbid as- 
 sociation accidentally contracted and impressed 
 by habit in childhood ; or from a wound of the 
 frontal nerve ; or a speck upon the cornea ren- 
 dering the vdsion oblique ; or from violence 
 done to the affected straight muscle. I have 
 seen a complete internal strabismus, the effect 
 of a blow on the temple, which a school-boy 
 received in fighting. From its suddenness and 
 the ecchymosis of the conjunctiva on the tempo- 
 ral side, T concluded the abductor was lacerated 
 or palsied ; and so it proved ; for in a few weeks 
 the distortion was entirely removed *. It is 
 also a symptom of irritation arising from difficult 
 dentition, worms, &:c. ; or of pressure at the ori- 
 gin or in the course of the nerve proper to the 
 affected muscle. 
 
 There is a complaint of cross sight occasion- 
 ally made by persons who have no perceptible 
 strabismus. It happens in looking downwards 
 as in ordinary reading. In looking at objects 
 on the same horizontal plane with the eyes, it 
 is not perceived. It is a relaxation of one of 
 the inferior straight muscles. 
 
 * IMr. Cheselden relates the case of a ffentleman who had 
 strabismus, with double vision, produced by a blow on the 
 head. By degrees, the most familiar objects came to appear 
 single again, and in time all objects did so, without any 
 amendment of the distortion.
 
 176 RETINA. 
 
 Hemiopsia Tlic retina is often partially affected in orga- 
 
 or partial . • T-i J 'U 
 
 impairment nic amaurosis. ihus some persons describe a 
 tina. " horizontal, others a vertical screen, eclipsing one 
 half of the object viewed, or even of the field 
 of vision. In order to see a given object en- 
 tire, which is upon a level with the eye, they 
 are compelled to move the eye or the head, in 
 the direction which the obliquity of their vision 
 requires. Again, cases now and then occur in 
 which persons have lost their lateral vision, 
 while they see objects in the direct line of the 
 axis of vision. In the greater number of cases 
 however, the vision of amaurotics is oblique, 
 and in perfect amaurosis, the perception of 
 light, if any, is also oblique. The gradual re- 
 turn of vision is generally first perceived in 
 this direction. The sensibility of the retina, 
 whether more or less, seems to be greatest at 
 the part farthest removed from the axis of vi- 
 _- sion, or rather from the entrance of the nerve, 
 
 for it is more frequently observed on the tem- 
 poral than on the nasal side. I am unable to 
 offer a satisfactory conjecture in explanation of 
 this fact. 
 
 A gentleman, who died of apoplexy in his 
 36th year, and who lost eight pounds of blood in 
 the three days preceding his death, had consult- 
 ed me for depraved sight of one eye, six months 
 before that event. The pupil was permanently 
 dilated. He had double vision whilst looking
 
 RETINA. 177 
 
 directly forward; if he looked obliquely to either 
 side, his vision was single. A slight strabismus 
 was perceptible. Many cases analogous to this 
 have fallen under my notice, in which no op- 
 portunity was afforded of ascertaining the cause 
 of disease *. The vision is sometimes perfect or 
 nearly so with the eye, which, by loss of corres- 
 pondence with its fellow, occasions the duplicity 
 of objects viewed with both. I have known it 
 equal in power to that of the other eye when 
 employed singly. The double vision and giddi- 
 ness cease, when either eye is employed alone, 
 or is closed. The paralysis affects the nervi 
 motores oculorum directly in such cases, and 
 the optic nerve suffers by sympathy. Where 
 the vision of the affected eye is materially 
 bedimmed, the ptosis or strabismus is more 
 marked, and the symptoms of double vision and 
 vertigo in proportion. 
 
 A distorted relative position of objects is also Distorted 
 
 position of 
 
 not an vuicommon symptom of organic amauro- objects, 
 sis. Thus, the lines of a printed page seem zig- 
 zag, and the two eyes of a face appear in dif- 
 ferent planes, whether one or both eyes are af- 
 fected. If one object be seen in its proper place, 
 the situation of a contiguous object is erro- 
 neous, both as to distance and parallel. If only 
 one eye be affected, the employment of the sound 
 eye exclusively, corrects the error. In the case 
 * See note E.
 
 178 RETINA. 
 
 of simple non-correspondence, it is corrected by 
 either eye indifferently. This is the reverse of 
 what happens when the eyes are perfect, in 
 which case, the delusions, arising from the use 
 of one eye only, are corrected by employing 
 both. Both this and the preceding are for 
 the most part, not always, symptoms of an or- 
 ganic affection. I have been led to this conclu- 
 sion from observing the morbid appearances and 
 the inefficacy of remedies, where such signs of 
 the disease were established. But I have known 
 instances of their removal. 
 
 Muscje, Muscae are either fixed, when they are usually 
 
 floating. allied to spectra, and belong to organic amau- 
 rosis ; or floating, when they are I believe cha- 
 racteristic of functional amaurosis, sympathetic 
 or proper. I have known the fixed musca, 
 permanent, without variation for years, darken- 
 ing a certain defined portion of the field of vi- 
 sion. In some rare instances, it precedes acute 
 choroid inflammation ; more frequently it is un- 
 connected with any particular morbid state. 
 Around the opaque spot persons have suffi- 
 ciently distinct vision. The spot varies in density 
 in different individuals, and under a long but 
 gentle mercurial course, I have known it be- 
 come considerably less dense, so as not to inter- 
 cept bright light. Its circumference sometimes 
 reflects a tinge of color or a luminous halo. 
 The fixed musca seldom presents the fantastic
 
 RETIXA. 179 
 
 shapes of the floatmg*, but it is not uncommon 
 for the two forms to co-exist. 
 
 The musca volitans is sometimes solitary, fol- 
 lowing the eye at a fixed angle as it passes along 
 a line; sometimes two, three, or more are pre- 
 sented ; more frequently an immense assem- 
 blage, descending in a cloud as the eye is raised, 
 and ascending as it is depressed. They are ob- 
 vious to so many analogies, and apprehension of 
 impending blindness makes patients so minute 
 in their observation and description of them, 
 that it is scarcely possible to do justice to our 
 experience in attempting to describe them. 
 Sometimes they are represented as globular, 
 sometimes annular and flat like a piece of money. 
 Portions of flue, of soot, insects' wings, transpa- 
 rent vesicles, or minute globules of quicksilver, 
 connected like the links of a chain, or short 
 hairs with their bulbs attached to them, are or- 
 dinary resemblances. They occupy the air 
 with some persons, and are seen upon looking 
 at the sky, or upon a white sheet of paper, and 
 especially in shifting the eye from one object to 
 another ; to some they appear in the fire or 
 candle only, and with others they seem to cover 
 the ground, so that they walk in them knee- 
 
 * To this remark there are exceptions. A gentleman, who 
 a short time ago consulted me, compared the spectrum con- 
 stantly before each eye to a large dragon fly, darkening the 
 field of sight. 
 
 N 2
 
 180 RETINA. 
 
 deep. Almost every person has, at some time 
 or other, seen these appearances, but especially 
 those subject to dyspepsia, and disordered func- 
 tion of the stomach and liver. At the moment of 
 approaching deliquium, they appear in one vast 
 cloud, and they are harbingers of the intense bi- 
 lious headache. At the instant of their appear- 
 ance, the sentient extremities upon the fingers 
 and tongue are so benumbed, that objects of 
 touch and taste convey a very indistinct impres- 
 sion, as if some muffle were interposed. These 
 sensations I am describing ad vivum, for I was 
 formerly often the subject of this attack, which 
 was followed by a certain degree of confusion of 
 intelJect, and temporary suspension of memory, 
 so as greatly to embarrass, if not to take away, 
 the power of intelligible expression. I mention 
 these opposite and transitory states of emptiness 
 and plethora concomitant with the floating 
 muscae, to show the purely functional origin of 
 the affection. The one (deliquium) is an unin- 
 jected, the other (sick headache) an over-inject- 
 ed or congested state of the nervous texture ; 
 or suspension from vacuity, and suspension from 
 plethora. An analogy is plainly to be perceived 
 between the corresponding states of the sen- 
 , tient and visual extremities, described in the 
 last affection, to that of a temporary incomplete 
 paralysis. 
 
 The fixed musca is generally an organic affec-
 
 RETINA. 181 
 
 tion, probably a deposit or extravasation be- 
 tween the choroid and retina, compressing to a 
 certain space the papillge of the retina, to which 
 the musca corresponds in figure. In other 
 instances, it is independent of deranged struc- 
 ture, and may be presumed to be only an insen- 
 sible point on the retina. The single muscae 
 sometimes coalesce, and form a larger spot. 
 The floating muscse are altogether a functional 
 affection, not interfering with useful vision, and 
 sometimes, though not often, removed. To some 
 persons they disappear upon looking through 
 glasses, and others see them only upon remote 
 objects. Their magnitude diminishes as the dis- 
 tance is increased, to those who see them at all 
 distances. They are simply a disordered circu- 
 lation in the vessels of the retina*, and occur 
 oftener in nervous and spare than in plethoric 
 and robust persons ; they are generally induced 
 by overstraining the organ, almost always ac- 
 companied with a weak and irregular digestion, 
 and varying with, if not depending upon, the 
 condition of the stomach. 
 
 Colored spectra, or luminous impressions of MorWd 
 objects remaining upon the retina, are usually ^p^"""^ 
 preceded by the fixed muscae, and may then be 
 regarded as a more advanced stage of the com- 
 
 * In some cases they have been supposed to depend on 
 floating particles in the humors or minute scabrous points in 
 the cornea.
 
 182 RETINA. 
 
 plaint. This is not always the case : I have known 
 them to be symptoms of functional derangement, 
 and to disappear as the vision recovered. In this 
 affection, a halo of light encircles the opaque 
 spot during the exercise of vision ; and if a 
 bright luminous object be contemplated, a co- 
 lored image or the reflection of it is presented 
 to the mind for a time, greater or less, after the 
 eye is withdrawn or closed. Of the same spe- 
 cies are the various morbid refractions of lumi- 
 nous bodies, presenting the object double to 
 one eye, or curiously divided and distorted, as 
 in looking through a crinkled pane of glass*; 
 and the appearance of prismatic colors in the 
 forms of circles, rainbows, cones, &c. Some- 
 times ordinary objects are imperfectly represent- 
 ed, or even dark, so that they would not be 
 known but from their outline being illuminated. 
 Thus a man, a tree, or a house, appears fringed 
 with a glory ; and on the other hand, it is not 
 uncommon for the outline of objects to be lost 
 in shade, while the centre is clearly discerned, 
 
 I might illustrate these observations by a mul- 
 titude of cases in my possession, which I omit 
 for the sake of conciseness, and in conformity to 
 the plan of this work. On this subject, how- 
 ever, I shall take the liberty of introducing the 
 
 * I have known cases in which interrupted vision was pro- 
 duced by several apertures made with the needle in a capsular 
 cataract^ so that the moon appeared as if cut in pieces.
 
 RETINA. 183 
 
 case of an intelligent young gentleman, very ac- 
 curately drawn up by himself, for the purpose 
 of shewing the gradations of this disease in its 
 progress, as well as its origin. 
 
 *• About a year and a half ago the first symp- Case of 
 
 muses and 
 
 toms appeared, which gave me any uneasiness Bpectra. 
 with respect to my sight. For several months 
 I read incessantly, not only throughout the day, 
 but also for five or six hours each night by 
 candle-light ; and I now perceived numerous 
 circular motes, which combining, formed clouds 
 of irregular figures before my eyes. These motes 
 always appear when I look at the sky or any 
 light-colored object in a strong light ; they move 
 with the eye, retaining for some time the same 
 position with relation to each other and to the 
 centre of vision : each consists of a slightly 
 opaque circumference and a central spot, the 
 diameter being, as well as I can judge, about 
 four or five minutes of the circle of vision. Some- 
 times films appear curved or twisted like hairs, 
 and of the same degree of opacity as the motes. 
 There is a collection of these films always before 
 the right eye, but at such a distance from the 
 centre of vision as not to disturb sight. The 
 number of the motes seems increased by violent 
 exercise as well as by close reading, or a disor- 
 dered state of stomach. Sometimes for a mo- 
 ment a small circular black spot appears near
 
 184 RETmA. 
 
 the centre of vision, and sometimes, though not 
 so frequently, one faintly luminous. 
 
 " The candle next appeared surrounded with a 
 faint halo, which became more vivid as I conti- 
 nued this severe exertion of my sight. When my 
 eyes are unusually weak, or a light is presented 
 to them after I have been some time in dark- 
 ness, instead of the halo a globular appearance 
 of a muddy yellow color surrounds the flame. 
 
 " About six months ago, I began to be an- 
 noyed by the retina retaining impressions made 
 upon it. After looking at any white or bright 
 metallic object, on turning away my eyes I dis- 
 tinctly perceive its outline in a darker shade, on 
 any surface to which I may direct my view ; the 
 impression lasting from two or three seconds to 
 half a minute, according to the strength of light, 
 the brightness of the object, and the length of 
 time for which I have viewed it. The flame of 
 a candle leaves its image impressed on the reti- 
 na frequently for a couple of minutes ; the sun 
 for a still longer time ; the image in both in- 
 stances being of a muddy yellow color. 
 
 " A kind of penumbra surrounds light-colored 
 objects in a strong light, and prevents me from 
 accurately distinguishing their outline. When 
 the object is under a sufficiently small angle to
 
 RETINA. 185 
 
 be seen entire without moving the eye, it seems 
 double, one image being such as would appear 
 to a healthy eye, the other much fainter ; thus 
 is the moon seen, a piece of money, or the gilt 
 letters over shop windows. These appearances 
 take place indifferently, whether I use either 
 eye or both. 
 
 "In a few instances, a very severe exertion 
 of my eyes produced the appearance of innume- 
 rable black particles dancing before them. 
 
 " When I read for any considerable time, I 
 have a disagreeable sense of heat in my eyes, 
 with pain in the eyeballs, extending to the lower 
 part of the forehead. I am not constantly sub- 
 ject to headaches, though occasionally afflicted 
 by them, especially if 1 delay breakfasting for any 
 length of time after rising. My tongue is fre- 
 quently foul for weeks together, my digestion 
 seems weak, and I seldom enjoy a good appetite. 
 
 " I ought to observe, that most of the above- 
 mentioned symptoms seem to have been miti- 
 gated since I came to London. Since the appli- 
 cation of the blisters, the halo round the flame 
 of the candle has nearly disappeared." 
 
 A very frequent and characteristic symptom AmWyopsia: 
 
 o o 1 • ^ • • r nebulous or 
 
 or functional amaurosis is a thui mist, tog, misty vision. 
 smoke, or gauze, or as I have heard some pa-
 
 186 RETINA. 
 
 tients represent it, an indefinable something, as 
 if vision required a peculiar atmosphere, inter- 
 vening between the eye and the object, which 
 takes off the * acies oculorum acer claraque,' the 
 sharp edge of clear vision. Letters of a book 
 run together, and the outline of all minute ob- 
 jects is indistinct. In some cases this indistinct- 
 ness is constant and unvarying ; in others it is 
 the result of exercise of the organ, for a period, 
 varying in different persons from ten minutes, or 
 even less, to half an hour. Repose of the organ, 
 whether obtained by closing the lids, or looking 
 vacantly on distant objects, or gentle friction of 
 the lids, or a slightly stimulant application, 
 enables the person to resume for a short time ; 
 but the hindrance returns, and if the employ- 
 ment be persisted in, the dimness becomes little 
 short of blindness, and sometimes occasions pain, 
 always a painful sense of weakness. This affec- 
 tion is unaccompanied with irritable conjunc- 
 tiva ; there is no tendency to suffusion. It is sel- 
 dom relieved by glasses, and never permanently. 
 It is sometimes combined with muscae, but more 
 frequently distinct. The iris appears irritable 
 and unsteady ; it contracts often quickly, but 
 vacillates between contraction and dilatation 
 without a change of the light. 
 
 Oscillatory 
 
 Another functional affection is an oscillation 
 or wavering of objects, so that the want of stea- 
 diness occasions a dazzling and confused per-
 
 RETINA. 187 
 
 ception. This may be the result of simple con- 
 gestion ; but I have known it unaccompanied 
 by any sign of this state, and in persons of a 
 frame and temperament distinctly opposed to it. 
 With this is often combined a delusion of some- 
 thing waving or flapping in an oblique relation 
 to the eye, as towards the temple, or pendulous 
 from the eyelash, or brow, unaccompanied by 
 any distinct perception of figure. 
 
 An occasional symptom of functional amauro- Loss of the 
 
 p ,. . . . adjusting 
 
 sis is a loss of the faculty of distmct vision at power. 
 different distances. A gradual abridgment of 
 the focal range at its near extremity, occurring 
 in advanced life, and requiring the aid of convex 
 glasses, has been supposed to depend upon a 
 permanent change in the figure of the globe ; I 
 should rather refer it to a loss of power of the 
 retina incidental to age, and a consequent im- 
 perfection of function in those parts, which ex- 
 ecute the office of adjustment. It is a change 
 similar to this, taking place in early or middle 
 life, and with more abruptness (the indistinct- 
 ness sometimes pervading near objects exclu- 
 sively, and in other cases, remote ones), which 
 I consider to be a symptom of amaurosis. It 
 cannot be admitted, that the distinct vision of 
 an object, at a permanent focal distance, proves 
 the power of the retina to be unimpaired. If the 
 organ be originally perfect as an optical instru- 
 ment, so that the rays of light flowing from near, 
 as well as from remote objects, form images upon
 
 188 RETINA. 
 
 the retina sufficiently perfect for distinct vision ; 
 and if the range of distinct vision be, whether 
 suddenly or gradually, so abridged, that the eye 
 is incapable of relieving itself by a change of 
 focus, the feebleness of the retina is invariably 
 demonstrated by other signs, for the imperfec- 
 tion of adjustment seems in all cases to be in 
 proportion to the loss of vigor of the retina. 
 Ordinary observation proves that the effect of 
 wear and tear is to allow of good distant vision, 
 in which the parallelism of the rays of light su- 
 persedes the necessity of adjustment, while the 
 near sight, which requires the active or tonic 
 state of the adjusting faculty, is impaired or lost. 
 But if, as sometimes happens, the vision of near 
 objects remains good, while the distant is ob- 
 scured, the evidence of the faultiness of the 
 retina is direct. The correction of a defective 
 adjustment by the use of glasses, in either case^ 
 proves no more than that the retina is not orga- 
 nically affected, while the failure of this correct- 
 ive, which is fi-equent in the cases referred to, 
 demonstrates the functional debility of the re- 
 tina. In most of these cases the use of glasses 
 is of temporary benefit, but if continued, it is 
 followed by uneasiness or pain in the eyeball. 
 
 Many phenomeua of impaired adjustment cor- 
 respond to the degree of mobility of the iris ; 
 for in some persons it is quick to contract, but 
 unable to preserve its contraction, and falls open 
 or fluctuates in the same quantity of light, and
 
 RETINA. 189 
 
 I have observed that the point of clear vision 
 shifts accordingly ; in others it contracts slowly 
 and imperfectly ; in others again it is perma- 
 nently contracted or dilated, and this, independ- 
 ent of any other defect of sight than an abridg- 
 ment of the original range of distinct vision, at 
 one or other extremity *. 
 
 I have met with different reports, as to the influence of 
 time of day in which persons affected with im- amaurotics, 
 perfect amaurosis, enjoy the best sight. Some 
 see clearest on first waking in the morning, 
 whereas others are particularly dim for an hour 
 or two after rising. In these cases, the state of 
 the stomach has an obvious influence. Empti- 
 ness will produce muscae, and a temporary blind- 
 ness. Some see only in a full light, others in a 
 weak one, as after sunset. Candle-light, though 
 generally least favorable to such persons, is not 
 invariably so. In a considerable proportion of 
 cases, amaurotic patients see clearest in the even- 
 ing, and their vision seems to gain strength by 
 exercise. They see better for example on re- 
 tiring to rest, than they have seen at any period 
 of the day. 
 
 These differences are, in most cases, referri- according to 
 
 . .the state of 
 
 ble to the varieties in susceptibility of the retina, the retina, 
 
 * See note F.
 
 pupil. 
 
 190 RETINA. 
 
 determining the requisite degree of illumination 
 of objects for vision, and the adaptation of the 
 pupil to that purpose. But in other instances, 
 as I have before hinted, a reflection takes place 
 within the eye, owing to some change in the 
 quality or quantity of the pigment, which ren- 
 ders a screen or colored glasses, or a dark day 
 or twilight, in their several degrees, favorable or 
 even essential to vision. This partakes of the 
 nature of an organic disease. 
 
 and of the I havc kuown persons absolutely blind for two 
 or three minutes, upon going into a darkened 
 room, owing to the imperfect sensibility of the 
 retina, and consequent slow dilatation of the pu- 
 pil; and they made no complaint, as persons 
 usually do, of dimness from the opposite transi- 
 tion. Such persons, indeed, require a full strong 
 light to see at all. But that such a defect is not 
 directly or exclusively depending on the state of 
 the pupil, is proved by the occasional coinci- 
 dence of good vision with a permanently con- 
 tracted pupil. I have met with cases of remark- 
 ably small and habitually contracted pupil, in 
 which the glare of light was even painful, and 
 where the inconvenience was at once removed 
 by moderating the light, without any perceptible 
 alteration in the diameter of the pupil. A lady 
 of quality, in whom I made this observation, 
 told me that it had equally attracted the notice 
 of Mr. Hunter, whom she had formerly consult-
 
 RETIXA. 
 
 191 
 
 ed. The cases of day and night bUndness pre- 
 sent the opposite extremes of variation in sus- 
 ceptibility of the retina, and these must be re- 
 garded as cases of proper functional amaurosis. 
 The remarkable efficacy of blisters upon the 
 temples in these cases confirms this fact. 
 
 I had abundant opportunities formerly of ob- 
 serving the influence of trades, in aggravating as 
 well as producing amaurotic affections : it was 
 a common remark with tailors and shoemakers, 
 that they never saw so well as upon Monday 
 morning, which they justly attributed to the re- 
 pose of the organ during Sunday. 
 
 The activity of the iris, evinced in the mo- Action of 
 tions of the pupil, is, generally speaking, the an index of 
 surest mdication ot the health or the retma. the retina. 
 The contraction is slow, or it is incomplete, or 
 both, upon the sudden admission of Hght to the 
 eye, where the retina is defective in sensibility. 
 The mean state of the pupil is that of dilatation 
 where an amaurotic affection exists, and this 
 will sometimes discover to an attentive observer, 
 which of the two eyes is affected. When the per- 
 ception of light fails altogether, the pupil is ge- 
 nerally fully dilated, and absolutely motionless. 
 It is in other cases not perfectly a circle. 
 
 The activity of the iris requires the free and ^h^" 
 
 ••■ non c 
 
 uncompressed state of the retina, iris, and ci- ''^e '"" '" 
 
 ome- 
 of ac-
 
 amaurosis. 
 
 192 RETINA. 
 
 perfect liai'y Herves. In the various forms of amauro- 
 sis, its activity is proportioned to the degree of 
 integrity which these several parts retain, and 
 the intensity of the stimulus. If the retina be 
 opaque, compressed, or unsupported, the iris me- 
 chanically disordered, or the ciliary nerves pal- 
 sied, the pupil is inactive, independently of the 
 state of vision. In the first of these cases, it is 
 evident the vision will be lost ; but we continu- 
 ally see useful vision combined with the second 
 and third, as after operations in which the iris 
 has been half destroyed, or has become perma- 
 nently adherent, or in malformations where it 
 is half wanting ; and in paralysis of the ciliary 
 nerves accompanying the state of ptosis. But 
 how shall we explain the activity of the iris in a 
 state of absolute blindness ? a case by no means 
 uncommon. We can only explain it by conclud- 
 ing the organ to be sound, and the cause of the 
 amaurosis remote, or at least external to it. Its 
 motions in such a case are purely involuntary ; 
 the mental perception being suspended or anni- 
 hilated. All that is required to excite them is 
 the impingement of the ordinary stimulus upon 
 the unchanged retina, the white sheet upon 
 which the images of objects are impressed, the 
 instrument, not the organ of perception. The 
 iris, in such a case, acts by a sympathy inde- 
 pendent of the brain. 
 
 Thus in a case of circumscribed tumor com-
 
 RETINA. 193 
 
 pressing the left optic nerve, immediately behind 
 the ganglion opticum, although the blindness 
 was complete, the iris was active. In two young 
 ladies, in whom the eyes, as in the former case, 
 were perfect, and the blindness complete, the 
 iris was even vivacious ; and there was the 
 strongest presumptive evidence, from the symp- 
 toms, that the amaurosis was in the cerebral por* 
 tion of the nerve*. 
 
 If this theory be correct, the activity of the 
 pupil in complete blindness proves, that the re- 
 tina and orbitar portion of the optic nerve are 
 unaltered, and that the disease has its seat in the 
 cerebrum, or cerebral portion of the nerve 5 
 while, at the same time, the ciliary nerves are 
 unaffected by it in their origin and course. On 
 the contrary, the fully dilated and motionless 
 pupil shews, that these nerves are paralysed — 
 the disease may be cerebral or orbital, or both. 
 We see this exemplified in hydrocephalus, and 
 in orbitar tumors compressing the nerve and 
 globe. In cases of perfect amaurosis, in which 
 the pupil, of its ordinary size, is absolutely 
 without motion, a case by no means uncommon, 
 the retina has most probably undergone a 
 change of texture. The ciliary nerves are un- 
 compressed, as may be inferred from the undi- 
 lated state of the pupil, but the source of their 
 
 * Janin relates two cases of lively pupil in a state of total 
 blindness — Mem. et Observ. sur I'CEil, p> 426. 
 
 o
 
 194< RETINA. 
 
 excitement, sympathy with the retina, is de- 
 stroyed. The symptoms of the disease, in its 
 early stage, will point out its seat, where its 
 locality is definable*. 
 
 Blindness, A man was trepanned for a fracture with de- 
 pupii, from pression of the right frontal and parietal bones. 
 basL!"^^ After the operation he became sensible, but it 
 was discovered that he was totally blind, being 
 unable to perceive a lighted candle held close be- 
 fore his eyes. The pupils were fully dilated and 
 insensible to light. On the fifth day he died of 
 inflammation of the membranes of the brain, 
 having continued until his death in total dark- 
 ness. On dissection, a fracture of the frontal 
 and parietal bones was discovered on the left 
 side, corresponding to that on the right, but 
 without depression j and these two fractures were 
 connected by a transverse fracture, extending 
 across the basis of the cranium, i. e. through the 
 orbitar plates of the frontal bone anterior to the 
 junction of the optic nerves. This transverse 
 fracture extended into the bones of the face, so 
 as to separate them from those of the cranium, 
 and there was displacement of the bones suffi- 
 cient to occasion a considerable pressure upon 
 the optic nerves. 
 
 * It is to be regretted that in the many excellent observa- 
 tions of Morgagni and others, of diseased states of the optic 
 nerve, the opportunity of learning the signs of the disease 
 during life was so seldom enjoyed.
 
 RETINA. 195 
 
 In this interesting observation, given to me 
 by my able and excellent friend Mr. Brodie, it 
 is evident that all the nerves entering the orbit 
 must have been compressed. Hence the paralysis 
 of the iris concomitant with that of the retina. 
 
 In hydrocephalus, the pupils are invariably 
 fully dilated and motionless. In apoplexy ge- 
 nerally, but with exceptions ; sometimes con- 
 tracted, but still immoveable ; which Dr. Cooke, 
 in his late Treatise on that subject, considers a 
 fatal prognostic. In injuries of the head, with 
 symptoms of depression, the pupils are gene- 
 rally dilated and motionless, but sometimes in- 
 considerably enlarged, and slightly moveable ; 
 in other instances contracted ; and very fre- 
 quently one is permanently dilated, and the 
 other contracted. These varieties depend on the 
 situation in which pressure is applied, and the 
 extent which it occupies, and in some degree on 
 the nature of the compressing cause, whether, 
 bone driven in or fluid effused ; in hydrocepha- 
 lus the result is uniform. But it is not the loss 
 of the sight which occasions the dilatation of the 
 pupil, in injuries where these circumstances 
 coincide, but compression of the ciliary nerves, 
 or of those from which they are derived ; the loss 
 of motion in the iris is a gradual and not a sud- 
 den effect of the loss of sight, and it seldom hap- 
 pens that the vision is lost in those casualties in 
 which the pupil is permanently dilated. 
 
 o 2
 
 196 RETINA. 
 
 Among the morbid changes of the retina, os- 
 sification has been rarely met with*. 
 
 It is remarkable that in the thickened, atte- 
 nuated, softened, ossified, or otherwise morbid 
 states of the optic nerve or its sheath, the diseased 
 appearance has seldom extended beyond the 
 ganglion opticum. The eyeball has frequently 
 been free from disease. The blindness has pro- 
 bably in as many instances proved a cause, as an 
 effect, of the degenerations of the nerve. Cases 
 indeed are related, of a considerable and very 
 obvious change in the structure of the nerve, 
 where the sight of the corresponding eye has 
 been unaffected. 
 
 Case of It has occurred to me, in concluding the sub- 
 
 ject of amaurosis, that the case of our great 
 Epic Poet, drawn up by himself for the purpose 
 of its being submitted to Thevenot, a celebrated 
 French oculist, may not be uninteresting to my 
 readers. I subjoin it as the best account that I 
 know of the symptoms of amaurosis, in its pro- 
 gress from the state of functional debility, to the 
 confirmed, perhaps organic, gutta serena. I 
 have preserved liis own words lor the sake of 
 accuracy. 
 
 * Vide Morgagni, Lett. 52, Art, 30. 
 
 i
 
 RETINA. 197 
 
 " Decennium, opinor, plus minus est, ex quo 
 debilitari atque hebescere visum sensi, eodem- 
 que tempore lienem, visceraque omnia gravari, 
 flatibusque vexari ; et mane quidem, si quid pro 
 more legere coepissem, oculi statim penitus do- 
 lere, lectionemque refugere, post mediocrem 
 deinde corporis exercitationem recreari : quam 
 aspexissem lucernam, Iris qua^dam visa est redi- 
 mere : baud ita multo post sinistra in parte oculi 
 sinistri (is enim oculus aliquot annis prius al- 
 tera nubilavit) caligo oborta, quag ad latus illud 
 sita erant, omnia eripiebat. Anteriora quoque, 
 si dexterum forte oculum clausissem, minora 
 visa sunt. Deficiente per hoc fere triennium sen- 
 sim atque paulatim altero quoque lumine, ali- 
 quot ante mensibus quam visus omnis abolere- 
 tur, quae immotus ipse cernerem, visa sunt omnia 
 nunc dextrorsum, nunc sinistrorsum natare 5 
 frontem totam atque tempora inveterati quidem 
 vapores videntur insedisse j qui somnolenta qua- 
 dam gravitate oculos, a cibo pragsertim usque ad 
 vesperam, plerumque urgent atque deprimunt j 
 ut mihi baud raro veniat in mentem Salmydessii 
 vatis Phinei in Argonauticis : 
 
 * Vertigo vero ipsum circumdedit 
 
 Atra, et terram opinatus est circumagi 
 Ab imo, in languidum vero soporem delapsus est elinguis. 
 beck's appollonius rhodius. Lib. 2. v. 203.
 
 198 RETINA. 
 
 Sed neqiie illiid omiserim, dum adhuc visus ali- 
 quantulum supererat, ut primum in lecto decu- 
 buissem, meque in alterutrum latus reclinassem, 
 consuevisse copiosum lumen clausis oculis emi- 
 care; deinde, imminuto indies visu, coloresper- 
 inde obscuriores cum impetu et fragore quo- 
 dam intimo exilire ; nunc autem, quasi extincto 
 lucido, merus nigror, aut cineraceo distinctus, 
 et quasi intextus solet se afFundere : caligo ta- 
 rn en quag perpetuo observatur, tarn noctu, 
 quam interdiu, albenti semper quam nigricanti 
 propior videtur j et volvente se oculo aliquantu- 
 lum lucis quasi per rimulam admittit." 
 
 LEONARDO PHILAR7E, ATHENIENSI : 
 
 Septemb. 28, 1654. 
 Miltoni Opera Amstelodamij 1698. p. 330.
 
 PATHOLOGY 
 
 HUMOUS. 
 
 CHAPTER IL 
 
 SECTION I. 
 
 AQUEOUS HUMOR. 
 
 The simple redundancy of the aqueous humor Hydroph- 
 is a sequel of chronic inflammation, affecting ^™^' 
 the internal texture of the globe. Its figure is 
 preserved, but the distended sclerotic has a dark 
 blue tinge ; the cornea is extended and promi- 
 nent, the pupil dilated and inactive, and the vi- 
 sion is inconsiderable, if not extinct. In other in- 
 stances, the state of hydrophthalmia is accompa- 
 nied with loss of figure of the globe, and staphy- 
 lomatous enlargement of the cornea, which is 
 specked or exulcerated, and frequently presents 
 fasciculi of red vessels on its surface. This state 
 is the result of a disorganizing inflammation.
 
 200 AQUEOUS HUMOR. 
 
 The bulged and transparent cornea, whether 
 spheroidal or conical, gives the appearance or 
 the idea of a redundant aqueous humor ; but 
 this is only the consequence of the increased ca- 
 pacity of the chamber. The distinction is im- 
 portant ; for the treatment of the hydrophthal- 
 mia and the conical cornea proceeds, as it seems 
 to me, on opposite principles. 
 
 Rapid re- 
 proJuction. 
 
 The aqueous humor is always rendered tur- 
 bid by inflammation of the choroid and iris, but 
 resumes its transparency when the inflammation 
 is subdued. When discharged by accident or 
 operation, it is reproduced in a period of from 
 eight to twelve hours. It is regenerated in all 
 states of the organ, in which the anterior cham- 
 ber is even in part preserved, in quantity suffi- 
 cient to give plumpness and figure to the globe, 
 and to refract the light with accuracy enough 
 for the distinct vision of large objects. 
 
 Effusions of lymph, from inflammation of the 
 iris, of puriform matter from internal ulcer of 
 the cornea and abscess of the eyeball, and of 
 blood from concussions and wounds of the organ, 
 are frequently observed in the chamber of the 
 aqueous humor. 
 
 Solvent 
 power in- 
 considera- 
 ble. 
 
 The solvent action of the aqueous humor over 
 the exposed fragments of the crystalline lens is 
 not, in my belief, superior to that of water.
 
 AQUEOUS HUMOR. SOI 
 
 which I have found by experiment to be ex- 
 ceedingly slow. A knife or needle, too highly 
 tempered, has occasionally been broken in the 
 operation for cataract, and the point has been 
 left in the anterior chamber. This accident 
 once happened in my own hands. The rusted 
 appearance of the aqueous humor, and the gra- 
 dual disappearance of the fragment, have led to 
 a conclusion that it underwent a chemical solu- 
 tion. The rapid removal of the fluid and floccu- 
 lent cataract, when dissipated in the chamber, 
 has been explained in the same way. I believe 
 that the aqueous humor has no greater solvent 
 property than common water, and that this 
 would be quite insufficient to explain the very 
 quick restoration of its clearness, which we often 
 witness, where it has been loaded with opaque 
 matter. The fragments of the lens have no more 
 power of resisting absorption than an extra- 
 neous substance, and the process improperly 
 termed solution, is essentially referrible to the 
 operation of the absorbents. The secreting func- 
 tion of the chamber is evidently a powerful one, 
 from the reproduction of the humor in the 
 course of a single night. That the absorbent 
 function is nearly equal to it, is proved by the 
 facts above mentioned, but still more strikingly, 
 by the rapid diminution and removal of the 
 matter effused under inflammation, when quick- 
 ened by the excitement of mercury.
 
 SECTION 11. 
 
 VITREOUS HUMOR. 
 
 The absorption of the vitreous humor is evi- 
 dent in cases of floating cataract, and in some 
 forms of organic amaurosis, marked by preter- 
 natural flaccidity, even without a diminution of 
 volume ; also in cases of absorbed crystalline 
 and membranous cataract, vi^ith adhesions to the 
 iris. 
 
 Diseased I examined the decayed eyes of horses, and 
 
 eyes of ^ 
 
 horses. fouud in a considerable number the opaque lens 
 sunk in the vitreous chamber, and this humor 
 almost entirely absorbed. The eye was filled by 
 a morbid accumulation of aqueous humor, so 
 that on a single puncture the whole fluid con- 
 tents of the globe, which was larger and more 
 tense than usual, escaped uninterruptedly. The 
 sclerotic and choroid in these cases, altliough 
 often thickened, and even the opposite sides co- 
 adliering, were entire. The retina was usually 
 drawn into folds, and partially absorbed. In 
 some cases the globe was greatly enlarged and 
 flaccid, resembling an undistended dropsical 
 cyst ; the crystaUine opaque, of its natural size
 
 VITREOUS HUMOR. 203 
 
 and firm, and sometimes its capsule thickened 
 and scabrous, bearing marks of inflammation, 
 but in place of the healthy vitreous humor, a 
 gelatinous fluid, of a deep yellow or amber 
 color, filled the globe. In other cases, where 
 the tunics were disorganized, and thickened from 
 injuries, the space occupied by the humors was 
 either exceedingly reduced, or obliterated alto- 
 gether, by the coadhesion of the opposite sides 
 of the globe. In most cases where the lens was 
 cataractous, and not impacted in the anterior 
 chamber, nor fastened by adhesions of its cap- 
 sule to the iris, the substance of the vitreous 
 humor was shrunk as before described ; and the 
 crystalline, partially absorbed, had receded and 
 sunk in proportion. The globe was supported 
 in its figure by a morbid collection of aqueous 
 humor. 
 
 The tremulous iris is, I believe, always con- Tremulous 
 
 iris. 
 
 nected with a relative disproportion in volume 
 of the vitreous humor, whether congenital or 
 the result of operations and injuries. Couching 
 and the operation by absorption, if roughly per- 
 formed, break down a portion of the vitreous 
 cells, which become obliterated ; hence the fre- 
 quency of floating cataract and tremulous iris 
 after these operations. The loss of a very con- 
 siderable proportion of the vitreous humor may 
 take place without permanently impairing the 
 vision, except of minute objects, as is proved
 
 S04 VITREOUS HUMOR. 
 
 by the successful issue of some cases of extrac- 
 tion, in which this accident has happened. 
 
 I have suspected a diseased state of the vi- 
 treous humor in some cases of cataract in el- 
 derly people, accompanied by a preternatural 
 convexity of the globe, in which a slightly glairy 
 fluid has distilled in quantity from the eye du- 
 ring the operation, of a consistency between 
 that of the vitreous and aqueous humors. 
 
 Discolored A discased state of this humor, frequent in or- 
 
 vitreous liu- . . , , . , j 
 
 nior. game amaurosis, with or without cataract, and 
 
 especially accompanying diseased changes of the 
 iris, is that in which it assumes a deep yellow or 
 a chocolate brown color. From its rapid and 
 uninterrupted egress, in this and the former 
 case, even to a partial collapse of the globe, 
 there is reason to infer that the cellular contex- 
 ture is broken down ; for although the cells of 
 the healthy humor communicate, a gush only of 
 the fluid ensues from wound or rupture of the 
 capsule ; the support afforded by the closed lids 
 prevents its further escape, and the obliteration, 
 by inflammation of the ruptured cells, speedily 
 follows. 
 
 Hemor- I havc kuowu blood efllised into the cells of 
 
 [he vltlelus the vitreous humor within twelve hours after 
 
 *^'^^' the operation of extraction, in consequence of 
 
 straining upon the night-chair, which was in-
 
 VITREOUS HUMOR. 205 
 
 stantly followed by severe pain darting towards 
 the occiput. The coagidum was visible both to 
 the patient and to the surgeon ; the former de- 
 scribed it as a central circular spot, intercepting 
 the light which was strongly reflected from its 
 circumference ;" in the sunshine it had a bright 
 scarlet hue, and was liver-colored in the shade ; 
 it was in the course of time absorbed, so that the 
 patient gradually recovered tolerable vision. 
 
 Another case was one of active and conti- 
 nued hemorrhage ; it was not occasioned, as far 
 as could be ascertained, by any improper exer- 
 tion. It produced an excessive distention of the 
 globe, and was attended v/ith exquisite pain. 
 These symptoms commenced in the evening of 
 the day of operation, and, on the day following, 
 the humor, loaded with an enormous coagulum 
 of blood, protruded at the section. 
 
 I have met with other cases, in which hemor- 
 rhage into the vitreous cells occurred in conse- 
 quence of a blow. Inflammation and swelling 
 of the globe ensued, and the cornea, yielding 
 to the pressure, sloughed, when the humor pro- 
 truded gradually in the form of a large spongy 
 mass, loaded with coagula of blood, so as forci- 
 bly to separate and distend the lids, and oc- 
 cupy the entire circle of the orbit. In these 
 cases a severe pain is felt in the head two or
 
 206 VITREOUS HUMOR. 
 
 three inches above the orbit, and in the tem- 
 ple. The occasional hemorrhage is profuse. 
 The pain is relieved by opiates, and the eyeball 
 ultimately sinks with a total loss of figure. 
 
 I have reason to believe that this disease, 
 which at one period assumes much of the as- 
 pect and character of a fungus, has sometimes 
 been mistaken for one of a malignant character j 
 a mistake not very unlikely to , occur, judging 
 from first appearances, where disorganization is 
 complete. 
 
 Change of The vitrcous humor is subject to a complete 
 the vitreous chauge of consisteucc and a total loss of trans- 
 parency, the texture of its cells and its volume 
 and figure remaining ; the secretion is convert- 
 ed from a transparent albumen into an opaque 
 substance resembling curd. In one case it was 
 like ground rice boiled. Although the opacity 
 is visible, the appearance differs widely from 
 that of cataract. While the crystalline remains 
 transparent, the same bright-colored appearance 
 is seen at the bottom or sides of the eye, which 
 is supposed to announce the incipient medullary 
 fungus. In the progress of the disease also, as in 
 the malignant disease, the lens appears to become 
 opaque, and is protruded so as forcibly to dilate 
 the pupil ; this becomes fixed, its edge rough- 
 ened by detached pigment, and the iris con-
 
 VITREOUS HUMOR. 207 
 
 vex, so as to give a conoidal figure to the 
 
 globe. 
 
 Several years ago I extirpated the eye of a 
 fine infant, eight months old, in whom this dis- 
 ease was concluded from the appearance de- 
 scribed, to be the malignant fungus in its nascent- 
 state. The child has since grown to be a fine 
 healthy boy ; the other eye has remained sound. 
 Upon section of the eye, the vitreous humor 
 presented the appearance which I have de- 
 scribed ; the tunics were all entire *. As the 
 loss of vision had been but recently discovered, 
 and the appearances had in the interval sensil)ly 
 changed, so as to denote the progress of the 
 disease, this case could not be considered as a 
 congenital mal-organization. 
 
 I have since seen several cases of a convex 
 and permanently dilated pupil, with a deep- 
 seated opacity of a splendid yellow tint in chil- 
 dren, and doubting, from the preceding history 
 and the child's freedom from indisposition, that 
 such appearances indicated a malignant disease, 
 I have abstained from operating. To my sur- 
 prise, the appearances have continued station- 
 ary for years, unaccompanied with any disorder 
 of the health. One, a child of four years old, 
 I have very recently examined, having seen it 
 
 * See Plate III. fig. 4.
 
 208 VITREOUS HUMOR. 
 
 at intervals during that period, since the first 
 notice of the disease at the age of three months. 
 I can discover no difference in the appearance 
 of the eye at this time, from that which it then 
 assumed. The bright yellow tint occupies the 
 temporal hemisphere of the globe, supposing it 
 were bisected in a vertical direction ; the figure 
 of the globe is slightly conoidal, the pupil much 
 dilated as if from pressure, not perfectly cir- 
 cular, and its edge apparently everted, form- 
 ing a narrow white line, while small detached 
 flakes of the pigment lie behind it next the 
 lens. The pupil of the other eye is constricted, 
 and closed by an opaque capsule. The child is 
 well grown and in perfect health. 
 
 I therefore regard these cases as a simple and 
 uniform conversion of the substance of the vi- 
 treous humor, by an altered action of the secret- 
 ing vessels, wholly independent of a malignant 
 character. Unfortunately we have no accurate 
 signs by which to distinguish, in their incipient 
 state, the malignant fungus and the disease 
 above described ; nor do we know that the dis- 
 ease may not sooner or later take on an active 
 and malignant character, as is certainly now and 
 then occurring in the testicle, female breast, and 
 other textures. 
 
 The peculiar tint and splendor of the opaque 
 substance (a mother described it to me as
 
 VITREOUS HUMOR. 
 
 resembling, when first perceived, the scale of a 
 tench,) is not to be depended upon as a sign of 
 malignity. It evidently depends upon an opaque 
 reflecting surface at the fundus of the globe j 
 and the appearance is produced equally by an 
 opaque retina, as by a morbid growth, except 
 that in the latter it is somewhat more lustrous, 
 from its greater density and projection ; the 
 convexity of the iris, the immobility of the pu- 
 pil, and the apparent opacity of the crystalline, 
 are secondary signs, and common to both. There 
 are, however, two marks of distinction suffi- 
 ciently strong, between the malignant fungus 
 and this disease of the vitreous humor ; viz. the 
 progressive or stationary condition of the dis- 
 ease, denoted by the state of the tunics and the 
 eyeball generally, and secondly, the presence 
 or absence of pain and constitutional irritation. 
 To these I might add, especially as regards 
 children, the affection of one or both organs, as 
 affording a strong presumption that the disease 
 is harmless in the first case ; in the second, a 
 conclusion that it is malignant. 
 
 It is remarkable, that both the fungus h^ma- 
 todes, or malignant fungus of the eyeball, and 
 the disease which I have just described, are of 
 most frequent occurrence in infancy ; I am not 
 aware of having seen the latter in the adult. I 
 have now under my observation a very remark- 
 
 p 
 
 209
 
 210 VITREOUS HUMOR. 
 
 able case of congenital malignant fungus. The 
 child is eight months old. At its birth the eye- 
 ball was of the size of a walnut, it is now of the 
 proportional size represented by Fig. 2^. Plate 
 V.
 
 SECTION IIL 
 
 CRYSTALLINE HUMOR. 
 
 I AM not aware of having witnessed any other Abscess of 
 result of inflammation of the crystalhne and its ^ "'^''" ^* 
 capsule, than opacity, with the exception of one 
 case. This was that of a lad, who, after a. se- 
 vere blow on the globe of the eye, which pro- 
 duced acute inflammation, had a suppuration 
 within the crystalline capsule, which projected 
 through the pupil in a globular form, and was 
 filled with pus. There was no deposit upon the 
 iris. Under the action of mercury the pus and 
 the lens were absorbed together. The continued 
 application of belladonna did not prevent the 
 gradual constriction of the pupil, and the case 
 terminated in a capsular opacity, with constrict- 
 ed and mis-shapen pupil, and co-adhesion of the 
 iris and cornea. 
 
 The capsule readily unites by adhesion, when Capsular 
 simply incised. This is of course prevented by '^^'^ 
 the intervention of any portion of lens. The 
 capsule, when adhering to the iris, receives de- 
 licate red vessels, which run in small brown pe- 
 duncles or foot stalks of lymph, produced from 
 the interior border of the pupil j small flaky 
 
 p2
 
 212 CRYSTALLINE HUMOR. 
 
 portions of the pigment are also frequently de- 
 tached, and conspicuous upon the margin of the 
 capsule. This is an appearance commonly seen 
 in the constricted pupil with partially transpa- 
 rent capsule, after chronic iritis. It is often the 
 result of repeated attacks of inflammation at, 
 short intervals, to which a constricted state of 
 the pupil certainly predisposes. The iris is 
 much thickened by repeated depositions of 
 lymph, until its texture becomes quite altered. 
 There is a very imperfect and deranged state of 
 vision, according to the degree and extent of 
 opacity of the capsule, which admits of no im- 
 provement by the direction of the light ; and 
 sometimes a marked and painful determination 
 of blood to the head. Except in this case, and 
 in punctured wounds, the capsule is seldom par- 
 tially opaque, but though its opacity is diffused, 
 it is often not of uniform density, so that it has 
 a dotted or mottled appearance. When calca- 
 reous matter is deposited, it is in small flakes or 
 scales, which have a brighter tint than the 
 opaque membranous portion. The opacity of 
 the capsule, as of the cornea, varies in degree, 
 from the slightest nebula to the opacity from 
 cliange or conversion of texture. The inci- 
 pient nebulosity is often, as before observed, 
 difficult of discernment. Where the capsule is 
 completely opaque, the lens undergoes a slow 
 absorption j the capsule, however, remains trans- 
 parent in most cases of senile cataract, not pre-
 
 CRYSTALLINE HUMOR. 213 
 
 ceded by inflammation. The capsule, like all 
 other textures of the body, undergoes absorp- 
 tion when detached. 
 
 The cataract, from opacity of the humor 
 Morgagni, is in my belief purely hypothetical. 
 There is an appearance of semi-opacity and Amaurosis 
 
 mistaken for 
 
 yellowness in the lens, in some cases of defect- cataract. 
 ive vision, insufficient to account for the de- 
 gree of dimness. I believe that this is not the 
 cause of it, and that the disease is amaurosis. 
 This I judge from the appearance being sta- 
 tionary, and the symptoms Jbeing those of the 
 latter disease. I have known it to be confident- 
 ly pronounced an incipient cataract, and tlie 
 patient to remain in anxious expectation of an 
 operation for years, without any sensible change 
 of its density, although in the interim the per- 
 son had lost his vision. On the contrary I may 
 remark, that the degree of opacity of some soft 
 caseous cataracts, when held up to the light im- 
 mediately after extraction, appears quite insuffi- 
 cient to explain the degree of blindness, although 
 the sight has been restored by the operation. 
 
 The fluid, flocculent, caseous, and hard cata- spedes of 
 ract, are the four principal and easily distin- Slra"'!'.'^ 
 guished degrees- of density of the opaque crys- 
 talline. The caseous admits of division into 
 soft and hard, as it approaches nearer in con- 
 sistence to tlie second or fourth species. The
 
 214 CRYSTALLINE HUMOR. 
 
 nucleated and mixed cataract — the first an opa- 
 city confined to the centre, the circumference 
 and superficies transparent, the second a soft 
 caseous or fluid superficies upon a firm centre 
 -—are well marked varieties. I refer the reader 
 to my Papers on this subject in the fourth and 
 fifth volumes of the Medico-Chirurgical Trans^ 
 actions*. The opacity of the posterior capsule, 
 i. e. the tunica hyaloidea, is very rare, which it 
 would not be if the lens were invested, as most 
 persons suppose, in a capsula propria, especially 
 after the operation of extraction, in which the 
 anterior capsule only is lacerated, and the lens 
 alone escapes. Where it is met with, the lens 
 and anterior capsule are usually transparent, 
 and when this is not the case, and the cataract 
 escapes with a posterior fold of opaque capsule, 
 it is always in my experience accompanied with 
 a considerable discharge of vitreous humor, for 
 it is owing to a detachment of the tunica hya^ 
 loidea, beyond the angle of union with the crys^ 
 talline membrane, or a separation, beyond the 
 margin of the lens, of the opaque from the trans-* 
 parent portion of that tunic t. 
 
 * Vol. IV. p. 278, and Vol. V. p. 391. 
 
 f Until the perfect capsule of the crystalline lens can be 
 exhibited detached from the eye, and the vitreous capsule and 
 Petitian canal at the same time demonstrated entire, and ca- 
 pable of complete inflation, I shall continue to believe, through 
 evil and good report, that the appearances actually and uni- 
 formly presented, and supported by all the phenomena of the 
 pathohtgy of these parts, warrant the opinion which I have
 
 CRYSTALLINE HUMOR. 215 
 
 What has been called * black cataract,' when 
 this term is used as applied to the lens, and not 
 synonymously for amaurosis, is a modification of 
 the fourth or hard species. A yellowish brown 
 is the ordinary tint, but I have seen it occasion- 
 ally of a blackish brown color. 
 
 Some peculiar circumstances relative to the Formation 
 formation of cataract deserve to be briefly no- 
 ticed *. 
 
 Although the period of its completion from 
 its first appearance is very variable, and can ne- 
 ver with any certainty be predicted, it is usually 
 slow ; and sometimes a clouded or semi-opaque 
 state or a distinct nucleated opacity remains 
 stationary for years, or even for life ; yet it oc- 
 casionally forms with rapidity although no in- 
 flammation is present. 
 
 The rapid formation of cataract is generally 
 attended by inflammation, or preceded by dis- 
 eases of other textures. This result of iritis has 
 been already explained. I have seen a yellow- 
 colored opacity posterior to the lens preceding 
 the rapid formation of cataract. The eye be- 
 came the subject of a superficial but violent in- 
 
 elsewhere given^ that the lens is incased betwixt the strong 
 membranous production, commonly called the anterior cap- 
 sule, and the proper capsule of the vitreous humor. 
 * See note G.
 
 <2l6 CRYSTALLINE HUMOR. 
 
 flammation, from sympathy with its fellow which 
 was acutely inflamed. The cataract was com- 
 pletely formed in two days. The pain was of 
 the most acute kind, affecting the eyeball, tem- 
 ple, and cheek. In the former state some useful 
 vision remained, which was now completely ex- 
 tinguished. The previous opacity was a morbid 
 state, I believe, of the vitreous humor, and the 
 lens transparent, until the attack of inflammation. 
 
 Partial dis- The residcncc of a perfect cataract in the eye 
 pacement. .^ Jnjurious, or at least attended with much risk 
 of destructive inflammation. The vitreous hu- 
 mor undergoes a partial absorption, and the 
 lens, losing to the same extent its support, 
 bulges forward and presses upon its capsule and 
 the iris. What operators call a narrow anterior 
 chamber, arises more or less from this cause. 
 Where the capsule yields from a blow or by ab- 
 sorption, and the pupil is dilated by the protrud- 
 ing lens, a violent inflammation, attended with 
 very acute pain, is the invariable consequence. 
 I have known this happen suddenly and inde- 
 pendent of external injury, where the formation 
 of the cataract has been gradual, and unattend- 
 ed with pain ; and the spontaneous occurrence, 
 though not so frequent, is precisely similar in 
 its effects to that produced by the too free la- 
 ceration of the capsule with the needle. 
 
 oJs^absoro, ^ ^^^^ heard of the complete spontaneous ab-
 
 CRYSTALLINE HUMOU. 217 
 
 sorption of the congenital cataract at an early 
 age, and although the eyes had a constant tre- 
 mulous motion, the person was in after-life 
 enabled to follow useful occupations. I have 
 never seen such a case, but I refer to an in- 
 stance which is well authenticated. The tre- 
 mulous motion of the globe is not incompatible 
 with a perfect state of vision. 
 
 The absorption of the matter of the opaque Progress of 
 
 •,..,. . IT /;. absorption. 
 
 lens is quick m proportion to the looseness oi 
 its texture, and its complete exposure, by break- 
 ing up and detaching its fragments, to the ope- 
 ration of the aqueous humor ; and also to the 
 plentiful secretion of healthy aqueous humor *. 
 In confirmation of the latter statement I have 
 observed, that in all cases of narrowed anterior 
 chamber, by the partial co-adhesion of the iris 
 and cornea, consequent upon the injury which 
 produced the cataract, or inflammation from any 
 other cause, it is slow; and that absorption does 
 not take place during the existence of inflam- 
 mation, in which state, the aqueous humor is 
 in a morbid condition, and if the inflammation 
 be deep-seated and protracted, the vitreous hu- 
 mor partakes of it. 
 
 * I do not consider this fact as militating against the opi- 
 nion given at page 200. The turbid state of the humor indi- 
 cates the arrest of its secretion ; and its copiousness and trans- 
 parency, the unabridged extent and health of the secreting sur- 
 face.
 
 ^18 CRYSTALLINE HUMOR. 
 
 I have seen a case of dislocated lens occupy- 
 ing the anterior chamber, and producing inflam- 
 mation of the iris ; from which membrane it has 
 derived an adventitious capsule of lymph, or- 
 ganized by colored vessels.
 
 SECTION IV. 
 
 DISEASES AFFECTING THE EYEBALL. 
 
 Under this head might properly be classed Effects of 
 the morbid changes which result from the va- 
 rious forms of injury, to which, as all parts are 
 exposed, all are liable in common. These, how- 
 ever, it is impossible to enumerate, and indeed 
 would be, for any practical purpose, unneces- 
 sary, after describing the peculiar morbid dispo- 
 sition of each texture, and the characters of in- 
 flammatory action which they severally exhibit. 
 The mode and extent of the injury, and the in- 
 strument with which it is inflicted, will deter- 
 mine its importance, as regards the preservation 
 of the organ and its functions. Concussion and 
 extravasation of blood are, both of them, fre- 
 quent causes of a sudden loss of vision, which is, 
 in many instances, gradually restored. The le- 
 sions of the internal tunics are to be seriously 
 apprehended, from the probability of the retina 
 being included in the mischief — the case of fo- 
 reign bodies penetrating deeply into the globe, 
 from the probable disorganization and dissolu- 
 tion of the vitreous humor, and the consequent
 
 220 DISEASES AFFECTING 
 
 suppuration, or state of atrophy of the globe. 
 Sometimes the organ is at once destroyed by 
 rupture of the nerve and muscles, and a partial 
 evulsion of the globe from its socket ; or by so 
 free a lacerated wound, as to occasion large sts- 
 phylomatous protrusions of the choroid, or the 
 escape of the humors in toto, and instant col- 
 lapse. More frequently, however, the cornea, 
 or lens, or iris, are so far severally or exclusive- 
 ly affected, as to leave the figure of the ball un- 
 injured, and to make the secondary changes 
 which may be expected to supervene, an object 
 worthy of the most interesting and anxious at- 
 tention ; and, I may add, to afford considerable 
 scope for the salutary exercise of art. 
 
 Suppuration From a long continued and exasperated in- 
 
 of the eye- . ^ , . , . , ^ 
 
 ball. flammation or the interior tunics, but more fre- 
 
 quently from injury, the eyeball suppurates, 
 and its texture is totally destroyed. The globe 
 becomes rapidly enlarged, greatly protruded, 
 and exceedingly tense. The conjunctiva, high- 
 ly tumid and vascular, is rolled out upon the 
 cheek) so as completely to evert the lower eye- 
 lid. The pain is very acute, lancinating 
 through the eyeball and head, and continues 
 day and night without intermission. The pa- 
 tient's health is greatly disturbed, and the symp- 
 tomatic or irritative fever, as in the thecal ab- 
 scess, or acute paronychia, is considerable. The 
 anterior chamber is at first filled by soft white
 
 THE EYEBALL. gSl 
 
 lymph, then pus collects in quantity; the cloud-, 
 ed cornea turns opaque and slowly yields by ul- 
 ceration, or dies and sloughs off, when the con- 
 tents of the globe are more or less discharged, 
 and the pain and symptoms of irritation gra- 
 dually subside. The eyeball afterwards shrinks 
 up, and the cornea is obliterated. The hypopion 
 or purulent secretion filling the anterior cham- 
 ber, originating from internal ulcer of the cor- 
 nea, is not accompanied by the enlargement, 
 6r the acute pain and high irritative fever which 
 mark the abscess of the globe ; these are refer- 
 rible to the extreme distention and correspond- 
 ing resistance of an unyielding texture like the 
 sclerotica, as in the abscesses of tendinous sacs 
 and thecaa. The termination is the same in both, 
 viz. the perishing of the cornea. 
 
 I had formerly been led to suppose, that the Malignant 
 
 1 • 1 • 1 /v» 1 1 diseases. 
 
 malignant disease termed cancer, affected the 
 bulb or globe of the eye. Such is the doctrine 
 of most writers on the subject. I have, however, 
 satisfied myself that, as regards the eye, this 
 disease is peculiar to the lacrymal gland, con- 
 junctiva, and eyelids ; and I have classed it ac- 
 cordingly. On the contrary, I had believed 
 that the disease termed soft cancer, medullary 
 fungus, or fungus hsematodes — for these latter 
 terms are descriptive of the appearances of the 
 same disease in its several varieties — had its ori- 
 gin in some individual and peculiar texture;
 
 ^9.% DISEASES AFFECtiNG 
 
 some writers giving it to the retina and meduU 
 lary substance, some to the vascular tissue of 
 the choroid, and others to the fibrous texture of 
 the sclerotic. I am, upon the evidence of many 
 cases and dissections, assured, that this is not 
 the fact as regards the eye ; that, on the con- 
 trary, each and every texture, if we except the 
 crystalline and cornea, is capable of generating 
 it, and is occasionally its proper nidus. The 
 disease, therefore, comes properly to be noticed 
 in this section. 
 
 Malignant Tlic carly appearanccs of this formidable dis- 
 ease, of which it has fallen to my lot to see nu- 
 merous instances, have been accurately described 
 by Mr. Saunders and Mr. Wardrop. The dis- 
 ease, in my experience, has proved speedily de- 
 structive, when arrived at that stage in which 
 the visible enlargement and loss of figure of the 
 ball, the consequent livid blue tint of the scle- 
 rotic, and the distended vessels of the conjunc- 
 tiva and eyelids present themselves. The cha- 
 racter of the disease is by these decided ; they 
 are proofs of its rapid and destructive progress, 
 and taken together with the primary appear- 
 ances, must be regarded as fatal prognostics. 
 The staphylomatous protrusions of the sclerotic 
 and choroid coats, may, without the exercise of 
 a careful discrimination, be confounded with this 
 disease. I speak from a distinct remembrance 
 of two cases in particular, in which the exist-
 
 THE EYEBALL. 225 
 
 ence of the malignant fungus was a matter of 
 dispute between very competent persons, prior 
 to the extirpation of the organ, by which its ex- 
 istence was instantly demonstrated ; and from 
 the recollection of several in which the proposal 
 of an operation was overruled, and as the event 
 proved, judiciously, the patients having remain- 
 ed well, and the organ tranquil. Abscess of the 
 globe, chronic enlargement and disfiguration of 
 it from choroidal inflammation, proptosis from 
 enlargement of the appendages, and tumors 
 within the orbit, hydrops oculi, &c. are, on the 
 contrary, sufficiently easy of distinction from 
 the malignant disease, by the absence of the 
 characteristic signs of the latter. Nevertheless 
 I have known some of these mistaken for it. I 
 have before noted a case, viz. protrusion of the 
 vitreous humor from the eyeball, with which the 
 fungus protruding through the slough of the 
 cornea might, prima facie, be confounded by a 
 person unacquainted with the history of the 
 case. But it rarely happens that the origin of 
 the disease has not been accurately noted by 
 the patient or his friends, or that the germ of 
 the disease, in the infant at least, is not apparent 
 upon inspection of the other eye. The com- 
 plexion, as the disease proceeds, acquires the 
 leaden paleness of cancer, and the rest is brok- 
 en by deep and lancinating pain. If a child is 
 the subject of the disease, it is heavy-headed 
 and lethargic, as one affected by hydrocephalus ; 
 disturbed by occasional convulsive starts ; the
 
 224 DISEASES AFFECTING 
 
 stomach often rejects food, the frame emaciates 
 rapidly, and the highest possible degree of irri- 
 tability and fretfulness is present. The child 
 usually expires in convulsions. The adult suf* 
 fers from spasmodic shoots of pain tlirough the 
 ball and head, and simultaneous startings in go- 
 ing to rest ; but the constitutional disturbance 
 is inconsiderable previous to tlie protrusion of 
 the fungus ; and haemorrhage, which usually 
 comes on at this period, is exceedingly distress- 
 ing. 
 
 The metallic appearance at the fundus of the 
 eye, sometimes presents colored blood-vessels, 
 branches of the arteria centralis, which penetrate 
 the vitreous humor ; the opacity seems to ad- 
 vance towards the pupil, and might be mistaken 
 for a protruding soft cataract, an appeai'ance 
 which, as Mr. Saunders has remai'ked, is alto- 
 gether delusive. In a case in which Mr. Hunter 
 was consulted, the operation for cataract was ac- 
 tually undertaken, and the lens being found trans- 
 parent, the eye was immediately extirpated, from 
 a conclusion that the disease was malignant. 
 
 A dissection of the eye, after tlie destruction 
 of the cornea, furnishes a very indistinct clue to 
 the original seat of this disease ; it is in this state 
 a firm semi-organized mass of lymph intermixed 
 with and surmounted by coagula of blood * -, all 
 
 * It is seldom that the blood-colored fungus acquires that 
 enormous size, and protrudes to such a deforming extent as
 
 THE EYEBALL. QQ5 
 
 the textures of the eye are broken up, but here 
 and there the vestiges of one or more may be 
 traced. If examined at an earlier period, that 
 is, before it fungates, the section presents the 
 real character of the disease, the medullary or 
 soft brain-like substance, which we see in other 
 organs of the body, commonly arranged in small 
 lobes or moleculge. Sometimes one, and some- 
 times another of the proper textures, appears to 
 be the matrix of the disease. The fungus, in 
 some instances, adheres intimately to the sclero- 
 tica, and detaching the choroid and retina, throws 
 these and the vitreous humor to the opposite 
 side of the globe. In others, it splits the scle- 
 rotic into two lamellae, distinctly originating in 
 the interstitial substance of that coat. Its pro- 
 gress, by absorption of a part of the sclerotic, 
 gives occasion to a rapid growth of the diseased 
 texture, external to it, within the orbit ; but 
 more frequently the diseased growth is luxuriant 
 upon the outer surface of the sclerotic, to which 
 it is as firmly attached as on the inner, while that 
 tunic retains its integrity and forms a perfect 
 septum between the diseased masses. Hence, 
 fibrous membrane has been supposed to give 
 origin to it. But in other cases, the disease un- 
 questionably begins in the choroid, and that 
 
 is seen in Saunders, PL III. It is to be regretted that an ex- 
 amination was refused in that case, although there can be little 
 doubt thaj it would have confirmed this description of the ul- 
 timate state of the disease. 
 
 Q
 
 226 DISEASES AFFECTING 
 
 tunic gradually degenerates into the diseased 
 mass which, occupying a large portion of the 
 globe, is throughout deeply tinged with the 
 black pigment. Sometimes the sclerotica has a 
 morbid growth externally, and the choroid on 
 the interior. Occasionally, these tunics seem 
 to be only secondarily affected, and are removed 
 by partial absorption in the progress of the dis- 
 ease ; the septiform productions, extended, dis- 
 placed, and broken down, of the tunica hyaloi- 
 dea, inclose the fungus, and although no vestige 
 of the vitreous humor remain, it is plain that it 
 has formed the nidus of the diseased growth. 
 The iris and corpus ciliare evidently degenerate 
 in the same manner as the choroid. Again, the 
 disease has seemed to originate at the point of 
 entrance of the optic nerve into the globe, push- 
 ing the humors before it ; and the nerve itself 
 has upon section been found diseased, both con- 
 tiguous to the sclerotic, and at the distance of 
 three quarters of an inch from that tunic, where 
 the intermediate portion has preserved its healthy 
 aspect. Nay, the optic ganglion, tractus opticus, 
 and thalamus, have been repeatedly found, one 
 or other or all diseased, and the surrounding 
 adipose substance in the orbit has exhibited the 
 disease in its genuine character, and to a consi- 
 derable extent, where it had no direct communi- 
 cation with the diseased contents of the globe*. 
 
 * I have a colored drawing which accurately exhibits this 
 state, taken at the moment of inspection.
 
 THE EYEBALL. 2^7 
 
 So also, the lymphatic glands, at the angle of the 
 jaw, frequently take on the same character of 
 diseased structure ; and in some instances the 
 bones of the cranium present periosteal tumors 
 resembling soft nodes, which upon section are 
 found to contain the medullary substance, the 
 external table of the bone being to the same 
 extent carious. It appears to me, therefore, 
 that this is not a disease of this or of that texture, 
 as writers would insinuate, but of all the textures, 
 the crystalline and cornea excepted, which yield 
 to its progress but never exhibit a specific change 
 of texture. The process of suppuration, ulce- 
 ration, and sloughing, have no share in the dis- 
 eased action, and are only seen in the cornea. 
 The other tunics and humors yield by progres- 
 sive absorption, without pus. Its appearance, in 
 comparing the sections before fungating, is evi- 
 dently modified by its situation, as for example, 
 in the sclerotica and choroid, adipose substance, 
 and vitreous humor ; the phenomena of color, of 
 hemorrhage, &c. depend much upon situation, 
 also the preservation of figure, degree of enlarge- 
 ment, and the rapidity of growth, according as 
 it is confined to the interior, or originally affects 
 the exterior of the globe, or communicates with 
 the orbit. We see these modifications of appear- 
 ance, upon comparing it in the different viscera, 
 and in the cellular membrane, tendinous apo- 
 neuroses, and the nerves. The deep blue and 
 black tubera characterise the choroid fungus ; 
 
 Q 2
 
 228 DISEASES AFFECTING THE EYEBALL, 
 
 the medullary, the substantia alba of the optic 
 nerve or brain ; a more dense fibrous brown 
 tuber, clear of stain, is the production of the 
 sclerotic. These several parts are found to be 
 directly and peculiarly involved, upon dissection. 
 
 I have a preparation exhibiting a genuine ex- 
 ample of the disease affecting the anterior right 
 lobe of the cerebrum, and protruding the eye 
 from its socket, while the eye itself was per- 
 fectly free from disease. This shews the pro- 
 gress of the disease by absorption, and not by 
 contiguity, conformable to our opinion of its 
 nature, 
 
 I must refer the reader to Plates 3, 4, 5, and 
 6, and the accompanying descriptions, for fur- 
 ther details on this subject.
 
 PATHOLOGY 
 
 APPENDAGES. 
 
 CHAPTER III. 
 
 SECTION I. 
 
 ORBITAR APPENDAGES. 
 
 Abscess sometimes forms within the orbit, and Abscess. 
 previous to its discharge occasions an equal 
 protrusion of the globe, with eversion of the 
 palpebra, dilated pupil, and suspended vision. 
 Its situation and effect upon the eye give much 
 pain and apprehension to the patient, as well as 
 considerable disturbance to the system at large. 
 The sight is sometimes permanently extinguish- 
 ed. In other cases it returns after the discharge 
 of the abscess, and consequent removal of press- 
 ure. 
 
 Adipose and steatomatous tumors are occa- Adipose 
 sionally formed in the cellular and fatty tex- ed tumo^rl
 
 230 ORBITAR APPENDAGES. 
 
 tare cushioning the globe. They occupy the 
 interspace of the recti muscles, and in their pro- 
 gress emerge between the globe and the orbitar 
 circumference. They have therefore an oblong 
 figure. The globe of the eye is turned and fixed 
 in an opposite direction, and so compressed as to 
 be rendered dim. I have removed them when 
 projecting over the top or on one side of the 
 globe, in several instances. When the conjunctiva 
 is freely divided, the fatty tumor is easily hooked 
 forward, and dissected out by a few touches of 
 the narrow bistoury. The cyst containing a fluid, 
 which is usually transparent, it is not so easy to 
 remove entire, owing to its tenuity and the in- 
 stant escape of its contents if it be accidentally 
 torn or wounded. In the empty or collapsed 
 state it is scarce possible to extirpate it com- 
 pletely, and even though the integrity of the 
 cyst be preserved, its extent backwards within 
 the orbit renders this in some instances a mat- 
 ter of much difficulty. If the cyst be cut in half, 
 although the lips of the wound heal kindly, it 
 suppurates periodically and discharges many 
 times at the cicatrix, which closes in the intervals. 
 The encysted tumor, although it extend to the 
 bottom of the orbit, seldom occasions the distor- 
 tion of the globe. A disagreeable sense of numb- 
 ness and coldness affects the integument of the 
 glabella and forehead, after the division of the 
 frontal and supratrochlear nerves; these therefore 
 should be avoided in the operation. The tumor
 
 ORBITAR APPENDAGES. g31 
 
 sometimes projects exterior to the tarsus, so as 
 to rise upon the palpebra, but more commonly it 
 is beneath the tarsus and contiguous to the globe. 
 In the former case the cyst lies upon the peri- 
 osteum of the orbit and is adherent to it ; in the 
 latter it is adherent to the globe. 
 
 In the last annual report of the London In- Hydatid 
 iirmary for diseases of the eye, is the notice of 
 a singular case of hydatid cyst protruding the 
 globe, with the following remark : " One of 
 these cases was a protrusion of the eye from the 
 orbit, by a cyst containing hydatids deeply seat- 
 ed in the cavity. The hydatids were evacuated 
 by a puncture in the cyst ; the eye returned into 
 its natural situation, and the patient was com- 
 pletely cured. This is the only instance of such 
 an affection that has occurred since the opening 
 of the Infirmary." 
 
 The looseness of the connecting texture in Anemismai 
 the orbit, and the number and tortuosity of the 
 vessels, seem to predispose to that disease of the 
 arterial and venal extremities, which gives ori- 
 gin to those peculiar vasculo-cellular tumors, 
 the precise nature of which is not yet satisfact- 
 orily ascertained ; which add to a structure most 
 resembling that of naevus maternus, the formid- 
 able character of aneurism. S'ee my case of 
 aneurism by anastomosis in the orbit, in the 
 Medico-Chirurgical Transactions, Vol. II. Art. I,
 
 232 
 
 Sarcoma 
 tons and 
 
 ORBITAR APPENDAGES. 
 
 and another by Mr. Dalryraple, the able and in- 
 genious surgeon to the Norfolk and Norwich 
 hospital, Vol. VI. Art. 7. 
 
 Tumors sometimes form beneath the perios- 
 cartiiagi- teum of the orbit, givino- to the touch a firm 
 
 nous tu- '-' ^ 
 
 I""''- resistance. I have seen several cases of this 
 
 description where the tumor appeared to extend 
 the depth of the orbit, and was presenting on 
 the nasal side. Their anterior edge is thin, being 
 bound down to the orbitar circumference, but 
 when they protrude and compress the globe to 
 blindness, as is sometimes the case, it is to be in- 
 ferred that they have attained considerable bulk 
 posterior to the globe. I once removed one on 
 the abductor side of the globe, by scraping it 
 clean away from the bone ; it was of the hard- 
 ness of cartilage and of geat extent. I am un- 
 able to say whether the disease returned, having 
 soon afterwards lost sight of the patient. The 
 impression I had of the case was unfavourable, 
 from the character, as well as the extent and 
 connections of the tumor. 
 
 Exostoses. Exostoses of the orbit are not common. I 
 have never seen them in the living subject of 
 a size to create deformity or material inconve- 
 nience. 
 
 Polypi. Polypi of the frontal, sphenoid, and ethmoid 
 
 sinuses in their progress burst through the eth-
 
 ORBITAR APPENDAGES. S33 
 
 moid and lacrymal bones, and sometimes ex- 
 trude the eyes, so as to occasion the most hor- 
 rible deformity. If when they first appear at the 
 inner canthus, having an elastic feel, we punc- 
 ture them, a thick glairy fluid is discharged, 
 but from the extent of the disease when it has 
 advanced thus far, the swelling does not subside. 
 I know of no disease which presents so truly 
 formidable an appearance as the polypus of these 
 parts, when it has arrived at such an extent as to 
 break up the bony structure of the nose or an- 
 trum, and shew itself in the orbits. 
 
 The lacrymal gland is subject to simple in- Diseases of 
 
 . . , , . , the lacrymal 
 
 terstitial enlargement, to suppuration, and to giand. 
 scirrhus, like other glands of similar structure ; 
 its enlargement is known by the lobulated ap- 
 pearance of the tumor, on further stretching the 
 skin of the projected eyelid. It often suppurates 
 in children, and occasions an excessive swelling 
 above the upper lid, depressing the tarsus upon 
 the globe so as completely to conceal it. The 
 abscess may be conveniently opened and dis- 
 charged beneath the lid, with a narrow curved 
 bistoury. I removed the lacrymal gland greatly 
 enlarged and in a state of true scirrhus, from 
 the orbit of a middle-aged man, a merchant's 
 clerk in this city*. The vision of that eye had 
 suffered considerably during the growth of the 
 
 * Represented by Fig. 6. Plate II.
 
 .234 ORBITAR APPENDAGES. 
 
 tumor; in other respects he continued quite well 
 when I last saw him, after an interval of some 
 years. There was no other deformity than a 
 slight drooping of the lid at the outer angle. 
 All these operations should be performed be- 
 neath the eyelid when the circumstances admit 
 of it.
 
 SECTION II. 
 
 FACIAL APPENDAGES. 
 
 Palpebrje. The little abscess called a stye, Hordeolum. 
 situated on either edge of the palpebra, com- 
 monly has its origin in an obstruction of one 
 or more of the meibomian follicles, like the mam- 
 mary abscess, which is an obstruction of one 
 or more of the lactiferous tubes. Obstruction is 
 followed by inflammation of the follicle and sur- 
 rounding cellular membrane, and it terminates in 
 a little painful abscess. Another description of 
 stye is an abscess forming around the bulbs of 
 the eye-lashes from inflammation of the ciliary 
 foveolse, which sometimes has its origin in a dis- 
 ease of the hair-bulb. After the discharge of 
 the abscess and before the falling off or evulsion 
 of the hair, the foveola appears exulcerated 
 within and at its mouth, and continues for a 
 long time to discharge a thin ichor by which 
 the edges of the tarsi are denuded of conjunc- 
 tiva, or this membrane is kept in a state of ex- 
 ulceration ; the discharge forms a scab, by which 
 the lids are firmly agglutinated during sleep, 
 but it is detached, and the diseased secretion 
 renewed by their separation. By the reco- 
 very of the foveola the healthy growth of the
 
 236 FACIAL APPENDAGES. 
 
 cilia is restored. Sometimes the affected fove- 
 olae become obliterated by the adhesive action, 
 when the hairs of course are not reproduced. 
 An habitual production of diseased cilia as well 
 as nails is not uncommon, and for this state 
 plucking in either case is only a palliative re- 
 medy. The disease is in the glandular structure 
 which forms them, and its obliteration or remo- 
 val, by a natural or artificial process, is in most 
 cases the only method by which it can be cured. 
 Independent of the abscess of the meibomian 
 follicle and ciliary foveol a, the conjunctiva upon 
 the margins of the tarsi, and the continuous 
 cutis, are liable to furuncular inflammation. 
 The term stye is I believe indiscriminately ap- 
 plied to all. The disposition to form stye is 
 generally a mark of scrofula, and from one or 
 other of these causes is continually recurring as 
 the system is affected. 
 
 Warts and Transparent vesicles and skin warts are not 
 
 vesicles* 
 
 uncommon upon the margins of the tarsi. The 
 former occur upon the meibomian border more 
 especially, the latter upon the ciliary. 
 
 Lippitudo. The first stage of lippitudo is a simple exco- 
 riation; the second, an ulceration of the borders 
 of the palpebrae. It is the result of inflammation 
 of the palpebral conjunctiva, aggravated by the 
 acrimonious quality of the vitiated meibomiaq
 
 FACIAL APPENDAGES. 237 
 
 secretion. In the chronic form of the disease 
 in strumous subjects, the conjunctiva is greatly 
 thickened, indurated, and altered in its texture ; 
 the ciliary glands are destroyed, together with 
 the fine cuticle of the lid, to some extent beyond 
 the ciliary margin ; and a partial eversion of the 
 lids, owing to the tumefied state of the conjunc- 
 tiva, increases the deformity. The mouths of the 
 meibomian glands are obliterated, and the ducts 
 plugged by their inspissated secretion ; some- 
 times the conjunctiva fungates so as to render 
 the eversion complete, and a process of cicatri- 
 zation makes it permanent. Thus the ectropeon 
 may result from a neglected lippitudo. 
 
 The eyelashes are subject to become mor- Diseased 
 bidly dry, harsh, and variously distorted, instead 
 of having an equal curve, and their natural 
 softness and pliancy. The inversion of one or 
 more cilia upon the conjunctiva produces, by 
 continued irritation, a painful degree of intole- 
 rance with an undue secretion of mucus and 
 tears, and an opacity of the conjunctiva of the 
 cornea with the prolongation of the colored 
 vessels upon this membrane. In this way the 
 marginal opacity extends over the surface of the 
 cornea and occasions blindness. This state fre- 
 quently exists independent of entropeon. The 
 disordered state of the cilia, above described, is 
 owing to a disease of the glands which secrete 
 
 cilia.
 
 2SS FACIAL APPENDAGES. 
 
 and nourish the cilia, as mentioned in speaking 
 of the hordeolum. 
 
 Tinea ci- The tiuca ciliaris is a disease of the ciliary 
 foveola, and hence is commonly combined with 
 lippitudo. In the slightest form a branny crust 
 surrounds the roots of the cilia, the skin of the 
 lid being very partially, if at all abraded ; in the 
 more advanced stage, a mucus is secreted by 
 the inflamed and excoriated ciliary border, and 
 the thinner part of it evaporating, leaves a scab. 
 In the most inveterate form, the disease is the 
 Same with the lippitudo which has advanced to 
 ulceration ; the cilia fall off, and either diseased 
 cilia are produced, so that the pore and the hair 
 mutually react and keep up the disease, or the 
 hair gland is permanently destroyed and the fo- 
 veola obliterated. The porrigo or crusta lactea 
 overspreading the eyelids and cheeks, with chaps 
 and exulcerations behind the ears, and within 
 the meatus auditorius, are concomitant affec- 
 tions, especially in children. 
 
 Trichiasis The trichiasis is a morbid incurvation of the 
 peon. tarsus, affecting either a part or the whole of 
 it, from the cicatrization and consequent con- 
 traction of wounds, burns, and lippitudinous 
 ulcers upon its meibomian edge, or the pal- 
 pebral fold of the conjunctiva. Whether the 
 entire cartilaginous border or only a part is in-
 
 FACIAL APPENDAGES. 239 
 
 verted, depends upon the situation and extent 
 of the disease which has produced it. But it 
 very frequently arises, especially in aged per- 
 sons, from a simple loss of elasticity in the carti- 
 lage, or a redundancy of the integument of the 
 lid and cheek, or these causes combined. There 
 is a case less frequent, in which trichiasis de- 
 pends on a thickened and callous roll of palpe- 
 bral conjunctiva, over which the lid turns. 
 From whatever cause the disease originates, 
 the eye becomes irritable, the motion of the 
 lids occasions pain and watering, and from the 
 incessant friction of the tarsus upon the globe, 
 results the inveterate chronic inflammation with 
 opacities, fed by vessels overshooting the cor- 
 nea. It is very rare, with the exception of the 
 case of protruded conjunctiva last mentioned, 
 that the excision of an elliptical fold of skin at 
 the basis of the lid, is not an efficient remedy. 
 In that case, the roll of conjunctiva must be 
 excised. The excision of the entire cartilage I 
 think superfluous, and a remedy far more severe 
 than the disease. 
 
 The ectropeon is the result of injury to the Ectropeon. 
 eyelid, as wound, burn, herpetic ulcer, or the 
 sequela of chronic lippitudo. The tarsus of the 
 lower palpebra sometimes falls outward from an 
 apparent loss of elasticity, or the unequal action 
 of the orbicularis muscle. The lid receding from 
 the globe, suffers the tears to collect in a pool
 
 <^,40 FACIAL APPENDAGES. 
 
 between them. An unhealthy state of the con- 
 junctiva is, if not the cause, as when villous and 
 redundant, a certain consequence of its ever- 
 sion and exposure. The case is much aggra- 
 vated when coadhesion after burns or neglected 
 wounds, ulceration from any cause, or long en- 
 during eversion, takes place between the skin 
 of the eyelid and cheek. This case admits of 
 palliation, but not of cure. I have much im- 
 proved several cases by first detaching the fas- 
 tened lid and forcing it to heal by granulation, 
 and afterwards, removing a triangular portion of 
 the cartilage, according to the proposal of a 
 modern author, for the correction of the ever- 
 sion, which is the best remedy for such eversions 
 as do not depend upon the protruded conjunc- 
 tiva*. In this, which is the simplest case of 
 ectropeon, the excision of the diseased conjunc- 
 tiva is sufficient. Where the everted lid is ad- 
 herent to the bone, there is a deficiency of 
 cellular substance to produce granulations, and 
 the case is, generally speaking, slightly if at all 
 benefited by operation. 
 
 * This remedy results from considering tlie relative condi- 
 tion of the tarsus and skin at the base of the eyelid^ in the 
 two diseases^ entropeon and ectropeon. In the first the in- 
 tegument is elongated, in the second the tarsus. As in the 
 first case by removing a portion of the redundant skin, we 
 turn out the inverted tarsus, so in the latter by removing a 
 portion of the elongated tarsus, we turn in the everted. It 
 will be understood, that it is only relatively that we speak of 
 tJie elongation of the tarsus. It is everted, and stricturcd in 
 the state of eversion, by the skin.
 
 FACIAL APPENDAGES. 241 
 
 Tumors of the eyelids are encysted, varying Tumors of 
 
 1 • • I • n n ■ 1 thepalpe- 
 
 m size, and contamnig a thin yellow tluid, or a br^e. 
 fluid of the consistence of honey, or a white and 
 dense caseous substance ; or like the common 
 steatom. They are adhering to the tarsi or 
 moveable. In the first case, they give a dif- 
 fused elevation to the skin of the lid, are cir- 
 cumscribed, and tense to the touch. Upon 
 examination on the interior of the tarsus, a white 
 hollow spot is discerned, surrounded by a blush, 
 which corresponds to the point of their intimate 
 adhesion to and partial absorption of the carti- 
 lage. Upon a free incision through the cartilage 
 at this point, the entire cyst is easily expressed 
 through the section. A thickening of the mem- 
 brane covering the cartilage, will give the sen- 
 sation of a tumor which does not exist. The 
 adhesion of these cysts to the tarsus is some- 
 times so intimate, that if their removal were 
 attempted by dissection externally, it would be 
 scarcely possible to detach them, without remov- 
 ing a portion of the cartilage. They are fre- 
 quently two or three in number, and their fluid 
 contents are not often absorbed. 
 
 The steatomatous tumors form in the cellular 
 substance beneath the cutis, and are freely move- 
 able, and easily turned out through a free inci- 
 sion of the skin. The atheromatous and larda- 
 ceous tumors form on or near the edges of the 
 tarsi, and are very common in weakly children, 
 
 R
 
 S42 , FACIAL APPENDAGES. 
 
 ill whom they acquire a considerable bulk. If 
 left, the skin ulcerates, and a scab forms upon 
 the top, when they may be readily expressed en- 
 tire between the nails of the thumbs. They re- 
 semble the sebaceous tumors behind the ears, and 
 on other follicular parts of the skin, arising from 
 obstruction of the follicles, which, being dilated 
 and their sides condensed by inflammation with 
 the surrounding texture, form these cysts. 
 
 Abscess of Suppuration of the upper eyelid occurs from 
 lid. slight causes of irritation. The matter should 
 
 be early discharged, for the cellular membrane, 
 owing to its laxity and abundance, is subject to 
 so rapid and excessive a distention, that if un- 
 relieved, it sloughs out, and an ugly puckering 
 or even a permanent eversion of the tarsus en- 
 sues, from deficiency of substance for granula- 
 tions. I have known this deformity produced 
 in an aggravated degree, by the suppuration 
 going on insidiously and unsuspectedly, under 
 the mask of oedema. The origin of it was snip- 
 ping off a small skin wart upon the palpebra 
 with a pair of scissors, and the subsequent irri- 
 tation of the wound by the application of court 
 plaster. 
 
 Constricted Lacrymal PASSAGES. The puucta are some- 
 
 and closed . , . ^ . ... , 
 
 puncta. tunes much constricted, sometimes obliterated 
 by preceding chronic inflammation j hence epi- 
 phora from imperfect or non-absorption of the
 
 TACIAL APPENDAGES. StS 
 
 tears, proportionate suffusion from excitement, 
 and dimness. The constricted or closed punctum 
 is always best opened with the point of a middle- 
 sized pin ; it afterwards readily admits the di- 
 lating probe ; but if no vestige of the punctum 
 remains, it is useless to attempt to form an arti- 
 ficial canal. I have seen a congenital deficiency 
 of the puncta, but the case is very rare ; oblite- 
 ration is much less so. 
 
 The over dilated or patulous puncta occur in Patuiou* 
 old people, with more or less separation of the 
 lower lid from the globe. They are so large as 
 apparently to have lost their contractile as well 
 as absorbing power ; the conjunctiva of the pal- 
 pebra is tumid and slightly villous, and the mei- 
 bomian secretion is morbidly increased. 
 
 The lacrymal conduits are subject to be Wounds of 
 wounded or divided, hence incurable fistulse. I ducts. 
 have met with several such cases, and have tried 
 in vain to heal them. Small abscesses occur in • 
 or adjoining the lacrymal conduits which are 
 broken and discharged by the passage of the 
 probe. In more than one instance, I have 
 turned out a considerable quantity of calcareous 
 matter wedged in these ducts, like the calculi of 
 the salivary ducts. 
 
 With the constricted punctum a stricture of stricture a* 
 r2
 
 241^ FACIAL APPENDAGES. 
 
 the mouth the lacrymal conduit, at the entrance of the sac- 
 
 of the sac. , . . „ i • t rrn • 
 
 cuius lacrymahs, is often combined, inis stric- 
 ture is readily ascertained, and easily yields to 
 the dilating probe. The tears regurgitate, and 
 cause suffusion, but there is no evidence of any 
 affection of the sac. The most frequent situa- 
 tion of stricture is at the point of termination of 
 the sacculus lacrymalis in the ductus nasalis. 
 The tumid state of the lining membrane during 
 Acute. acute inflammation of the palpebral conjunctiva, 
 occasions a temporary obstruction, and this will 
 continue for a time after the subsidence of the 
 inflammation, but in a less degree. The canal 
 in this state is exquisitely sensible, and the use 
 of probes is improper. The obstruction is gra- 
 dually removed under the treatment adapted to 
 the inflamed palpebral conjunctiva, with which 
 the lining membrane is continuous. 
 
 Chronic. A morc considerable and permanent obstruc- 
 
 tion arises from continued vascularity and slow 
 thickening of the lining membrane, the sac be- 
 comes slightly elevated from habitual distention, 
 and a little mucus on pressure is returned upon 
 the eye. Yet there is no discoloration of the 
 skin, or sign of inflammation of the sac, and the 
 epiphora is partial, that is, the tears are only im- 
 peded, and the epiphora only occurs when the 
 eye is employed or in any way excited, and the 
 secretion quickened.
 
 FACIAL APPENDAGES. ^^ 
 
 In the state of incomplete obstruction, if thj© ObstmcUon 
 
 Til partial, 
 
 tarsi are unaffected, no mucus is discharged on 
 pressure, nor is the sac perceptibly enlarged, 
 nevertheless the suffusion upon reading, writ- 
 ing, working, or exposure to cold air, is exceed- 
 ingly troublesome. Water injected by the punc- 
 ta will find its way into the nostril, but slowly 
 and only in part ; so it is with the tears. When or complete. 
 from long continuance of this state the obstruc- 
 tion is confirmed, the epiphora is incessant, the 
 sac becomes sensibly dilated into a tumor, and 
 upon pressure a very considerable discharge of 
 purulent mucus takes place so as to flood the 
 eye. The sac, when once habituated to a state 
 of over distention and a secretion of purulent 
 mucus, will not contract upon its contents. Thus 
 a very moderate degree of obstruction, or no 
 obstruction at all may co-exist with this state ; 
 it may continue, even though the bony part of 
 the canal should be destroyed, and the matter 
 on pressure flow readily into the nostril. 
 
 The lacrymal sac is liable to acute inflamma- Abscess of 
 tion and abscess, a very troublesome, painful * '^ ^^'^' 
 and disfiguring disease, the signs and progress 
 of which are well known. The surrounding 
 cellular membrane becomes oedematous, and the 
 cheek and side of the face are enormously swol- 
 len, so as to obliterate the orbitar fossa and fold 
 of the lower eyelid. When the abscess is chro-
 
 246 FACIAL APPENDAGES. 
 
 nic, the sac having been previously distended 
 owing to obstruction, the contiguous cellular 
 membrane passes into the state of adhesive in- 
 flammation, so that the swelling is not dropsical 
 but firm and hard. This occasions considerable 
 embarrassment to the young surgeon, from the 
 obliteration of the points, the infra-orbitar edge 
 especially, by which the operator directs his in- 
 cision, and the depth of the sac from the sur- 
 face. If the disease be left to pursue its course, 
 the skin discolors, the sac ulcerates, and its con- 
 tents are diffused in the cellular substance ; or 
 as more commonly happens where a previous 
 obstruction has existed, the skin and sac, being 
 condensed by the adhesive inflammation, yield 
 Fistula. together, and the discharge is external. Hence 
 the fistula lacrymalis properly so called, a term 
 incorrectly applied to all stages of the disease, 
 of w^hich it is but the last. It must not be sup- 
 posed, however, that abscess of the lacrymal sac 
 is always preceded by obstruction to the tears, 
 any more than that abscess of the prostate is al- 
 ways preceded by obstruction to the passage of 
 urine. It is frequently a sudden and rapid dis- 
 ease, unpreceded by epiphora. In other cases it 
 is slow and obviously progressive from the state 
 of imperfect obstruction and retention of mu- 
 cus and tears. The termination of acute ab- 
 scess is more speedy and favourable for this rea- 
 son, than of the chronic. In the former case.
 
 FACIAL APPENDAGES. 247 
 
 upon introducing a common sized probe after 
 opening the sac, it passes readily into the nose. 
 
 The lining membrane of the lacrymal sac is Fungus of 
 liable to take on a morbid action. It forms a 
 hard and dense tumor, which slowly ulcerates 
 and destroys the skin to the extent of the sac. 
 An irritable button-like fungus, of a mahgnant 
 aspect, is then protruded. A fungus of a looser 
 texture sometimes follows the abscess of the sac, 
 or, in other words, the sac laid open by ulcera- 
 tion, throws up luxuriant granulations. 
 
 The sac is also subject to dropsy, in which Dropsy of 
 state it acquires the size of a pigeon's egg, pro- 
 jecting the lower lid next the nose ; the tumor 
 is perfectly transparent, containing a fluid like 
 that of hydrocele. Its natural openings are 
 closed, for it does not admit of evacuation by 
 pressure ; it is very considerably extended with- 
 in the orbit on the nasal side. This has been 
 termed the hydatid tumor of the lacrymal sac. 
 
 Injuries, as blows flattening the nose in early Diseases of 
 
 1-r • • . • n ,^ • ^^^ canal 
 
 lite, or occasioning exostosis ot the ossa nasi, or and sur. 
 unguis, produce incurable disease, or permanent pans. 
 destruction of these passages. To these may be 
 added polypi and fungous tumors so situated, 
 or of such magnitude as to compress the sac or 
 nasal extremity of the canal, or occasion absorp-
 
 2'i8 FACIAL APPENDAGES. 
 
 tion of its bony parietes ; and caries of the 
 spongy, lacrymal, aethmoid, or maxillary bones. 
 The ulcerative absorption or exfoliation of the 
 bones renders the opening into the nose preter- 
 naturally large. But in obstinate chronic fistu- 
 lae, accompanied with erysipelatous or herpetic 
 inflammation, or ulceration of the surrounding 
 integument, it is not uncommon to find the 
 bones denuded of the periosteum on the orbi- 
 tar side, still preserved by the pituitary mem- 
 brane which remains attached to the nasal. In 
 such cases the proper canal is usually oblite- 
 rated. 
 
 There is a sponge-like fungoid growth, some- 
 times affecting the interior chambers of the face, 
 which speedily fills and obliterates the nasal duct j 
 it is firm and almost brittle, much disposed to 
 profuse bleeding, and very quickly regenerated 
 when broken down in attempts to remove it en- 
 tire. It occasions considerable deformity by 
 forcibly expanding the nasal cartilages. I have 
 long had a case of this description under my 
 care, in a middle-aged woman. Many severe 
 operations have been only available to keep it in 
 check. The fungus is of five years growth. 
 
 I have often found the canal completely obli- 
 terated by ossific inflammation at its upper ori- 
 fice in skulls ; and I know cases of enlargement
 
 FACIAL ArPENDAGES. 24<0 
 
 of the ossa nasi, and of periosteal inflammation 
 and thickening, marked by liabitual overflowing 
 of the tears and occasional erysipelatous in- 
 flammation of the surface, in which the canal is 
 evidently destroyed. Malignant herpetic ulcers 
 of the lupous class, not unfrequently occurring 
 at this part, expose and destroy the whole la- 
 crymal apparatus.
 
 FART III. 
 TREATMENT 
 
 OF THE 
 
 DISEASES OF THE EYE. 
 
 CHAPTER I. 
 
 It will be necessary in this department of my 
 work to refer to the states of disease described 
 in the Pathology, but I shall endeavour to avoid 
 repetition, and to seize upon the principles of 
 treatment, to the exclusion of over-minute prac- 
 tical details. The leading object of my under- 
 taking, I have already accomplished, however 
 imperfectly ; namely, the desci'iption of the 
 principal phenomena of disease in the several 
 textures of which the organ is composed. For 
 the purpose of illustration 1 have unavoidably 
 anticipated, in some instances, the subject of 
 treatment, and the remarks which I have yet to 
 offer will lie in a small compass ; for it would be 
 idle to suppose that general principles of treat-
 
 TREATMENT OF THE DISEASES OF THE EYE. 251 
 
 ment require to be enforced, after the nature of 
 a disease is clearly pointed out. The maxims 
 and modes of successful practice, so far as they 
 are hitherto known, are accessible to all enquirers 
 of ordinary capacity ; and that man is unworthy 
 of his profession who seeks to mystify them, for 
 the purpose of being esteemed wiser than his 
 neighbours. The innumerable modifications and 
 varieties of disease render it impossible to lay 
 down rules that admit of universal application, 
 and the general intelligence of the profession in 
 the present day, forbids such an attempt, if it 
 were in the contemplation of any individual to 
 make it.
 
 SECTION I. 
 
 SIMPLE INFLAMMATION. 
 
 Causes. The causes of ophthalmia, like those which 
 
 lead up to inflammation in other organs, refer 
 first, to the state of the system ; secondly, to the 
 direct operation of external agents upon the 
 
 Predispo- organ. A person whose general health is dis- 
 
 *'"^* ordered, or who is recently convalescent from 
 
 some other malady, frequently becomes the sub- 
 
 Occasionai. jcct of Ophthalmia. The extreme states and 
 sudden changes of temperature ; the prevalence 
 of easterly winds, of fog and damp, and peculiar 
 conditions of atmosphere ; exposure to draughts 
 of cold air; concentrated heat and Hght; extra- 
 neous particles, and other less obvious circum- 
 stances, are regarded as occasional causes. 
 
 Whatever is the exciting cause of inflamma- 
 tion of the conjunctiva, the first visible pheno- 
 menon is a state of congestion, owing to an in- 
 creased influx of blood into the capillaries : it 
 may pass away, but the continuance and in- 
 crease of this, with certain other phenomena,
 
 SIMPLE INFLAMMATION. 253 
 
 determine that the act of inflammation is set 
 up. 
 
 The sensation of a foreign particle within the Symptoms, 
 litis, whether real or delusive, commencing with 
 the state of congestion, gives occasion to a 
 spasmodic contraction of the orbicularis palpe- 
 brarum. A pungent pricking pain in the organ 
 creates a copious secretion of tears, which col- 
 lecting within the palpebraa gush out at inter- 
 vals, and their discharge affords a temporary 
 relief. The increased temperature, volume, and 
 sensibility of parts under inflammation, explain 
 the following symptoms, viz. the sensation of 
 burning heat and scalding tears, the constric- 
 tion or girthing of the eyelids, and a sense of 
 weight upon the globe ; the involuntary exclu- 
 sion of air and light, and sympathetic pains in 
 the region of the orbit. 
 
 The simple inflammation of the conjunctiva, Treatment 
 i. e. an inflammation not sympathetic with in- opiuhS-^ 
 jury to the organ, nor depending upon any """* 
 established disorder of the system, nor modified 
 by a scrofulous diathesis, is easily and speedily 
 reduced by the ordinary means adapted to this 
 end. In its acutest form the loss of a few ounces 
 of blood, and some brisk doses of purgative me- 
 dicine are sufficient to subdue it. Even when 
 it arises from superficial injury to the cornea, if 
 treated in tlie commencement, it is scarcely less 
 manageable.
 
 S54< 
 
 Febrile irri- 
 tation. 
 
 SIMPLE INFLAMMATION. 
 
 It is rarely that any sensible febrile irritation 
 is present in simple acute ophthalmia, but if 
 there be any, and in certain irritable habits the 
 constitution sympathises with the smallest local 
 malady, it yields to the means above mentioned ; 
 repose of the organ, soothing applications, sus- 
 pension of ordinary employments, a light vege- 
 table diet and diaphoretic diluents. 
 
 Blood- 
 letting. 
 
 In many inflammations it is unnecessary to 
 draw blood ; the organ recovers speedily on the 
 removal of excitement, the use of soothing ap- 
 plications, and the operation of cathartics. In 
 some, general blood-letting is contra-indicated, 
 both by the character of the inflammation, and 
 the habit of the patient ; while on the other 
 hand, the degree of congestion makes it desira- 
 ble to assist the recovery of the organ by un- 
 loading the vessels in the vicinity. In others, a 
 question may arise as to the mode of proceeding 
 to be adopted, in which the patient*s conve- 
 nience or preference may be consulted, or a 
 disposition habitual to not a few persons, to a 
 troublesome erysipelatous inflammation after 
 leech-bites, may be admitted as an objection * ; 
 but there are cases in which the indication is 
 peremptory, both as to the use of topical and 
 general blood-letting. If it be important to 
 
 * The swelling and discoloration which so often follow the 
 application of leeches to the eyelids, especially the lower, 
 make the remedy little less an evil than the disease.
 
 SIMPLE INFLAMMATION. 255 
 
 make the system sustain and feel a reduction of 
 power, blood must be taken by the lancet, either 
 from a vein or the temporal artery*. Cupping 
 has a V ery decided superiority over leeches ; both 
 are well adapted to relieve local congestion. But 
 these modes of depletion are obviously too indi- 
 rect, however extensively employed, to be used 
 with the first-mentioned view, as a substitute for 
 the lancet. Bleeding from the angular vein, and 
 scarification of the conjunctiva are other means 
 adopted for the relief of the turgid vessels. The 
 latter practice is, in most cases, objectionable in 
 the acute stage of inflammation ; in the chronic 
 it is highly beneficial, as in the thickened and 
 over-vascular state of the palpebral conjunctiva; 
 and a considerable discharge of blood may be 
 thus obtained if it be briskly performed with a 
 sharp lancet, the lower lid kept everted, and con- 
 tinually fomented with hot water. 
 
 On the subject of local applications in acute Topical ap. 
 ophthalmia, there is considerable variety of pro- '' '"^ '""'' - 
 fessional opinion, but little in the evidence of 
 patients. Dr. Johnson, whose opinion in these 
 matters there can be no presumption in criticis- 
 ing, had a saying, *' that there is little virtue in 
 a lotion." In the main, and speaking of them 
 comparatively, if it refers, as I conclude, to me- 
 dicated lotions, I am much of his opinion ; but 
 
 * See Note H.
 
 256 
 
 SIMPLE INFLAMMATION. 
 
 warm and Warm and cold baths, whether employed for a 
 part or the whole, have very unequivocal and 
 sensible effects. These effects are likewise very 
 different, as might be expected. Although the 
 sensation of cold is most agreeable to an organ 
 under acute inflammation at the moment of its 
 application, it is generally followed by increase 
 of heat and pain ; and in familiar instances, the 
 pulsatile action of the vessels leading to an in- 
 flamed part, is so increased as to evince its stimu- 
 lating effect, and the re-action thereby induced. 
 When, however, the acuteness of inflammation 
 has subsided, and the sensibility of the part is 
 in proportion diminished, the effect of cold is 
 only tonic, and has a salutary tendency to restore 
 the balance of circulation. I therefore decidedly 
 prefer, as a general practice, a tepid application 
 in the painfully acute stage of inflammation, and 
 I appeal to general observation in proof of its 
 efficacy in promoting a grateful sense of cool- 
 ness, and a more permanent relief from pain. It 
 is objected to as being in the common phrase, 
 " relaxing,'* which term exactly expresses its 
 recommendation at the period of which I speak. 
 We see its relaxing and resolving effect in inci- 
 pient acute inflammations of the skin, the lym- 
 phatic glands, absorbents, &c. Moisture is a 
 condition almost necessary to inflamed organs, 
 and when the application is continued for some 
 hours, as in poultices, it partakes so soon of the 
 temperature of the surface, that tliis question is
 
 SIMPLE INFLAMMATION. 257 
 
 of less importance, but the indication is the same 
 with very few exceptions. To conclude these 
 remarks on what may be regarded as too tri fling- 
 to excuse prolixity, I prefer tepid water to all 
 applications in the painfully acute stage of in- 
 flammation. 
 
 It is remarkable that even the weaker forms Anodyne 
 
 lotions, 
 
 of medicated lotions irritate, and none more 
 than that which is esteemed of all the most se- 
 dative, I mean opium. The relief afforded by 
 anodyne fomentations in general, is very various. 
 I have often known them objected to as painful, 
 and patients to inquire if they might not substi- 
 tute warm water for the aqueous solution of 
 opium, and infusions of poppy and hemlock. 
 The same observation applies especially to pain- 
 ful herpetic cutaneous affections, and . acutely 
 irritable ulcers. Upon these a solution of opium 
 often acts as a stimulant and augments pain, 
 while the lunar caustic solution as often assuages 
 it. I do not deny that there are occasional ex- 
 ceptions to this remark. I have met with cases 
 in which no other application than the aqueous 
 solution of opium could be borne. I have also 
 known the vapor of laudanum afford the most 
 marked relief to the characteristic symptom of 
 the strumous ophthalmia, viz. irritability to 
 lisht. 
 
 *&• 
 
 Although during the state of morbidly elevat-
 
 258 SIMPLE INFLAMMATION. 
 
 ed sensibility accompanying the outset of acute 
 inflammation, warm applications are most sooth- 
 ing, and therefore most eligible ; the continuance 
 of them beyond their necessity is a loss of time, 
 if not injurious. When the extreme vascular 
 congestion and excessive sensibility are reduced, 
 and the inflammation tends to become chronic, 
 the use of cold lotions of a slightly tonic quality 
 is substituted with great advantage for ablutions 
 of warm water. The sulphates of alum and zinc 
 are the best. The smearing of the tarsal edges 
 with cetaceous ointment or cold cream at bed- 
 time is useful in the acute stage, and as it sub- 
 sides, the tutty or lead, or very dilute citrine 
 ointment may be advantageously substituted. 
 
 cEiiematous The oedcmatous elevation of the conjunctiva 
 opht la mia. .^ significant of a feeble action, and is by some 
 regarded as erysipelatous. A more than ordi- 
 nary fulness of the sclerotic conjunctiva is often 
 combined with the nausea, foul tongue, and prae- 
 cordial oppression, which manifest disorder of 
 the stomach and liver in cutaneous erysipelas ; 
 and the solution of emetic tartar given at sliort 
 intervals, operates very beneficially in reducing 
 it. 
 
 Atonic There are inflammations which assume a chro- 
 
 ouhthalmia. . i • ,i • ,-1,1 
 
 nic character in tlieir commencement, evidently 
 depending on a state of atony, of very partial 
 extent, void of pain, and scarcely possessing any
 
 SIMPLE INFLAMMATION. 2S9 
 
 sign of inflammation, except the congestion of 
 vessels, or if any, so feebly marked as to en- 
 courage us to disregard them in treatment. In 
 such cases, a single stimulus will often restore 
 the healthy action at once. The vinous tincture 
 of opium has acquired a nostrum-like import- 
 ance, from its restorative operation in such cases ; 
 a virtue I believe not proper to it. A drop or 
 two of the zinc or the lunar caustic solution, of 
 water impregnated with calomel, or a minute 
 portion of the citrine ointment, or any other 
 stimulant introduced within the palpebrae would 
 do as much. Some old women use their morn- 
 ing's urine with admirable effect in these cases. 
 It is the character of the morbid action, not the 
 application, that explains this sudden recovery. 
 The re-excited or increased momentum of the 
 arteiial action clears the stagnant capillaries, 
 and the unloaded vessels recover their tone. 
 Such cases are frequently relapsing, unless means 
 similar to those of cure are continued as pro- 
 phylactics. 
 
 In certain habits, or states of the system — whe- initaUe 
 ther the ophthalmia arises from constitutional "^ ^ ' ' 
 disorder or local injury — bleeding, purging, and 
 blistering, the ordinary means of arresting in- 
 flammation, are employed without apparent be- 
 nefit, or at least with a very disproportionate 
 degree of advantage ; and if the plan is perse- 
 vered in, it soon becomes injurious; the irri- 
 
 s 2
 
 260 SIMPLE INFLAMMATION. 
 
 lability by which it is marked, increasing as the 
 strength fails. These are cases in which opium, 
 if we so combine it as to countervail its ten- 
 dency to check the natural secretions, has an 
 admirable effect, viz. with calomel, antimony, or 
 ipecacuanha. 
 
 inflamma- In the treatment of simple acute ophthalmia, 
 eSng the ' the objcct to be kept in view is the soundness 
 
 cornea. 
 
 of the cornea; the organ is in no danger of 
 deeper injury. The main indication for an acti- 
 vity of treatment beyond that successfully adopt- 
 ed in ordinary cases, is furnished by the state of 
 this membrane. Where the sclerotic conjunc- 
 tiva is much raised, and the surface of the cor- 
 nea has in any degree lost its polish, and still 
 more when lymph is effused in or upon the cor- 
 nea, so as to obscure vision, the anti-inflamma- 
 tory measures must be as vigorous and decided 
 as the integrity of the organ is important. Blood- 
 letting and blisters, calomel, antimony, and the 
 neutral salts comprise all the requisite means. 
 
 Chronic It is scldom that the simple inflammation be- 
 
 Smation. comcs chrouic. Blisters, and issues or setons, 
 the zinc and acetous acid washes, and tonics, 
 especially pure air and exercise, are the most 
 efficacious remedies ; but the red and thickened 
 state of the conjunctiva at the margins of the 
 lids, is an occasional and not unfrequent termi- 
 nation of it. Here scarification and the diluted
 
 SIMPLE INFLAMMATION. 261 
 
 mercurial ointments are employed with obvious 
 advantage ; but with some persons all greasy 
 applications inflame so much as to aggravate the 
 complaint, and in such instances moderately sti- 
 mulant washes, of which a portion is to be ad- 
 mitted within the lids, may be substituted.
 
 SECTION II. 
 
 INFLAMMATION MODIFIED BY STRUMA. 
 
 The aphthous inflammation, the inflammation 
 of the foUicles, and that characterised by in- 
 tolerance of light in excess, and commonly de- 
 nominated strumous ophthalmia, are almost 
 always of an atonic character ; and although 
 obstinate when to a certain degree established, 
 are easily subdued in the early stage, or at least 
 prevented from arriving at such a height as to 
 do permanent mischief to the cornea. They are, 
 with very few exceptions, constitutional diseases; 
 and the same remark applies to many instances 
 of the mild acute suppurative ophthalmia. This 
 is proved by the disorder prevailing in the sys- 
 tem of nutrition, by the general debility of the 
 habit, and by the concurrence of local affections 
 in other parts referrible to the same source. The 
 habit, age, and sex of the patient frequently con- 
 tribute to the predisposition. The sphere and 
 mode of life have also a decided influence in 
 the production of these diseases. Children are 
 most frequently affected by them, and those es-
 
 INFLAMMATION MODIFIED BY STRUMA. 26S 
 
 pecially, subject from infancy to glandular en- 
 largements, chilblains, cutaneous eruptions and 
 chaps, psoriasis, tinea, and porrigo. Imperfect 
 nutriment, whether from the nature or deficient 
 quantity of their food or defect in their powers 
 of assimilation and absorption, contributes to 
 them. To this may be added an impure at- 
 mosphere and want of cleanliness. The ten- 
 dency to such diseases is demonstrated before 
 they exist, and to prevent their recurrence is 
 often more difficult than to remove them. It is 
 common for a parent to say, " I know what will 
 remove the complaint, but I cannot prevent its 
 return." This however arises from neelectinff to 
 follow up the cure to its completion, and pro- 
 perly to employ the interval of the attacks. 
 
 A gentleman determined to relinquish animal 
 food, and lived wholly upon vegetables and 
 water. From the enjoyment of good ordinary 
 health, he was in the course of six months re- 
 duced to a lamentable state of disease. The 
 whole mucous surface became aifected succes- 
 sively, after a severe and obstinate attack of 
 mild acute suppurative ophthalmia. His sys- 
 tem was so alarmingly debilitated by the pro- 
 traction of his disease, owing to the prostration 
 of his restorative powers rather than to the vio- 
 lence of the morbid action, that a residence in 
 the south of Europe became necessary for the 
 final re-establishment of his health. The dispo-
 
 !v!64 INFLAMMATION 
 
 sition of such a class of diseases to fasten on the 
 organ when once seated, in other words, to be- 
 come chronic, is as characteristic as their ten- 
 dency to re-appear when for the time removed. 
 They come slowly, and so depart. Violent 
 means fail to cure them. They are, to the sur- 
 prise of persons who mistake their character, 
 unaffected by such measures ; which if persist- 
 ed in produce a change for the worse. If the 
 remedies employed increase the debility of the 
 system at large, it must follow that the part suf- 
 fers, if this account of their constitutional ori- 
 gin be correct. Hence it is not uncommon for 
 those who treat all inflammations alike, to ex- 
 press their surprise at the obstinacy of these af- 
 fections, after going through and through again 
 the routine of an active antiphlogistic treat- 
 ment. 
 
 When the inflammation is of a sthenic cha- 
 racter, as is more frequent where rapid changes 
 are taking place upon the cornea, as a diffused 
 opacity, or the formation of pustule and its 
 passing into ulcer on that membrane, especially 
 where the deeper- seated tunics are partaking by 
 continuance of the inflammation, the necessity 
 of a more active practice is sufficiently demon- 
 strated. But, as a general observation, blood- 
 letting is not salutary in these inflammations. 
 They are rarely attended with any very acute 
 pain. Rough and depressing purgatives, either
 
 MODIFIED BY STRUMA. 
 
 from quantity or quality, are injurious. Warm 
 applications are of no advantage, if not inju- 
 rious. Blisters on the nape of the neck and be- 
 hind the ears, are for the most part of very great 
 utility, where the severity or permanency of the 
 inflammation calls for them. When the corneal 
 surface is affected, and the sensibility is from 
 this cause painfully augmented, this is espe- 
 cially the case. Blisters, when required in such 
 cases, should be kept open as long as they do not 
 irritate the system. Where the morbid appear- 
 ances upon the cornea are notwithstanding sta- 
 tionary, or slowly progressive, issues and setons 
 are of great avail. 
 
 The principle of treatment indicated in such 
 cases is, to lessen the irritability without ma- 
 terially depressing the power of the system. 
 The selection of medicine and applications, the 
 regulation of diet, the degree of relief proper 
 for the organ from its natural stimulus, when 
 painful, must of course be determined by the 
 circumstances of the case under consideration. 
 The arrangement of the vessels at the verge of 
 the cornea, and the condition of that membrane, 
 are the special points for observation. 
 
 If the cornea be opaque, calomel, or the blue 
 pill, or the oxymuriate of mercury should be 
 exhibited in combination with opium, slightly to 
 affect the system. The efficacy of the mercu- 
 
 Q65
 
 266 INFLAMMATION 
 
 rial preparation mainly depends on its combina- 
 tion with opium ; it irritates too much if ad- 
 ministered alone in quantity sufficient for the 
 purpose. 
 
 The following may serve as a synoptical sketch 
 of the treatment for each form. 
 
 1. Strumous inflammation ^without change of 
 texture, vascularity more or less, intolerance ex- 
 cessive. 
 
 Calomel and opium, or hydr. c. creta and 
 Dover's powder at night j emetic tartar to 
 nausea 5 gentle alvine evacuants ; diaphoretic 
 drinks ; large open blister on the nape of the 
 neck ; leeches ; tepid bath j tepid or cold water 
 washes, as most agreeable ; vapor of opium ; 
 large bonnet shade ; no bandages * ; spacious 
 airy apartments and light bed clothing. 
 
 2. With recent diffused opacity of corneal con- 
 Jimctivay and vessels raised ujwn and over-shoot- 
 ing the corneal margin. 
 
 Calomel and antimony, or opium, or any other 
 more appropriate exhibition of mercury, to pty- 
 alism ; occasional purgatives j leeches ; blisters 
 
 * Close bandages, I would observe^ are always prejudicial. 
 They create a morbid sensibility where it had not before ex- 
 isted, and greatly add to it when present.
 
 MODIFIED BY STRUMA. 267 
 
 alternated behind the ears and on the nape of 
 the neck and temples. 
 
 3. With herpetic ulcers of the cornea. 
 
 The same; blisters on the temples ; as the in- 
 flammation yields, sol. argent, nitrat. : vin. opii: 
 sol. cup. sulph. : dilute zinc lotion. 
 
 4. With pustules. 
 
 If partial, weak zinc or alum lotion ; ung. 
 hydr. nitr. ; occasional brisk purgatives ; infu- 
 sion of roses with additional acid ; tonic bit- 
 ters J calumba, gentian, &c. ; blisters behind the 
 ears, repeated if necessary. If the vascularity 
 is diffused by the multiplication of pustules or 
 the duration of inflammation wdth irritability to 
 light J treatment as in strumous inflammation 
 without breach. Ung. zinci. et sub-acet. plum- 
 bi. 
 
 5. With inflammation of the follicles and puri- 
 form discharge. 
 
 Active measures at first, but not long conti- 
 nued. Blisters, when becoming chronic, if with 
 thickened lids, scarifications ; zinc, alum, or 
 copper wash, dilute ; ung. hydr. nitr. : hydr. 
 nitr. oxid. : sub-acet. cupri j tonics and seda- 
 tives. If obstinate, issue or seton.
 
 268 INFLAMMATION MODIFIED BY STRUMA. 
 
 6. Convalesceiit state. 
 
 Infusion of roses ; cascarilla ; calumba ; de- 
 coction of bark, with dilute sulphuric or nitric 
 acid ; steel : rhubarb and soda, or magnesia, as 
 aperients. Tonic collyria and gently stimulant 
 ointments ; nutritive diet ; country air ; shower 
 or sea bath in the warm months.
 
 SECTION III. 
 
 ACUTE SUPPURATIVE INFLAMMATION OF 
 THE CONJUNCTIVA. 
 
 The suppurative inflammation is of all the 
 most dangerous to the organ ; and its sequelae, 
 even under a favorable termination, lingering, 
 and sometimes difficult of removal. It is in its 
 nature acute, but this acuteness is either mild 
 or vehement. The former has been confounded 
 with the inflammation of the follicles with puri- 
 form discharge, known also by the name of psor- 
 ophthalmia, ophthalmia tarsi, mucosa, &c. I 
 believe, as I have before explained*, that the 
 diseases are in their seat and nature distinct, and 
 that the discharge is the only symptom common 
 to both. From the occasional presence of dif- 
 fused vascularity of the conjunctiva with the 
 inflammation of the palpebra, the misconception 
 has probably arisen. The flakes of mucus lying 
 in the palpebral sinuses are not indicative of the 
 suppurative inflammation, for these are often 
 seen in the inflammation of the follicles, where 
 
 * See Page 97-
 
 270 ACUTE SUPPURATIVE 
 
 the palpebral conjunctiva is very slightly affect- 
 ed, and the secretion is not that of suppurative 
 inflammation, but of an irritated mucous surface. 
 (Fluor albus and gonorrhoea.) The intumes- 
 cence and elevation of the palpebral conjunctiva 
 (chemosis palpebrarum), its villosity, and the 
 fluid and truly puriform nature of the secretion, 
 are characteristic of the mild acute form of sup- 
 purative ophthalmia, in which the conjunctiva 
 of the globe is also tumid and vascular ; but I 
 do not deny that under aggravation, the inflam- 
 mation of the meibomian border and follicles 
 may be followed up by the mild suppurative in- 
 flammation of the conjunctiva. 
 
 wikj. In the mild form of the complaint the cornea 
 
 is not endangered, unless the disease be neglect- 
 ed or exasperated by stimulants. A very slight 
 haze of the cornea is the worst direct result of 
 it. There is not that excessive swelling of the 
 lids, that intense pain, nor that profuse secre- 
 tion, which characterises the vehement acute 
 form of the disease ; but these symptoms exist 
 in a degree sufficient to require immediate and 
 active treatment, and to this the acuteness of 
 the inflammation speedily yields. The alum so- 
 lution should be early substituted for the emol- 
 lient fomentations, which, during the acute pe- 
 riod, should be freely used ; and this should be 
 directed in a gentle stream over the conjunc- 
 tival surface, from a syringe furnished with
 
 INFLAMMATION OF THE CONJUNCTIVA. 271 
 
 an ivory pipe, introduced at the temporal angle 
 of the lids, without forcibly separating them. 
 Simple purging and abstinence are generally 
 sufficient to allav the febrile irritation, which is 
 moderate. Topical bleedings and a suppurating 
 surface opened by blistering the back of the 
 neck, are of great efficacy. When the pain and 
 irritability to light subside, and the discharge 
 becomes gleety, the conjunctiva pale and flac- 
 cid, tonics, especially tlie extract of bark and 
 the acids, do great good. As an application, 
 the liquor plumbi acetatis may now be advanta- 
 geously employed. While we are permitted to 
 see the cornea, and to see it clear and bright, 
 for this is the index by which we are guided, we 
 need be under no apprehension. 
 
 The vehement acute suppurative inflamma- Vehement. 
 tion is sudden in its attack, accompanied with 
 most severe darting pains ; the upper lid is in a 
 few hours prolonged upon the cheek, owing to 
 the infiltration and enormous swelling of the 
 tissue connecting the conjunctiva to the tarsus. 
 The cornea is nearly concealed by the fold of 
 conjunctiva which overlaps it all around, and 
 the corneal surface is dusky. The system sym- 
 pathises, chilliness is succeeded by a hot and dry 
 skin, and the pulse is frequent and hard. The 
 instant relief of a large venesection is indescrib- 
 able. The pain is mitigated, if not removed ; 
 the pulse softened, and the patient sinks into a
 
 272 ACUTK SUPPURATIVE 
 
 sound sleep, and perspires freely. Upon inspec- 
 tion we observe the high scarlet hue and bulk 
 of the chemosis sensibly reduced, and the cor- 
 nea has a brighter aspect. 
 
 But it is rarely that a single blow suffices to 
 vanquish the disease, especially where it arises, 
 as is most frequently the case, from the contact 
 of morbid matter. The most violent cases in my 
 experience have been thos^ produced by the 
 matter of gonorrhoea applied to the eyes, of which 
 I have seen several unequivocal examples. With 
 large blood-lettings repeated, subject to the dis- 
 cretion of the practitioner, until the inflammation 
 yields, a brisk catharsis should be combined, and 
 this followed by a tea-spoonful of a solution of 
 emetic tartar every hour, so as to keep up a state 
 of nausea, perspiration, and faintness. The dis- 
 charge, at first ropy, viscid, and sparing in quan- 
 tity, becomes thin, gleety, and more abundant ; 
 as the swollen lid subsides, the conjunctiva sinks 
 and becomes pale and flabby ; and if at this pe- 
 riod, the pain and febrile irritation being past, 
 the cornea retains its tone and brightness, all is 
 well ; the disease has given way, and a careful 
 but prompt exhibition of tonics, with the use of 
 cooling astringent lotions, will prevent its laps- 
 ing into a chronic form. But if, when the lower- 
 ing practice has been pushed to the extent of ar- 
 resting acute inflammation, the patient being 
 at the same time sunk and exhausted, the cornea
 
 INFLAMMATION OF THE CONJUNCTIVA. QJS 
 
 shews a lack-lustre and raggedness of its whole 
 surface, as if shrunk by immersion in an acid, 
 or a grey patch in the centre, or a line encircling 
 or half encircling its base, assuming a similar 
 appearance, the portion so marked out will in- 
 fallibly be detached by a rapid slough, unless by a 
 successful rally of the patient's powers we can 
 set up the adhesive action so as to preserve in 
 situ that which may remain transparent. 
 
 To know how far to go and not outstep the 
 boundary ; to know when to venture upon a 
 short and sudden reverse of treatment, is the 
 great difficulty of this highly important case. It 
 is a fatal mistake to consider the first change, 
 which is a true adhesive nebula, as the sign of 
 gangrene or death, and thus to temporise, or 
 even under this delusion to support the diseased 
 action *. Another and scarcely less mischievous 
 error, is to treat the discharge as the disease, 
 which is in fact but an inconsiderable sign of it 
 as regards its importance, and to stimulate by 
 strong astringent injections in its commence- 
 ment. But the pathology which attributed the 
 destruction of the cornea to the corroding quality 
 of the matter secreted, was so lamentably erro- 
 neous, that we cannot be surprised at any effects, 
 however mischievous, which resulted from the 
 treatment thence deduced. 
 
 In closing my observations on the treatment 
 
 * See page 119. 
 T
 
 274* ACUTE SUPPURATIVE 
 
 of inflammation of this organ, I shall take the 
 liberty of making one or two general remarks. 
 When inflammations in their nature destructive 
 are arrested by the vigor of the means employed, 
 the system stands in great need of the power thus 
 lost for its recovery ; to restore parts partially 
 injured, and to supply the place of those which 
 are destroyed. We see this fact exemplified in 
 many instances both of disease and injury. A 
 patient labouring under pneumonia is relieved 
 by excessive bleedings of his attack, and dies 
 a month afterwards of dropsy. A person threat- 
 ened with apoplexy, who by the advice of his 
 physicians is cupped once a month, soon falls a 
 victim to erysipelas. 
 
 If much blood is lost in severe injuries, espe- 
 cially of aged people, the healing powers are 
 prostrate and gangrene ensues. I mention this 
 as a caution against that inconsiderate detraction 
 of blood (and it applies as forcibly to the abuse 
 of mercury) which proceeds without proportion- 
 ing the quantity to the absolute necessity of the 
 case, and, secondly, without balancing the effect 
 upon the system at large against the importance 
 of the organ. When I hear, as I often have heard, 
 of sixty and seventy ounces of blood taken at one 
 time for an ophthalmia, and this followed by re- 
 peated smaller bleedings, I must protest against 
 the necessity of such a practice, and say with 
 Falstaff*, " the better part of valor is discre- 
 tion."
 
 Inflammation of the conjunctiva. 275 
 
 One of the great errors, it appears to me, in 
 the treatment of inflammations of the eye, though 
 of late years much corrected, has been the irri- 
 tation of the inflamed organ by stimulant drops 
 and ointments. The advantage of them is fully 
 admitted at a proper season ; but during the pre- 
 sence of active inflammation their use is as re- 
 volting to common sense as it is injurious *. I 
 am satisfied many eyes have been thus destroyed. 
 An anomalous species of ophthalmia, or a pseudo- 
 ophthalmia is produced by it, which differs as 
 much from the real character of the disease in 
 either of its forms, and may be as readily distin- 
 guished from it, as an artificial from a natural 
 flower. Thus, to mention one of many cases, I 
 have seen the star-like arrangement of the ves- 
 sels around the margin of the cornea, the cornea 
 and remaining portion of the conjunctiva clear, 
 and the choroid and iris perfectly free from in- 
 
 * I have mentioned certain cases in which stimulants act 
 beneficially- Even mustard has been applied to inflamed eyes, 
 with some real or supposed benefit. The temporary relief 
 which follows pungent applications is to be attributed to the 
 copious secretion and flow of tears which they occasion, which 
 is nature's own mode of relieving the distention of the vessels, 
 quickened by additional excitement. The pain of every in- 
 flamed organ is augmented by the retention of its secretion, 
 and in proportion relieved by its discharge. But the means 
 employed to promote this end should not be such as are likely 
 to support and increase the morbid action. Pain is only an 
 effect of this morbid action, and to assuage it by measures 
 calculated to perpetuate the cause, is, to say the least, a most 
 unscientific method of proceeding. 
 
 T 2
 
 276 ACUTE SUPPURATIVE, ETC. 
 
 flammation, the sequel of an inflammation of the 
 follicles which had been incessantly stimulated; 
 and I know cases of permanent and excessive 
 congestion, or rather varices of all the veins of 
 the conjunctiva with an actual discoloration of 
 the sclerotica, such as would lead to the belief 
 that the person laboured under confirmed organic 
 amaurosis, in which however the sight is perfect. 
 Here the plan of irritative applications had been 
 unremittingly pursued by several practitioners in 
 succession. The anomaly consists in the exist- 
 ence of such appearances unallied with the states 
 of which, by their habitual association, we con- 
 sider them characteristic. An apprehension sug- 
 gests itself to my mind, when I see such cases, 
 that the external character may be the prototype 
 of internal disease, or, at least, that the confirm- 
 ed existence of the one may predispose to the 
 production of the other.
 
 SECTION IV. 
 
 SECONDARY DISEASES OF THE 
 CONJUNCTIVA. 
 
 The granular state of the tarsal conjunctiva Granular 
 is a very common result of the mild suppurative Sva.""*^ 
 ophthalmia. It is characterised by a gleety dis- 
 charge, irritability to light, drooping of the upper 
 lid, a pricking sensation as of sand in the eye, 
 and a preternaturally irritable and vascular state 
 of the sclerotic conjunctiva; with these are fre- 
 quently combined, opacities of the cornea. The 
 lid should be everted, and the projecting gra- 
 nules shaved off from the surface and orbitar 
 edges of the tarsus, with a keen-edged lancet, 
 or, if peduncular and prominent, they will be 
 more conveniently snipped off with the flat scis- 
 sars. In doing this, care should be taken to 
 avoid injuring the continuous membrane. 
 
 When in addition to the state above described, with vas- 
 vessels are ramifying over the cornea, opacity of nea" ^°'^' 
 its covering conjunctiva being a contemporane- 
 ous result of the inflammation, or a consequence 
 of the irritation excited by the granulations, a 
 section of the membrane should be made at one
 
 278 
 
 SECONDARY DISEASES 
 
 line's distance from the margin of the coi'nea. 
 For this purpose, the globe should be thrown 
 forward and fixed in a state of tension by dcr 
 pressing the edges of the palpebras with the lin- 
 gers. The membrane yields instantly to a light 
 hand, and its edges gape asunder; in aggravated 
 cases, the operation, which is painful, requires 
 to be repeated, and some adroitness in exposing 
 and fixing the globe is requisite to its complete 
 performance. After the excision of the granu- 
 lations and the division of the conjunctiva, a so- 
 lution of the sulphate of copper, or some astrin- 
 gent, is very advantageously employed in the way 
 of injection. A few drops of the liq. plumb, 
 acetatis, or the tinct. opii vinos, are often highly 
 effective. It should be observed that the two 
 states above described often exist apart, but the 
 treatment adapted to them respectively is equally 
 essential. The application of the blue stone, or 
 of the lunar caustic, is useful in preventing the 
 regeneration of the granulations after their ex-^ 
 cision *. 
 
 Fungous 
 conjunc- 
 tiva, elon- 
 gations, eX' 
 crescences, 
 
 Another consequence of the disease above 
 described, are folds and flap-like elongations of 
 the conjunctiva filling the palpebral sinuses, and 
 pannus, &c. Qccasiouing such a fulness of the lids as to pre- 
 vent the patient from more than half opening 
 the eye. Upon eversion of the lids they roll 
 out upon the cornea. Another state ensuing 
 
 * See note I.
 
 OF THE CONJUNCTIVA. 279 
 
 upon the excessive chemosis, is a fungoid pro- 
 trusion of the conjunctiva in a thickened and in- 
 durated state. The conjunctiva also, at the point 
 of its reflection from the Hd upon the globe, oc- 
 casionally forms a tumor of considerable magni- 
 tude. I have seen it projecting from beneath 
 the upper lid equal in bulk to a middle-sized 
 walnut, producing great distortion and inconve- 
 nience, and rapidly increasing so as completely 
 to cover the eye. Such states more frequently 
 result from injuries, as falls and blows. The 
 treatment of all these cases consists simply in 
 the excision of the tumors, which is most conve- 
 niently done with a lancet-shaped knife, cutting 
 on both sides. The same may be said of the 
 disease which I have denominated pannus *, the 
 elongated valvula semilunaris, and the caruncu- 
 lar excrescences which sometimes form in clus- 
 ters between the tarsus and the globe. In the 
 first named disease, a circular excision of the re- 
 dundant opaque membrane should be made with 
 the curved scissars at a short distance from the 
 margin of the cornea, and the scissars will be 
 found most convenient in the removal of elon- 
 gations and excrescences, while such parts are 
 raised by a pair of small forceps. The broad 
 
 * This term is diiFerently appropriated. In the disease to 
 which I have applied it, the conjunctiva clothes and covers 
 the cornea from that side to which the eye is directed, but it 
 has no affinity to the membranous pterygium, or any form of 
 nebulous opacity of that membrane.
 
 280 SECONDARY DISEASES 
 
 or ring-ended forceps are often convenient on 
 these occasions. 
 
 Pterygium Tlic flcshj pterygium is sometimes a chronic 
 
 and encan- . . n ->• 
 
 this. and even a stationary condition oi disease pro- 
 
 ducing no inconvenience, nor threatening to in- 
 terfere with vision. Whenever this is the case, 
 I am decidedly of opinion that it should be let 
 alone. When, by its progress, it is encroaching 
 upon the sight, it should be raised by dissection 
 as close as possible to the margin of the cornea, 
 and the relaxed portion of the membrane re- 
 moved by an incision mid-way between the base 
 of the pterygium and the cornea, and concen- 
 tric to that membrane. I have experienced the 
 inconvenience pointed out by Professor Scarpa, 
 of carrying the excision to the caruncula, viz. 
 the deposit of lymph in the site of the cicatrix 
 becoming united with the caruncula, and form- 
 ing a hard frenum or cord which prevents the 
 abduction of the eye. I am also satisfied that 
 the disease is permanently arrested when the 
 ' connection with the cornea is dissevered. In 
 this operation I prefer the cornea knife to the 
 scissars. It is inadmissible to interfere with any 
 portion of the pterygium that may have en- 
 croached upon the cornea. It may be necessary 
 to repress the tendency to reproduction by the 
 application of the caustic pencil to the section 
 of the tumor ; but the frequent or diffused ap- 
 plication of escharotics is objectionable, as a
 
 OF THE CONJUNCTIVA. 281 
 
 morbidly thickened and tubercular state of the 
 membrane is the consequence of the irritation 
 thus excited. The treatment of the membra- 
 nous pterygium consists in nipping up a cres- 
 centic portion of the opaque membrane as near 
 as convenient to the cornea, and freely excising 
 it with a pair of curved scissars. The extremi- 
 ties of the line of excision both in this and the 
 former species should extend beyond the dis- 
 eased part. 
 
 The encanthis, when it attains any consider- 
 able bulk, becomes condensed with the valvula 
 semilunaris, and presents appendices correspond- 
 ing to the cornua of this fold. The treatment 
 consists in simple excision. 
 
 The membranous bands connecting the lid Frena. 
 to the globe should be divided, with the precau- 
 tion to avoid wounding the palpebral conjunc- 
 tiva. No bandage should be employed, and 
 during the day the patient should not be suffered 
 to keep the eyelids closed. In my experience, 
 escharotics only exasperate the evil. 
 
 Tumors upon the globe, unconnected with Tumors. 
 the palpebra, should be dissected from the scle- 
 rotica ; and this is the more important, in pro- 
 portion as they are seated near to the cornea. 
 Where the tumor is tied by angular folds to the 
 eyelid, considerable attention is necessary to
 
 t282 SECONDARY DISEASES OF THE CONJUNCTIVA. 
 
 prevent the adhesion of the conjunctival sur- 
 faces during the stage of healing, as in the case 
 of frena. The best mode of preventing the ap- 
 proximation of the opposed surfaces, is to pro- 
 duce a partial e version of the lower lid, by a 
 strip of plaster carried from its margin in an 
 oblique direction across the cheek, and fre- 
 quently renewed.
 
 TREATMENT 
 
 DISEASES OF THE EYE. 
 
 CHAPTER II. 
 
 SECTION I, 
 
 DISEASES OF THE CORNEA. 
 
 The term, inflammation of the cornea, must be 
 understood as applied to the compound tex- 
 ture so denominated, and not to the lamellae of 
 horny substance, which has no vessels proper to 
 itself, but derives them from the covering and 
 connecting cellular tissue. These vessels nou- 
 rish and preserve it in the condition essential 
 to its economy. The crystalline humor is a 
 simpler texture, being wholly dependant on its 
 capsule — ^as the nails, like the horse's hoof, are 
 sustained by the lamellae of the cutis in which 
 they are implanted — or the hair, by the bulb 
 alone to which it is attached. It is rarely that 
 red vessels are seen in the inter-lamellar texture 
 of the cornea. Deposits of adhesive matter and 
 of pus are frequent ; the former most so; those
 
 284 DISEASES OF THE CORNEA. 
 
 of blood are rare, being only a result of severe 
 injury, superadded to a state of inflammation. 
 The cornea is rendered turbid by a congestion 
 in the vessels of its covering or connecting tex- 
 ture ; and in this, and the case of interstitial in- 
 flammatory secretions, may, if in any, be said 
 to be inflamed. But its subserviency in these 
 processes to the conjunctiva and sclerotica, make 
 the strict propriety of the term questionable as 
 applied to the corneal lamella. It would be as 
 incorrect to speak of an inflamed crystalline, 
 hair, or nail. 
 
 Nebula and It is Only ncccssary to observe, that the prac- 
 
 onyx. 
 
 tice employed to reduce inflammation is then 
 most strongly indicated, when the cornea is ren- 
 dered opaque, or presents an onyx of adhesive 
 matter. 
 
 Superficial The supcrficial ulcer is commonly attended 
 ulcer. with much inflammation of the conjunctiva, and, 
 by continuance, of the sclerotica. The eye is 
 very irritable to light, and the sensation of a fo- 
 reign particle in the motions of the lids acutely 
 painful. The pain is often spasmodic, and re- 
 lieved by profuse lacrymation at intervals. Opium 
 should be so combined as to operate on the skin, 
 and the bowels must be kept freely open. 
 
 Touching the ulcer with a fine pointed caus- 
 tic pencil, or the solution of argentum nitratuni,
 
 DISEASES OF THE CORNEA. 285. 
 
 is the best local treatment ; much superior, as 
 an anodyne, to sedative lotions. Warm fomenta- 
 tions afford temporary relief. It will be found 
 advantageous, if not indispensable to prevent re- 
 lapse, to affect the system with mercury where 
 the inflammation of the sclerotica is intense. 
 The cicatrix being confined to the superficial 
 lamellae is of very inconsiderable density, so as in 
 time to be scarcely perceptible, and in children 
 to wear quite away. 
 
 The indolent and the deep sloughing ulcer indolent 
 may be touched once, or oftener, with the caustic sloughing 
 pencil, or washed once a day, or oftener, with 
 the solution. The cleansing of the ulcer, and 
 the opaque adhesive circle is the sign for a less 
 frequent use of it, and the deposition of new mat- 
 ter, undergoing a vascular organization, renders 
 its further use hazardous. The occasional use 
 of leeches is often a necessary accompaniment 
 to this treatment. The administration of tonics 
 and sedatives is at the same time essential. 
 
 The acute interstitial ulcer cannot be treated Acute in- 
 distinctly from the adhesive inflam'mation ; it is ulcer. 
 a sign only of the inflammation which consti- 
 tutes the disease. In proportion as this is re- 
 duced, its disposition to extend is checked, or 
 we are enabled to employ auxiliaries to that end. 
 But in favorable circumstances of constitution 
 they are not wanted. Healing is a spontaneous
 
 286 DISEASES OF THE CORNEA, 
 
 action, vicarious with destruction, and com- 
 mences on the arrest of inflammation. 
 
 Abscess. A large collection of matter in the cornea, 
 
 whether tlie puriform onyx, or central abscess, 
 requires, at the same time, a supporting consti^ 
 tutional treatment, mild cathartics, and the ap- 
 plication of blisters; calomel should be avoided, 
 as in most instances where ulceration is present. 
 The puncture of the cornea is seldom practised 
 with advantage. By the means above-named, 
 I have seen large effusions absorbed, and no 
 trace left of their existence. 
 
 Hypopion. When the hypopion is so large as to rise 
 towards the pupil, and the ulceration of the 
 cornea is extending, I think its discharge by 
 section near its margin advisable. If not too 
 long delayed, the ulcerative process is checked 
 by it, which would otherwise run into sloughing, 
 and the cornea recovers with only partial opacity 
 and disfigurement. 
 
 Procidentia The prolapsus iridis from ulcer should, if small, 
 be touched with the caustic pencil, ground to 
 a fine point. If large and extending, it should 
 be snipped off with a pair of curved scissars, and 
 the caustic pencil immediately applied to the cut 
 surface and margin of the ulcer. In this way I 
 have seen many cases recover with good though 
 abridged vision. This circuqistance depends on 
 
 iridis.
 
 DISEASES OF THE CORNEA. 287 
 
 the site of the ulcer and the relation of the pro- 
 lapsed portion of the iris to the pupil. The same 
 treatment is best adapted to prolapsus from 
 wound, as after extraction. The inflammation 
 accompanying these states requires the occa- 
 sional application of leeches, gentle purgatives, 
 sedatives, light tonics, and mild nutritive diet. 
 
 The chronic interstitial ulcer requires only Chronicin- 
 
 . . . ,. • terstitial 
 
 stimulant and astringent injections ; blisters in uicer. 
 the neighbourhood of the eye, bark and opium, 
 pure air and good diet, with a due attention to 
 the secretions. Rhubarb and aloe are the best 
 aperients. 
 
 The opacities, in their nature removable, are opacities. 
 the nebulous, which depend on a loss of trans- 
 parency from recent inflammation, or recent in- 
 terstitial deposition without breach of texture. 
 Cicatrices are only so far benefited as the sur- 
 rounding deposit is of this description, and sus- 
 ceptible of absorption. The actually changed 
 texture of the entire cornea depending on an 
 obliteration of the interstitial texture, like the 
 cicatrix itself, undergoes no change from the 
 use of stimulant applications. The most effect- 
 ive injections are the lunar caustic and the oxy- 
 muriate of mercury, one or two grains to one 
 ounce of water ; the former may be used in the 
 decline of the inflammation ; the latter, not until 
 after its disappearance. Levigated glass, calo-
 
 288 DISEASES OF THE CORNEA. 
 
 mel, loaf-sugar, are by some coarse practitioners 
 blown into the eye for this purpose. The prin- 
 ciple of their operation is the same. In the use 
 of applications to remove opacities, the points of 
 importance to be determined are the time and 
 the frequency of their use. They are mischiev- 
 ous when inflammation is excited or increased 
 by them ; their effects as excitants should be 
 temporary. The mercurial ointments are less 
 effective, in my experience, than the injections. 
 Where the internal use of mercury is indicated 
 by the character and duration of the inflamma- 
 tion which has given rise to opacity, its eflTect 
 upon the latter is more marked than that of any 
 local remedy. 
 
 Strumous Uudcr the head of strumous nebula with vessels 
 the cornea, ovcrshootiug the comca, I have advised ptyalism, 
 upon the strength of several decided proofs of its 
 efficacy; but no form of recent opacity is so in- 
 tractable ; and I should be uncandid not to 
 state that I have seen it increase from day to 
 day under the mercurial action. The vessels 
 which shoot in radii upon the cornea and at 
 length meet in the centre of the membrane, if 
 the disease is unchecked, are situated beneath 
 the conjunctiva and belong to the sclerotica, as 
 may be easily ascertained by close inspection ; 
 and the uncontrolable nature of sclerotic in- 
 flammation, of which I shall speak presently, is 
 well known to those who have seen much of it.
 
 DISEASES OF THE CORNTEA. ^S9 
 
 The deposition is interstitial. The oxymuriate 
 or the hydr. c creta, in small but frequent doses, 
 will sometimes succeed better in this case than 
 the other forms of mercury ; and the combina- 
 tion of blue pill or calomel with antimony, better 
 than that with opium. 
 
 In constitutions which discover an insuscep- 
 tibility to be affected by the mercurial pill, or in 
 which its exhibition in sufficient doses is at- 
 tended with griping pain and diarrhoea, friction 
 should be employed ; and indeed in all cases in 
 which the saving of time and strength is pecu- 
 liarly an object, this is the more certain and ef- 
 ficacious proceeding. I know that the preju- 
 dice often existing against the use of the re- 
 medy in any shape, is most strongly opposed to 
 this, its best form. But among persons other- 
 wise intelligent, such a prejudice soon gives way 
 to the more rational feeling of confidence in the 
 practitioner. It is necessary, however, that he 
 should support this feeling by a proper confi- 
 dence in himself — by a steady perseverance in 
 his design : having, therefore, upon mature de- 
 liberation decided, that the mercinial action 
 should be set up, nothing but the clearest de- 
 monstration of the patient*s inability to support 
 it should interfere with the full and fair execu- 
 tion of the plan. A character notoriously abused 
 by indiscriminate excess, is in much danger of 
 being further injured by half measures. This, 
 
 u
 
 290 DISEASES OF THE CORNEA. 
 
 I think, has been the case of mercury. It is 
 not the most delicate frame which is most ready 
 to admit, or least able to support it ; and it is 
 not the quantity consumed, but the quantity 
 absorbed, which is to be taken into account by 
 the practitioner. The progress of disease dur- 
 ing its exhibition is no argument against its con- 
 tinued employment ; in this view, unless the 
 system be fairly under its influence, all that has 
 been given goes for nothing ; nay, I have had 
 occasion to see many cases in which, after all 
 the signs of absorption were manifest, its opera- 
 ration upon the disease was for a time unob- 
 served, or was null, and was yet ultimately all 
 that could be wished. I venture upon these re- 
 marks from having myself felt "afraid to go 
 forward lest I should go wrong," in some very 
 obstinate cases of strumous nebula in young and 
 very delicate subjects, the issue of which gave 
 me no reason to regret that my confidence had 
 triumphed over my fears. And therefore the 
 stationary condition, nay, the natural progress 
 of a disease during the period occupied by the 
 introduction of mercury, or even after its intro- 
 duction, for a time to be limited, would not 
 deter me from prosecuting it in a case wherein 
 1 placed my dependence upon its power ; but 
 an alarming degree of arterial excitement, or 
 certain morbid appearances of the organ, not 
 looked for in the natural and ordinary progress 
 of the disease, would, as a matter of course,
 
 DISEASES OF THE CORNEA. g9| 
 
 determine me to withhold it. These remarks 
 are not confined to the case under notice ; they 
 are of general application. 
 
 I shall take this opportunity of briefly advert- 
 ing to another point of the ordinary treatment 
 of this case, of some importance. The division 
 of the conjunctival vessels on the decline of the 
 inflammation is injurious during the acute stage 
 of the disease, and at any period its effect upon 
 the vessels, by which the nebula is secreted and 
 maintained, is from their situation indirect ; so 
 that it stands upon the same ground as scarifi- 
 cation, and no other. 
 
 The staphyloma, if purely corneal, and of such staphyloma. 
 size as to occasion deformity, and expose the 
 organ to further injury, or if producing habitual 
 irritation and inflammation of the tarsal borders, 
 should be excised ; the ligature passed through 
 and including two-thirds of the diseased cornea, 
 by means of a curved needle, assists the opera- 
 tor, by steadying the globe. If the staphyloma 
 is from dilatation, the iris will be left ; if from 
 breach, it is compacted, and removed with the 
 cornea. This circumstance makes no material 
 difference in the healing, unless the section be 
 made much posterior to the ciliary ring, when 
 the globe collapses from the escape of the vitre- 
 ous humor; which is not the case when the 
 section is at the base of the cornea, although 
 
 u 2
 
 292 DISEASES OF THE CORNEA. 
 
 the iris should be included in it, for the vitreous 
 humor is in a considerable degree sunk by ab- 
 sorption in the staphyloma, and the aqueous as 
 much superabundant. A flat double-edged knife 
 is the most convenient instrument for a circum- 
 cision of two-thirds of the staphyloma, which is 
 executed in its passage across the globe ; the 
 remaining portion may be finished by one stroke 
 of the scissars. A compress of soft linen should 
 be laid upon the closed lids, and retained by a 
 roller. Where the staphyloma is partial and co- 
 nical, the section is corneal, and its edges should 
 be touched with the argentum nitratum to pre- 
 vent a corneal fistula. But when, as in many 
 cases, the protrusion is not such as to prevent 
 the easy motion of the lids, or occasion inconve- 
 nience, it should be left, screened or not, at the 
 option of the patient. No benefit results from 
 tapping the globe of the aqueous humor, either 
 in this case or in the hydrops oculi. 
 
 Fungous tumors of the cornea must be treated 
 as the staphyloma. They are of very rare oc- 
 currence. 
 
 cornea. 
 
 Conical The discharge of the aqueous humor is useless 
 
 in this case, and all attempts to remove the dis- 
 ease have hitherto proved ineffectual. I have 
 found repeated blisters, and the more powerful 
 tonics, as steel or arsenic, decidedly serviceable. 
 To these may be added, cold bathing, and the
 
 DISEASES OF THE CORNEA. 293 
 
 practice of often opening the eyes in cold 
 spring water. I am unable to say, whether a 
 section of the cornea, as in extraction, would 
 be productive of benefit. It has occurred to me 
 as not improbable. The disease, however, is 
 constitutional, and must be so treated. The 
 tubular spectacle frame with a pupillar aperture, 
 affords more aid in correcting the vision, than 
 any form of lens.
 
 SECTION II. 
 
 SCLEROTITIS, CHOROIDITIS, AND IRITIS. 
 
 The signs of inflammation extending to the 
 sclerotica have been described. It is seldom, 
 if ever, the cornea being the seat of diseased 
 actions, that the sclerotica does not participate. 
 Inflammation cannot pass from the surface of 
 the eye to the interior tunics, without involving 
 this membrane, and the impediment, which is 
 happily opposed to its progress, the slowness 
 with which it is in consequence propagated, is 
 accounted for by the texture and properties of 
 the sclerotica, and the minuteness of the vas- 
 cular communication through its medium be- 
 tween the conjunctiva and the choroid. The 
 structure and properties of the sclerotica also 
 explain why the primary sclerotitis is a rare dis- 
 ease. In the commencement of this disease, 
 the cornea is slightly, if at all clouded, and the 
 activity of the iris but little impaired. An ob- 
 tuse pain in the eyeball is materially relieved by 
 blood-letting, and by antimony and ipecacuanha 
 with opiates. It is by no means so decidedly in- 
 fluenced by mercury as the iritis, and its obsti- 
 nacy and disposition to relapse, render the case
 
 SCLEROTITIS, CHOROIDITIS, AND IRITIS. 295 
 
 often difficult of treatment. The subject of it 
 is usually reduced and irritable in a high degree, 
 from suffering with rheumatic inflammation in 
 the elbow, knee, or ankle-joints *. I have gene- 
 rally observed that the previous use of mercury 
 has more or less contributed to this state. I 
 have also noticed the frequent accompaniment 
 of gonorrheal inflammation with this disease, or 
 its existence a short time previous. Though it 
 is necessary to use mercury with more reserve 
 than in other forms of inflammation, to suspend 
 its operation at intervals, and allow the system 
 to recover from its immediate effects, yet its ex- 
 hibition will be found in the majority of cases, 
 indispensable. The rude and profuse employ- 
 ment of it hurries on the disease, and the exten- 
 sion of the inflammation to the interior tunics 
 ultimately destroys the organ. The nitric acid 
 may often be exhibited with marked benefit, in 
 the intervals of the mercurial action. 
 
 The Plummer's pill, the oxymuriate in doses 
 of one-twelfth to one-eighth of a grain, or in 
 feeble subjects, the hydr. cum creta, five grains 
 to ten, twice or thrice a day, are most available 
 and beneficial forms of the remedy in these cases. 
 As auxiliaries, soothing and allaying irritation, 
 I should mention the Dover's powder, hemlock, 
 and hyoscyamus, and the extract of sarsaparilla, 
 either dissolved in the decoction, or taken freely 
 
 * See note K.
 
 29G SCLEROTITIS, CHOROIDITIS, AND IRITIS. 
 
 in the solid form. I have seen an obstinate 
 chronic inflammation yield before these latter 
 remedies, in which mercury had been productive 
 of no benefit. In the motley diseases now known 
 by the cant term of pseudo-syphilis, their efficacy 
 is admitted by the most competent authorities. 
 
 On the treatment of deep-seated inflammation, 
 whether affecting the choroid or iris, I shall not 
 now dwell, having in an Essay on this subject, 
 published three years ago, pretty fully stated my 
 opinion ; and when treating of the signs of these 
 diseases in the present volume, having repeated 
 my conviction of the remarkable efficacy of mer- 
 cury, and of the comparative insignificance of 
 every other remedy. One full blood-letting or 
 more should be premised in the acute stage of 
 the disease; and topical blood-lettings are ge- 
 nerally required at short intervals during its 
 exhibition. I have now and then found that 
 the incipient inflammation, where it has extend- 
 ed from the conjunctiva, yields to a copious ve- 
 nesection, and two or three brisk doses of calomel 
 and rhubarb, followed up by the infusion of sen- 
 na ; but, generally speaking, the system must 
 be made to feel the influence of mercury before 
 the disease is permanently subdued. The in- 
 flammation which has proceeded to the effusion 
 of adhesive matter, never, in my experience, 
 yields either to the lancet, continued nausea, or 
 full purging ; and it is remarkable that the cases
 
 SCLEROTITIS, CHOROIDITIS, AND IRITIS. 297 
 
 presenting this termination of inflammation are 
 always most sensibly and immediately benefited 
 by the remedy in question, whether the cornea 
 or the iris be affected, or any other texture of the 
 body. 
 
 That in many instances, however, the depo- 
 sition takes place notwithstanding, or immedi- 
 ately succeeding to the action of mercury, and 
 is most prone to do so (I do not say from that 
 cause), I am as sure, as that it seldoni fails to 
 yield to its continuance or renewal. But when 
 the mercury arrests inflammation previous to this 
 event of it, there is reason to infer that it pre- 
 vents such termination, and its less rapid and 
 decided influence under these circumstances, is 
 not a reason why, if the inflammation resists the 
 ordinary antiphlogistic measures, it should not 
 be employed. I believe that the mode of action 
 of the remedy varies according to the degree of 
 its influence, which again varies according to 
 the habit of the patient, the form or stage of the 
 disease, and the quantity of the remedy which 
 is received into the system. But if any two 
 facts are well established in modern medicine, 
 I apprehend they are these : — first, the power of 
 mercury to arrest acute membranous inflamma- 
 tion, both prior to and after the effusion of ad- 
 hesive matter ; and second, its power rapidly to 
 remove, by an excitement of the absorbing sys- 
 tem peculiar to itself, the newly effused adhe-
 
 298 SCLEROTITIS, CHOROIDITIS, AND IRITIS. 
 
 sive matter. If these facts are admitted, then 
 the propriety of its use is indicated in iritis, as 
 in carditis, pleuritis, peritonitis, and the only 
 practical question that can arise respecting it is, 
 how far the patient's strength is equal to support 
 the remedy. There are, I admit, states of the 
 organ as well as of the constitution, in which it 
 cannot be borne, and no sooner is its influence 
 felt, than the inflammation threatens disorganiza- 
 tion, and if the plan is persevered in, quickly runs 
 on to it. The globe becomes enlarged or mis- 
 shapen, the sclerotica assumes a livid hue, and 
 the veins a state of varicose congestion ; some-- 
 times the eyeball suppurates, and the little re- 
 maining vision is completely extinguished. In 
 cases where age, or the existence of other dis- 
 eases, or the already extessive use of mercury, 
 has greatly enfeebled the powers of the system, 
 it must be used, if ventured upon at all, very 
 sparingly, or with intermissions, and the system 
 must be supported by every admissible means, 
 both of nourishment and medicine, during its 
 employment.
 
 SECTION III. 
 
 AMAUROSIS. 
 
 The term amaurosis comprehends all those 
 imperfections of vision which depend upon a 
 morbid condition, whether affecting structure 
 or function, of the sentient apparatus proper to 
 this organ. That the term is not so defined ac- 
 cording to its etymological import is well known, 
 but it is thus employed by pathologists, if I have 
 rightly understood its meaning. 
 
 The diseases of the other coats and humors of Organic 
 
 1 1 • 1 • "111 amaurosis 
 
 the eye which are present in a considerable num- from in- 
 ber of these cases, are effects of an inflammation 
 which has destroyed the retina. Such are es- 
 pecially, discoloration and absorption of the 
 vitreous humor, or a bright yellow opacity of 
 the crystalline lens, which is indurated — its cap- 
 sule condensed with it, and firmly adhering to 
 the constricted and perhaps irregular pupil, with 
 peduncles of lymph or detached flakes of the 
 black pigment projecting from its posterior bor- 
 der — or a capsule containing calcareous concre- 
 tions with an absorbed lens, and a concave and 
 tremulous iris, or an obliterated pupil, or a sta- 
 phyloma of the sclerotica or choroid.
 
 300 AMAUROSIS. 
 
 From a But there are cases in which a change in the 
 
 text"ifre?i- structure of the retina is to be inferred, of a 
 oSlm-' description less conspicuous indeed, but not less 
 mation. £^^^| ^^ vision. This is the result of a slow and 
 insidious morbid action, and although sometimes 
 accompanied with superficial inflammation, is 
 more frequently altogether independent of in- 
 flammation. The congestion of the superficial 
 vessels, the extenuation and consequent blue tint 
 of the sclerotica, the appearances supposed to 
 indicate a caligo of the vitreous humor, or an 
 opacity of the retina, or a deficiency of the pig- 
 mentum nigrum, seen upon looking towards the 
 fundus of the eye, are signs of this change. 
 
 Functional When the eyeball has the appearance of 
 health, and the loss of vivacity in the motions 
 of the pupil, is the only sign of an amaurosis 
 obtained from inspection of the organ, we are 
 scarcely warranted to suppose any disease of 
 structure. 1 have called such cases functional, 
 and my object in doing so is to discriminate 
 them from the organic, in the belief that much 
 practical advantage may be gained from the dis- 
 tinction. Diagnosis is a study interesting in 
 a scientific view, but it is awfully important 
 as it aflfects practice and character. An amau- 
 rosis depending on a change of structure in the 
 brain or eyeball, is an irremediable case. The 
 same may too often be said of that which pre- 
 sents no evidence of structural disease, of which 
 
 amaurosis.
 
 AMAUROSIS. ^Qi 
 
 I shall presently mention examples. It is cre- 
 ditable to a practitioner to know such cases ; 
 and if his ingenuousness is equal to his know- 
 ledge, he will be a gainer in reputation in every- 
 way. 
 
 Functional amaurosis 1 have arranged under 
 three heads : the symptomatic, the metastatic, 
 and the proper. The first includes a class of 
 diseases so large and diversified, that to consider 
 them and the rationale of their treatment in de- 
 tail, would occupy a volume. Suffice it there- 
 fore to say, that the amaurosis being subservient 
 to the disease which affects the system at large, 
 or some one important organ, the latter is the 
 proper object of medical treatment. I may 
 instance the morbid states and actions of the 
 vascular system, the disorder of the digestive 
 organs in its several degrees from impaired ap- 
 petite to confirmed hypochondriasis, the inter- 
 ruption to the healthy functions of the uterus, 
 the excess, or deficiency, or accumulation of the 
 wonted secretions and excretions, the presence 
 of local irritation, as wounds and abscesses, 
 caries, w^orms, &c., and the influence of strong 
 mental emotion producing a morbid irritability. 
 These co -existing with an amaurosis must be 
 regarded as the original and substantive disease, 
 the removal of which is the aim and end of 
 treatment. It must be obvious that it is rather 
 the degree, than the nature and origin of the
 
 302 AMAUROSIS. 
 
 functional disease, that should in most cases influ- 
 ence our prognosis, yet the latter circumstances, 
 it is equally clear, afford more or less encourage- 
 ment, in proportion as the pre-existing states of 
 diseases ordinarily admit of relief or otherwise. 
 Thus, for the sake of illustration, I may observe, 
 that the amaurosis from gastric diseases, from 
 plethora, from irritation, are all of them reliev- 
 able, and, if treated at an early period, remedi- 
 able. Whereas paralysis, the sequel of fever or 
 of epilepsy*, or severe constitutional diseases, 
 whether acute or chronic, or depending upon 
 habitual cerebral congestion combined with or- 
 ganic visceral disease, or induced by the opera- 
 tion of noxious agents on the system, is a hope- 
 less form of the malady. It resembles in appear- 
 ance and character the ordinary gutta serena, 
 or idiopathic palsy of the retina, which occurs 
 in early as often as in advanced life, in which, 
 excepting the gaping and motionless pupil, and 
 the absence of physiognomical expression, no 
 defect appears ; on the contrary, the fine, large, 
 well-opened, and singularly brilliant eye, often 
 excites admiration of its beauty as an organ, 
 though unillumined by the mind. 
 
 * I know a family of several well-formed children, three of 
 whom have dark hair and eyes, the others light hair and blue 
 eyes. Towards puberty, all the dark haired children have 
 become epileptics, and gradually lost their sight ; the eyes, 
 except in the expansion and immobility of the pupils, retain- 
 ing every appearance of health.
 
 AMAUROSIS. 303 
 
 The metastatic amaurosis is rare but well 
 marked. The restoration of the original ma- 
 lady, if it be practicable without involving the 
 patient's safety, or the substitution of an artificial 
 excitement or discharge, which may serve as an 
 equivalent, appears to be the natural indication, 
 and such a practice has been attended with suc- 
 cess*. But the prognosis is necessarily one of 
 great uncertainty. 
 
 The proper functional amaurosis presents 
 great variety; but if treated at an early period 
 is very often cured. The extreme states of light 
 and temperature, and the over-exertion of the 
 organ, are the chief causes of it. The remission 
 or removal of these hurtful circumstances even 
 of itself does much towards the cure. The con- 
 tinuance of them frustrates the end of treatment, 
 and the amaurosis becomes confirmed, and ulti- 
 mately passes into the organic form. The 
 emeralopiat, and many other cases not assum- 
 
 * See a remarkable case of " Amaurosis from suppressed 
 purulent discharge," successfully treated by Professor Beer, 
 in the " Analecta" of the " Quarterly Journal of Foreign 
 Medicine and Surgery, No. IV." 
 
 Although the metastasis of gout, of which I have known 
 two marked instances, has been fatal to vision ; yet in three 
 cases, in Avhich I extracted the cataract from gouty subjects, 
 and a smart attack of the disease followed the operation, the 
 eyes were unaffected and the sight was well recovered. 
 
 f See an excellent paper on this disease as it affects sea- 
 men in tropical climates, by Mr. R. W. Bampfield, Surgeon 
 of the Royal Navy, in the 5th Vol. of the Medico-Chirurgical 
 Transactions.
 
 304 AMAUROSIS. 
 
 ing this precise character, are essentially depend- 
 ing on the injurious influence of the extremes of 
 temperature, and light, and intense colors. I 
 call to mind several cases distinctly referrible to 
 each of the above-named causes. During the 
 correction of this sheet I have been consulted 
 for an amaurosis immediately succeeding to ex- 
 posure, during several hours, to cold and inces- 
 sant rain ; and which 1 have the pleasure to say 
 is advancing towards recovery. I have exem- 
 plified the treatment of these cases in the patho- 
 logy * ; if active measures are taken without 
 delay they generally warrant a favourable prog- 
 nosis, but only on this condition. 
 
 The functional amaurosis varies in its rate of 
 progress as well as in its ultimate extent. Some 
 are sudden in their accession and perfect, as 
 many instances of the metastatic and the proper ; 
 others advance steadily but sensibly to a point 
 little short of blindness, at which they begin 
 to assume an organic character ; and of others 
 again the actual progress is scarcely perceptible 
 for months in succession, fluctuating from day 
 to day between better and worse. I should say 
 that the slow and the steadily progressive amau- 
 rosis are more to be apprehended in the result, 
 that is, are less tractable than either the sudden 
 or the rapidly advancing disease, supposing all 
 to be alike free from the unequivocal signs of 
 organic change. 
 
 * Page ltJ8 et seq.
 
 AMAUROSIS. 30^ 
 
 The removal of an irritating or oppressing 
 cause will often effect a sudden and marked re* 
 lief, as by clearing the intestinal canal of vitiated 
 secretions therein accumulated, by restoring the 
 digestive functions labouring under manifest de- 
 rangement, or by taking away blood where the 
 necessity is indicated. I have seen an incipient 
 amaurosis directly arrested by the extraction of 
 a diseased tooth, when the delay of a similar 
 operation had occasioned gutta serena on the 
 opposite side two years before. 
 
 The floating muscse, when the disease is once 
 established, are seldom if ever removed, yet pa- 
 tients retain good sight who have been troubled 
 with them during half their lives. When the 
 mind becomes indifferent about them, they are 
 no longer observed, except in states of anxiety, 
 irritation, or bodily weakness ; and the subjects 
 of them are usually aware of this fact. 
 
 It appears then upon this representation that 
 certain cases purely functional, whether the af- 
 fection originates in the organ, or in a remote 
 part of the system, are, in their character, so 
 nearly approaching to the organic class, as at 
 once to convey the impression of their irreme- 
 diable nature. In common with these they have 
 many symptoms, hence the difficulty of diag- 
 nosis ; and some of them quickly tend to alter- 
 ed structure, although the external signs of this 
 
 X
 
 306 AMAUROSIS. 
 
 change are faintly indicated. On the other hand, 
 cases are of frequent occurrence, more frequent 
 than has been generally supposed, which admit 
 of material and decided improvement, and even 
 of complete recovery ; and I would repeat, with 
 the exception of those above adverted to, that 
 it is rather the degree than the nature and origin 
 of the functional disease that should influence 
 our prognosis. 
 
 External The treatment of amaurosis is almost exclu- 
 
 remedies 
 
 sively constitutional. To the various forms of 
 external remedies, such as stimulant vapours, 
 drops, and ointments ; spirituous, ethereal, and 
 aromatic embrocations ; sternutatories, &c. &c. 
 my experience leads me to attach no value. 
 The faith yielded to such applications is a relic 
 of the not very remote superstition, which as- 
 cribed miraculous powers to the hand of a living 
 king, or a dead culprit. Ophthalmic surgery has 
 been more degraded by manual officiousness, 
 and the confidence placed in externals has been 
 more injurious to its improvement, than to 
 that of any other branch of the profession. It 
 is fortunately not now necessary to do some- 
 thing when nothing can avail. I am quite aware 
 that the transient effect of stimuli is in many of 
 these cases grateful, and seems partially to re- 
 move the obscurity of vision, but the patient 
 soon discovers that this is but a fillip. When, 
 indeed, a disordered state of the conjunctiva and
 
 AMAUROSIS. ,S07 
 
 eyelids exists in conjunction witli an imperfect 
 amaurosis, a more permanent benefit is often 
 obtained by the rectification of this state, suffi- 
 cient not only to afford encouragement in the 
 use of topical remedies, but to induce a belief 
 that the affection of the retina is, in a degree at 
 least, sympathetic with that of the surface *. 
 I should make a reserve of cupping, issues, or se- 
 tons, in certain cases which it is unnecessary to 
 specify, and of blisters in almost all. These, if Blisters. 
 managed as the case directs, are a remedy of 
 great value. In some, as temporary irritants 
 only ; in others, as irritants and drains. With 
 the former view either the vesicle should be 
 preserved by simply puncturing it, or the cuticle 
 should be removed on dressing the blister, and 
 the simple ointment applied. The process should 
 be frequently repeated, and alternately over the 
 superciliary ridge, upon the temple, upon the 
 mastoid process, or the nape of the neck, as most 
 eligible. Or if a more extended surface of irri- 
 tation is desired in the immediate vicinity of the 
 eye, the blister should take the shape of a che- 
 mist's retort, reaching from the zygoma to the 
 glabella. It should be borne in mind, that the 
 operation of blisters is very different in different 
 individuals, as regards their susceptibility. The 
 irritation and discharge of an efficient blister, as 
 
 * See page 163. 
 X 2
 
 308 AMAUROSIS. 
 
 big as a crown piece, will sink the powers of a de- 
 licate female for days, and this effect will be es- 
 pecially felt in a weak retina. I have often known 
 the obscurity of vision decidedly increased for a 
 time by the application. Such cases are yet 
 more affected by the direct loss of blood, even 
 in the smallest quantity, and the permanent blis- 
 ter would be injurious. How is it that a blister 
 is as useful in a proper nervous or paralytic 
 amaurosis, as in one depending upon the con- 
 gestion of the blood-vessels ? I have been ask- 
 ed this question by intelligent persons. The 
 fact is unquestionable, and the answer obvious, 
 that the simple and temporary irritation is the 
 object in one case, and a permanent irritation 
 and derivation of blood in the other ; and the 
 blister is to be managed accordingly. Hence 
 in a very susceptible subject, or a very irritable 
 skin, a mustard plaster applied for ten minutes, 
 and repeated now and then, may answer the first 
 purpose more conveniently. It is in this parti- 
 cular view that the moxa is used in this and 
 other diseases with so much advantage on the 
 Continent. The eschar, if left to itself and not 
 converted into an issue, is superficial, but the ir- 
 ritation is of the severest kind. 
 
 Electricity. I havc heard and read of the effects of elec- 
 tricity and galvanism in amaurosis. Some nar- 
 rators of their occasional efficacy are undoubt-
 
 AMAUROSIS. 809 
 
 edly entitled to credit. I have had recourse to 
 them in many cases, some of a very favourable 
 description, but have never witnessed a single 
 instance of benefit arising from the application 
 of these powers. 
 
 The degree of constitutional power which en- General 
 ters into the disease forms the first and most 
 important question in the general treatment. 
 Extremes, it is said, meet, and it is certain that 
 a strong and delusive similarity often prevails 
 between the signs of diseases, which result from 
 conditions diametrically opposite. The treat- 
 ment in cases of general plethora and of cerebral 
 compression I need not point out. But I have 
 mentioned cases of undue determination of blood 
 to the organ, which are especially common after 
 deep-seated chronic inflammation, or distress 
 from over-excitement, by which its vessels have 
 lost their tone ; an effect decidedly increased by 
 depletion. Such cases are not difficult of discri- 
 mination from the former, if a due attention is 
 given to the history. 
 
 All the cases of direct debility and proper pa- 
 ralysis of the retina are aggravated by loss of 
 blood, and the great prevailing mistake in the 
 treatment of amaurosis is the indiscriminate de- 
 traction of blood. The same observation, it ap- 
 pears to me, applies to the treatment of cases of 
 general palsy. The practical idea of compres-
 
 310 . AMAUROSIS. 
 
 sion derived from the demonstrated instance of 
 apoplexy, prevails over and puts aside the theo- 
 retic idea derived from the admitted condition 
 of nervous debility or exhaustion. 
 
 I have never known any real benefit derived 
 from what are called antispasmodic and anti- 
 nervous medicines, camphor, assafoetida, vale- 
 rian, &c. Neither do I recollect an instance 
 of decided benefit from the emetic practice, 
 although in respect to high authority, I have 
 tried it fairly in many instances. The cases of 
 gastric disorder to which it is especially appli- 
 cable are most benefited by a long continued 
 course of the blue pill, with gentle saline purga- 
 tives and tonic bitters. 
 
 In most of these cases we must depend, first, 
 on the regulation of the visceral functions j and 
 secondly, on the employment of such restoratives 
 as the system requires and can hear. The blue 
 pill, with colocynth, rhubarb, or aloes, and the 
 combination of soda with rhubarb and calumba 
 or gentian, are best adapted to the former pur- 
 pose. The exhibition of general tonics is often 
 strongly indicated, and I have seen much benefit 
 derived from the mineral acids, bark, steel, when 
 admissible, and arsenic, after a due regulation 
 of the digestive functions. I know of no article 
 - of the class of stimulants that has any direct 
 claim to notice, or any approach to a specific
 
 AMAUROSIS. 311 
 
 virtue, such as has been ascribed to the arnica 
 montana, aconite, &c.* 
 
 When the amaurosis is recent and sudden, Mercury. 
 and either the signs of an obscure inflammation 
 are present, or only the ampHtude and inactivity 
 of the pupil correspond to the patient's history, 
 the indication is less simple ; mercury should be 
 introduced with all convenient rapidity into the 
 system, I mean so as to ruffle it in the least pos- 
 sible degree. No advantage is obtained by sa- 
 livation ; on the contrary, I think it hurtful j 
 when mercury is beneficial, its efficacy is per- 
 ceived as soon as the mouth is sore t. I have 
 seen it tried, and have myself tried it in many 
 cases of perfect amaurosis, without the smallest 
 advantage y but in cases of recent occurrence, 
 imperfect, but rapidly progressive from bad to 
 worse, I have been witness to its power in sud- 
 denly arresting the disease in too many instances, 
 not to entertain a far higher opinion of it than 
 of any other article of the materia medica. I 
 shall not again discuss the knotty question of 
 its modus operandi j " causa latet : vis est notis- 
 sima." The form of its administration must be 
 regulated by the circumstances of the case. 
 
 * Some oculists still adhere to the practice of the arch- 
 angel, and 
 
 — " purge with euphrasi/ and rue 
 The visual nerve." 
 t See note L.
 
 312 AMAUROSIS. 
 
 Dietetic. Superadded to the entire repose of the organ, 
 
 the natural tonics, viz. a pure, dry atmosphere, 
 the cold bath, horse exercise, nutritious diet, 
 early and sufficient rest, agreeable society, and 
 a mind as much as possible diverted from the 
 object upon which it is unfortunately and per- 
 tinaciously prone to dwell — these are of greater 
 avail than drugs ; and some lighter forms of 
 sympathetic amaurosis are as effectually cured 
 by them as by the blue pill and rhubarb, and 
 upon the self-same principle.
 
 SECTION IV. 
 
 DISEASES AFFECTING THE EYE-BALL. 
 
 The treatment of those injuries to which the Suppura- 
 organ is subject from external violence, is com- bail. 
 prehended in the directions given for the treat- 
 ment of inflammation and its consequences. 
 In the suppuration of the ball, when the pa- 
 tient's suffering is acute and the constitutional 
 irritation severe, and the part notwithstanding 
 its great tension affords no immediate prospect 
 of relief by a natural opening, the cornea, iris, 
 ciliary ring, and some extent of the sclerotica 
 should be so divided by a deep transverse inci- 
 sion, as to evacuate the globe of its contents. In 
 this manner about a tea-spoonful of pus, more 
 or less, is discharged. The section of the cornea 
 alone, effects this object so imperfectly as to af- 
 ford little if any relief. The eye should after- 
 wards be lightly covered with a soft poultice 
 confined in a cambric bag. 
 
 The extirpation of the eye, when that ope- Extirpation 
 ration is determined upon, is most conveniently 
 performed with a straight double-edged knife,
 
 314 
 
 DISEASES AFFECTING THE EYEBALL. 
 
 which is to be employed for the purpose of 
 freely dividing the septum of the conjunctiva 
 and oblique muscles, so as to separate the globe 
 and lacrymal gland from the palpebr^e and base 
 of the orbit. When this is done, the globe admits 
 of being drawn gently forward by a ligature 
 previously passed through its anterior segment. 
 A double-edged knife, curved breadth-wise, 
 should then be introduced at the temporal com- 
 missure of the lids, for the purpose of dividing 
 the muscles, vessels, and nerves, by which the 
 globe remains attached, with greater conve- 
 nience and despatch. The hemorrhage is re- 
 pressed by means of a small portion of fine 
 sponge introduced into the orbit, and a light 
 compress of linen should then be laid upon the 
 lid supported by a roller. The sponge should 
 not be suffered to remain longer than the follow- 
 ing day, when a soft poultice in a muslin bag 
 may be substituted for the compress. An opiate 
 should be given at bed-time. 
 
 The practice of cramming the orbit with lint 
 or charpie, and leaving it to be discharged by 
 suppuration, is objectionable. I knew one case 
 in which this measure was followed by a most ex- 
 tensive suppuration within the cavity, and by 
 abscesses in the neighbouring integument of the 
 lids and forehead ; and another has been com- 
 municated to me, in which its ill effects were 
 evident.
 
 DISEASES AFFECTING THE EYEBALL. 315 
 
 I once lost a patient, a middle-aged country- 
 man, otherwise in health, within a fortnight 
 after this operation, owing to a suppuration of 
 the dura mater, on the same side of the head. 
 The attack of inflammation was sudden and 
 rapid, commencing about a week after the ope- 
 ration, and ushered in by a severe rigor after 
 exposure to cold, in the square of the Hospital ; 
 an imprudence quite unauthorized. There was 
 no continuity of inflamed surface to account 
 for this, although the morbid appearances were 
 confined to the membranes of the corresponding 
 hemisphere. I have performed the operation 
 many times without any serious after-symp- 
 tom. 
 
 The propriety of this measure, from its seve- Glandular 
 rity and the uncertainty of its preserving life, mentrand 
 should be always matter of very deliberate 
 consultation. I will only observe, that if but 
 one eye is affected with the disease, and the 
 patient free from any material disorder of health, 
 we should be slow to reject the operation on 
 account of glandular enlargements in the vici- 
 nity of the orbit, or of tubercles of a suspicious 
 character in other parts of the body. Such af- 
 fections, supposed to be of the same morbid 
 character, have disappeared in more than one 
 case of malignant fungus, after the removal of 
 the diseased part. 
 
 tubercles.
 
 SI 6 DISEASES AFFECTING THE EYE-BALL. 
 
 A gentleman, whose case, a fungoid tumor 
 involving the knee-joint, was considered des- 
 perate, and was absolutely abandoned as hope- 
 less by the ablest surgeons in this town, on 
 account of many tubercular swellings on other 
 parts of his body, in addition to extreme weak- 
 ness and emaciation, put himself under the care 
 of an older practitioner, who considered the ob- 
 jections theoretical ; the limb was amputated 
 by this gentleman, and the patient recovered ; 
 all the tumors subsiding as he regained his 
 health. 
 
 The recent enlargement without induration 
 of one or more lymphatic glands in the track of 
 absorption, in cases of scirrhus of the mamma, 
 or the testis, or the lower lip, has not unfre- 
 quently proved to be the result of simple irrita- 
 tion, by speedily subsiding after the healing of 
 the wound. I have known cases in which swell- 
 ings of a more suspicious nature remained sta- 
 tionary after the extirpation of a malignant fun- 
 gus, and the patient has sunk under visceral 
 disease of a character totally dissimilar. It is 
 right however to state, that the period of sur- 
 vival has been short in these cases. An exten- 
 sive abdominal abscess proved destructive to a 
 man whose leg had been amputated three months 
 before for a genuine fungus haematodes ; an- 
 other died suddenly of apoplexy, several months
 
 DISEASES AFFECTING THE EYEBALL. 317 
 
 after the removal of a fungoid testicle of great 
 size. In both these cases the glandular swellings 
 of the inguen and iliac region of the same side 
 had subsided in the interval. 
 
 Admitting therefore the malignant character 
 of a disease, if the symptoms do not indicate the 
 affection of vital organs, it is possible that the re- 
 moval of the principal source of irritation may 
 admit of a change in favour of the constitution, 
 and put a stop to its progress. We know not 
 how far the multiplied production of tubercles 
 may be a result of sympathetic irritation, and 
 when doubts of this description arise, cases like 
 that above mentioned should be borne in mind, 
 that the patient's chance of recovery may not 
 be forfeited by indecision.
 
 TREATMENT 
 
 DISEASES OF THE EYE. 
 
 CHAPTER III. 
 
 SECTION I. 
 
 ON THE OPERATIONS FOR THE 
 CATARACT. 
 
 Before speaking of the operations, I shall offer 
 a few preliminary considerations. 
 
 The extent and importance of the subjects of 
 this and the following chapter, the deep profes- 
 sional interest wliich they have of late years ex- 
 cited, and the copiousness of the historical de- 
 tails connected with them, render it impossible 
 for me to go minutely into them, consistently 
 with the plan of the present work. Such an un- 
 dertaking, if it were not superfluous, would of 
 itself furnish materials for a volume of ordinary 
 size ; but so much has been ably written upon
 
 OPERATIONS FOR THE CATARACT. 319 
 
 the subject, that the inquiring student can be at 
 no loss for all requisite elementary information. 
 This premised, I shall take the liberty of confin- 
 ing myself to those general results of my per- 
 sonal observation, which appear to me worthy 
 of communication. 
 
 It has been a custom with oculists where a Cataract in 
 
 one eye, 
 
 person has a full formed cataract in one eye, 
 and retains the vision of the other, to advise 
 the postponement of the operation until that 
 also is dark — this advice I think erroneous. I 
 am satisfied that the cataractous eye, if it be- 
 come the subject of an accidental inflammation, 
 is strongly disposed to go into amaurosis ; and 
 further, that the retina loses its vigor by the per- 
 manent exclusion of light. I speak from re- 
 peated observation of the fact. The objection 
 to the operation on the ground of inconvenience 
 arising from the difference of focus of the two 
 eyes, when one only is the subject of the disease, 
 is trivial, and a consideration altogether subor- 
 dinate ; such a defect may always be remedied 
 by glasses properly adjusted. In several cases 
 of amaurosis ensuing upon cataract, I have been 
 disposed to regard the change in consistence and 
 volume of the lens, as productive of a destroy- 
 ing inflammation, in others of a partial absorp- 
 tion of the vitreous humor. 
 
 The cataractous eye is not unfrequently amau- 
 
 with amau- 
 rosis :
 
 320 OPERATIONS FOR THE CATARACT. 
 
 rotic ; nor is it always possible to determine the 
 presence of amaurosis, when the opaque lens 
 is so dense as to account for complete dark- 
 ness. 
 
 It often happens that a patient has a full 
 formed cataract in one eye which presents the 
 signs of amaurosis, and an incipient cataract, or 
 one as much advanced in the other which is at 
 present free from these symptoms. In this case 
 the cataract of the latter should be removed 
 . without delay. 
 
 with ab- 
 sorbed lens. 
 
 In cases of congenital or infantile cataract, 
 which become the subjects of operation at an 
 adult age, the lens is found to have undergone 
 absorption, and the capsule alone remains. This 
 absorption does not take place, except in cases 
 of injury, in the cataract formed during adult 
 life. When the lens has early undergone a na- 
 tural absorption, and the cataract is simply cap- 
 sular, the organ is always imperfect ; the opera- 
 tion therefore seldom increases the distinctness 
 although it may enlarge the field of sight. The 
 fluid cataract of the adult is always joined to a 
 weak, often an insensible retina. 
 
 Degree of Jt would bc iucorrcct to say that the opera- 
 tion was unadvisable in all cases of cataract in 
 which the patient has no sense of light, for it is 
 possible that the density of the lens may be 
 
 vision.
 
 OPERATIONS FOR THE CATARACT. 3Sl 
 
 such as absolutely to exclude the light, and that 
 the motions of the iris may be therefore sus- 
 pended, or from some degree of pressure of the 
 lens, or adhesion of the uvea to the capsule, 
 that the pupil may be undilated, and the cir- 
 cumference of the lens permanently covered. 
 But undoubtedly a case of this description is 
 unpromising. A strong sense of light by which 
 at least to know the direction in which it enters 
 the apartment — to be sensible of its falling on 
 the eye, and of a shade, as the hand, for ex- 
 ample, intercepting it, with a corresponding 
 freedom of motion in the pupil, is the most 
 favourable state for the operation. There is in 
 this case perception enough to determine the 
 sensibility of the retina, and not enough to oc- 
 casion the unsteadiness of the globe. If a pa- 
 tient has vision, the eye is irritable to light, and 
 involuntarily rolls as far as possible towards the 
 nose on the introduction of the instrument, one 
 of the greatest perplexities in the operation. 
 Another reason why an operator may naturally 
 prefer an eye in which vision is interrupted, is ' 
 this : patients are practical and not speculative 
 philosophers, and estimate operations by the 
 amount of the good conferred, not by the mag- 
 nitude of the evil averted. A blind person re- 
 stored to sight, is thus gratified in a much 
 greater degree than one whose partially ob- 
 scured vision is rendered clear. These how- 
 ever are not reasons for deferring the operation 
 
 Y
 
 322 OPERATIONS FOR THE CATARACT. 
 
 beyond the period at whicli useful vision ceases, 
 nor do I think any reason can be given for de- 
 lay, tantamount to the risk of injury from in- 
 cidental inflammation, or impotence from a con- 
 tinued suspension of the function of the organ. 
 
 Local cir- Thcrc are several circumstances in the struc- 
 ture and condition of the organ which have an 
 important influence on the facility and success 
 of operations *. These are, shortly, the degree 
 of projection of the orbit, or the relative volume 
 of the eyeball and its socket ; the absolute size, 
 prominence, and tension of the ball ; the dimen- 
 sions of the anterior chamber ; the clear and 
 healthy, or thickened and partially opaque state 
 of the cornea ; the absence or presence and en- 
 croachment of the arcus senilis ; the propor- 
 tional diameter of the cornea to the globe, and 
 its actual diameter ; the healthy state and pro- 
 portion of the aqueous and vitreous humors ; the 
 free and active, or adhering and constricted 
 state of the pupil. A small cornea, a narrow 
 or partially obliterated chamber, and a contract- 
 ed pupil, are circumstances decidedly unfavor- 
 able to any and all operations. 
 
 Couching. The operations have been so repeatedly and 
 
 * To these might be added circumstances of temperament, 
 viz. a calm and steady, or an irritable and very moveable 
 *ye.
 
 OPERATIONS FOR THE CATARACT. SS3 
 
 minutely described, that I shall not fatigue my 
 reader with a prolix detail of them. Tliey are 
 three in number. Couching or depression, ex- 
 traction, and absorption. The first and most 
 antient is now seldom performed in this country. 
 The cases to which it is alone applicable are 
 those cataracts of iirm consistence, the circum- 
 stances of which offer a serious impediment to 
 the much more eligible method of extraction. 
 These circumstances may be inferred from the 
 enumeration above given. The needle em- 
 ployed by Scarpa is best adapted to the pur- 
 pose. The couching-needle may be passed 
 through the sclerotica at a line's breadth from 
 the cornea, and a little below the horizontal 
 diameter, so as to avoid the long ciliary artery ; 
 or through the inferior part of the cornea and 
 pupil ; and the lens may be depressed vertically 
 or horizontally. The term * reclination ' has 
 been applied to the latter method. In both cases 
 the lens must be hitched into a breach of the 
 vitreous humor below the border of the pupil. 
 Its anterior capsule, and the capsule of the 
 vitreous humor, must be divided or torn through, 
 to render the operation effective. The lens cor- 
 responds in diameter to the iris, and there is 
 therefore no natural space into which it can be 
 depressed. The posterior capsule, identical 
 with that of the vitreous humor, must be la- 
 cerated, to admit of its dislocation backwards 
 and downwards ; and if its anterior capsule was 
 
 Y 2
 
 324> OPERATIONS FOR THE CATARACT. 
 
 left entire, it would become a secondary capsular 
 cataract, and require a subsequent operation. 
 
 Kerato- The opcratiou of couching through the cornea 
 
 has of late years been warmly advocated, as be- 
 ing unattended by the injurious consequences 
 ascribed to the perforation of the sclerotica and 
 choroid. It is reasonable to prefer that opera- 
 tion which inflicts tlie smallest injury, and to 
 conclude that it is least liable to be followed 
 by severe inflammation. But the subtilties of 
 theory have little weight in the scale against ex- 
 perience, and no one who has seen much of these 
 operations considers the puncture of the tunics 
 to form a material objection, if it is executed 
 with a proper instrument, and agreeably to the 
 directions which are furnished by a knowledge 
 of the organ. I have so often seen the eye per- 
 fect in its aspect and function, after several such 
 penetrations of the larger tunics, and the in- 
 flammation immediately resulting from each 
 operation so slight and transitory, as to be con- 
 vinced that the objection is either hypothetical, 
 or is drawn from unskilful and rash procedures. 
 
 The real objection to couching is the ultimate 
 step of the operation, viz. the breaking up of the 
 fine texture that fills the globe by the forcible 
 depression of the lens. Whether it be de- 
 pressed edge-ways or breadth- ways, makes no 
 difference in the result ; it must still occupy a
 
 OPERATIONS FOR THE CATARACT. 325 
 
 breach in the cells of the vitreous humor, and 
 must derange and disorder that delicate texture 
 and those connected with it. A slow insidious 
 inflammation marked by a gradual develope- 
 ment of the symptoms of disorganization, viz, 
 congestion of vessels, turbid humors, flaccid 
 tunics, and palsied iris, is too often the conse- 
 quence. The sight, instead of improving when 
 the immediate effects of the injury are passed 
 away, remains habitually weak and dim, or de- 
 clines and fades altogether. The advocates for 
 reclination seem to forget that the principle, 
 which is the same in both operations, is the 
 real ground of objection. As to the position 
 of the lens, I suspect less mischief is done by the 
 old method of depression, as less force is re- 
 quired to break a space for the vertical than the 
 horizontal lens, provided the depression be car- 
 ried to no greater extent than is necessary to 
 clear the inferior border of the pupil. After 
 all, the argument is mere trifling about the po- 
 sition of the lens, absolute or relative ; it can 
 occupy no place but that made for it without 
 serious injury to the organ. It is not fair to 
 bring against any operation objections that 
 apply only to the unskilful performance of it; 
 and this, it is easy to see, is the secret of the 
 frightful catalogue of disasters which the spirit 
 of controversy promulgates, and which those who 
 practise these operations declare to be totally 
 unauthorized in their experience. For example,
 
 326 OPERATIONS FOR THE CATARACT. 
 
 what has the wound of the retina, of the ciliary 
 body and processes, of the iris, &c. to do with the 
 operation of couching properly performed ? Yet 
 all these are marshalled in formidable array as 
 objections, for the obvious purpose of demon- 
 strating the superior advantages of couching 
 through the cornea. 
 
 Absorption. If the opcratiou just described is attempted 
 upon a flocculent cataract, the lens, instead of 
 descending solidly, breaks into pieces, which un- 
 dergo a gradual absorption. This is the ope- 
 ration by absorption ; the perfection of which 
 however consists in making the free central 
 aperture by laceration of the anterior capsule, 
 the preliminary step. The needle is introduced 
 either through the cornea or the sclerotica. In 
 most instances the anterior operation is to be 
 preferred, as I have elsewhere stated. The more 
 minutely the lens is broken up and divided in 
 its texture, and the more its fragments are dis- 
 sipated in the anterior chamber, the quicker the 
 progress of absorption ; and the softer the tex- 
 ture of the lens, the more readily and safely is 
 this object accomplished. If the substance of 
 the lens is dense and compact, this division is 
 not accomplished without considerable force, 
 and the inflammation which follows is hazard- 
 ous ; if the fragments are bulky, and press upon 
 the iris, such a result is still more to be appre- 
 hended. If therefore this operation is resorted
 
 OPERATIONS FOR THE CATARACT. 327 
 
 to in a case o^firm cataract, it must of necessity 
 be several times repeated if we would preserve 
 the organ uninjured, and this forms an insupe- 
 rable objection to it in all such cases*. I would 
 add, that even the utmost caution is inadequate 
 to prevent an internal inflammation from the 
 bulging of the lens after its capsule is freely 
 rent, or its separation, during the absorbing pro- 
 cess, into fragments of such a size as to oppress 
 the iris. On this account an amaurosis is not 
 unfrequently the result of this operation, al- 
 though the slower and milder method is deci- 
 dedly attended with the least risk. These ob- 
 jections are not applicable to the soft caseous 
 and flocculent cataract, but even in this case the 
 cure is often lingering, and subject to be inter- 
 rupted by inflammation. It is especially to the 
 cataract of infancy that the operation of absorp- 
 tion is applicable. Here indeed there is no al- 
 ternative, it is fluid, or flocculent; often so far 
 absorbed, that only a thin scale or flake of lenti- 
 cular substance remains betwixt the capsules, so 
 that its consistence does not allow of depression, 
 and the eye is too unsteady to admit of extrac- 
 
 * I pass over the description of an operation which consists 
 
 )m the introduction of a knife, whether through the cornea or 
 sclerotica, for the purpose of cutting up the hard crystalline in 
 situ, and throwing the slices into the anterior chamber ; and I 
 mention it only by way of caution, if caution be necessary 
 tgainst a measure so desperate and ill-advised. It levels with 
 the proposal to extract through the sclerotica.
 
 328 OPERATIONS FOR THE CATARACT. 
 
 tion with safety, if this operation were otherwise 
 as ehgible, which in fact it is not. It is impos- 
 sible to conceive a more simple, sufficient, or 
 gratifying operation than that of Mr. Saunders, 
 if the intention is perfectly executed. I have 
 now enjoyed extensive opportunities of ascer- 
 taining its value ; having operated, during a pe- 
 riod of ten years, upon children of all ages, from 
 four months upwards, and I do not hesitate to 
 affirm that it ranks, in my estimation, as one of 
 the finest discoveries of modern science. 
 
 Cataract Thc primary cataract adhering to the iris is 
 
 sion to the for thc mos^ part capsular ; but whether it be so 
 
 irjs. 
 
 or not, the needle is best adapted to it. Its 
 toughness and the firmness of its attachment, 
 and the difficulty of couching it, when detached, 
 are circumstances which often render the ope- 
 ration imperfect. The aperture by laceration of 
 the capsule in the centre, and its extension as 
 much as possible by the varied movements of 
 the needle, should be the object of the surgeon, 
 rather tlian the detachment of the membrane 
 entire. In tliis, and in all cases in which the 
 needle is used, the employment of the extract 
 of belladonna, softened by the addition of a 
 little water, is a point of the first importance, 
 both prior and subsequent to the operation. 
 The skin above and below the eyebrow should 
 be thickly painted with the solution once or 
 pftener in the twenty-four hours, and this var-
 
 OPERATIONS FOR THE CATARACT. 3Q9 
 
 nish should be preserved moist for a period of 
 half an hour, in order to admit of its absorption. 
 The frequency of the application must be deter- 
 mined by its effect upon the pupil. The preter- 
 natural dilatation should not be incessantly main- 
 tained ; for if it be, the pupil will, in all probabi- 
 lity, be misshapen when the application is sus- 
 pended, and the iris recovers its power. 
 
 The operation of extraction is by far the most Extraction. 
 perfect ever devised for the cure of cataract ; 
 but it is one of considerable difficulty, and the 
 several modifications which have been at various 
 times suggested, owe their origin to the disap- 
 pointments and defeats which operators meet 
 with in learning to execute it with success. The 
 preference entertained for couching rests on no 
 better ground than its greater facility, and there- 
 fore less risk. No operation in surgery, I am 
 well satisfied, requires an equal degree of temper 
 and experience for its accurate and successful 
 performance. 
 
 The Baron de Wenzel is reported to have said 
 that he had * spoiled a hat-full of eyes' before 
 he had learned to extract. This was doubtless 
 a figure of speech, but it serves to shew the ap- 
 preciation of its difficulty by a great master of 
 the art. Excellent directions for the operation 
 have been given by Wenzel in his treatise, 
 translated by the late Mr. Ware j and the essay
 
 330 OPERATIONS FOR THE CATARACT. 
 
 of the latter gentleman, who was in no respect 
 inferior to the Baron as an operator, upon the 
 impediments to the success of the operation, is 
 a work of much merit, and should be diligent- 
 ly studied by all who undertake it. It is object- 
 ed to this operation , that it is one of which 
 the result is a matter of hazard. I reply, not 
 more so, in the hands of qualified persons, than 
 hernia, lithotomy, aneurism, and other import- 
 ant operations. Secondly, if it fails, it fails 
 beyond recovery. This I contend is rarely the 
 case in the hands of competent persons. That 
 it sometimes is the case I do not deny, nor 
 would I believe that man on his oath who ven- 
 tured for himself to deny it ; but I may be al- 
 lowed to ask, is not this exception to the gene- 
 ral issue of the operation, a condition of every 
 human work ? What operation, I should be glad 
 to learn, is not impugnable by such an argu- 
 ment? Thirdly, it is followed by a higher degree 
 of inflammation, and one of a less manageable 
 kind. This again, as the former and all the ob- 
 jections in detail, admit of this general answer. 
 They apply to the performance, not to the prin- 
 ciple of the operation. Thus, if the corneal 
 section be clean, and situated midway between 
 the pupillar edge and the margin of the cornea, 
 or a little nearer to the latter, if it be of such 
 extent as to allow of the perfectly easy escape 
 of the lens, if the sclerotic conjunctiva, scle- 
 rotica, and especially the iris be untouched, and
 
 OPERATIONS FOR THE CATARACT. ^51 
 
 the capsule freely lacerated, without laesioii of 
 the vitreous capsule, then the operation is per- 
 fect. But although all these points should be 
 imperfectly, that is, not strictly fulfilled, yet the 
 result of the operation is ordinarily successful 
 with a due attention on the part of the surgeon. 
 There is not one of them that I have not re- 
 peatedly seen reversed, and yet the patient has 
 recovered excellent vision. So that the failure 
 of the operation is by no means a necessary 
 consequence of the casualties that may attend it, 
 even although they should be such as to excite 
 a considerable degree of alarm in the mind of 
 the operator. The deviation of the section from 
 the course intended, the wound, or removal, or 
 prolapsus of a portion of the iris, the escape of 
 a part of the vitreous humor, these, I grant, are 
 derogations from the perfection of the operation. 
 But if the lens be extracted with tolerable faci- 
 lity, such accidents are seldom, with the aid of 
 care and time, permanently injurious to vision. 
 Nevertheless, they are such departures from the 
 fair procedure of the operation, as ought in com- 
 mon candor to clear it of all imputation from an 
 imperfect result. 
 
 section. 
 
 The main impediment to the success of this inadequate 
 very valuable operation is, as I have elsewhere 
 stated, a section of insufficient magnitude. The 
 easy extraction of a cataract, like the easy ex- 
 traction of a stone, almost invariably does well,
 
 332 OPERATIONS FOR THE CATARACT. 
 
 and the difficult and forcible removal of either as 
 certainly augurs unfavorably. The enlargement 
 of the section, if too short, is difficult, and always 
 dangerous to the iris in the collapsed state of 
 the cornea; it is attended moreover with im- 
 , minent risk of a laceration from the want of 
 due support of the vitreous capsule, the loss of 
 a portion of this humor, and the consequent 
 sinking of the lens behind the iris. Thus one 
 difficulty leads on another. 
 
 Again, the protrusion of the iris before the 
 lens in its exit, which only happens from a too 
 narrow section, is almost always followed by the 
 falling of that membrane into the wound, a 
 protracted healing of the wound, and a loss of 
 figure of the cornea. 
 
 Escape of The free escape of the vitreous humor, owing 
 mor." ' to an imperfect section, undue pressure, &c. 
 occasions the sinking of the lens in the globe. 
 Such a circumstance may embarrass an operat- 
 or, and induce him to leave the cataract, in the 
 hope of its absorption, or of removing it at a 
 future time, rather than hazard the further loss 
 of vitreous humor. This should never be done. 
 For as soon as the wound closes, the cataract is 
 raised by the renewal of the aqueous humor 
 / and pressed forward upon the iris. I have seen 
 
 an inflammation supervene in such a case which 
 speedily went on to suppuration, and destroyed
 
 OPERATIONS FOR THE CATARACT. 333 
 
 the eye. If, upon making the section, an inor- 
 dinate quantity of aqueous humor escape, and 
 the lens sinks from this cause, the case is dif- 
 ferent ; here the vitreous humor is ah'eady par- 
 tially absorbed, and the lens is supported by the 
 aqueous. The same ill consequences will not 
 follow in this case, if the surgeon prefers to re- 
 linquish the operation. The cornea heals kindly, 
 and he may afterwards operate with the needle. 
 However, in most instances, the lens may be 
 supported by gentle pressure on the inferior part 
 of the globe, and extracted or rather turned out 
 with the hook or spoon end of the curette ; and 
 I should always pursue this method under such 
 circumstances, as long as the globe retained its 
 figure. 
 
 It is a point of considerable importance that Section 
 
 t" . ■, verging on 
 
 the section should be purely corneal. I mean the sciem- 
 that it should not be carried so low as to verge 
 upon the sclerotica, and thus to leave the cor- 
 neal margin of an insufficient breadth for 
 union *. Two ill consequences arise from this : 
 
 * I have stated elsewhere an additional reason for making 
 the section not too distant from the pupil, viz. the easier es- 
 cape of the lens. See " Observations on the Cataract." Med. 
 Chir. Trans. Vol. V. I prefer it midway between the pupil 
 and margin of the cornea. If it be higher than this, the lower 
 margin of the pupil insinuates itself into the section, and the 
 cicatrix not only disfigures the cornea in the greatest 
 degree, but encroaches very disadvantageously upon the 
 pupil.
 
 S8i OPERATIONS FOR THE CATARACT. 
 
 iirst, the iris, unsupported at its base, commonly 
 falls into and prolapses at the wound, even 
 though the section be ample in extent, and the 
 escape of the lens perfectly easy; and secondly, 
 from the defect or narrowness of the corneal 
 margin and the non-opposition of homogeneous 
 parts, the healing is always remarkably slow, 
 even though no prolapsus should take place. An 
 oozing of humor is continually occurring, and 
 I have sometimes seen a portion of the capsule, 
 now turned opaque, protrude, and subsequently 
 slough out at the section. When a prolapsus, of 
 whatever kind, prevents the healing of the wound, 
 it should be completely snipped off with a pair 
 of iris scissars, and the surface and edges of the 
 wound touched with the caustic pencil. This 
 practice I have repeatedly adopted with the best 
 effect, in prolapsus from wound as well as from 
 ulcer. 
 
 Extraction Soft and scmi-trausparcnt and unadhering* 
 catampi. capsular cataracts may all be conveniently ex- 
 tracted. They pass through a smaller section. 
 The capsule is easily laid hold of with a hook or 
 forceps. The semi-transparent, by which I mean 
 the cataract with an opaque nucleus and trans- 
 parent circumference and capsule, forms in most 
 cases a secondary cataract ; that is, a portion of 
 the transparent lamellae and capsule become 
 opaque, and occupy the pupil or a part of it. It 
 is rent and detached with the greatest ease by a
 
 OPERATIONS FOR THE CATARACT. 335 
 
 touch of the needle passed through the cornea 
 after the heahng of the section. 
 
 The construction of instruments employed in instm- 
 
 , . , merits. 
 
 operations is a point which every man must 
 decide for himself. The knife of the eminent 
 Professor Beer of Vienna is that which I am in 
 the habit of using, thinking it on the whole 
 better adapted than either Ricliter*s or WenzePs, 
 to make a safe and expeditious section. 
 
 The more or less inflammation which follows Preparative 
 the operation is of course depending in great ^"eatment. 
 measure upon the habit of body. The patient 
 should be well purged, and live abstemiously 
 for a short time previous to it. If disposed to 
 fullness in the vessels of the head, cupping may 
 be premised the day before the operation. It is 
 a matter of some importance to examine the 
 section, and adjust it accurately before finally 
 closing the eye. I think it useful to let the 
 patient rest for a few minutes with his eye 
 closed, and then to direct him to open it two 
 or three times successively ; a slight friction of 
 the lids assists the pupil to recover its figure, 
 and dissipates any small floating particles of 
 lens. The sitting posture in an easy chair is 
 most favourable after the operation, until the 
 patient feels fatigued and desires to go to bed. 
 Confinement to bed produces great restlessness, 
 and is of no advantage to persons not constitu-
 
 336 OPERATIONS FOR THE CATARACT. 
 
 tionally ill. If the patient complains of pain 
 on the evening of the day of operation, a full 
 blood-letting removes it, and should not be 
 omitted*. I never give opiates. A light band- 
 age passed round the night-cap and fastened to 
 it is a suflScient covering for the eyes. Com- 
 presses on the eyelids are generally better omit- 
 ted ; the bandage may in most cases be laid 
 aside on the second or third day, and a deep 
 black shade substituted for it. During the 
 night, however, the bandage should be applied 
 for the first week to prevent the accident of rub- 
 bing the eyes in sleep. 
 
 I know of no peculiarities requiring a distinct 
 notice in the treatment of inflammation after ex- 
 traction. Topical blood-letting and blisters are 
 sometimes necessary, and a strict antiphlogistic 
 regimen should always be enforced. There is 
 often an irritability to light, and aversion to 
 open the eye, which is removed by two or three 
 brisk doses of calomel. When the section pro- 
 trudes only in a small degree, it soon levels 
 down so as to restore the figure of the mem- 
 brane. When the protrusion is more consider- 
 able, the patient is afterwards subject to repeated 
 irritable ophthalmia, and a troublesome exulce- 
 ration of tlie cicatrix sometimes occurs. I have 
 
 * It is the custom of M. Roux, of Paris, a dexterous and 
 successful operator, to apply a blister to tlie nape of the neck 
 after the operation.
 
 OPERATIONS FOR THE CATARACT. 3HJ 
 
 hi one case seen small transparent vesicles form 
 on the line of the cicatrix at intervals, which 
 occasioned much intolerance and distress to the 
 patient for a long time subsequent to the healing 
 of the section. 
 
 The inflammation of the iris, the interstitial Unfavor- 
 ulceration and opacity of the cornea, the sepa- of the ope- 
 ration of the edges of the section by the inter- 
 vention of another texture, the redundant depo- 
 sit of lymph in the section,- or the ulceration of 
 its edges, are the mischiefs which occur after un- 
 favorable extractions. Blood shed by a wound 
 of the iris in the anterior chamber is quickly 
 absorbed. Where it has even filled the entire 
 chamber, I have found the aqueous humor clear 
 on the succeeding day. 
 
 The coalition of the iris and cornea adjoining 
 the section, occasioning a disfigured pupil, is the 
 result of a prolapsus or a laesion of the iris. Al- 
 though the process of healing is painfully re- 
 tarded, and the corneal cicatrix is ever after 
 conspicuous from its breadth and prominence, 
 excellent vision is often obtained under these 
 circumstances. The iritis may, however, be vehe- 
 ment, and proceed to amaurosis, or it may termi- 
 nate favorably in constricted pupil. This state is 
 seldom uncombined with a secondary cataract, 
 i. e. a portion of continuous capsule, which hav- 
 ing become opaque, knits up the pupil by adhe-
 
 338 OPERATIONS FOR THE CATARACT. 
 
 sion to its margin. The dimness of the cornea, 
 if any, is shghtand transient, except an intersti- 
 tial herpetic ulcerative action, connected with 
 a bad condition of the edges of the section, be 
 present, when the cornea takes on an opacity 
 of a very intractable kind. The sclerotica is in 
 this case inflamed, and very minute depressions 
 appear on the surface of the cornea, which un- 
 dergoes a total loss of brilliancy, although it 
 remains obscurely transparent. The restoration 
 of smoothness to the surface does not diminish 
 the lack-lustre appearance of the membrane. 
 The patient has a perception of light, but no 
 vision of objects. In fact, the cornea precisely 
 resembles that of the dead subject. Mercury 
 is of uncertain efficacy in this case, which for- 
 tunately is very rare. Time and tonics do most 
 for it. 
 
 I have now adverted to the principal miscar- 
 riages of the operation, both during and conse- 
 quent upon its performance, which I have met 
 with, or witnessed in the practice of others. 
 When the operation is perfect, its pre-eminence 
 is too conspicuous to require illustration. It 
 exacts the homage of admiration beyond any 
 effort of the art. 
 
 The adjustment of the light, its exclusion from 
 the other eye by the compress and bandage,
 
 OPERATrONS FOR THE CATARACT. 339 
 
 tlie regulation of the seats of the patient and 
 the surgeon, the light and firm support of the 
 upper lid, the calm and easy penetration, and 
 the quick and steady passage of the knife across 
 the chamber, and without a pause, through the 
 opposite border of the membrane, so as to an- 
 ticipate the escape of the humor, and preserve 
 the iris in situ ; the deliberate completion of the 
 section, all pressure being removed, either by 
 the progress of the knife, or by a clean back 
 stroke, or by the aid of the finger-nail dividing 
 the cornea upon its edge, as may be most expe- 
 dient, are, in brief, the material points of the 
 operation. I will only add the capsule should 
 be freely lacerated in the centre, not incised 
 concentrically to the lower border of the pupil. 
 
 It would scarcely be credited by a by-stander 
 who saw the operation happily executed upon 
 a steady and well-formed eye, that it presented 
 any difficulty ; a conclusion applied to every 
 thing well done, whether warranted or not. 
 But the incidental embarrassments are too fre- 
 quent and numerous to admit of being always 
 anticipated, and the only security against them 
 is the constant habit of practising the operation, 
 and the confidence thence acquired, tempered 
 with a due sense of responsibility. 
 
 Habit will make any man ambi-dexter j and the 
 rest for the elbow, so much insisted upon, having 
 
 z 2
 
 340 OPERATIONS FOR THE CATARACT. 
 
 been once laid aside, would prove a hindrance ra- 
 ther than a help to the operator. After thorough- 
 ly understanding the minutiaa of the operation, 
 habit will also render it unnecessary for him to 
 rehearse the several steps and stages of the per- 
 formance before advancing to it. The memory 
 of a successful operator is altogether technical, 
 and his mementos are carried, to use a homely 
 figure, " sur le bout du doigt."
 
 SECTION II. 
 
 OF THE OPERATIONS FOR ARTIFICIAL 
 PUPIL. 
 
 From morbid alterations of the cornea, or iris, 
 or both, result those several states of the organ 
 which suggest the formation of an artificial pupil. 
 The disease may be simple, that is, affecting ex- 
 clusively the cornea or the iris, or it may be 
 complicated, and involve both textures. 
 
 Simple states : 
 
 1. An indelible central opacity of the cornea, 
 more or less eclipsing the healthy pupil. 
 
 2. A closed or obliterated pupil ; the crystal- 
 line capsule opaque, and adhering to the iris ; 
 and probably the lens also opaque, unless the 
 disease is consequent upon the operation of 
 couching or extraction. 
 
 The first supposes a healthy state of the iris 
 and anterior chamber, the second a transparent 
 cornea.
 
 342 OF THE OPERATIONS 
 
 Complicated states : 
 
 1. A closed pupil, with or without concealed 
 cataract, combined with a partially opaque 
 cornea. 
 
 2.. A central opacity of the cornea combined 
 with a constricted pupil and cataract. 
 
 3. In addition to the closed pupil, a partial 
 adhesion of the iris to the opposite surface of 
 the opaque cornea. 
 
 4. A permanent prolapse of the iris through 
 an ancient breach or section of the cornea, in- 
 volving more or less of the pupillary margin. 
 
 In both the latter cases, the anterior chamber 
 is reduced in dimensions in proportion to the ex- 
 tent of the adhesion or prolapse. 
 
 These are the chief circumstances — it would 
 be endless and useless to detail all their possible 
 modifications, — which have given rise to the pro- 
 posal of an operation, having for its principle, 
 the formation of a permanent aperture in the iris 
 opposed to a transparent portion of cornea. 
 
 Many very ingenious methods of accomplish- 
 ing this object have been devised both by fo- 
 reign and British surgeons and oculists. The
 
 FOR ARTIFICIAL PUPIL. 34}3 
 
 tracts of the late Mr. Gibson of Manchester, and 
 of my friend Mr. Guthrie, surgeon to the West- 
 minster Eye Infirmary, are well entitled to the 
 diligent perusal of students investigating this 
 subject. A remark, which I had early occasion 
 to make in reference to the treatment of cata- 
 ract, is pointedly applicable to this subject, to 
 wit, that no one method of operating commands 
 an exclusive preference, and that the eligibility 
 of either can only be determined by the pecu- 
 liar character and bearing of the case before us. 
 It follows, therefore, that a particular description 
 of the various modes of operating, without re- 
 ference to the precise conditions to which they 
 are applicable, althoughinterestingas an expose 
 of professional ingenuity, can have no other ten- 
 dency than to embarrass by a multiplicity of 
 materials, and that it is quite impossible to ar- 
 rive at a fair estimate of the respective merits of 
 each operation by such a mode of proceeding. 
 Infinitely varied as are the states which call for 
 the operation, a sufficient fertility of invention 
 has been exhibited to admit of an unhesitating 
 preference of some one or other method well 
 suited to every case that can occur ; and so far 
 as regards this point, the judgment of the young 
 surgeon requires only to be assisted in its de- 
 cision by the experience of those who have en- 
 joyed repeated opportunities of putting the 
 merits, general and comparative, of each ma- 
 noeuvre to the test.
 
 344 OF THE OPERATIONS 
 
 In the hope of simplifying a subject which has 
 been in some degree complicated by useless am- 
 plification and over refinement, I shall content 
 myself with setting down the operative method 
 which I regard as best adapted to each parti- 
 cular state described. 
 
 Simple states : 
 
 1. A central opacity eclipsing the pupil. A 
 section is to be made, with the cornea knife, in 
 the transparent portion of the cornea, from two to 
 three lines in length. This being done, by a gentle 
 pressure upon the opposite side of the eyeball, 
 the iris protrudes in the form of a little sack or 
 bag at the wound, which is to be snipped off 
 with a fine pair of scissars. The iris then re- 
 cedes, and presents a permanent aperture more 
 or less circular. The corneal section may be 
 made on either side of the pupil as required. 
 The merit of this highly ingenious operation is 
 due to the late Mr. Gibson. It is applicable 
 only to the above state, for if the pupil is closed 
 and in adhesion with the capsule, or if adhe- 
 sions exist between the iris and cornea, no pro- 
 trusion will take place. In making the section, 
 it is very important that the direction of the 
 knife should be perpendicular to the cornea, for 
 • if its passage is oblique, the cicatrix will be so 
 much extended as to obscure the new pupil. 
 On this account, the practice of Professor Beer
 
 FOR ARTIFICIAL PUPIL. 345 
 
 to draw out with forceps and excise the pupil- 
 lary margin, more completely answers the in- 
 tention. 
 
 There is another operation which I have per- 
 formed successfully in tliis case. A narrow 
 bladed and finely pointed knife, cutting on one 
 edge, such as was used by Mr. Cheselden for 
 dividing the iris, is introduced through the 
 sclerotic coat and ciliary margin of the iris into 
 the anterior chamber, with its cutting edge op- 
 posed to the face of the iris ; that membrane is 
 then to be completely divided on the tem- 
 poral side, including the border of the pupil, by 
 repeated gentle nickings. The iris being sound, 
 and consequently elastic, the section imme- 
 diately assumes the figure of an equilateral tri- 
 angle. The superiority of the operations before- 
 mentioned consists in their less liability to be fol- 
 lowed by cataract. If cataract ensues, as is pretty 
 uniformly the case in the simple division, it 
 must be broken up for absorption in a subse- 
 quent operation with the needle, provided that 
 measure should ultimately be necessary. 
 
 2. A closed pupil, the crystalline capsule 
 opaque and adhering, and probably the lens also 
 opaque, if not previously extracted or depressed. 
 It should be observed, that in the majority of in- 
 stances the capsule and lens have undergone the 
 change here presumed j but this is a matter not
 
 346 OF THE OPERATIONS 
 
 always possible to be ascertained, and one which 
 affords no ground for varying the plan of ope- 
 ration. It is therefore best to provide for it. 
 The section should be made precisely as in ex- 
 traction. The centre of thei iris should then be 
 raised under the flap of the cornea with the 
 forceps, and as largea piece of the membrane as 
 can be embraced by the convex scissars, should 
 be clipped off. Through such an opening there 
 will be no impediment to the passage of the 
 lens. I have repeatedly performed this opera- 
 tion with perfect success. 
 
 Wenzel, finding the mere division of the 
 closed fibres then only useful when they are on 
 the stretch, included a central portion of the 
 iris in the section of the cornea, and removed 
 the triangular flap thus formed, with a stroke of 
 the scissars ; a method perfectly efficacious in 
 the state of closed pupil, whether the cataract 
 remains or not. It is only necessary to bear 
 in mind, that a sufficient portion of the iris 
 must be excised to allow of the easy escape of 
 the lens, a point to which WenzePs directions 
 do not extend, since his operation supposed the 
 previous depression or removal of the cataract. 
 
 In the seventh volume of the Medico-Chirur- 
 gical Transactions is an interesting paper by 
 Professor Maunoir, of Geneva, relating three 
 successful operations for artificial pupil perform-
 
 FOR ARTIFICIAL PUPIL. SV/ 
 
 ed with his scissars in the manner recommended 
 by him. In two of these cases the pupil was 
 constricted upon an opaque capsule and lens. 
 To this paper is appended a letter from Scarpa, 
 justly complimenting M. Maunoir on his skill 
 and success, and adding his opinion that an 
 operation compounded of Wenzel's and Mau- 
 noir's, is the most appropriate to the case of 
 constricted or closed pupil with opaque lens. 
 
 Complicated states : 
 
 1. Closed pupily combined with a partially opaque 
 coniea. To this state either of the operations 
 last described may be applicable ; this must 
 however depend upon the extent of the opacity, 
 A section of the opaque part of the cornea is un- 
 advisable, as it is strongly disposed to ulcerate in- 
 stead of healing kindly. I should therefore avoid 
 it, if a portion of the cornea remained sound, 
 sufficient to allow of the unavoidable encroach- 
 ment of the cicatrix. But in all cases of 
 closed pupil, the iris retaining its position, I 
 hold it to be expedient, if possible, to remove a 
 portion of that membrane ; and to this end the 
 section of the cornea is indispensable. The mere 
 division of the fibres of the iris is ineffective, by 
 reason of the loss of its elasticity. An opacity of 
 the cornea however may be of such extent as to 
 leave no choice of operation, as the cicatrix of
 
 S4S OF THE OPERATIONS 
 
 the section of that membrane would obscure tlie 
 small portion which remains transparent. In 
 such a case, the separation of the ciliary margin 
 of the iris, after the manner of Scarpa or Schmidt, 
 is the only practicable proceeding. 
 
 2. Central opacity of the cornea, combined with 
 constricted pupil and cataract. In this case we 
 need only deviate from the usual method of 
 extracting, by dipping the point of the knife 
 behind the pupillary margin on the nasal side, 
 so as to include a sufficient portion of the iris. 
 If after the removal of the lens, the incised por- 
 tion should not be completely detached, the 
 flap may be easily snipped off with the iris scis- 
 sars. It may be useful to remark, that pressure 
 should, as much as possible, be avoided during 
 the extraction of the lens. Other modes of pro- 
 cedure in this case are as follow : 
 
 1. An opening is to be made in the cornea, 
 distant about three lines from the point at which 
 the new pupil is to be formed. Through this 
 aperture the ciliary margin of the iris, detached 
 by the double hook of the ingenious M. Reisin- 
 ger of Augsburg, is to be drawn out and excised. 
 If the cataract should impede vision, it must be 
 treated in a subsequent operation. 
 
 2. Dividing the iris horizontally on the nasal
 
 FOR ARTIFICIAL PUPIL. 349 
 
 side, and couching or breaking up the cataract 
 before withdrawing the needle, w4iich must be 
 adapted to that purpose. 
 
 I do not hesitate to prefer to either of these 
 modes the extraction of the lens by excising a 
 portion of the iris, a thing so easy to be done that 
 it is often difficult to avoid it. The distinct 
 performance of the operation for artificial pupil, 
 and the treatment of the lens by the absorbing 
 process, after the lapse of an interval, is for ob- 
 vious reasons objectionable, when it is possible 
 to do otherwise. 
 
 S. Closed pupil and partial adhesion of the iris 
 to the opaque cornea. The separation of the 
 cornea and iris when in adhesion, is an attempt 
 altogether unadvisable. It is only at that part 
 of tlie transparent cornea, which is free from ad- 
 hesion to the iris, that the attempt to make an 
 artificial pupil can be of any avail. The re- 
 moval of a portion of the fixed iris, by hooking 
 it through a limited section of the cornea, for 
 the purpose of strangulation or excision, is an 
 operation of much delicacy. It is however in 
 high repute with the German surgeons. If the 
 iris is at any part rendered tense by adhesion 
 to the cornea, an extensive vertical or oblique 
 division of its fibres with the iris knife, or 
 Maunoir*s scissars, is best adapted to this case. 
 The simple incision of the iris is enough, if it
 
 350 OF THE OPERATIONS 
 
 either retain its natural and healthy texture, or 
 be placed upon the stretch ; and if not, it is in- 
 efficient, as before observed, owing to its inelas- 
 ticity. But in this, as in all cases, if the opacity 
 of the cornea is of such extent as not to allow of 
 incision, the operation of Scarpa must be re- 
 sorted to. 
 
 4. Permanent prolapse of the iris through a 
 breach of the cornea, involving more or less oftJie 
 pupillat^y margin. This is the state for which 
 the operation was first devised and practised, 
 and when it is consequent upon the removal 
 of the lens, is the most favourable condition for 
 the artificial pupil. The appropriate procedure 
 is that of Mr. Cheselden, viz. the transverse 
 division of the stretched fibres of the iris ; and 
 which, if the section be made in front of the 
 membrane, i. e. from before backwards, admits 
 of no improvement. The edges of the section 
 instantly recede, and form an excellent pupil. 
 If the lens has been previously extracted, the in- 
 tention is completed at once ; otherwise the lens 
 must be couched or broken up, and in the latter 
 case may require a subsequent operation. Sharp, 
 Woolhouse, and others, who followed Chesel- 
 den's plan indiscriminately, naturally complained 
 of their want of success. Wenzel discovered the 
 cause, and demonstrated the necessity and the 
 mode of removing a portion of the membrane. 
 This was a very important step in advance, and
 
 FOR ARTIFICIAL PUPIL. 351 
 
 is the principle of the most successful operation 
 since performed for the artificial pupil. 
 
 It may happen that a partial adhesion of the 
 pupillary margin to the cornea may he combined 
 with a healthy lens. In this case, the removal 
 of the free border of the pupil, drawn by a pair 
 of forceps through an incision of the cornea, 
 is preferable, on account of preserving the trans- 
 parency of the lens. 
 
 I am fully aware, not only that other states 
 than those which I have mentioned, may fre- 
 quently occur ; but that even in these, circum- 
 stances may possibly arise, to render other modes 
 of operation more expedient, than those which I 
 have recommended. In fine, I consider it quite 
 impossible to reduce a subject in its nature so 
 purely circumstantial, and therefore discretional, 
 to the rule and line. The rationale of such 
 operations is simple and intelligible, and it may 
 safely be left to the genius of the surgeon to 
 meet the exigencies of each individual case, 
 in this as in many other instances. Manual 
 adroitness is, in an especial degree, required in 
 these operations, not only because the space 
 within which the instrument is to move is so 
 confined as to endanger contiguous parts, but 
 because the division of textures in a morbid 
 state is opposed — especially of the iris, on ac- 
 count of its inelasticity and over-vaspularity —
 
 352 01^ THE OPERATIONS 
 
 by a greater degree of resistance and a larger 
 effusion of blood, than the division of the same 
 parts in health. Hence the operation must be 
 executed as quickly as is consistent with gentle- 
 ness. For another reason this is important j the 
 organ upon which we are operating is an un- 
 sound one, and having been recently and per- 
 haps repeatedly the subject of inflammation, is 
 in too irritable and delicate a state to admit of 
 violent or long continued manual efforts. For 
 the latter reason, it is also highly desirable to 
 finish the operation at one sitting, and I there- 
 fore decidedly disapprove of coupling with the 
 formation of an artificial pupil, the displacement 
 and breaking up of the lens to undergo the te- 
 dious process of absorption, whenever it is possi- 
 ble to extract or even to couch it. The organ has 
 already suffered too much, and the operator 
 should either not interfere with the transparent 
 lens, or should remove that which is already 
 opaque ; and as the latter may almost always be 
 presumed, while it remains in situ behind a 
 closed pupil, that operation is preferable, which 
 provides for its removal. 
 
 So much for the mechanism of the operation ; 
 it now only remains for me to add a remark or 
 two on the more important question of its prac- 
 tical application and value, and the circum- 
 stances which should influence our prognosis 
 and determine our practice. There are two
 
 FOR ARTIFICIAL PUPIL. 553 
 
 main questions for consideration when these 
 cases present themselves to our notice, both of 
 which should be determined as far as we are 
 able to decide them, before the operation is 
 undertaken. The first in importance as in order 
 is, whether the retina retains its sensibility, and 
 the vitreous humor its texture and transparency. 
 The second, whether the manipulation required 
 is so far practicable as to afford a fair prospect 
 of success. The circumstances under which 
 vision has been suspended are more or less 
 favorable, according to the seat, extent, dura- 
 tion, and character of the inflammation. If 
 the disease is confined to the cornea, the case 
 affords the best encouragement. In the pro- 
 lapsus iridis from ulceration of the cornea, the 
 iris is only passively concerned, and here it sel- 
 dom happens that the retina has suffered. If the 
 closure of the pupil has supervened upon wound 
 or injury, as the operation of couching or extrac- 
 tion, it is in general more favorable than when it 
 results from idiopathic inflammation of the cho- 
 roid and iris of long standing, or from repeated 
 attacks of inflammation. In the latter cases, 
 the organ usually presents certain signs of an 
 organic change in its altered volume and figure, 
 in the yielding and crumpling of the flaccid scle- 
 rotica under the impression of the finger, the 
 permanent congestion of tbe sclerotic and 
 choroideal vessels, the great convexity and dis- 
 coloration of the iris, and the yellowness of 
 
 A A
 
 354 OF THE OPERATIONS 
 
 the opaque lens, if any part of it is visible, the 
 partial detachment of the pigmentum nigrunij 
 &c. An extensive adhesion of the iris to the 
 cornea denotes the greatest degree of organic 
 derangement, and constitutes the most unfavor- 
 able state for operation. 
 
 In a great proportion of cases in which the 
 operation might, in a manual view, be executed 
 with perfect success, no advantage would re- 
 sult from it ; as in cataract, complicated with 
 amaurosis, the extraction proves to be of no 
 avail. 
 
 Difficult as the operation may be and often is, 
 it is the state of the eye by reason of the disor- 
 ganizing inflammation which has preceded it, 
 that forms the most frequent impediment to its 
 success. When the signs of organic change 
 in the eyeball are present, it should never be 
 attempted; without some healthy perception 
 of light, I should think it offered a very 
 small chance of usefulness*. In the most fa- 
 vorable circumstances, the patient should be led 
 to entertain a moderate degree of expectation ; 
 and as persons in a state of blindness are inva- 
 riably over-solicitous to submit to any experi- 
 
 * I say, healthy, because the morbid perception, as of 
 gleams and flashes of blue or variegated light, stars, and 
 sparks, so common in these cases, is decisive of the disorgani- 
 zation of the retina. 
 
 f
 
 FOR ARTIFICIAL PUPIL. S55 
 
 ment for the recovery of vision, the surgeon, for 
 his credit*s sake, should be careful not to limit 
 his inquiry to the mere practicability of an 
 operation ; nor, when taking a larger and more 
 deliberate view, to be drawn into it against his 
 judgment. If this is undecided, let him so state 
 the circumstances as to make himself respon- 
 sible only for the mechanical process. Let it, 
 for example, be expressly understood that with- 
 out it the case is hopeless, and that if unhappily 
 nothing should be gained, nothing will be lost 
 by the operation. It is seldom, if ever, wise to 
 do the operation upon one eye, the other re- 
 maining sound. 
 
 The ensuing inflammation is in general mo- 
 derate, particularly so, if the lens has been pre- 
 viously removed. The success of the operation, 
 however, is sometimes foiled by the train of 
 morbid actions which ensues from the thorough- 
 ly diseased condition of the cornea and iris, 
 where the instant result had inspired a hope of 
 better fortune. 
 
 A A ^
 
 TREATMENT 
 
 DISEASES OF THE EYE. 
 
 CHAPTER IV. 
 
 DISEASES OF THE APPENDAGES. 
 
 Of the treatment of diseases of the orbitar ca- 
 vity and appendages much need not be said. I 
 have spoken of the excision of adipose tumors 
 and cysts. Such cases are sufficiently within 
 the observation of the general surgeon to render 
 a fuller discussion of them unnecessary in a 
 work, the more particular object of which is to 
 communicate information upon a department of 
 pathology, which, unfortunately for mankind, he 
 has too much neglected to cultivate.
 
 SECTION I. 
 
 DISEASES OF THE EYELIDS. 
 
 Styes, if large and painful from inflaming Hordeolum. 
 the eyelids, should be discharged witli the point 
 of a lancet, and poulticed, or bathed with a slight- 
 ly astringent wash, according to circumstances. 
 When phlegmonous, indurated, and slow to sup- 
 purate, occasional friction will often promote ab- 
 sorption of these little swellings, as we may con- 
 jecture was known of old, from the reputed spe- 
 cific effects of a wedding-ring, or the tail of a 
 black cat. 
 
 The disposition to stye is not only very trou- 
 blesome, but very injurious to beauty. The per- 
 manently conspicuous redness of the borders of 
 the tarsi, a slight degree of thickening and ele- 
 vation of the conjunctiva, and small cuticular 
 denudations, are the results of their frequent 
 formation, and the loss or scantiness of the cilia 
 greatly increases tlie deformity. The nitrated, 
 or red or white precipitate ointment of mercury, 
 diluted so as to give a momentary smart upon 
 closing the lids, should be used daily or thrice 
 a week at bed-time, till the part acquires a 
 healthy aspect ; and the lids should be occa- 
 sionally smeared with any soft and unirritating 
 salve at intervening periods. Alum and zinc
 
 358 DISEASES OF THE APPENDAGES. 
 
 washes assist this object. The chronic indu- 
 rated stye, if not dispersed by the stimulant 
 ointment, should be excised. An appropriate 
 attention to the habit of patients is essential, for 
 this is always faulty. 
 
 Lippitudo. The acute lippitudo generally yields to a single 
 stimulant application. Some exceptions however 
 occur. The lead and zinc ointment, or one com- 
 bined with opium, will often agree with those 
 slight, but very irritable lippitudos sometimes 
 met with* ; but there are persons to whose sen- 
 sations even cetaceous ointment is painful, and 
 who derive no benefit whatever from unctuous 
 applications. In this case hot water affords 
 most relief, and it is a remarkable fact, that it is 
 soothing and refreshing to the eye, at a tempe- 
 rature which is not endurable to the hand. 
 
 The chronic lippitudo is a very deforming dis- 
 ease, and often very intractable. It is accom- 
 panied with much intolerance. The vessels of 
 the palpebral conjunctiva are turgid, and at 
 length varicose, the membrane a little overlaps 
 the thickened tarsal border ; this is partially if 
 not quite denuded of cilia, and small surfaces 
 of the adjoining cutis are excoriated. The folli- 
 cles are plugged, and here and there is one so 
 
 * The addition of ten or fifteen drops of the liq. plumbi 
 licet, to two drachms of the ung. ziuci, I have found to answer 
 completely in such cases.
 
 DISEASES OF THE APPENDAGES. 359 
 
 jnuch distended by inspissated mucus, as to oc- 
 casion acute inflammation. These should be 
 opened with the point of the lancet, and the 
 white consolidated secretion removed, the con- 
 junctiva should be occasionally scarified, and the 
 meibomian borders stimulated by one of the oint- 
 ments above-named. The tarsal edges should 
 also be frequently bathed with an astringent lo- 
 tion. In the aggravated and obstinate cases of 
 lippitudo, where the conjunctiva is altered in its 
 texture, the sulphate of copper lightly carried 
 over the thickened conjunctiva and ulcerated 
 border of the tarsus, is highly useful ; and sti- 
 mulant solutions of copper, zinc, lunar caustic, 
 or sublimate, applied with a camel-hair brush to 
 the tarsal edges before smearing them with the 
 ointment, are likevv^ise advantageous. 
 
 The degree of strength in which the ointment 
 should be used, the quantity to be used, and 
 the mode of applying it, are points of no small 
 importance in the treatment of these diseases. 
 Unless it excites a pretty smart irritation and 
 provokes a copious flow of tears, it does little 
 if any good ; but the irritability of the conjunc- 
 tiva varies so much according to the stage of the 
 disease, the time of making the application, and 
 even the general habit, that it is impossible to 
 fix a standard of strength. As to the manner, 
 patients should be instructed in the intention : 
 and for the strength and quantity, in the de-
 
 360 DISEASES OF THE APPENDAGES. 
 
 sired effect of the remedy. The degree of irri- 
 tation should be such as to prevent the patient 
 from keeping his eyes open for some succeeding 
 minutes ; but no increased congestion should be 
 apparent on the following day. The patient 
 therefore should feel his way, and measure the 
 irritability of the conjunctiva, by advancing gra- 
 dually from a lower to a higher stimulus. In 
 acute lippitudo a little cold cream or spermaceti 
 will occasion a severe smarting and profuse flow 
 of tears, whereas in the chronic form, the strong 
 mercurial ointment is often necessary to produce 
 this effect*. 
 
 * The ' golden ointment, ' as it is called, is an excellent re- 
 medy. I shall be accused of heterodoxy : but I must in jus- 
 tice assert, that the inventor of this arcanum deserves well of 
 his country, for if his patriotism be equivocal, the virtue of his 
 nostrum is at least certain, when judiciously prescribed. If it 
 did not unfortunately aspire to be a panacea, its beneficial ope- 
 ration would be without exception ; and indeed the greatest 
 evil of quack, as of regular medicines, is their abuse. Few 
 things capable of doing much good, are not also capable of 
 doing mischief. An old lady of Paris, M'hose husband had be- 
 come famous for an eye-water, had the misfortune to lose her 
 spouse and his secret together. In this dilemma, harassed by 
 applications for the nostrum, she had recourse to the water of 
 the Seine, and was not more gratified than surprised to find 
 that the collyrium had lost nothing of its virtue. — After hav- 
 ing enriched herself by a successful traflic, it so chanced that 
 she fell sick, and conscience-stricken at the prospect of death, 
 she applied to an eminent professor of surgery, instead of a 
 priest, to relieve herself of the burthen of sin with Avhich her 
 soul was encumbered. " Soyez tranquille, mon amie," said the 
 professor, " de tous les i^Iedecins vous etes le plus innocent ; 
 yos remedes n'ont fait du mal a personne ! "
 
 DISEASES OF THE APPENDAGES. S6l 
 
 The correction of the diseased states and se- Tinea d- 
 
 1 liaris. 
 
 cretions of the cihary apparatus proceeds upon 
 the same principle as the cure of lippitudo, with 
 which, in a greater or less degree, they are very 
 generally combined. The re-establishment of a 
 healthy conjunctival surface and a healthy mei- 
 bomian secretion, is the object to be attempted. 
 In general the mercurial ointments are the best 
 remedies for this disease. 
 
 Cleanliness is a point of the first importance, 
 and it is the more necessary to mention it, be- 
 cause the disease is often set up, and is always 
 aggravated, by neglect of it. The margins of 
 the lids, and the roots of the cilia should be 
 thoroughly cleansed from loose scabs and branny 
 incrustations before anointing them ; the oint- 
 ment, liquefied by a gentle heat, should be ap- 
 plied upon both edges of the cartilage with a 
 camel-hair brush ; keeping them through the 
 day slightly besmeared with a mild ointment, as 
 the tutty, prevents the formation of fresh crusts. 
 It is needless to say, that more depends upon the 
 patient than the surgeon in the cure of these 
 complaints, and that the incurable states, those 
 which admit only of palliation, are invariably 
 the consequence of neglect, and might, there- 
 fore have been prevented. 
 
 When cilia are inverted from a diseased growth, Trichiasis. 
 they must be kept plucked until by the improved
 
 362 DISEASES OF THE APPENDAGES. 
 
 condition of the hair-gland, under th^ meilns 
 used, the disease is removed. If a case occurs 
 in which the vitiated site or incurvation of one 
 or more ciUa does not admit of correction, the 
 corresponding folUcle should be obliterated by 
 repeatedly touching it with a fine caustic pencil. 
 When the incurvation is depending on a dis- 
 ease of the tarsus, the case must be treated as 
 entropeon. 
 
 Entropeon. Tlic treatment of the inverted eyelid, upon the 
 plan recommended by Scarpa, will, according to 
 my experience, be effective in nine cases out of 
 ten ; that is, by the removal of a fold of skin with 
 a pair of scissars from the surface of the eyelid. 
 The relaxation of the integument operating as 
 U cause of the disease, is more frequent upon the 
 lower than the upper lid, but the operation is 
 applicable to cases originating from other causes. 
 The surgeon should be careful to adapt the po- 
 sition and extent of the wound to the site and 
 degree of the inversion. I have now and then 
 met with a case in which the inversion was 
 clearly depending upon a callous roll of conjunc- 
 tiva at the orbitar edge of the tarsus, in which 
 case the disease was removed by the excision 
 of this roll ; of itself a disease requiring such 
 a remedy, as before noticed. In cases of a 
 circumscribed inversion produced by cicatrix 
 from burn or wound, I have found an operation 
 similar to that of Dr. Crampton, an effective
 
 DISEASES OF THE APPENDAGES. 363 
 
 remedy ; sometimes the complete division of 
 the conjunctiva and tarsal cartilage, including 
 the inverted portion, and parallel to its border, 
 with the aid of sticking-plaster, has proved suf- 
 ficient. I should see no objection to the entire 
 removal of that portion of the tarsal edge which 
 was incorrigibly inverted from such a cause, 
 especially when combined with distichiasis, by 
 which is meant a preternatural growth of cilia 
 from the meibomian border of the tarsus ; but 
 the removal of the entire cartilage, which I have 
 twice performed in aggravated cases of this dis- 
 ease, although by no means difficult of execu- 
 tion, is an operation of great and needless seve- 
 rity, and one which, in my experience, is not 
 warranted by the degree of relief which it affords ; 
 to say nothing of the permanent deformity which 
 it occasions. 
 
 The ordinary ectropeon is cured by the ex- Ectropeon. 
 cision of a portion of the thickened or redun- 
 dant conjunctiva which occasions it. The per- 
 pendicular division, or the removal, as the cir- 
 cumstances require, of a triangular portion of 
 the tarsal border by a double incision, as men- 
 tioned p. 240, is the operation best adapted to 
 the long-established and aggravated forms of the 
 disease ; an adhesion of the everted eyelid to 
 the cheek, adds much to the difficulty of the 
 case, and renders all modes of treatment merely
 
 36^ DISEASES OF THE APPENDAGES. 
 
 palliations of the deformity. I have, however, 
 succeeded in greatly lessening the deformity in 
 some such cases. 
 
 Palpebral 
 tumors. 
 
 Concerning tumors of the eyelids I have little 
 to add to what will be found in the pathology. 
 Often the encysted tumor is seated superficially, 
 and loosely connected to the tarsus, in which 
 case it must be removed on the outside of the 
 eyelid, by just separating and turning to either 
 side the fibres of the orbicularis muscle. It is 
 only when an intimate adhesion subsists, (the 
 cyst is often formed betwixt the cartilage and 
 the ligamentary membrane which covers it,) and 
 the appearance of a white circumscribed inden- 
 tation is seen upon everting the tarsus, that the 
 excision is to be made from the, interior by divi- 
 sion of the cartilage ; in which case it is always 
 executed with perfect facility. If the cyst be 
 not extirpated, but merely incised and its con- 
 tents expressed, the tumor speedily re-appears. 
 If its adhesion to the tarsus be such as to 
 prevent the entire removal of it, the remnant 
 of the cyst should be touched with the caustic 
 pencil. 
 
 Lsgoph- ^or the permanently drooping lid, if an opera- 
 
 tion be ever desirable, — which, as an unclosed 
 state of the lids is a pretty certain fore-runner 
 of diseased conjunctiva, amounts with me to a
 
 DISEASES OF THE APPENDAGES. 365 
 
 question — a fold of integument may be removed 
 by the knife, or by pencilling out a portion of it 
 with the strong; nitric acid. It is unnecessary to a"'^ ''o^^- 
 
 '-' "^ ring tarsi. 
 
 describe an operation for dividing the cohering 
 tarsi. When complicated with adhesion to the 
 globe, the case is incurable.
 
 SECTION IL 
 
 OBSTRUCTION OF THE LACRYMAL 
 PASSAGES. 
 
 Stricture of The treatment of the disease improperly 
 
 the lacry- i n ^ ^ t ^ • i 
 
 mai and termed " fistula Jacrymalis," has occupied a 
 large share of the labor and talent of the pro- 
 fession * ; yet, notwithstanding this advantage, 
 the practice is to this day unsettled and unsatis- 
 factory t. 
 
 * See the numerous papers in the Memoirs of the French 
 Academy, and the worlcs of Sharpe, Pott, Desault, and 
 other eminent ^vriters. 
 
 t In proof of this remark, I may observe that nearly all the 
 schemes hitherto suggested have been executed Avithin my 
 knowledge, by different surgeons, viz. the small probe and in- 
 jecting syringe of Anel, the sound and syringe for the nasal 
 duct, the seton of silk or catgut, the bougie or nail-headed 
 style, the metallic tube, &c. In Paris, M. Dubois employs the 
 silk seton of Mejan, M. Dupuytren the permanent tube of 
 Wathen, M. Roux the'mesh seton, introduced by means of. a 
 watch-spring from the sac. M. Beer, of Vienna, uses, for a se- 
 ton, a coil of catgut, such as is used for hddle-strings. Among 
 the surgeons of London, IMr. Ware's style is chiefly in use, 
 although the practice is evidently losing credit.
 
 DISEASES OF THE APPENDAGES. 367 
 
 Mr. Pott was in error when he conchided in 
 his criticism of Anel's practice, that the strict- 
 ure of the lacrymal ducts was very rare, be- 
 cause the mucus of the sac was habitually, or 
 upon pressure, discharged at their orifices j the 
 stricture of the ducts is, on the contrary, fre- 
 quent ; and although this morbid secretion of 
 the sac is often present with a free state of the 
 lacrymal ducts, the cases of obstruction on the 
 nasal side are very frequent, in which no such 
 symptom exists. 
 
 The absoi*ption of the meibomian mucus by Mucous 
 
 . . . discharge. 
 
 the puncta lacrymalia, and its regurgitation on Professor 
 pressure, as described and considered by Scarpa hypothesis. 
 to constitute the first stage of the disease, inde- 
 pendent of a permanent stricture, is, I think, 
 hypothetical ; for, if founded in fact, this symp- 
 tom would be present in every severe lippitudo 
 or ophthalmia with puriform discharge, which 
 every body knows is not the case. Besides, if 
 the duct were open, there is no reason why the 
 fluid, once admitted, should be arrested or re- 
 gurgitate instead of passing into the nose ; but 
 the office of the puncta is the absorption of the 
 lacrymal fluid, as that of the lacteals is the ab- 
 sorption of chyle, and absorbent mouths are 
 distinguished from capillary tubes by the selec- 
 tion of their proper fluid. It by no means fol- 
 lows because a purulent secretion is discharged 
 from these orifices that they have derived it
 
 368 DISEASES OV THE APPENDAGES. 
 
 from tlie eye. Further, there is every reason 
 to beUeve that the fluid so discharged is the 
 proper secretion of the sac, and cases are fre- 
 quent in which it is retained and cannot be ex- 
 pressed, owing to strictures both of the lacry- 
 mal and nasal ducts. As to the proof of the 
 meibomian border of the Ud of the aifectal eye 
 being more vascular than the other, I need only 
 remark that the irritation of an obstructed sac 
 naturally produces this appearance upon a con- 
 tinuous and highly sensible membrane ; if the 
 redness prove any thing, it proves the presence 
 of irritation, and stricture is as probable a 
 source of it as any. But it is demonstrable that 
 the "flusso palpebrale" is as seldom present 
 with the symptoms of obstruction in a degree 
 sufficient to support the hypothesis of obstruc- 
 tion from that cause, as the actual obstruction 
 is rare in those cases of its excess which are of 
 ordinary occurrence. 
 
 Origin of The effect of a severe cold in the head to 
 produce a coryza and troublesome watering of 
 the eye, may enable us to form a pretty accurate 
 idea of the cause of a permanent stillicidium ; 
 for although an over-excitable state of the con- 
 junctival surface may occasion a more plentiful 
 secretion of the lacrymal fluid, yet it cannot be 
 questioned that the same temporary condition 
 may prevail in the membrane lining the sac and 
 duct, as in tlie other parts to which it is distribut-
 
 DISEASES OF THE APPENDAGES. 369 
 
 ed ; I mean a state of vascular congestion and in- 
 tumescence. This continued, would lead to a 
 permanent thickening of this membrane, and 
 from that cause a diminution of the calibre of 
 the canal. An adhesive process, whether pri- 
 mary or consecutive to the states of suppuration 
 and ulceration, finally closes the duct, so as to 
 render it absolutely impervious. The actual 
 obliteration of the canal by the degeneration of 
 the membrane into a texture resembling carti- 
 lage, is a secondary morbid change, and only 
 the result of long continued obstruction. 
 
 I have had occasion before to observe that Abscess in- 
 the inflammation and abscess of the sac, although stricture. 
 frequently preceded, and in great measure pro- 
 duced by obstruction of the nasal duct, is by no 
 means always referrible to that cause ; a conside- 
 rable degree of obstruction endures for years 
 without a tendency to excite inflammation of 
 the sac ; and on the other hand, the inflamma- 
 tion and abscess of the sac in its acutest form, 
 as from exposure to cold and other exciting 
 causes, and sometimes from injury, often exists 
 without any degree of obstruction. In proof of 
 this, I may remark that the incipient inflamma- 
 tion of the sac often admits of resolution by the 
 use of leeches, &c. without further inconve- 
 nience to the patient j and the w^hole treatment 
 required for the abscess in many cases, is simply 
 
 B B
 
 370 DISEASES OF THE APPENDAGES. 
 
 the discharge of the matter, or, in other words, 
 the treatment appUcable to a common abscess. 
 
 A free opening of the sac for the purpose of 
 discharging its contents, shortens the sufferings 
 of the patient, and saves the skin j but unless 
 the previous existence of symptoms demonstrates 
 the presence of a stricture, an abscess of the 
 lacrymal sae is by no means a sufficient proof of 
 it, to warrant the employment of any further 
 measures. The existence of an abscess is of it- 
 self a cause of temporary obstruction, and the 
 stage immediately preceding the formation of 
 abscess may have been the cause of a temporary 
 stricture, of which the abscess audits discharge 
 are the termination. Of this I am well satisfied : 
 that the supposed invariable connection of an 
 abscess of the lacrymal sac with a stricture of 
 the duct, enforced in the writings of the French 
 Academicians, Mr. Pott, M. Desault, and 
 others, have led to an officious and often inju- 
 rious treatment of this painful and sufficiently 
 distressing malady ; and at all events, the first 
 indication is simply that of giving issue to the 
 matter, by a free incision of the sac, and apply- 
 ing a soft poultice in a bag to the inner angle 
 of the orbit. 
 
 Treatment Supposiug, therefore, the case of abscess so 
 abscess. ^^^ advanccd, instead of introducing a style into
 
 DISEASES or THE APPENDAGES. Syl 
 
 the ductus nasalis, after opening such abscess, I 
 recommend simply the examination of the duct 
 with a fine probe ; if the probe pass without 
 resistance into the nose, the case requires no 
 further operative treatment, the integument re- 
 covers its healthy condition under an emolHent 
 appHcation, the discharge gradually diminishes, 
 and the wound heals. If, on the other hand, 
 upon examination with the probe introduced 
 through the wound into the sac, resistance be 
 offered to its passage into the nose, no more fa- 
 vorable opportunity will be presented for over- 
 coming such resistance. This therefore should 
 be accomplished, but to this the operative pro- 
 cess should be limited, and the wound should be 
 suffered to heal without further disturbance. 
 
 An erysipelatous inflammation of the integu- Erysipeia- 
 ments of the face in the vicinity of the lacry- mation. 
 mal sac, in which the peculiar characters of 
 that inflammation seem to indicate that the cu- 
 tis is primarily affected, however this may be in 
 fact the case, requires to be narrowly watched, 
 especially if it extend to suppuration ; for then 
 there will be reason to apprehend a sloughing 
 ulceration of the cellular texture, and probably, 
 the destruction of a portion of the sac from this 
 cause ; so that a lacrymal fistula will be the 
 termination of the disease. But a more imme- 
 diate cause for apprehension exists, if inflamma- 
 tion has been preceded by any sign of obstruc- 
 
 B B 2
 
 372 DISEASES OF THE APPENDAGES. 
 
 tion to the passage of the tears, and this, I be- 
 Heve, will be found to be most frequently the 
 ^ case. The inflammation symptomatic of deep- 
 
 seated suppuration is erysipelatous, as is well 
 known to every practical surgeon, and this is 
 more especially the case where any fascial or li- 
 gamentous texture intervenes, like that which 
 covers and supports the sacculus lacrymalis. 
 Therefore, although the incision of the sac is 
 manifestly improper and unadvisable, unless it 
 is distinctly ascertained to be the seat of sup- 
 puration, the erysipelatous nature of the inflam- 
 mation must not be considered to indicate the 
 confinement of the disease to the integument, 
 and the previous healthiness of the sac. I do 
 not hesitate to say that the^evil of an uncalled- 
 for incision of the sac is, in every point of view, 
 less than the opening formed by a process of 
 disease under the circumstances supposed, for 
 in the latter case it will be difficult to prevent a 
 permanent fistula. 
 
 Moist or The tear falling over the cheek is a sign of 
 
 ry eye. ^Q^^pjg^g obstructiou, cxccpt uudcr strong ex- 
 citement, when indeed it happens even though 
 the duct is free ; but the moist or watery eye 
 indicating the retardation, not the arrest of the 
 tear, is by much the more frequent case. This 
 depends upon an imperfect obstruction of the 
 nasal duct. This state often exists without any 
 other external symptom of disease, and it is a
 
 DISEASES OF THE APPENDAGES. 373 
 
 source of considerable inconvenience from the 
 continual suffusion which it occasions, and the 
 necessity it imposes of incessantly wiping the 
 eye. 
 
 The epiphora, or, more properly, the stillici- Constricted 
 
 , . 1 1 • n 1 • puncta and 
 
 dium lacrymarum, resultmg irom the constrict- obstructed 
 ed puncta, or obstructed lacrymal ducts, is re- 
 lieved by the introduction of a small silver 
 probe into the sac once, or oftener, as may be 
 required. Frequently the obstruction is con- 
 fined to the saccular extremity of the duct. The 
 case is common, the inconvenience considerable, 
 and the relief complete. Tlie obliterated punc- 
 tum or canal is a case which admits of no re- 
 medy. 
 
 The patulous puncta are usually combined Patulous 
 with a swollen and atonic state of the canals atmiVofli.e 
 and sac ; there is no contraction of the orifice 
 on contact with the probe, no obstruction to its 
 passage into the nose, nor any excretion of mu- 
 cus upon the eye or from the nostril ; the situa' 
 tion and figure of the sac are conspicuous from 
 its prominence. Such a state, most frequent in 
 elderly persons, may in part depend upon a 
 feebleness or paralysis of the orbicularis muscle, 
 and a redundant fulness of the skin producing 
 a partial eversion, or an enlargement of the se- 
 mi-lunar fold of the conjunctiva, displacing the
 
 374 DISEASES OF THE APPENDAGES. 
 
 puncta, or disturbing their relative position. It 
 results also from long continued distention of 
 the sac, owing to a morbid increase and reten- 
 tion of its secretion; and under such circum- 
 stances, it may be partially relieved by astrin- 
 gent washes, but it is not, in my experience, 
 curable. 
 
 Stricture 
 symptoma- 
 tic of con- 
 junctival in- 
 flammation. 
 
 The stricture which is occasioned by the ex- 
 tension of conjunctival inflammation to the la- 
 crymal excretories, should be treated only as a 
 siffn of that disease. When under the influence 
 of a treatment purely antiphlogistic, and sooth- 
 ing applications, the inflammation subsides, the 
 temporary interruption to the function of these 
 organs ceases ; or if it should not cease altoge- 
 ther, the use of a gentle stimulant collyrium will 
 put an end to it. When, however, the state of 
 distended sac, the regurgitation of mucus upon 
 the eye, and the gathering of the tears in the 
 lacus lacrymalis, are altogether chronic, there 
 can be little doubt of the existence of a stric- 
 ture, partial or complete ; and I am unac- 
 quainted with any other mode of treating this 
 disease than such as is adapted to the removal of 
 the stricture, and the restoration of the canal. I 
 am satisfied that the practice of introducing sti- 
 mulant liquids into the hollow of the inner can- 
 thus, in the supine position of the head, and of 
 injecting the sac with astringent lotions, has no
 
 DISEASES OF THE APPENDAGES. 375 
 
 other effect than that of aggravating the symp- 
 toms of the complaint ; how indeed can any 
 other result be rationally expected ? 
 
 When from the duration of this state the Permanent 
 overflow of tears becomes continual, the dis- trrStaTng 
 tention of the sac and the discharge of mucus '"pp""^"''""- 
 excessive — the conjunctiva towards the inner 
 angle has a preternatural vascularity, the outline 
 of the sac assumes a circumscribed phlegmonous 
 hardness, and a blush begins to appear upon the 
 skin covering it — when the eminences of the 
 puncta lacrymalia are shrunk and absorbed in 
 the swelling, and in short, the mucous is about 
 to pass into the purulent secretion — ^even at 
 this period I have repeatedly averted the forma- 
 tion of abscess by re-opening the nasal duct. 
 But when the disease has advanced another Fluctuation. 
 stage, and the pointing of the tumor and sense 
 of fluctuation are perceptible, no advantage 
 could be expected from the introduction of the 
 probe through the lacrymal canal, if it were 
 possible J we have now a disease requiring a dis- 
 tinct treatment, and to prevent a complicated fis- 
 tula — such as results from the yielding of the sac, 
 the diffusion of its contents into the cellular sub- 
 stance, and sinuses spreading in various direc- 
 tions beneath the integument, — the free incision 
 of the sac should be made without delay, and the 
 treatment of the original disease postponed. -
 
 376 DISEASES OF THE APPENDAGES. 
 
 The nail- Wlieii thc integrity of the parts is restored, it 
 
 headed -ii i • i • i 
 
 style. Will be necessary m this case to have recourse 
 
 to the same mode of proceeding which is adapt- 
 ed to the other stages of the disease, and which 
 appears to me to be the only method of treat- 
 ment applicable to it upon a rational principle ; 
 for I confess myself at a loss to understand how 
 relief can be afforded by the practice of intro- 
 ducing a style to remain in the duct, and I am 
 strongly disposed to doubt whether any perma- 
 nent benefit was ever derived from such a prac- 
 tice. I am quite aware that the mere opening 
 of the sac affords an immediate and considerable 
 degree of relief; and if a stricture has existed 
 in the nasal duct, which is at the same time 
 overcome by the introduction of the probe, the 
 relief will be still more complete ; but the style 
 which occupies the sac and duct can have no 
 conceivable beneficial influence until it is with- 
 drawn. The disease is transferred from the 
 eye to the cheek, and the oozing of the tears 
 through a small fistulous aperture in the sac, is 
 substituted for their overflow of the natural 
 channel. The state is, upon the whole, less irk- 
 some to patients, and in so far the practice must 
 be considered as palliative j but I may fairly say 
 that I have scarcely seen one instance in which 
 this practice had been adopted, and the style was 
 still retained, whether at the expiration of 
 three weeks, or three months, or three years, or
 
 DISEASES OF THE APPENDAGES. 377 
 
 double the latter period, in which the disease 
 did not exist in undiminished force, under the 
 modifications which I have just described, that 
 is, as an established lacrymal fistula. Patients 
 are reluctant to part with the style, because, as 
 is natural, they ascribe the degree of relief they 
 have obtained from the opening of the sac, and 
 the diversion of the excretion, to what appears 
 to them to be an essential part of the process. 
 
 I have recommended the introduction of a Dilatation 
 
 1 • 1 7 1 • gradual or 
 
 probe into the nose, when such an opportunity immediate. 
 is presented, from unwillingness to lose one so 
 favorable for the restoration of the canal ; and 
 the only case in which the permanent dilata- 
 tion is required, is when the passage of the in- 
 strument in the direction of the duct is so firmly 
 resisted, as to compel the forcible renovation of 
 the canal. In this case it is obvious that some 
 means must be used to preserve it, and for this 
 purpose two modes of practice are employed. 
 Some surgeons having introduced a dilator into 
 the duct, so far as the obstruction permits, fasten 
 it there, and from day to day renewing the at- 
 tempt to overcome the obstruction, gain upon it 
 by little and little, until at length the instrument 
 enters the nostril ; here it is left for some days, 
 when either an instrument of larger dimensions 
 or a seton is substituted for it, which is not finally 
 withdrawn until the object is accomplished. — 
 Others forcibly overcome the obstruction at once.
 
 378 DISEASES OF THE APPENDAGES. 
 
 and afterwards place a style or tube in the newly- 
 formed passage. I am not now speaking of the 
 penetration of the os unguis or the breaking 
 through of the bony parietes, but of the re-open- 
 ing of the original passage ; which being obli- 
 terated by a morbid structure of the lining mem- 
 brane, of such firmness as to require the employ- 
 ment of force, and to occasion a free hemorrhage 
 from the nostril, is, in fact, the same thing as an 
 artificial channel. Of the two practices, I de- 
 cidedly prefer the latter ; the former is drivel- 
 ling, tedious, and painful to a degree. 
 
 Averse to any and every permanent tent, I 
 formerly introduced a probe into the nose for 
 many days in succession, but the daily increas- 
 ing facility with which it passed was not a com- 
 pensation for the pain it inflicted, and the ulce- 
 ration of the wound by the repeated interruption 
 of the cicatrizing process. 
 
 Theau- The practice ^vhich I have long employed, 
 
 ^ M s prac- ^^^^ which I adopted as the most successful, after 
 a trial of the several methods of which I have 
 made mention, the tube only excepted, is too 
 obvious to have the merit of novelty. In a large 
 proportion of cases, it has proved successful in 
 curing the disease, both in slight and aggravated 
 forms, in early and advanced stages, without en- 
 tailing the inconvenience and deformity insepa- 
 rable from the various contrivances for perma-
 
 DISEASES OF THE APPENDAGES. 379 
 
 nent dilatation, and avoiding altogether a fistu- 
 lous aperture. Contented with accomplishing 
 the passage of a moderate sized probe into the 
 nose, after the incision of the sac, my attention 
 is exclusively directed to the reduction of the in- 
 flammation, and the restoration of the soft parts, 
 with which, be it expressly understood, I never 
 interfere, except in the case of abscess disco- 
 loring the skin, and threatening fistula. Thus, 
 with this single exception of abscess, the treat- 
 ment of the obstruction is one and the same, so 
 far as the point of obstruction is concerned; and 
 it is a point always important to be ascertained ; 
 the more so, as it is by no means of uniform oc- 
 currence. 
 
 It can hardly be required that I should oc- 
 cupy the time of the reader in shewing that the 
 practice of restoring a passage partially closed, 
 or even establishing an artificial passage, as near- 
 ly as possible in the same direction, when the 
 natural channel is obliterated, commands a de- 
 cided superiority over the practice of making an 
 artificial opening. This applies to the treat- 
 ment of the urethra, as well as of the ductus 
 nasalis, and it is onlv in case of abscess, in which 
 the distended and inflamed integument threatens 
 to give way by ulceration, that in either case it 
 becomes necessary to deviate from it. 
 
 A set of silver probes, of about five inches Lacr>mai 
 
 probes.
 
 380 DISEASES OF THE APPENDAGES. 
 
 long, varying in size, flattened at one end, and 
 slightly bulbous at the point, are the instru- 
 ments I use for the purpose of restoring the 
 passage. The probe is introduced with perfect 
 facility by one who is familiarly acquainted 
 with the anatomy of the part, from either of 
 the puncta lacrymalia into the corresponding 
 nostril, when no obstruction is offered to its 
 passage. If the punctum be constricted, it is 
 readily entered and dilated by a common pin ; 
 and upon withdrawing it, by one of the smaller 
 probes ; the direction and relative situation of 
 the lacrymal ducts, the sac, and the nasal canal, 
 point out the proper course of the instrument. 
 It is confirmed by its advance without the em- 
 ployment of force, and the sensation conveyed 
 by the free and unencumbered motion of its 
 point ; until the point is fairly within the sac, it 
 is necessary to keep the eyelid gently stretched 
 and slightly everted; the upper lid being drawn 
 a little upward toward the brow, the lower as 
 much downward toward the zygoma. The 
 point carried home to the sac and touching 
 lightly its nasal side, the lids may be left at li- 
 berty, while a half circular motion is per- 
 formed by the instrument ; the surgeon neither 
 suffering the point to recede, nor, on the other 
 hand, allowing it to become entangled in the 
 membrane. 
 
 The probe now rests in a perpendicular di-
 
 DISEASES OF THE APPENDAGES. 381 
 
 rection upon the eyebrow towards its inner 
 angle, and in this direction it is to be gently 
 depressed until it strikes upon the floor of the 
 nostril, where its presence is readily ascertained 
 by a common probe, passed beneath the infe- 
 rior turbinated bone. The probe of smallest 
 dimensions is of sufficient firmness to preserve 
 its figure in its passage through the healthy 
 duct, but it is too flexible to oppose any con- 
 siderable obstruction, without danger of a change 
 of figure : for the stricture of the lacrymal ducts 
 it is of sufficient strength. 
 
 Very many cases of recent origin, and in 
 which the stricture has no great degree of firm- 
 ness, are completely cured by three or four in- 
 troductions of the probe into the nostril, at in- 
 tervals of one or two days. 
 
 I have seldom met with a stricture so firva as 
 not to yield to the full-sized probe. I am fully 
 aware of the objection that immediately pre- 
 sents itself, viz. that a passage so obtained is not 
 permanent ; by several repetitions of the opera- 
 tion it is often rendered so ; but if the resist- 
 ance is not altogether removed, after a trial of 
 the experiment for some days in succession, I 
 introduce a style having a small flat head, a lit- Lacrymai 
 tie sloped, through the punctum lacrymale into ^'^^^^" 
 the nose, and leave it for a period of twenty- 
 four hours in the duct. If worn longer, as for 
 two days, it ulcerates the orifice ; but I have
 
 382 DISEASES OF THE APPENDAGES. 
 
 never seen it injure the punctum in the smallest 
 degree, when worn for the full period first 
 named. A day or two should be suffered to 
 elapse before the style is again introduced, and 
 it should then be passed through the other la- 
 crymal duct. The injection of tepid water 
 should be made on the intervening days with 
 Anel's syringe. The plan requires persever- 
 ance, as may be said of all plans by which so 
 difficult an object is sought to be effected. In 
 many cases the resistance, in the first instance 
 opposed, is inconsiderable, yet it is sufficient to 
 maintain the disease. The probe passes daily 
 with increasing facility, and after a very few re- 
 petitions, with as much ease as througli tlie 
 healthy canal ; yet the stillicidium, and even the 
 mucous discharge do not immediately subside, 
 because, although the obstruction is removed by 
 which these symptoms were originally set up, 
 the parts have not yet recovered the loss of tone 
 which the state of habitual obstruction and inac- 
 tion has induced; and here the use of the probe 
 is unavailing, if not injurious, as in all cases in 
 which the full-sized probe passes without impe- 
 diment. It is important that operators should 
 consider this, and not lose sight of the vital 
 function of the parts, in treating the morbid al- 
 terations of structure which have interrupted 
 and deranged them. For this mitigated, but 
 not recovered state, time alone, with attention 
 to prevent distention by occasional gentle pres- 
 sure of the sac if accompanied with mucous dis-
 
 DISEASES OF THE APPENDAGES. 383 
 
 charge, is often sufficient ; but the injection of 
 a solution of alum, or even of cold spring M^ater, 
 and the use of astringent washes, will assist. 
 Sniffing a stimulant vapour, as of vinegar, or di- 
 luted nitric acid, into the nostril, I have also 
 found useful. It is of course unnecessary to 
 pass a probe, when the fluid injected by the 
 punctum drips in a stream through the nostril 
 or into the throat, as the head of the patient is 
 inclined forwards or backwards ; but this test 
 of the freedom of the passage should be had, 
 before the use of the probe is laid aside. 
 
 If it be objected to this operation, that it is 
 always painful, and often tedious, I can only re- 
 ply, that there is too much truth in the objec- 
 tion. I shall be happy to be instructed in one 
 equally effective, and free from these objections. 
 I am far from assuming that all the other mea- 
 sures employed might not be crowned with suc- 
 cess in favorable cases ; this, like other com- 
 plaints, sometimes recovers, not so much in 
 consequence, as in despite of treatment. 
 
 Of all the other modes, the seton of Mejan Seton. 
 alone appears to me to be a rational practice ; 
 it too is tedious, and, during its use, deforming. 
 The tube seems, on the other hand, to be of all Tube. 
 the most objectionable. I have seen cases of 
 its employment, in which it very speedily be- 
 came plugged with mucus, the sac habitually 
 loaded, the nostril dry, and the stillicidium per-
 
 384 DISEASES OF THE APPENDAGES. 
 
 manent. But how a metallic tube can be ex* 
 pected to form a substitute for the natural duct, 
 an inorganic to serve in lieu of an organized 
 part in perpetuity, the functions of the puncta 
 and sac to be restored, and as it were in con- 
 sent with it, I confess myself at a loss to con- 
 ceive. I have more than once heard patients 
 sorely regret that they had submitted to its in- 
 troduction, having received no degree of per- 
 manent benefit from the operation, and I have 
 been called upon to remove it, which is not 
 easily done, in one case from the disease which 
 it had set up in the contiguous soft parts, and 
 in others from an exasperation of the symptoms 
 of the complaint. I am now speaking from 
 what has incidentally passed under my notice of 
 the practice of others ; but I ought in candor 
 to add, that some very intelligent surgeons, both 
 English and Foreign, have lately assured me of 
 the general success of the practice in the able 
 hands of M. Dupuytren, at Paris*. 
 
 In the use of the lacrymal probes, caution is 
 requisite ; they must be passed with great gen- 
 tleness, and if the extremity becomes confined, 
 a little withdrawn, so as to prevent their hitching 
 in the membrane, and passing beneath it j the 
 size should never be such as to distend the la- 
 crymal canal, lest it should injure the texture 
 and destroy the tone of the part j and no consi- 
 
 * See note M.
 
 DISEASES OF THE APPENDAGES.' 385 
 
 derable degree of pressure should be made with 
 one so slight as to be in danger of becoming 
 curved. A probe of sufficient dimensions and 
 firmness to preserve its straightness, is quite 
 within the measure of the lacrymal orifices and 
 ducts, and has strength enough to overcome 
 an ordinary stricture. Injections should be fre- 
 quently employed to ascertain the progress of 
 the case towards recovery. They are of great 
 use in almost all stages of the disease. 
 
 There are undoubtedly many cases of slight Epiphora 
 epiphora not depending upon mechanical ob- enfjf ot 
 struction of the lacrymal excretories *. The zinc s"^"'^t'°"- 
 and the lunar caustic solutions, the thebaic tinc- 
 ture, the mercurial ointments introduced be- 
 tween the lids will remove such forms of the com- 
 plaint, if the patient is so far inconvenienced as 
 to apply to his surgeon for relief, which is not 
 always the case. Again, the gleety discharge 
 of the sac, as it is not always present with stric- 
 ture, is sometimes, though not often, present 
 without it. Stimulant collyria,. cold water, 
 alum injections, and constitutional tonics, must 
 be employed to cure it. The chronic, thicken- 
 ed, and hardened state of the sac after abscess, 
 and in the state of fistula, is removed by leeches, 
 cold poultices, and saturnine lotions ; and if the 
 skin be free from inflammation, it is reduced by 
 the mercurial ointment. A small fistulous aper- 
 
 * See Note N. 
 c c
 
 386 
 
 DISEASES OF . THE APPENDAGES. 
 
 tore, where tlie disease has been left to nature, 
 is a common and troublesome case. The aperture 
 should be freely dilated, the open state of the 
 canal ascertained by the pocket probe, and the 
 part afterwards treated as above directed. 
 
 Abscess 
 
 with caries. 
 
 No peculiar treatment is required in the ab- 
 scess with caries of the bones ; a case much less 
 frequent than would be imagined from its de- 
 scription as a stage of the disease. In this case, 
 as in that where the sac has yielded to ulcera- 
 tion before the integument, the skin should be 
 freely divided, that is, beyond the confines of 
 the sac. I never met with a case requiring the 
 use of a trocar, nor do I believe the perforation 
 of the OS unguis is ever really required. 
 
 Relaxed 
 sac. 
 
 I am not practically acquainted with the effect 
 of pressure upon the relaxed or hernial lacrymal 
 sac. It is an old, and, I believe for a better 
 reason, an obsolete practice, viz. that it is diffi- 
 cult of application and inefficient. 
 
 Dropsy of 
 the sac. 
 
 For the opportunity of seeing and treating an 
 interesting case of dropsy of the sac (the dis- 
 ease described at page 247) I am indebted to 
 the kindness of Mr. Alexander, to whose exten- 
 sive observation of this class of diseases it was 
 new, as it was to mine. I exposed the distended 
 and transparent sac by dissection, and removed 
 by the scissars the two anterior thirds of it. A
 
 DISEASES OF THE APPENDAGES. 387 
 
 process of suppuration which ensued was for 
 some time troublesome, but the wound at length 
 healed soundly, and the complaint was cured by 
 this treatment. 
 
 With the disease in which the sac is said to Mucocele. 
 acquire the size of a pigeon's egg from an accu- 
 mulation of inspissated, or rather indurated se- 
 cretion, having a cartilaginous hardness, and a 
 livid color, I am entirely unacquainted. But a 
 confinement and inspissation of its proper mu- 
 cous secretion in such accumulated quantity as 
 to distend and morbidly enlarge the sac, giving 
 it the appearance of a firm incompressible glo- 
 bular tumor, 1 have repeatedly seen and remov- 
 ed by persevering in the use of the probe and 
 syringe. In this case the lacrymal and nasal 
 ducts are equally obstructed. It may be pro- 
 perly termed * mucocele*, and should not be 
 permitted to continue. 
 
 \_Third Edition.'] — On the general treatment 
 of this disease I have only to observe, that ad- 
 ditional experience has fully confirmed the effi- 
 cacy of the practice which I have here recom- 
 mended. I have frequently anticipated the im- 
 pending suppuration of the sac by the early and 
 gentle introduction of the probe, by which the 
 disease has been arrested ; and it is only when 
 the skin partakes of the inflammation as a conse- 
 quence of distention, that I have recourse to an 
 external opening. After the relief of the sac, a 
 
 c c 2
 
 388 DISEASES OF THE APPENDAGES. 
 
 poultice reduces the inflammation ; and in a 
 few days the use of the probe may be resumed. 
 In recent obstructions, the disease yields to a 
 very limited course of treatment. In the chro- 
 nic, perseverance is required, and the early al- 
 ternate employment of the syringe greatly pro- 
 motes the object in view. The lacrymal style 
 I have discontinued, finding the benefit result- 
 ing from, its use disproportionate to the incon- 
 venience. 
 
 When the sac has been long over distended, 
 its contents should be gently expressed by the 
 point of the finger from time to time during the 
 injection ; which should in this case be made 
 persaltem, and always slowly and with very mo- 
 derate force, much counter resistance rends the 
 sac, and extravasates the fluid ; and although 
 this accident is of no ultimate importance, it 
 had better be avoided. 
 
 Some little time is required for the recovery 
 of the tone of the parts after the canal is re-esta- 
 blished. In some cases the symptoms of obstruc- 
 tion only in part disappear during the process of 
 cure ; but completely, a short time afterwards. 
 In most cases of inveterate or bony obstruction 
 the patient finds great relief from the open state 
 of the lacrymal ducts and the occasional ablution 
 of the sac, and I believe makes a compromise on 
 better terms with the disease than by wearing 
 the permanent tube or style.
 
 APPENDIX. 
 
 Dr. Christian Salamon, of the Medical and Chirurgical 
 Academy of St. Petersburg, one of ten gentlemen deputed 
 three years ago, by his Majesty the Emperor Alexander, to vi- 
 sit foreign schools for the purpose of acquainting themselves 
 with the state of medical science, an appointment equally ho- 
 norable to both parties, has politely favored me with the fol- 
 lowing anatomical sketch, which is the result of some very 
 delicate and laborious dissections. Some of these I have de- 
 rived much instruction and pleasure from being permitted to 
 witness, and although I do not feel satisfied in all points of 
 the accuracy of Dr. Salamon's conclusions, I have nevertheless 
 seen enough of his general professional intelligence, his talent 
 for minute investigation, and his method of conducting it, to 
 feel assured that the following brief memoir, in his own words, 
 will make no inconsiderable addition to the interest of this 
 work. I have the pleasure, at the same time, to announce, 
 that those who take an interest in these researches, will shortly 
 be gratified by the appearance of an anatomico-physiological 
 dissertation on this subject, upon which Dr. Salamon is at pre- 
 sent employed.
 
 OBSERVATIONS 
 
 SOME POINTS 
 
 ANATOMY OF THE EYE. 
 
 Sclerotica, before reaching the cornea^ increases in thickness, 
 and divides into two layers ; the outer advances beyond the 
 inner, and is connected with the exterior layers of the cornea; 
 the inner corresponds to the interior layers of the cornea. On 
 the inside of the inner layer of the sclerotica, near its termina- 
 tion, is an annular groove in the whole circumference, which 
 receives a tendinous ring (annulus tendinosus*); this ring is 
 situated without the choroid, and firmly adlierent to the scle- 
 rotic coat; on its inside it is connected with the origin of the 
 venous layer of the choroid coat. 
 
 Cornea consists of layers which are more firmly united at 
 its centre than at the circumference. The inner surface of it 
 is covered with a serous membrane (membrana humoris aquei, 
 Wrisbergi), the existence of which is easiest shewn in eyes of 
 aged persons; this membrane can be separated from the inner- 
 most layer of the cornea, and difiers from it in its greater te- 
 nacity and transparency. The latter quality it preserves in 
 spirit ; the greater firmness and more express character of a 
 serous membrane distinguish it from the layers of the cornea ; 
 it is not so liable as these to ulceration, or to be destroyed by 
 an ulcerative process, and, therefore, sometimes protrudes and 
 forms the disease called by Professor Beer, ' Keratokele.' 
 
 * Doellingeri descriptio oculi humani. Wurceburgi.
 
 APPENDIX. 391 
 
 Iris. Having subjected the iris to maceration, as I knew that 
 by such a process the choroid coat might easily be divided into 
 two layers, I succeeded in doing the same with this membrane. 
 To such a division of the iris into two layers I was led by the 
 observation of some writers on the anatomy of the eyeball, that 
 the membrane of the aqueous humor is continued over the iris 
 into the posterior chamber; but with them it has been a mere 
 supposition, and not proved by dissection. If there is such a 
 <;ontinuation over the iris, this membrane must be divided into 
 two layers ; in ascertaining this I succeeded, and shall now 
 endeavour to give a description of my dissection. I performed 
 the division more easily from the pupillar margin of the iris, 
 where this membrane is thicker, and at this place I could evi- 
 dently distinguish the turn which is formed by the anterior 
 layer of the iris continued into the uvea; betwixt these two 
 membranes I saw distinctly the nerves and vessels distributed 
 in a tortuous manner. Both membranes appeared somewhat 
 transparent. The anterior layer, constituting the forepart of ^ 
 the iris, secretes on its inside and between the two layers a 
 pigmentum, which exhibited itself to me in dark eyes, darker 
 than in light ones. From the remarkable diiference of this pig- 
 mentum in its color, I am inclined to think, that the different 
 color of the iris particularly depends upon it, which then only 
 €an appear evident, when the uvea secretes its pigmentum. 
 The anterior layer is afterwards continued to the tendinous 
 ring, where it unites with a serous membrane, which I con- 
 sider the origin of the venous layer of the choroid coat, under 
 an acute angle. The posterior layer or uvea secretes on its 
 back part the pigmentum nigrum; when this pigmentum is 
 removed, there appear small white processes going off from the 
 ciliary processes to the uvea, being continued from the ciliary 
 towards the pupillar margin, but not quite reaching the lat- 
 ter; these processes are, like the ciliary processes, more dis- 
 tinctly seen in dark eyes, and differ from them only in their 
 smallness. 
 
 Choroidca is easily divided into two layers, after maceration 
 of several days. 1. The outer layer, or c/ioroidca^ dricte sic
 
 392 APPENDIX. 
 
 dicta, is tlic thinner serous membrane, in which the ciliary 
 veins are distributed to form the vasa vorticosa; it appears 
 more distinct at its origin on the inside of the tendinous ring, 
 where it unites with the anterior layer of the iris, and exhi- 
 bits here evidently in its transparency the nature of a serous 
 membrane. I think that this origin of the venous layer of the 
 choroid coat has been described by Duverney as a peculiar 
 serous membrane, covering the choroid coat. This venous layer 
 appears more pallid at its beginning, on account of the ciliary 
 ligament situated under it, and the deficiency of pigment ; 
 just behind the ciliary ligament it is perforated by the ciliary 
 nerves and vessels of the iris. 2. The inner layer, or ruys- 
 chiana, is firmer, and secretes its pigmentum nigrum in the 
 back part of the eyeball on its outside; as soon as it reaches 
 the origin of the zonula ciliaris, it forms the ciliary body (cor- 
 pus ciliare), which begins with a dentated margin, and se- 
 cretes here its pigmentum nigrum on the inside ; hence the 
 impression of it appears on the zonula ciliaris. Professor Beer 
 distinguishes the posterior part of it as the ' pars non plicata 
 corporis ciliaris,' which is larger on the temporal than on the 
 nasal side of the globe, on account of the retina advancing 
 more forward on the nasal side, as the optic nerve enters more 
 on that side of the globe. This pars non plicata is the very 
 part through which the needle is brought into the vitreous 
 humor in operations through the sclerotic coat, and it is the 
 part which is united by cellular tissue with the zonula ciliaris, 
 .to which the processus ciliares have no adhesion in the human 
 eye. Professor Beer calls the anterior part of this body, pars 
 plicata, to the formation of which the ciliary processes contri- 
 bute. The ruyschiana, after having formed this body, con- 
 tinues forward — having to its inner surface firmly united the 
 ciliary processes, and to its outer the ciliary ligament — to the 
 back part of the iris into the uvea; so that I consider the 
 ruyschiana as the mere continuation of the uvea. This conti- 
 nuity is not disturbed, after having separated the ciliary pro- 
 cesses with their origins ; and the appearance of both mem- 
 branes is completely the same, each exhibiting the nature of 
 a thin scrou^i membruuc.
 
 APPENDIX. 393 
 
 Having noAV described the choroid coat and the iris^ and 
 the connexion of them anterior to the tendinous ring, I must 
 here remark, that when this tendinous ring is separated from 
 the sclerotic coat, the venous layer of the choroid and the ante- 
 rior lamina of the iris form one membrane turning towards 
 the cornea for the space of about one line; which appearance 
 makes me believe, that it is the membrane of the aqueous 
 humor, though I could not follow this membrane further 
 by dissection, so as to shew clearly its continuation. Yet 
 it is evident that this membrane divides before the tendin- 
 ous ring into two, the outer and posterior forming the ven- 
 ous layer; the inner and anterior, forming the iris, conti- 
 nues, uvea and ruyschiana. That it is a division of this mem- 
 brane in these two different directions, I conclude from the 
 tiner structure of each of these two membranes than of that 
 before the tendinous ring. The expressed character of a ser- 
 ous membrane in the latter, and its similarity in structure 
 with that of the aqueous humor, make me believe, that it 
 is really the membrane of the aqueous humor itself; patholo- 
 gical observations prove also such a contiguity to the iris, i. e. 
 the corneitis so quickly followed by iritis, and vice versa; so 
 that the primary inflammation of the cornea is denied by emi- 
 nent pathologists. 
 
 As to the nature of the iris, choroidea, and ruyschiana, I 
 am inclined to think that they are of a serous kind, from the 
 appearance which they exhibit in their natural state, and the 
 more so, from the morbid alterations to which they arc sub- 
 jected during inflammation, which is most evident in the 
 iris, viz. the disposition to throw out coagulable lymph even 
 in the slightest degrees of inflammation, and thus to produce 
 an adhesion of the uvea to the capsule of the lens, or to 
 close the pupil entirely; in other cases to form partial or 
 total adhesions of the iris to the cornea. The tubercles in the 
 syphilitic iritis, which Beer calls condylomata, and appear at 
 the ciliar or pupillar margin of the iris, are of a more or less 
 brownish and red color, which variety of color depends on 
 the smaller or greater organization of the coagulable lymph.
 
 394f APPENDIJi. 
 
 In a higher degree of iritis, though more rarely, there may be 
 formed an abscess, which occupies, as Beer observes, the mid- 
 dle of the iris ; in these respects, as to the liability of adhesive 
 inflammation, and rare occurrence of suppuration, in the sub- 
 stance of the iris, it coincides in its nature with that of serous 
 membranes. The same liability to adhesion we may observe 
 in the choroid coat, when a dissection of the eyeball is per- 
 formed after a deep-seated inflammation, when we shall find 
 not rarely adhesions of the venous membrane to the sclerotic 
 coat, but more frequently of the ruyschiana to the retina ; or 
 after the operation for cataract, adhesion of the zonula ciliaris 
 to the ciliary processes. The ditiference of function in the iris 
 and ruyschiana, though they are the continuation of a serous 
 membrane, I explain from the addition of other parts, as in 
 the iris, of the ciliary nerves and vessels, to which I think the 
 motion of the iris is to be attributed; amd in the uvea and 
 ruyschiana, from the other ciliary arteries, which secrete the 
 pigmentum nigrum. 
 
 Ligametitum ciliare, is a cellular substance of a conical shape, 
 situated between the choroidea and ruyschiana, just above the 
 corpus ciliare and ciliary processes, its basis turned to the iris, 
 its apex backwards. It is of various colors ; in light eyes it is 
 lighter, looser, and larger. As to the use of it, I think it is for 
 defending the vessels and nerves of the iris, which go through 
 it. These vessels and nerves are situated at the back part of 
 the globe without the venous layer of the choroid coat, and as 
 soon as they reach the ligament perforate this membrane. 
 
 Processus ciliares, are situated on the inside of the ruyschi- 
 ana, occupying nearly the anterior half of the ciliary body; 
 they originate by their bases in the angle formed by the uvea, 
 continuing into the ruyschiana ; they are situated outwards 
 and backwards ; their attenuated termination -is where the 
 connexion of the zonula ciliaris with the ciliary body begins. 
 They may be separated from the corpus ciliare by the help of 
 a needle, and elevated. There appear some larger and some 
 smaller processes, and two commonly arise together. The ori-
 
 APPENDIX. 
 
 gins of these processes form the boundary of the posterior 
 chamber in its entire circumference. From this description, 
 it is evident that the depression of the crystalline lens into 
 the posterior chamber (as described by some oculists) cannot 
 be done without a violent injury to the ruyschlana or iris. 
 From these processes arise smaller ones, continuing to the back 
 part of the uvea. As to these processes, I have still to remark, 
 that they are described by some anatomists as connected with 
 the choroid coat, but I could not find such a connexion. That 
 they are formed by the ruyschiana, I can also not admit, be- 
 cause, 1. they may be separated and raised from the corpus 
 ciliare without injuring the continuity of the ruyschiana; 2d. 
 they are different in their structure, endowed with greater 
 firmness and elasticity ; 3d. they do not secrete pigmentum 
 nigrum in the human eye. I consider these processes as con- 
 sisting in themselves of a different stmcture from that of the 
 membranes of the eyeball ; they appear to me very elastic, and 
 of a substance which I might call one betwixt tendon and li- 
 gament. These processes are covered with a cellular tissue, 
 which I have seen fully injected ; this cellular tissue seems to 
 be the secreting apparatus of the aqueous humor in the pos- 
 terior chamber. 
 
 Retina, covers the corpus hyaloideum, and is connected with 
 it at its back part, after having entered the eyeball, but much 
 firmer in its connexion at the anterior part, where the zonula 
 ciHaris originates at the dentated margin of the ciliary body; 
 here it forms the ora serrata, which is considered the end of 
 the retina. Professor Doellinger describes a thinner continua- 
 tion under the zonula ciliaris as far as the canal of Petit. I 
 repeated these dissections, and found that there exists a sub- 
 stance exhibiting itself as cellular texture, destitute of medul- 
 lary substance ; whether this is mere cellular texture, or a con- 
 tinuation of the inner layer of the retina, is uncertain. As to 
 the membrane described by Jacob in a late number of the Phi- 
 losophical Transactions, I have seen it in brutes; it appears 
 evidently of a serous nature. 
 
 39S
 
 390 APPENDIX. 
 
 Zonula Ciliaris. An accurate description of this part has 
 been given by Professor Doellinger (iiber das Strahlen-bliitt- 
 chen), of which I shall mention shortly the anatomical facts. 
 The zonula ciliaris is situated under the corpus ciliare^ and 
 the serrated margin of that body denotes its commencement^ 
 from which place it goes to the anterior capsule, and unites 
 with it intimately. The ruyschiana is easily separated from 
 the retina until it reaches the zonula ciliaris ; it is united with 
 this by firm cellular texture. The zonula Zinnii has about 
 three lines of breadth, has an anterior and posterior margin, an 
 outer and inner surface; the outer one is connected with the 
 corpus ciliare ; the inner surface is connected with the atte- 
 nuated continuation of the retina ; the anterior part of the zo- 
 nvda is free. The canalis Petiti is formed by the zonula Zinnii 
 and hyaloid membrane; the hyaloid membrane is connected 
 with the posterior capsule of the lens more backward, and the 
 zonula Zinnii more forward with the anterior capsule, so as 
 to leave a triangular space. The zonula consists of fascicles, 
 which appear more evident when the canal is filled with air 
 (Zinn); these fascicles are connected with the serrate promi- 
 nences of the retina. Since Winslow's time, this zonula is 
 derived from a splitting of the hyaloid membrane ; but the 
 following observations are opposed to this opinion: 1, The 
 hyaloid membrane has such a thinness, that it cannot be di- 
 vided into tAvo layers, as Zinn had already observed. 2. The 
 zonula has a quite diflferent structure; the hyaloid membrane 
 has nothing fibrous. 3. The hyaloid membrane is at the pos- 
 terior convexity of the lens not thinner than in the other re- 
 gions of the vitreous humor. 4. Between the corona ciliaris 
 and hyaloid membrane is situated the continuation of the re- 
 tina under the zonula. I have to mention last, the distribution 
 of vessels in the zonula, which also proves, that it is not a con- 
 tiimation of the hyaloid membrane; the anterior part of the 
 zonula obtains its vessels with the anterior capsule of the lens; 
 the posterior part of the zonula from the artoria centralis after 
 its division upon the posterior capsule of the crystalline lens, 
 and forming here an anastomosis with the other vessels; and
 
 APPENDIX. 397 
 
 finally the zonula has been injected with the capsule, but the 
 hyaloid membrane has not shewn the least trace of injection. 
 
 Lens crystaUina, is included in a proper capsule ; the an- 
 terior is firmer than the posterior, which depends on the con- 
 nection with the zonula ciliaris, and obtains its vessels from 
 the corpus ciliare. In the posterior capsule is distributed 
 the arteria centralis, and it is connected with the hyaloid 
 membrane by loose cellular tissue. 
 
 Humor vitretis, consists of cells, filled with a fluid like 
 aqueous humor. It obtains its vessels from the retina, and 
 the central artery going to the capsule gives off the arteria 
 lateralis Albini. When the cells are destroyed, they are not 
 restored, but the space is filled by a fluid, which resembles 
 aqueous humor.
 
 y'i. 
 
 7- 
 
 V^-vfT^ 
 
 FIA7 
 
 ^>:?.^. 
 
 ■"/■ /• 
 
 .-/>;, 
 
 /\yi^. 6^ 
 
 Dnanif H.Jkmsen. 
 
 Eny^bf J.SBKirt,.
 
 EXPLANATION OF THE PLATES. 
 
 PLATE I. 
 
 Fig. 1. A plan of the muscular branches of 
 the ophthahnic artery, from Soemmering. Icon. 
 Ocul. Hum. Tab. 4<ta. 
 
 Fig. 2, Simple acute inflammation of the 
 conjunctiva. See page 9I» 
 
 Fig. 3. A plan to shew the cicatrization of 
 an ulcer of the cornea, whether pustular or in- 
 terstitial, and communicating with the surface 
 by a fasciculus of vessels carrying red blood. 
 See page 109. 
 
 Fig. 4. The state of strumous nebula with 
 vessels in the form of radii overshooting the 
 cornea. These are not continuous with, but 
 distinct from the vessels of the conjunctiva, and 
 beneath it. See page 110. 
 
 I have seen cases of the prolongation of these 
 vessels even to the centre of the cornea, orga- 
 nizing the nebulous deposit, affecting both eyes 
 of the same patient, and occasioning total opa-
 
 400 EXPLANATION 
 
 city and blindness, perfectly restored by con- 
 tinued ptyalism. The first change was the 
 breaking and clearing of the dense deposit of 
 lymph, then the fading away of the rose-colored 
 zone at the verge of the cornea, and lastly, the 
 gradual disappearance of the vessels on the 
 cornea. See page 288 and seq. 
 
 Fig. 5. A plan of the anastomosis of colored 
 vessels upon an opaque cornea ; * chronic inflam- 
 mation with vascular cornea.* See page 110. 
 
 Fig. 6. Aphthous or pustular inflammation 
 of the conjunctiva. Two large aphthae are seen, 
 one on either side of the cornea, situated nearly 
 in the transverse axis of the globe. This figure 
 was selected for the purpose of shewing the pe- 
 culiarity of two distinct orders of vessels bound- 
 ed by -the pustules. The upper segment of the 
 hemisphere presents the ordinary superficial 
 vessels of the conjunctiva, having the areolar 
 distribution. The lower are the straight ves- 
 sels penetrating the sclerotica, and appearing 
 through the transparent conjunctiva. This two- 
 fold arrangement is seldom so distinctly seen. 
 See pages 95 and 128. 
 
 Fig. 7' The blue tumor of the sclerotica, 
 * staphyloma scleroticae,' accompanying various 
 disorganized states of the globe. See page 
 130.
 
 OF PLATE I. 401 
 
 The figures 2, 4, 6, and 7, in this plate, are 
 from nature. The three former have an appear- 
 ance of unnatural magnitude, from the artificial 
 elevation of the upper and the depression of the 
 lower lid, for the purpose of exhibiting the con- 
 junctival surface around the cornea. 
 
 » D
 
 ( 402 ) 
 
 PLATE 11. 
 
 Fig. 1. Carcinoma of the conjunctiva afFect- 
 ng the globe and eyehds. 
 
 This very accurate representation of the dis- 
 ease was taken from the eye of a patient of mine 
 in St. Thomas's Hospital, by Dr. Zuckerbecker, 
 a very intelligent physician now settled at Mos- 
 cow. See page 100. 
 
 Fig. 2. A section of the fungous growth re- 
 presented in situ, Fig. 4. 
 
 Fig. 3. The state of central slough of the cor- 
 nea in the last stage of acute suppurative in- 
 flammation. 
 
 Fig. 4. A peculiar fungous growth intersti- 
 tial to the conjunctiva and cornea. See page 
 102. 
 
 This figure represents the appearance of the 
 disease, as it was presented to me in the person 
 of an elderly lady from Somersetshire, and the 
 idea I then formed of it was that the fungus had 
 originated from the iris, or choroid tunics, con- 
 sequent to a slough of the cornea. Finding 
 that the sclerotic tunic was sound, I proposed 
 the excision of tlie tumor by an operation simi-
 
 ^\\v 
 
 
 ^^c/. fi. 
 
 L<^ndi)n,Puilished JSZi^.dyM^Z'I'Omjman Marst Jtees, Ortru &.3roirn.
 
 EXPLANATION OF PLATE IL 403 
 
 lar to that for staphyloma. This was executed 
 with faciUty, and the patient quickly recovered, 
 the remaining portion of the globe collapsing 
 in the orbit. The surface had the deep blue tint, 
 and the currant or berry~Uke appearance de- 
 noted, likening it to what is termed by the Ger- 
 mans, 'Staphyloma racemosum,' but it proved 
 to be totally different in its nature from that dis- 
 ease. 
 
 The section Fig. 2. is shrunk from immersion 
 in spirit ; it is vari-colored and of unequal con- 
 sistence ; in some parts pulpy, in others firm ; the 
 sclerotica is not altered in its structure ; the iris 
 is thickened by inflammation, the pupil closed, 
 and the capsule of the lens, which is shrunk and 
 opake, adherent to the uvea. The red line is 
 the section of the iris, and the yellow substance 
 beneath and adhering to it represents the shrunk 
 crystalline. These parts were quite free from 
 the disease and changed only by compression. 
 The cornea which is seen at the base of the fun- 
 gus, has lost its lamellated structure, and hence 
 appears firmer ; its surface is rough and has a 
 brownish tint, as if beginning to degenerate into 
 the morbid mass which lies above it. This not 
 only covers the cornea, but at one part a little 
 overlaps the sclerotica. The section discovers a 
 subdivision of the larger into lesser lobes, sepa- 
 rated by whitish lines intersecting the mass per- 
 pendicularly. The lobes differ in structure and 
 D D 2
 
 404* EXPLANATION OF PLATE II. 
 
 in color, as if originating in cells and distinct from 
 each other. In one part adjoining the surface 
 a whitish spot is conspicuous, of a cartilaginous 
 hardness. The fungus is covered by a mem- 
 brane easily torn ; if this be not the conjunctiva, 
 no trace of -that membrane remains ; but I am 
 disposed to think from its relation to the tumor, 
 and the continuity of the conjunctiva sclerotica^ 
 with this membrane, at that part of the circum- 
 ference of the cornea where the pulpy mass has 
 encroached upon the sclerotica, that the covering 
 membrane is formed of the conjunctiva in an 
 altered state. The intimate adhesion of the fun- 
 gus to the covering membrane, the total change 
 in texture of the conjunctiva, and the fuller evo- 
 lution of the disease next the surface, lead me 
 to suppose that it originates from that membrane ; 
 and from its lobular arrangement I conclude, 
 that the morbid growth occupies the cells of the 
 connecting membrane indicated by the white 
 lines intersecting it. 
 
 Fig. 5. Abscess of the eyeball terminating 
 in ulceration and death of the cornea and dis- 
 organization of the globe. See page 220. 
 
 Fig. 6. Scirrhus of the lacrymal gland. See 
 page 233. The deformity was removed by ex- 
 tirpation of the gland.
 
 cjjv- / 
 
 ^'1.1,. :j. 
 
 "/■ 
 
 
 ■vi 
 
 MT' 
 
 pun 
 
 S'nmfL Ij M. Jhmstfo. 
 
 £ng'^ fy J. Strmrt. 
 
 loTUbilubUthti 1^20.hi 2Iei's^Jtymin.Mur.'C.lUfS. Prmc !t Brmiu.
 
 ( 405 ) 
 
 PLATE III, 
 
 Fig. 1. and 3. represent in different positions 
 the eye of a child affected with the maUgnant 
 fungus, prior to the opacity of the cornea ; in 
 which are observable the change of figure of the 
 globe and annihilation of the anterior chamber, 
 by the bulging of the opake lens and iris. 
 
 Fig. 2. is a section of the same eye. 
 
 These drawings having been made imme- 
 diately upon the removal of the eyes after death, 
 represent accurately the recent appearances, 
 but by a minute dissection after hardening in 
 spirit, I have been enabled to trace some ves- 
 tiges of the several textures which the mere sec- 
 tions do not exhibit, in a manner which would 
 have given the representation, if that had been 
 possible, additional interest, as it throws much 
 light on the origin and progress of the diseased 
 growth. 
 
 A substance answering the description of the 
 * sarcoma meduUare,* occupies the upper and 
 back part of the eyeball, by which the vitreous 
 humor, which has undergone a similar degene- 
 ration, is compressed and pushed forward and 
 downward. The sclerotica is in a nerfectly
 
 406 
 
 EXPLANATION 
 
 healthy state, as are also the cornea, iris, and a 
 considerable part of the choroid ; the lens ab- 
 sorbed, its capsule firmly adherent to the uvea. 
 The diseased mass is evidently deposited be- 
 tween the venous and arterial layers of the 
 thickened choroid coat ; the former adherent to 
 the sclerotica, being situated external to the 
 morbid mass j the latter (which has been de- 
 scribed as the tunica ruyschiana), separated and 
 protruded by it, is denoted by a line crossing 
 the section obliquely. Here no pigmentum ni- 
 grum is secreted. The corresponding posterior 
 part of the retina is destroyed, the anterior is 
 adherent to the choroid. At the back of the 
 eyeball is a medullary tumor contained in a cap- 
 sule, formed by the surrounding cellular texture. 
 A similar tumor is formed by the optic nerve at 
 its entrance. The texture of these is somewhat 
 firmer than that within the ball, and between 
 these tubera and the internal diseased mass there 
 is no communication. 
 
 Fig. 4. represents the other eye of the same 
 subject, when by the progress of the disease the 
 cornea had perished by ulceration, and the fun- 
 gus, represented Fig. 5., was just about to pro- 
 trude. The leaden tint of the extenuated scle- 
 rotica is characteristic. - 
 
 Fig. 5. represents the contents of the orbit 
 on removal after death.
 
 OF PLATE III. 
 
 Fig. 6. is a section of the fungous mass. 
 
 The optic nerve filled with the morbid de- 
 position has its neurilemma thickened ; and a 
 similar substance occupies the cellular texture 
 within the orbit. The white lines bifurcating 
 from the extremity of the nerve, represent the 
 sclerotica thickened. On both sides of the en- 
 trance of the optic nerve, a mass is formed on 
 the interior of the sclerotica, resembling that on 
 its outside, except that its texture is firmer. 
 Forwards, on the right side of the figure, the 
 sclerotica is distinctly split into two layers by 
 the pulpy substance which has insinuated itself 
 between them. This corresponds to the upper 
 half of the globe. 
 
 The plate, which represents only a recent sec- 
 tion, does not illustrate the remaining points of 
 the description. They have been since made 
 out by subdivision and careful separation of 
 the several parts of the mass from each other. 
 As they are highly curious I siibjoin them. 
 
 The interstitial deposit is seen in the whole 
 anterior circumference of the sclerotica, but the 
 layers of this membrane are less widely separated 
 from it at the inferior part of the ball. At the 
 posterior part, where the sclerotica is single, the 
 membrane is much altered, but it has no where 
 given way, so that the diseased masses upon its 
 
 407
 
 408 EXPLANATION 
 
 opposite surfaces have no direct communication. 
 By the mass formed on its inside, the choroid 
 coat is distinctly seen to be protruded forwards. 
 At the anterior part, the sclerotica is llrmly con- 
 nected with the thickened choroid coat. The en- 
 tire centre of the cornea has perished by an ul- 
 cerative process, but a fragment of corneal la- 
 mella remains to denote its place, and behind 
 it is a portion of membrane adhering, and re- 
 sembling the iris much altered in its structure. 
 The softest part of the fungus is connected with 
 this membrane, and between it and the choroid 
 no trace appears of the humors or retina. This 
 anterior mass is distinguished from the posterior 
 growth of the sclerotica, from which it is sepa- 
 rated by the choroid, by its softer texture and 
 darker color. Hence it appears that the mor- 
 bid substance within the ball consists of two 
 different formations ; first, of the sclerotica de- 
 generated on its exterior and interior surfaces, 
 and likewise in its substance ; secondly, of the 
 choroid degenerated on its interior surface. 
 
 Fig. 7' This figure represents the section of 
 the eye of a child, aged eight months, which I 
 extirpated several years ago. The subject of 
 the operation has since enjoyed perfect health. 
 See page 207, where Fig, 4. is referred to by a 
 misprint. 
 
 The cells of the vitreous humor are filled
 
 OF PLATE III. 409 
 
 with an opake lardaceoiis substance, by which 
 the lens was shghtly protruded, and the iris ren- 
 dered convex. The eyeball was but little in- 
 creased in size or altered in figure. The scle- 
 rotica was in some parts thinner than usual, and 
 had a bluish hue from the preternaturally firm 
 adhesion of the choroid coat. The retina was 
 for the most part absorbed, the other tunics per- 
 fect, and the optic nerve free from disease. 
 
 There is no evidence to prove this change of 
 structure malignant, although the external ap- 
 pearances closely resembled those of Fig. 3.
 
 ( 410 ) 
 
 PLATE IF. 
 
 Fig. 1. 2. and 4. are from preparations in the 
 Museum at St. Thomas's Hospital. 
 
 Fig. 1. Is the section of an eye extirpated 
 by the late Mr. Ware. The morbid growth 
 fills the thickened sheath of the nerve, and tu- 
 bera are seen on both sides of the globe formed 
 in the substance of the sclerotica. The mass, 
 distinguished by a greyish tint and occupying 
 the posterior third of the globe, protrudes the 
 choroid tunic. The crescentic line of division 
 is formed by the choroid. The anterior mass, 
 which is darker, and closer in texture, cor- 
 responds to the vitreous humor. The choroid 
 and iris are anteriorly compacted with tlie scle- 
 rotica and cornea ; the retina has disappeared. 
 
 Fig. 2. Section of an eye in which the dis- 
 ease spreads from the sheath and substance of 
 the nerve through one side of the sclerotic tunic 
 almost as far as the cornea. It forms a broad 
 and compact mass of a yellow color. On the 
 opposite side this tunic is unaltered. The 
 choroid adjoining the tumor of the sclerotica 
 has undergone a similar change, being of a deep 
 claret color, equally dense in structure, and about
 
 FLATE 
 
 .9^.3. 
 
 '/>:/. r. 
 
 f 
 
 «l 
 
 .y/a. J). 
 
 Mra-^m. fy M.ThsmsaTi, 
 
 ^naraycd- iy J.MvsdidL. 
 
 L^Tidon.Fublislied. 2P20. hy MefsT^lormnari.I^trst. JRus. Orme. Sr Browrv.
 
 EXPLANATION OF PLATE TV. 411 
 
 half the breadth of the diseased sclerotica with 
 which it is compacted. The shrivelled retina 
 is seen proceeding from the extremity of the 
 nerve encompassed by the choroid tunic, which, 
 on the side opposite to the morbid growth, re- 
 tains much of its color and texture. 
 
 Fig. 3. is a representation of a fine specimen 
 of this disease in its more acute form. See page 
 315. The man from whose eye this drawing 
 was taken, was a farmer's servant, of temperate 
 habits, who had always enjoyed good health. 
 
 The following brief particulars of the case are 
 extracted from my clinical register. 
 
 Five months before his admission into St. 
 Thomas's Hospital, October I8I7, he first per- 
 ceived a dimness in the vision of this eye, and 
 after this had continued about a week, he was 
 attacked with an ophthalmia, accompanied by 
 severe pain across the forehead and orbits. 
 The pain was much exasperated by stooping, 
 which excited a sensation of the eyes being ex- 
 truded from their sockets. After a period of three 
 weeks the inflammation subsided, and he after- 
 wards felt only occasional pains darting through 
 the temples. About eight weeks since, he dis- 
 covered that he had totally lost the vision of 
 his right eye, and about a month ago the fun- 
 gus seen beneath the cornea first made its ap-
 
 412 EXPLANATION 
 
 pearance. On his admission into the hospital, the 
 fiingushad thesize of a filberd, of a reddish brown 
 color and irregular figure, protruding from the 
 under part of the ball, driving up and shrivelling 
 the cornea with which it was unconnected, and 
 covering the lower lid. He now suffered little, 
 if any pain ; and was free from glandular en- 
 largements. His digestive functions were un- 
 impaired, his general health good, and the op- 
 posite eye healthy in appearance. Towards the 
 end of the month the fungus had much increased 
 in size, and was disposed to frequent and free 
 hemorrhage. On the 7th of November, I per- 
 formed the operation of extirpation. Some 
 pieces of soft lint weie afterwards placed with- 
 in the orbit, and the lids supported by a com- 
 p^ress. The patient continued in a perfectly 
 favorable state until the 10th, when he had a 
 slight chilliness followed by perspiration. He 
 complained of pain darting towards the back of 
 the head ; his pulse was 72, and hard. A free 
 suppuration having commenced, the lint was 
 removed from the cavity of the orbit. Sixteen 
 ounces of blood were drawn from his arm. His 
 bowels had been freely open since the operation. 
 From this day until the 15th he continued free 
 from fever and from pain ; a healthy and copious 
 suppuration was established ; he had a soft and 
 natural pulse,except that it was sometimes a little 
 irregular. On the l6th he left his ward, and re- 
 mained for some time in the square of the hospital.
 
 OV PLATE IV. 413 
 
 thinking the air would be of use to him. Soon 
 after coming in he was attacked with a very se- 
 vere rigor, followed by heat and profuse sweat- 
 ing. On the 17th he had considerable fever. 
 The scalp above the external angle of the orbit 
 was considerably puffed and tender to the touch, 
 and a free incision was made to the bone, when a 
 collection of matter was discharged from beneath 
 the periosteum. On the 18th, his febrile symp- 
 toms having yielded to the exhibition of anti- 
 monials, the skin clammy, occasional intermis- 
 sion of the pulse, and great lowness, he was put 
 upon a nourishing diet, and ordered to take bark, 
 and an opiate at night. 19th. He had slept 
 well, but his looks were much altered for the 
 worse ; he was partially comatose, and his an- 
 swers were lingering and not always coherent. 
 The pulse was slow and feeble, and the inter- 
 missions more frequent and longer ; his tongue 
 when protruded was tremulous and drawn a little 
 to the left side. On the 20th he was attacked 
 with convulsions, which continued until an early 
 hour of the morning of the 21st, when he ex- 
 pired. 
 
 On examination, thirty five hours after death, 
 a large quantity of purulent matter escaped 
 from beneath the dura mater. Upon raising that 
 membrane, a purulent deposition extended over 
 the whole of the right hemisphere, to which it
 
 "^l^ feXPLAl^ATION 
 
 was confined. The dura mater retained its at- 
 tachment to the cranium ; no communication 
 could be traced between the morbid appearance 
 of this membrane and the orbit ; the optic fora- 
 men being completely closed and the nerve in a 
 perfect state. The substance of the brain had 
 a natural appearance, allowing for some conges- 
 tion occasioned by pressure. 
 
 I cannot avoid remarking the importance of 
 this history, setting aside the consideration of 
 the malignant disease, with which in fact the se- 
 quel had no connection. 1st. To shew the ten- 
 dency of an extraneous substance to provoke a 
 more copious suppuration from the orbitar ca- 
 vity, than otherwise follows the operation. 2ndly. 
 To demonstrate the tendency of membranous 
 inflammation to spread, both by continuity (pe- 
 ricranium) and by contiguous sympathy (inte- 
 rior membranes of the brain). 3dly. To prove 
 the ill effects of exposure to cold during a free 
 suppurative process in the vicinity of the visceral 
 cavities, of which I have seen several well mark- 
 ed examples ; two, for instance, of the extension 
 of the suppurative action from the parietes of 
 the chest to the pleura, under circumstances 
 very similar. 
 
 Dissection of the Eye. 
 The whole cavity of the eyeball is filled with
 
 OF PLATE IV. 415 
 
 a dark friable fungous mass, and no trace of the 
 textures within the choroid can be distinguished. 
 The sclerotica, much extended and thinner than 
 in health, is in various parts of a purple hue, 
 from the intimate adhesion of the choroid, which 
 is thickened and filled with blood-vessels. An- 
 teriorly this coat could be separated from the 
 sclerotica; but backwards it had completely de- 
 generated into the morbid substance. On the 
 outside of the optic nerve, in the situation of 
 the foramen central e, the sclerotica had given 
 way, and the morbid mass projected in the form 
 of a tumor of the size of a large pea. The iris 
 and lens were completely destroyed, the cornea 
 in its middle part ulcerated, and the tumor be- 
 ginning to protrude through it j the optic nerve 
 was free from disease. 
 
 Fig. 4. is the section of a diseased eye, the 
 history of which is not known. The sclerotica, 
 it will be observed, is in parts morbidly thicken- 
 ed, the cavity appears to be divided into cham- 
 bers which are filled by a dark-coloured sub- 
 stance, compacted with the sclerotica, and inter- 
 spersed with specks and patches of white, giving 
 it a marbled appearance. The light-coloured 
 mass on the lower and right side of the drawing, 
 corresponds to the vitreous bodyj and a remnant 
 of lens, inclosed in its capsule, retains its relative 
 situation to that body, but is so displaced by the
 
 416 EXPLANATION 
 
 extension of the morbid growth adherent to the 
 cornea, as to be situated ahuost at right angles 
 with that membrane. The sheath of the nerve 
 is thickened. The disease seems to be a dege- 
 neration of the choroid and iris. 
 
 Fig. 5. is a very exact representation of an 
 eye which I extirpated at the commencement of 
 the year 1820. 
 
 The subject of this disease was a respectable 
 tradesman, forty-two years of age. He had en- 
 joyed good health until two years before, when 
 he experienced a sensation of heaviness in the 
 upper eye-lid, as if unable to raise it, though no 
 ptosis appeared. Pain commenced in the same 
 side of the head, extending from the forehead 
 to the occiput, and was subject to frequent ex- 
 asperation, depriving him of rest. By slow de- 
 grees the sight of the eye, at first only misty, 
 totally failed. The cornea became glazed and 
 dead in appearance. Three months prior to 
 the operation, the eyeball became also the seat 
 of pain, for that in the head was not diminish- 
 ed by day or night, and the ball at the same 
 time began to enlarge. The vessels assumed 
 the varicose appearance represented, and the 
 sclerotica protruded in several points which had 
 a deep blue color, and seemed threatening to 
 burst. About this time he was three or four
 
 OF PLATE IV. 417 
 
 times seized with a dazzling of vision, giddiness, 
 and momentary confusion, like slight shocks of 
 apoplexy. Lastly, the principal protrusions gave 
 way, and a continual hemorrhagic oozing took 
 place. In this state the operation was done. It 
 was followed by scarce any indisposition ; in a 
 fortnight he resumed his employment, and has 
 continued to this time free from uneasiness and 
 in the enjoyment of perfect health. 
 
 Fig, 6. is a section of the same eye. The 
 disease is here in its most advanced stage ; the 
 eyeball is double its natural size ; the sclerotica 
 of a deep blue color, being in some parts so 
 much extenuated as to seem on the point of 
 bursting -, the veins of the conjunctiva varicose 
 and turgid with blood. The mass contained in 
 the eyeball, wherein are no traces of the internal 
 parts, has a greater vascularity than in Fig. S. 
 At the upper part of the cornea, the sclerotica 
 has yielded to the disease, and a large tumor 
 projects. The cornea is not altered in structure, 
 otherwise than by compression and collapse. By 
 the side of the optic nerve, and beneath it, a 
 distinct tuber presents itself, the section of which 
 corresponds in appearance to that of the mass 
 which occupies the globe. The nerve is not af- 
 fected with the disease. 
 
 Third Edition. — Since the last edition of 
 this work the subject of this operation is de- 
 
 E E
 
 418 EXPLANATION OF PLATE IV. 
 
 ceased. The following particulars have been 
 obligingly transmitted to me by Messrs. Kent 
 and Ledger, Surgeons in Southwark, who at- 
 tended him in his last illness. 
 
 In December following the operation (March 
 1820) one of the submaxillary glands on the 
 same side became swollen ; after this Mr. J. was 
 frequently attacked with pain in the chest, and 
 hypochondria, and his intellect was occasionally 
 confused. In this way he at times suffered un- 
 til November 1822, when other glands about the 
 neck became enlarged ; the axillary glands were 
 afterwards similarly affected, and tubercles of a 
 livid hue were discovered on the parietes of the 
 chest and abdomen. The diseased glands as- 
 sumed the same livid appearance as the tuber- 
 cles, and the patient became the subject of 
 phthisis, of which disease he died in June 1823. 
 The swellings, which at this time amounted to 
 about fifty, had never given any considerable 
 pain, and the patient sunk before the integu- 
 ments ulcerated, which from their appearance 
 was daily expected. Examination after death 
 was refused.
 
 FLAT/', 
 
 J^y. / 
 
 ^Siia. 2. 
 
 l>ramt by // Tfumsort. 
 
 Kfiff by J.MurJirJi. 
 
 I.orido/v. J*n/>/ifh'd JS20. by Mc/s"^*' £/}iiqnym-.Mir3f-.Rf.c>: Orm<\ .C' Jiivwn.
 
 ( 419 ) 
 
 PLATE V. 
 
 Fig. 1 . represents the eye of a girl, a patient 
 of Sir Astley Cooper, in Guy's Hospital. The 
 disease was accompanied with glandular enlarge- 
 ments, and of several months standing. 
 
 Fig, 2. is the eye of an infant, aged eight 
 months, likewise a patient of Sir A. Cooper, in 
 Guy*s Hospital, in whom the disease was conge- 
 nital. See page 210. 
 
 From the central position of the cornea, and 
 the enormous protrusion, and equal figure of the 
 ball, the disease was supposed to be seated in 
 the orbitar appendages. It is remarkable that 
 the child was well nourished and apparently suf- 
 fered little constitutional disturbance. The right 
 eye was sound. 
 
 This child, I have since learned, died very 
 shortly after leaving the Hospital *. 
 
 * Second Edition. — I regret that the part was not ex- 
 amined. But from a careful dissection recently made of the 
 disease in a child of three years, which (except that it was 
 more advanced, having fungated) resembled it in size and 
 figure, and from the analogy it bore to other specimens in 
 their earlier stage, I entertain no doubt that the entire con- 
 tents of the orbit would ultimately have been converted, if 
 they were not already, into the medullary or white pulpy 
 substance, and that a luxuriant bleeding fungus would have 
 E E 2
 
 420 EXPLANATIOX 
 
 This engraving was reduced from a drawing 
 of the size of life, upon a scale of 25 to 36. 
 
 A proptosis or protrusion of the ball conveys 
 a delusive idea of the increased magnitude of the 
 organ. I have occasionally met with cases of 
 proptosis to such an extent as to occasion a 
 morbid change upon the cornea, with a varicose 
 state of the vessels of the conjunctiva ; and with 
 others, in which, although the cornea remained 
 clear, the vision was materially deranged, where 
 the cause of the protrusion was altogether ob- 
 scure, and the progress of the disease had been 
 so slow as to occupy a period of several years. 
 
 In these cases both eyes are equally affected ; 
 they are attended with a distressing degree of 
 deformity, obtuse pain in the forehead, and other 
 occasional signs of determination of blood to the 
 
 been thrown up on the sloughing of the cornea. In the case 
 just referred tOj this haematoid fungus was of the size of a 
 small orange, and the morbid growth, a true medullary sar- 
 coma, filled up, and corresponded in shape to the pyramidal 
 form of the orbit. The nerve was imbedded in the centre 
 of the sarcoma, and the periosteum of the orbit, thickened 
 and detached from the bone, invested it closely as a sheath, 
 while the fibrous section of the sclerotica, the only texture 
 distinguishable, plainly shewed the disease springing from 
 both its surfaces. On the os frontis were situated two me- 
 dullary tubera, one adhered to the external surface of the pe- 
 riosteum, the other to the internal ; and the latter had ab- 
 sorbed the outer table, being seated in the diploe of the 
 bone.
 
 OP PLATE V. 421 
 
 head. It is probably a morbid increase of the 
 adeps contained in the orbit, obstructing its cir- 
 culation, as well as protruding the eyeball. The 
 disease, when acute, is of a different and more 
 formidable nature. The following short history 
 is an example : — 
 
 Highland, a lighterman, stout and healthy, 
 aged twenty-nine, after frequent bleedings from 
 the right nostril, with an obstructed and snuf- 
 fling respiration, for which he w^as unable to 
 account, was attacked with a sevei^e pain over 
 the whole front of the head, with a sense of 
 weight in that part, and extreme lethargy. Al- 
 though naturally of an active cheerful disposi- 
 tion, he became morose, indolent, and fond of 
 solitude ; at intervals he was attacked with 
 tremors, cold perspirations, and syncope. These 
 symptoms had become established, when the 
 right eye began to protrude from its socket; 
 his pain was at this time more severe, and a 
 copious glairy discharge was set up from the 
 nostril. As the disease advanced, his manner to 
 his relations became strange, his intellect con- 
 fused, and his gait unsteady. The protrusion 
 steadily increased for several weeks without 
 abatement of his pain, except for a few hours 
 after occasional blood-letting. Convulsions at 
 length ensued, and terminated his existence 
 about three months after the commencement of 
 the proptosis. It is remarkable that he retained
 
 422 EXPLANATION 
 
 the vision of the affected eye up to the period of 
 its protrusion ; and before that was obvious to 
 his friends, he described the sensation of some- 
 thing pushing the eye out of its socket. It is 
 also remarkable, that through the whole period 
 of his disease, although his bowels were ex- 
 tremely torpid, he had a good appetite, and 
 little, if any, febrile irritation. These particu- 
 lars I learned from his surgeon and relatives, 
 having myself seen him only a few days before 
 his death. Upon dissection I found the follow- 
 ing appearances : — behind the cavity of the right 
 orbit lay a tumor, which had the appearance of 
 an oblong polypous cyst, and anterior to this was 
 a blood-colored fungus filling the orbit and ex- 
 truding the globe. The cyst lay anterior to the 
 dura mater, adhering to its surface, and so si- 
 tuated as to make the right hemisphere of the 
 cerebrum appear truncated of its anterior lobe. 
 The sethmoid bone, frontal sinus, and orbitar 
 plate of the os frontis on the same side were in 
 a state of caries, so that the finger passed readi- 
 ly from the orbit into the cavity of the cranium 
 and posterior nares. A large quantity of yel- 
 low viscid matter occupied the frontal sinus, 
 such as had been discharged during life by the 
 nostril. The os frontis in front of the sinus and 
 above the orbit was denuded, and presented nu- 
 merous worm-hole ulcerations. The anterior 
 lobe of the brain was discolored and softened ; 
 there was an extra quantity of water in the lei't
 
 OF PLATE V. 423 
 
 ventricle, and some fluid blood in the right. On 
 a transverse section of the right hemisphere of 
 the brain, it was found broken down in its tex- 
 ture, and the dura mater partially absorbed at its 
 basis, the tumor having opened into the ventri- 
 cle. The right thalamus was much diminished 
 in bulk, though entire. The haematoid fungus 
 in the orbit was mingled with spicula of bone, 
 and distinct from the tumor. The dura mater 
 to which the cyst adhered was continuous be- 
 hind the cyst, except at the lower part, where 
 it was destroyed. The disease appeared, there- 
 fore, to be connected with the external surface 
 of the dura mater, by its increase to have oc- 
 casioned absorption of the bones and displace- 
 ment of the eye (which was sound, as were also 
 the optic nerve and muscles of the globe), and 
 ultimately to have ulcerated through the dura 
 mater and anterior cerebral lobe, and discharged 
 itself into the right ventricle. All the nerves 
 were sound except the olfactory j this had dis- 
 appeared, together with the aethmoid bone, on 
 the right side. 
 
 Second Edition. — I have two cases at present 
 under my observation, of malignant proptosis 
 from some such formidable and inaccessible dis- 
 ease as that above detailed. In one, a polypous 
 tumor plugs and distends the nostril on the same 
 side ; in the other, the temporal wall of the or- 
 bit has given way, and the disease is extending 
 to the integuments.
 
 ( 424 ) 
 
 PLATE VL 
 
 The drawings in this plate are from the port- 
 folio of Dr. Savenko, a gentleman whose accu- 
 rate knowledge of anatomy adds greatly to the 
 value of his elegant talent for delineation. 
 
 Fig. 1. represents a malignant tumor of the 
 eyeball in a boy aged four years. This dread- 
 ful disorganization had attained a magnitude 
 nearly equal to that of half the head. The eye- 
 lids were enormously extended and swollen, with 
 varicose veins running over the surface, many 
 times larger than their natural size. The tumor 
 was of a reddish color, elastic, and very painful 
 to the touch. Betwixt the margins of the lids 
 grew a fungus, having an unequal surface, which 
 during the progress of the disease, assumed va- 
 rious colors from red to black, secreting a bad 
 smelling ichor intermingled with blood. At the 
 most prominent part of this fungus, the cornea 
 could be distinguished. The continual flowing 
 of the blood and ichor into the mouth increased 
 the hideous appearance of the face. The tumor, 
 from the excessive elongation of the upper lid, 
 hung over the cheek and covered one side of 
 the mouth. 
 
 The origin of the tumor could not be dis- 
 tinctly ascertained, and the case was dismissed
 
 .^//. / 
 
 i^f'fF"- 
 
 
 PLAT. 
 
 4 
 
 
 
 M 
 
 \^: U ill 
 
 
 \s. 
 
 
 
 <^^.:3. 
 
 ur. ^f. 
 
 Dra-m. iyT Saycnix. 
 
 ruUm..JMbh''hedje20, fy Mefs^ Zdrmrum,. Eurst,£cv, OrmCtS: Brown. .
 
 EXPLANATION OF PLATE VI. 425 
 
 from the hospital as incurable : its termination 
 is not known. 
 
 Fig. 2. is a section of the eye of a woman 
 aged 46, which was extirpated by Sir Astley 
 Cooper, at Guy's Hospital, in August 1820. 
 
 Two years before that time, the cornea of her 
 left eye became opaque from chronic inflam- 
 mation. 
 
 In this state, after a severe attack of fever, the 
 surface of the eye began to throw up a vascular 
 fungoid tumor. On her admission it was of the 
 diameter of a shilling, covering the cornea and 
 a part of the sclerotica, and protruding between 
 the eyelids. It was slightly lobulated, of a dark 
 purple color mingled with red ; it sometimes 
 bled, but was never painful. She was the mother 
 of nine children, and her health had been gene- 
 rally good. She recovered speedily from the 
 operation. 
 
 Dissection of tJie Eye. 
 
 The tumor is situated without the globe ; it 
 appears pulpy, vascular, and of an unequal 
 dark color. It is of a square figure, formed 
 of various lobes separated by delicate fibrous 
 bands, and adheres to the sclerotica and the 
 margin of the cornea. These two membranes
 
 426 EXPLANATION 
 
 could be traced entire beneath tlie tumor. 
 The globe being divided, the vitreous humor 
 escaped in a liquid state and of a yellow color. 
 The lens had disappeared. Within the globe 
 and opposite to the outer tumor, is another and 
 smaller morbid growth which has no communi- 
 cation with the former, and is of a softer and 
 very vascular substance. It occupies the lower 
 and anterior part of the globe, raises and com- 
 presses the retina, and is distinctly situated be- 
 tween the layers of the choroid coat ; the venous 
 layer on the outside is thickened ; it can be 
 traced backwards, and is firmly adherent to the 
 sclerotic coat, from which it is separated with the 
 help of a needle. The arterial (ruyschiana) is 
 thickened, but much less so than the venous 
 layer ; it forms a tumor within and behind the 
 morbid mass, which thus produces a complete 
 separation between the two layers of the choroid 
 coat. The retina, though displaced, is entire and 
 adhering to the ciliary body, the whole of which 
 is beginning to change into a similar morbid mass, 
 covered with pigmentum nigrum. The processes 
 are only in some places slightly distinguishable. 
 The uvea is also changed. The iris preserves 
 its color, though imperfectly ; it is adherent at 
 its centre to the cornea. The optic nerve is not 
 diseased, but thinner than in health. All the 
 points of situation and figure are distinctly and 
 faithfully exhibited in the engraving.
 
 OF PLATE VI. 427 
 
 I beg leave to offer a few additional observa- 
 tions on the several specimens of fungoid disease 
 exhibited in Plate II. Figures 2. and 4 : Plates 
 III. IV. V. and Plate VI. Figures 1. and Q. The 
 first of this series is unique in my experience. 
 In the explanation, I have stated my opinion that 
 the seat of the disease is the cellular texture 
 connecting the conjunctiv^a to the cornea. I find 
 no other texture degenerated, nor otherwise 
 affected than the contiguity and extent of the 
 disease explain. It was not characterized by 
 any symptom of malignity; neither pain in the 
 ball nor in the head worthy of notice, nor any 
 affection of the constitution. The deformity and 
 the fear of its increase were the inducements to 
 the operation, which was performed in the year 
 1819. This was attended by no untoward symp- 
 tom, and up to this time the subject of the dis- 
 ease has continued well. 
 
 In its fresh section the tumor nearly resembled 
 that described in Plate VI. Figure 2. ; in its 
 situation is not very dissimilar ; the cornea sup- 
 ports the former, the sclerotica the latter; but in 
 the latter the covering membrane is not trace- 
 able; and I have little doubt that the conjunctiva 
 gave origin to the fungus in both instances. The 
 internal tumor, however, gives a more compli- 
 cated and formidable character to the disease 
 depicted in the last plate.
 
 428 EXPLANATION 
 
 Plate III.) with the exception of Figure 7«> 
 exhibits the various appearances of the medul- 
 lary sarcoma in its several stages, in the eyes of 
 a child who was under my observation from tlie 
 commencement of it to the termination. In 
 one eye (^Figure 2.) the disease seems to have 
 begun in the interstitial texture of the choroid ; 
 the sclerotica is also affected on its outer sur- 
 face, and both the nerve and the vitreous humor 
 have undergone a kindred change. In the other 
 (^Figure 6.), which had advanced to an ultimate 
 state of disorganization, both surfaces of the 
 sclerotica, the interstitial texture of that mem- 
 brane, and the adipose membrane of the orbit, 
 are loaded with the diseased growth ; and by 
 after-dissection the choroid too was distinctly as- 
 certained to have partaken of the same action, as 
 is seen in the preparation in my possession. In 
 Plate IV. Figures 1. and 2; shew the disease 
 affecting the integral texture of the sclerotic 
 and choroid coats, and optic nerve. In Figure 
 1. the vitreous humor is evidently the basis of 
 the disease. In Figure 2. the retina retains 
 its character, and what remained of the vitreous 
 humor was, it is presumable, fluid. In Figure 4. 
 the vitreous and crystalline humor are still 
 marked, notwithstanding the displacement, re- 
 duced bulk, and total deterioration of the former. 
 The sclerotica is not specifically affected ; the ir- 
 regularities of its figure are owing to the several
 
 OF PLATE vr. 429 
 
 protrusions of the morbid mass, deeply stained 
 in parts as in Figure 1. with the pigment of the 
 choroid, by which tunic it is formed. Figures 
 S. 5. and 6. have a common character; they are 
 specimens of the genuine fungus hsematodes in 
 its acute form. This, in my belief, is not the 
 character of either of the preceding, or of the 
 figures in Plate V. ; but as the last-mentioned 
 were not subjected to dissection, I cannot speak 
 of them decidedly. 
 
 Figure 1. of Plate VI. is a rare disease : — a 
 child was lately brought to the hospital with a 
 large and rapidly increasing tumor upon the fore- 
 head, just above the orbit, and depressing the 
 upper eyelid. The eye was free from disease. 
 The swelling had a firm but elastic feel, and was 
 immoveable. The child was irritable, and of an 
 unhealthy aspect. The disease was concluded 
 to be a medullary osseous fungus. I am disposed 
 to think that this disease had a similar origin, and 
 that the bony parietes of the orbit have been ab- 
 sorbed, and by its increase the eye-ball protrud- 
 ed and disorganised in the manner represented. 
 
 Figure 2. shews conclusively the proper inter- 
 stitial origin of the disease in the choroid ; it is 
 separated by the outer layer of this membrane 
 and the healthy sclerotica from the similar fun- 
 goid degeneration of the conjunctiva.
 
 430 EXPLANATION 
 
 If the reader will compare with these the spe- 
 cimens delineated and described in Mr. Saun- 
 ders's Treatise, Plate II. and Mr. Wardrop's 
 Essay on the Fungus Hasmatodes, Plates II. and 
 ///. a striking analogy will be obvious to him in 
 the seat and texture of these diseases. They 
 appear to me to substantiate the observations at 
 page 227, that the disease is not peculiar to any 
 individual texture, but in turn affects nearly all 
 of which the organ is composed, 
 
 1. The cerebrum, optic nerve, in its medullary 
 and neurilemmatous texture; the sclerotica, cho- 
 roides, and its appendages ; the iris, retina, tu- 
 nica hyaloidea, and vitreous humor ; the mus- 
 cles, cellular and adipose substance, and the tu- 
 nica conjunctiva, are all susceptible of it. 
 
 2. The cornea and crystalline lens are alone 
 insusceptible. These structures are least vas- 
 cular, being naturally igipermeable to red blood. 
 
 3. The choroid is the most strongly disposed 
 to assume it, the retina least so. In Mr. Saun- 
 ders's Plate II. Figure 4. this tunic intimately 
 involves, and is indeed assimilated in texture 
 with the morbidsecretion occupying the vitreous 
 humor. 
 
 4. Some of these diseases appear to be chro- 
 nic J those, for example, which have a dense.
 
 OF PLATE vr. 431 
 
 firm, and semi-organic character. The pulpy or 
 brain- like are also slow by comparison with the 
 highly organized or haematoid species. The lat- 
 ter is sometimes engrafted on the medullary, but 
 it is as often primary. They frequently co-exist 
 in distinct parts of the same structure. 
 
 5. The comparative firmness and rapidity of 
 growth seem to depend on the texture from 
 which the growth proceeds. Speaking gene- 
 rally, the sclerotica and sheath of the nerve de- 
 generate into the dense and firm sarcoma, spar- 
 ingly organized ; the cerebral substance and the 
 medullary part of the nerve into the pulpy or 
 curd-like matter, which is the secretion also of 
 the vitreous cells ; the haematoid fungus is, I 
 believe, the production of the choroid and its 
 appendages. While the disease is confined to 
 the sclerotica, or to the vitreous cells, it is slow ; 
 when the choroid partakes of it, it is luxuriant, 
 increases rapidly, and bursts up the containing 
 textures. 
 
 6. So also the color distinguishes the share 
 which the choroid takes by the profuse morbid 
 secretion of pigment. In the rich collection of 
 specimens at St. Thomas's Hospital, to which I 
 have been much indebted, is one in which, ex- 
 cept the shell of the sclerotica, no traceable part 
 of the organ remains but an immense flocculent 
 mass, a sort of tomentum of black pigment. It
 
 432 EXPLANATION 
 
 was extirpated some years ago by my lamented 
 colleague, Mr. Henry Cline. The patient left 
 the Hospital well, and has not since been heard 
 of. It is probable then that the texture, color, 
 and rate of progress of the disease, vary accord- 
 ing to the texture which is affected j and proba- 
 bly a similar observation applies to other organs 
 as they are more or less vascular. 
 
 7. Cellular structure seems to form the com- 
 mon nidus of the morbid deposit, whether the 
 membrana adiposa, or the common connecting 
 tissue, or that proper to an organ, as the vitre- 
 ous humor. Hence it is as often interstitial as 
 superficial to the several tunics ; and often both 
 in combination, as in some of the instances 
 described. 
 
 As regards the pathological history and rela- 
 tions of these truly formidable and hitherto ob- 
 scure diseases, much interesting information may 
 be obtained by the perusal of Mr. Langstaff's 
 valuable cases and observations in the VIHth 
 and IXth Volumes of the Medico-Chirurgical 
 Transactions. 
 
 Unfortunately, in a practical view, our know- 
 ledge of them does not enable us to say when 
 they are, or are not (if ever not) constitutional j 
 when to anticipate success from an operation, 
 or the contrary, with sufficient certainty to afford
 
 OF PLATE VI. - 433 
 
 US encouragement to be active, or a pretext for 
 doing nothing. I have said that certain morbid 
 appearances in other parts should not always 
 preclude the consideration of relief — much less 
 the most advanced state of the malignant disease 
 confined to one organ ; yet it has not unfre- 
 quently destroyed the patient when so confined; 
 and after the operation, it often re-appears in a 
 remote part. Sir A. Cooper removed some years 
 ago a fungoid tumor from the shoulder of a gen- 
 tleman, who soon afterwards died of the disease 
 in the eyeball. In another case he removed the 
 fungous eyeball, and the patient died of the dis- 
 ease in the kidney. Unfortunately such instances 
 are not rare. But on the other hand, there are 
 not wanting cases to shew that the malignant 
 disease in some of its forms, or in certain tex- 
 tures, may be strictly circumscribed to a part 
 and almost stationary during a period of years ; 
 and, secondly, parts to all appearance so affect- 
 ed have been removed without any return of 
 the disease, during a similar period of observa- 
 tion ; and these facts warrant the operation 
 whenever the fungus is so placed, and the con- 
 stitution so supported as to admit of it. 
 
 Fig. 3. A fleshy pterygium. The subject of 
 it was a female about 21 years of age and of a 
 scrofulous habit. She had experienced repeated 
 attacks of the scrofulous ophthalmia, in one of 
 
 F F
 
 434 EXPLANATION OF PLATE VI. 
 
 which the cornea gave way, and the iris pro- 
 lapsed at the cihary margin. A pterygium 
 was then formed originating from beneath the 
 whole base of the upper eyelid ; it w^as of a tri- 
 angular form, extending to the lower margin of 
 the cornea J of a sarcomatous density, about one 
 line thick, and forming a fold when the eye was 
 directed upwards. It was completely cured by 
 the operation of dividing and detaching it at its 
 basis. The patient recovered her sight, and ul- 
 timately no vestige of the disease remained. 
 
 Fig. 4. A membranous pterygium. The sub- 
 ject of it was a girl sixteen years of age ; it su- 
 pervened upon chronic ophthalmia, and resem- 
 bled the former in size and shape, but was trans- 
 parent, so that the cornea and pupil appeared 
 through it. This was likewise successfully re- 
 moved.
 
 OTES. 
 
 NOTE A. 
 
 The relations of structure in every organ are such as to 
 render it impossible that any texture can long be singly af- 
 fected. But it seems reasonable to consider that texture 
 as the proper seat of the morbid action which presents the 
 earliest, or strongest^ or exclusive signs of it. I do not there- 
 fore adopt the term " Ophthalmitis Scleroticse/' as applied 
 to all the deeper seated inflammations ; nor do I consider 
 the corneal and iritic inflammations merely symptomatic, and 
 as having their proper seat and base in the sclerotica (al- 
 though in rare instances it may be so), because from the 
 aflinity and vascular connection of the parts, that membrane 
 presents the ordinary appearances of inflammation during 
 their existence. However inflammation may deviate from 
 the ordinary course and the order of local relation, and, how- 
 ever complicated its results may be, it is to be referred to the 
 texture primarily and principally aifected, and is thence pro- 
 perly denominated ; as in the instances of sclerotitis to M-hich 
 this note refers. 
 
 Intolerance of light is considered by some respectable au- 
 thors to be diagnostic of sclerotic inflammation. This is 
 not my opinion, having in numberless instances witnessed 
 that symptom in the most aggravated degree in the absence 
 of every external sign of inflammation. But on the other 
 hand, I am willing to admit, on the ground above stated, that 
 sclerotic inflammation is often present in such instances. 
 
 The sympathy of the sclerotica and the ligamentous cap- 
 sules with the urethra in gonorrhea, is as unquestionable as 
 that which has been more generally observed, because more 
 F F g
 
 436 NOTES. 
 
 frequently occurring, between the latter and the synovial 
 membrane. I have seen cases so nearly resembling that 
 described by Dr. Vetch in his late valuable treatise*, under 
 the head of ' gonorrheal ophthalmia' (page 243), that I can 
 vouch for the accuracy of the description. This phenomenon 
 it is not so easy to explain as the coincidence of the suppura- 
 tive inflammation of the conjunctiva with acute gonorrhea, 
 which, notwithstanding the apparent contradiction of some 
 experiments, I am convinced originates from contact, as is 
 indeed proved by the history of the ophthalmia of infants, and 
 by the fatal efi*ects which have unfortunately fallen more than 
 once under my observation, of an accidental application of 
 morbid matter to the sound organ. 
 
 The disposition between remote parts to be reciprocally 
 affected admits of two modes of explanation. First, by a 
 partial sympathy depending on identity of structure (serous, 
 synovial, mucous surfaces). Second, by a mode of the uni- 
 versal sympathy which prevails throughout the system, in- 
 dependent of the alliances of structure and organization, 
 which disposes parts different in properties to be affected re- 
 ciprocally by the same form of diseased action (joints of 
 the hand and foot, stomach and retina, in gout ; muscular 
 fibre and ligamentous capsules in rheumatism ; skin, mu- 
 cous membrane, and iris, in syphilis). To the numerous, 
 extensive, and complicated sympathies of the latter class 
 belong many cases of metastasis, in which the secondary 
 often differ from the primary forms of diseased action. In- 
 flammation in one organ occasions in another congestion, 
 and vice versa ; and the cessation of an habitual secretion in 
 one, whether natural or morbid, gives occasion to inflamma- 
 tion in another. Preternatural irritability, swelling, pain, 
 spasm, are thus excited by this reciprocal sympathy, in re- 
 mote organs ; or a metastasis, a change of place, strictly 
 speaking, occurs; the morbid action abruptly quitting one 
 part before it appears in the other. But not only does the 
 
 * See " A Practical Treatise on the Diseases of the Eye," by John Vetch, 
 M.D. F.R.S.E. London, 1821.
 
 NOTES. 437 
 
 reflected action often differ in its nature from the original, 
 but this, in many instances, continues in undiminished act-, 
 ivity, so that the metastasis is only an incidental feature of 
 the association. Now, if the sclerotica and the ligamentous 
 capsule are liable to be reciprocally affected, we may refer it 
 to the first stated sympathy of kindred textures, as in the 
 case of hernia humoralis and gonorrhea, whether simply 
 propagated or metastatic ; and of rheumatic or scrofulous in- 
 flammation passing from joint to joint. But if the above men- 
 tioned parts are, as I believe, subject to be consensually af- 
 fected during gonorrheal inflammation*, I should explain it 
 by reference to the second and more diffused sympathy which 
 connects all organs and textures through the medium of the 
 common sensory, with various degrees of affinity, according 
 to their vital powers and properties. 
 
 NOTE B. 
 
 In the history of the idiopathic iritis, by Dr. Schmidt of 
 Vienna, a yellowish red tubercle is described as forming upon 
 the surface of the membrane, which enlarges, and at length 
 bursts and discharges its contents into the chamber. This he 
 denominates an abscess, of which the cyst remains visible for 
 some time afterwards. But for the general accuracy of this 
 author's descriptions, I should decide against the correctness 
 of this observation. I have never been able to discover any 
 thing resembling an abscess in the iris, though perfectly fa- 
 miliar with the appearance of a tubercle like that described; 
 and it is highly improbable that IjTuph should be effused in 
 tubercles, which in some parts become rapidly organized and 
 absorbed, and in other parts form cysts of abscesses, upon the 
 same texture, at one and the same time. Such abscesses would 
 
 * I spealv- here of true sclerotic inflammation independent of any mixture of 
 puriform conjunctival ophthalmia.
 
 488 NOTES. 
 
 degenerate into ulcers, an appearance never witnessed. Pus, 
 .as I believe, is never formed in pure iritis. 
 
 A species of iritis is described by the same aiithor, which 
 he names the arthritic, an inflammation either primary or 
 secondaiy in a gouty habit to a conmion ophthalmia. It is 
 attended Avith excruciating pain. Its diagnostic signs are 
 the appearance of a narrow white ring at the verge of the 
 cornea, and a varicose disposition of the vessels of the con- 
 junctiva. In spare and irritable individuals the pupil be- 
 comes contracted as in the idiopathic iritis, the blood vessels 
 of the iris are varicose, and the disease terminates in a di- 
 minution of volume of the eye-ball. In persons of full habit 
 and relaxed fibre, the pupil, on the contrary, becomes re- 
 markably contracted, but not uniformly, being transversely 
 oval. No lymph is effused, but a greenish j'ellow appear- 
 ance of the humors is observed, and the lens bulges for- 
 ward, of a sea-green color. This pain, which is periodical, 
 and announced by a burning sensation around the organ, and 
 a profuse flow of tears, is of the most severe description. 
 The vessels of the choroid assume the same varicose state as 
 those of the conjunctiva, and the transparent sclerotica pre- 
 sents a dark ring in the situation of the corpus ciliare. Total 
 blindness accompanies this state, and atrophy of the globe 
 ensues. 
 
 In this country we have not been accustomed to distin- 
 guish gouty inflammations in this organ. If an inflamma- 
 tion, characterised as above, is peculiar to the arthritic dia- 
 thesis, the distinction is borne out ; if not, the division is 
 frivolous. I am unable to decide upon the value of the diag- 
 nostic sign first mentioned ; not that it has altogether escaped 
 my observation, as being in some instances of deep seated in- 
 flammation more strongly marked than in others ; but that no 
 evidence has been conclusive to my mind of the existence of 
 a distinct species of iritis affecting gouty subjects. A varicose 
 state of the vessels is the ordinary result of continued inflam- 
 mation, whatever be the texture affected. The same may be 
 said of the ultimate state of atrophy of the entire organ from 
 interstitial absorption. But to speak my opinion candidly.
 
 NOTES. 4^ 
 
 the two states which are here described as varieties of iritis, 
 according to the different habits of body in which it appears, 
 are essentially different forms of disease. The fully dilated 
 and transversely oval pupil, the collapsed and disorganised 
 iris, the varicose vessels of the choroid and conjunctiva, the 
 attenuation of the sclerotica and bulging of the ciliary ring, 
 aU indicate not an existing inflammation, but a disease gone 
 by ; they are slow after-changes which ensue upon acute 
 destructive inflammation of the choroid and retina ; and the 
 agonizing attacks of pain Avhich I have often witnessed in this 
 precise condition, are the result of an universal congestion of 
 the vessels and consequent distension of the eyeball, for every 
 loss of blood gives temporary relief, and when the loss of vo- 
 lume is observed to commence, these attacks cease and return 
 no more. That the angularities of the pupil are in one form 
 of the iritis (syphilitic) observed to be upward and downward, 
 and in another (arthritic) from side to side ; that the sclerotic 
 vessels, in one case, advance boldly to the cornea ; and, in 
 another, are separated by a line which is only visible through 
 a magnifier, are circumstances too much of a contingent and 
 casual nature to be admitted, as affording a ground for in- 
 variable and specific distinctions ; and to look at them as 
 types of corresponding constitutional states, is almost ludi- 
 crous. 
 
 NOTE C. 
 
 This head and that of amblyopsia, page 185, include a 
 very considerable proportion of the cases of functional 
 amaurosis. The amblyopsia may be regarded as the ad- 
 vanced stage of the symptomatic amaurosis, and borders 
 upon paralysis. The disorder of the conjunctival surface, 
 in many instances of pure weakness of sight, unattended 
 by any degree of dimness, is so slight, as either to induce 
 a belief that it has no share in the disease, or that it 
 stands in the relation of an indirect effect, rather than of an 
 exciting cause of the complaint. We must therefore con-
 
 440 NOTES. 
 
 sider it in such cases as a primary nervous affection ; or as 
 originating from sympathy with some other organ, or some 
 peculiar state of the system. The existence of such causes, 
 in many instances, is too obvious to escape notice : in others, 
 I have looked for it in vain. Neither has the organ been 
 over-exerted nor oppressed ; nor. have the functions of the 
 stomach, liver, uterus, &c. varied from a state of health. 
 Excepting the absolute suspension of all such employments 
 as demand the exercise of what may be called active vision, 
 I know of no remedy for the disease. It is more frequent in 
 early and middle, than in advanced life ; and in females than 
 in males. There is no unusual intolerance of light, nothing 
 amounting to actual pain, no defect of vision ; in short, the 
 sum and substance of the complaint is the sensation of an 
 effort to see, and the want of power to continue it. The 
 removal of the exciting cause, the first and most import- 
 ant step in the treatment of all diseases, although so ne- 
 gative as almost to amount in the patient's estimation to 
 an abandonment of the case, is in this more efficient than 
 active measures, as abstinence may on some occasions be ad- 
 vantageously substituted for cathartics. Accordingly I have 
 known the complaint materially mitigated by perseverance in 
 this system for six or twelve months, with a scrupulous atten- 
 tion to regimen ; and perhaps by extension of the principle, 
 a state of protracted sleep, if it were possible, might be the 
 readiest mode of cure. 
 
 A young gentleman who consulted me three years ago for 
 muscae, a weakness of sight, and inability to exercise his sight 
 in any way requiring continued attention, a painful sensation 
 from looking at pointed objects, as pins, needles, or the 
 corner of a chimney piece *, I have lately seen. There is not 
 now, nor ever has been, the slightest deviation from a healthy 
 
 * This is the only example I have met with of this very expressive s^'mp- 
 tom of a tender, or highly irritable retina. It seems to me to resemble those 
 disagreeable bwt natural sensations, viz. the teeth on edge, or the cutis anse- 
 rina, when amounting, as in some individuals, to a morbid excess, and excited 
 by impressions of which they alone are susceptible.
 
 NOTES. 441 
 
 appearance of tlie eyes ; the pupils contract freely, and there 
 is no intolerance of light, nor does his uneasiness, though it 
 compels him to desist from employment, ever amount to pain. 
 He has a frame rather spare than plethoric, a healthy com- 
 plexion, good appetite, animated disposition, and spirits corre- 
 sponding to his health, if some apprehension about his sight 
 did not occasionally depress him. His education has been 
 from this cause interrupted, and he is unable to indulge his 
 inclination in the choice of a profession. 
 
 Before I saw him he had been subjected to different plans 
 of treatment. First, undue determination of blood without 
 any sufficient reason was presumed ; for this hypothesis he 
 suffered leeching, cupping, and blistering. Secondly, it 
 was regarded as a nervous affection ; evacuations of blood 
 were countermanded, and a particular attention to the 
 bowels, sea-bathing, exercise, and various tonics substituted. 
 I gave my opinion in writing three years ago, that the 
 disorder was purely functional, that the systematic regula- 
 tion of the bowels, attention to diet and exercise, Avith as 
 much indulgence of the organ as was possible, comprised all 
 the means of treatment which my experience suggested. That 
 depletion on the one hand and the higher tonics on the other, 
 would not amend, if they did not aggravate the complaint. 
 At the same time, I recommended a trial to be given to the 
 blue pill, the bitter infusion, and blisters. The disease is as 
 nearly as possible the same at this moment, as when I was 
 first consulted. His own observation is, that his sight is evi- 
 dently more affected by the state of his stomach than any 
 other circumstance, that the more observant he has been of 
 the plans laid down for the regulation of diet, &c. the more 
 tranquil and comfortable has been the state of his eyes. Read- 
 ing a few pages of a book is infinitely more distressing than 
 the glare of a theatre or a ball room ; and the sense of de- 
 bility is greater during the morning than at any other time. 
 But even though the bowels are perfectly regular, and the 
 digestion strong, the same feeling prevails ; and on the other 
 hand, when these functions have been very irregular, it has
 
 442 NOTES. 
 
 often happened, that the state of vision has been as good as at 
 the best. 
 
 NOTE D. 
 
 Professor Beer refers to many cases of this description, as 
 from suppression of febrile diseases of the skin, scarlatina, 
 variola, &c. in the first period of the eruptions. The pupil 
 in these cases is much contracted and immoveable ; the 
 prognosis favourable, if treated early. lie has also seen the 
 disease after suppressed chronic diseases of the skin, as psora ; 
 after the amputation of the plica polonica, and very many in 
 consequence of an abrupt healing of old leg ulcers. The 
 prognosis in these cases is unfavourable. In that arising from 
 suppressed catarrhus narium, in which the pupil is angular and 
 drawn toward the outer canthus, he considers the prognosis 
 encouraging. He mentions as rare and unfavorable forms of 
 the metastatic amaurosis, those arising from suppressed secre- 
 tion of milk in lying-in women, and from suppressed passions 
 of the mind. 
 
 NOTE E. 
 
 An elderly gentleman, the subject of confirmed organic 
 amaurosis, whom I had seen at intervals, died lately, and his 
 friends kindly afforded me an opportunity of examining his 
 head after death. In the year 1816 he first complained of 
 dimness — was unable to mend his pen as usual, changed his 
 spectacles repeatedly — and from writing a small neat hand 
 wrote large and straggling. In walking he imagined that he 
 saw objects on the ground which intercepted his path, and 
 endeavoured to avoid them by taking long and high steps. 
 The flames of the candle at night appeared multiplied and 
 undefined. There was little if any differehce between 
 the two eyes. About the time that his sight grew dim, he 
 complained of uneasiness and oppreiSsion in the head. He
 
 NOTES. 443 
 
 often described the horrible sensation of passing under an 
 archway, with the fear of being crushed by its falling*. His 
 habit was plethoric, and he was apparently in the full vigor of 
 health. As these symptoms, together with much lethargy, w.r^re 
 considered to threaten apoplexy, he was freely and repeatedly 
 blooded, and in other respects treated accordingly. He be- 
 came totally blind and soon afterwards dark. His eyes were 
 perfect in appearance. They had the unmeaning roll charac- 
 teristic of the disease in its last stage. Pupils a good deal 
 dilated and motionless. A full course of mercury and elec- 
 tricity Avere employed without any effect. The latter was 
 persisted in for six months. 
 
 In the progress of the case he was attacked with, fits of a 
 mixed kind, partly apoplectic, with temporary hemiplegia, 
 and in part epileptic ; his mind and speech failed him. 
 Great torpor of bowels and indigestion, scantiness of urine 
 and pain in voiding it, coldness and cedematous swelling of the 
 lower extremities, with frequent and severe convulsions of his 
 whole frame, were the symptoms most remarkable towards the 
 close of his life. 
 
 On inspection of the head, the ventricles of the brain 
 were found greatly surcharged with serous fluid, and the 
 optic nerves to and from the ganglion opticum shrunk, or 
 rather absorbed; so that they appeared flat instead of cylin- 
 drical, and of a straw color instead of a silvery whiteness. 
 In slitting, and cutting them across, it was evident that only 
 the sheath of the nerve remained, the medullary substance had 
 entirely disappeared. The eyes nevertheless were in all re- 
 spects sound, and had the plumpness and clearness of health. 
 There was no vestige of an apoplectic effusion. 
 
 The following case exemplifies the exclusive paralysis of 
 the tiervi motores referred to in the paragraph to which this 
 note belongs. 
 
 * Another morbid horror, somewhat resembling this, 1 have heard de- 
 scribed, viz. the approximation of the walls of the apartment, so as to give 
 the patient the impression of being in a closet just large enough to contain 
 his person. I need scarcely observe that all such delusions have their origin 
 in the sensorium.
 
 4>4fi^ NOTES. 
 
 ' Mrs. W. a healthy woman, aged 28, suckling an infant of 
 five months, was attacked, in June 1820, with severe pain in 
 the head on first rising in the morning, Avhich in an hour 
 or two subsided, but after some time it continued during the 
 whole 'day, affecting chiefly the left side. She, of her own 
 accord, applied leeches to her temples and a blister behind 
 each ear, but without relief. In August following finding 
 the pain almost insupportable, her family surgeon was con- 
 sulted. The bowels, he informed me, were so obstinately 
 costive as to be with difficulty acted upon by powerful 
 cathartics. Being still unrelieved after brisk and effective 
 purgative medicine, she concluded it to be rheumatism, and 
 wrapped her head in flannel. In crossing the road on the 
 8th of November following, she felt a sudden smart shock 
 between the orbitar processes, like a pea striking her forehead. 
 From this moment the pain in the head ceased ; but she found 
 the vision imperfect — that is, she saw objects in unnatural 
 positions, and although she could see distinctly with either 
 eye, she could not with both, and therefore tied up one^ th^ 
 left, which was rather the weakest, when engaged in business. 
 Both eyes appeared perfectly healthy, and the pupils were 
 equally active. On the third of December following, she 
 first saw objects double, and the strabismus was so marked as 
 very sensibly to disfigure a pretty and pleasing countenance. 
 Both eyes were turned towards the nose, the left most so. 
 Both pupils nevertheless acted freely. She had suffered no 
 return of pain since the 18th ultimo. She was now cupped 
 to twenty ounces from the nape of the neck and temples. 
 Her bowels had been kept in action by the pil. hydrarg. and 
 an occasional purgative draught. Since the double vision 
 began, these were directed to be continued. A large blister 
 was applied to the occiput after the bleeding, and three days 
 afterwards no improvement appearing, each temple was bled 
 with six leeches, and these parts were also blistered. The 
 dose of blue pill ■was gradually raised to ten grains twice 
 a day, and in a fortnight the mercurial action was estab- 
 lished. 
 
 Previous to this event, it was noticed that her vision had
 
 NOTES, 44^ 
 
 been less confused. She was cupped twice in this period to 
 six ounces, and blisters applied behind the ears were kept 
 open for some days. Her mouth continued sore about a 
 month, during which time she gradually recovered single and 
 perfect vision, and the strabismus was corrected. During her 
 recovery she saw but one object on looking stedfastly in a 
 straight direction ; but upon turning her eyes to either side, 
 or upwards, she still saw objects double; and even now that 
 her vision in all directions is ordinarily single, whilst in a 
 supine posture, and especially whenever her mind recurs to 
 the subject, her vision is occasionally double. 
 
 During her treatment, she was seldom free from a sense 
 of heaviness about the forehead and occiput, and vertigo. 
 The pulse was quick and feeble, countenance pale and hag- 
 gard, mind irritable and anxious ; and she laboured evi- 
 dently under great debility, both muscular and nervous. 
 The recovery of the eyes was very gradual ; no sensible ac- 
 celeration of the rate of progress was observed during the 
 mercurial influence. She did not however lose what had 
 been gained in sight, though she lost strength. Even since 
 the recovery of the sight, and in a great measure of her 
 flesh and strength by country air, the continuance of weight 
 and uneasy sensations in the head, led me to recommend a 
 seton in the nape of the neck, which she adopted with ad- 
 vantage. 
 
 This young woman, I should observe, the mother of se- 
 veral children, acted as her husband's book-keeper, and, 
 whilst pursuing this sedentary and anxious occupation, had 
 been accustomed to drink freely of potent home brewed 
 beer. 
 
 This case is contra-distinguished to that in which the affec- 
 tion of the retina precedes the strabismus. Here, it is the 
 symptom — there, the cause of the strabismus. The sympa- 
 tJietic affection of the retina in the case just related, is the 
 slightest possible. In the majority of such cases, it is more 
 marked, so that the vision of one eye is much stronger and 
 clearer than that of the other, and one eye may be said to
 
 4.46 NOTES. 
 
 be in fault. When strabismus ensues upon amaurosis, this 
 difference is still more conspicuous. But the prognosis is 
 not least serious when the retina is least affected ; a squint 
 from blindness adds little to the case but confirmation that 
 the retina is insensible ; but strabismus coming first connects 
 the origin of the disease with the cerebrum;, and what alarm 
 we feel in one case for the sense of vision, we feel in the other 
 for life, or, what is of yet more value, for intellect. 
 
 I must beg my reader's excuse for still farther lengthening 
 this note. A few days ago I was desired to visit a gentle- 
 man between thirty and forty years of age, who had just 
 arrived from the West Indies, on account of a large and hard 
 tumor seated in the abdomen, about the nature of which his 
 medical attendants were in doubt, from its external character, 
 its apparent insulation, and frequent change of place, being 
 sometimes in the epigastrium or beneath the umbilicus, and 
 at other times distinctly felt in the right iliac region, in the 
 position of the caput coli. Sometimes it was concealed and 
 could not be felt any where. The disease was of seven 
 months' standing, attended with marked symptoms of stric- 
 ture in some part of the intestinal canal : a very imperfect 
 and disturbed state of the alimentary functions, frequent 
 hiccough, sharp pains in the belly, and great emaciation. 
 
 On the day of my seeing him, he was suddenly seized with 
 a new symptom ; viz. convulsions and total blindness ; and 
 in the interval of the fits, which were protracted and severe, 
 he complained of pain across the top and front of the head. 
 His pulse was regular, but compressed ; his skin was covered 
 with a cold perspiration ; except during the convulsive parox- 
 ysm, his mind was perfect, but his manner was changed from 
 anxiety to apathy. The pupils were dilated to the ut- 
 most, as in hydrocephalus; he had no sense of light, no 
 perception of its interruption. I directed his head to be im- 
 mediately shaved, and twelve ounces of blood to be taken by 
 cupping from the temples, and above each mastoid process. 
 Afterwards a blister to be applied in the direction of the co- 
 ronal and sagittal sutures, sinapisms to his feet, and a pill to
 
 NOTES. 447 
 
 be taken, composed of five grains of calomel and half a grain 
 of opium. Two hours afterwards, the convulsions recurring, 
 and his skin being still cold and clammy, he was ordered a 
 cordial draught and a small quantity of brandy in gruel occa- 
 sionally. At the same time a turpentine glyster was adminis- 
 tered ; this was soon followed by a very plentiful discharge 
 from the bowels, a warm and copious perspiration, and a sound 
 sleep of several hours. The next morning he awoke free from 
 pain, and his vision was as perfect as ever. He had no return 
 of convulsion or cerebral disorder of any kind. No material 
 change occurred in the symptoms of the original malady during 
 this short but truly alarming attack. 
 
 This amaurosis, there can be no doubt, was an example of 
 sympathetic irritation and congestion. The cupping was a 
 precautionary measure indicated by the amaurosis ; there was 
 pain, a firm pulse, and this unequivocal symptom of compres- 
 sion; effusion was instantly threatened; a stimulus at this 
 moment appeared hazardous. We expected to see him expire 
 in each fit. The piU, followed by the stimulant glister, was 
 remedial, and for the time saved him. 
 
 P. S. Since the above was Avritten, this gentleman is de- 
 ceased. On inspection, a firm, very irregular, fungoid tumor, 
 of the size of a man's double fist, knobulated, fissured, and of 
 a truly malignant aspect, was found occupying the head of the 
 colon ; and, by its origin from an extensive surface of the mu- 
 cous membrane, partially inverting and concealing the termi- 
 nation of the ileon and the caecum., of which only the appendix 
 vermiformis was seen. He had no other organic disease. 
 
 NOTE F. 
 
 The different forms of amblyopsia amaurotica enumerated by 
 
 Professor Beer are as follow : — 
 Visus interruptus — the person in reading sees only single words 
 
 or letters.
 
 448 NOTES. 
 
 Visus dimidiatus — S. hemiopsia. 
 
 Visus muscorum — S. myodesopsia. 
 
 Visus reticulatus — a higher degree of the former. 
 
 Visus lucidus — Photopsia. Marraaryge. (Hipp.) Sparks and 
 
 flashes of lightning perceived by the patient. 
 Photophobia — flight painful. 
 Oxiopsia — a state of vision which enables the patient to see 
 
 with perfect accuracy the smallest point when deprived 
 
 of light. 
 Visus nebulosus. 
 
 Visus duplicatus — S. Diplopia, Luscitas, et Strabismus. 
 Visus coloratus — S. Crupsia, all objects seem colored, green, 
 
 blue, yellow, &c. 
 Visus defiguratus — S. Metamorphosia. 
 Myopia and Presbyopia. 
 Nyctalopia and Emeralopia. 
 Amblyopia vaga — periodica — intermittens. 
 
 NOTE G. 
 
 Professor Walther, in an essay on-this subject, has stated 
 some very original and curious notions. He thinks that cata- 
 ract is the primiti^'^e and natural state of the lens, and that 
 congenital cataract is therefore not an altered but an unaltered 
 condition, in consequence of a check given to the developement 
 of the embryon. Like other malformations, it is not owing to 
 the influence of any active or formative cause, but having been 
 originally present in every embryon at certain periods of its 
 existence, does not disappear in its progress to a more perfect 
 state, as it does where this progress is unchecked. The three 
 months' foetus has a hare lip, and but one cavity for the mouth 
 and nostrils. The iris is imperforate, and so are all the aper- 
 tures of the perfect body. The eyelids are fastened together 
 over the naked eye, and the cavity of the umbilical cord being
 
 NOTES. 449 
 
 one with the abdomen, exomphalos is the natural and original 
 state. 
 
 Walther considers cataract to be always the result of inflam- 
 mation of tlie capsule, acute or chronic. By a powerful magni- 
 fier he has discovered a wreath of vessels about a quarter of a 
 line distant from the pupillary edge of the iris, forming a con- 
 centric circle with the pupil. To this vascular wreath vessels 
 pass in radii from the circumference of the capsule^ and into 
 the posterior surface of the iris. Nay, a network of more de- 
 licate vessels is described to have been seen deeper seated in 
 the lens itself, " the larger trunks of which are not always 
 derived from the circumference of that body, but evidently 
 come from its posterior surface directly forwards, and then 
 divide into branches*." This is an appearance entirely mor- 
 bid, the same authority deciding that there is no organized 
 connection between the lens and its capsule in health, and that 
 the lens is nourished by inhibition or absorption of the humor 
 Morgagnii, secreted by the vessels of the capsule, into which 
 it again deposits its waste, being merely furnished with absorb- 
 ent and exhalent vessels. Hence inflammation of the lens is 
 always secondary to that of the capsule, in the same manner 
 as inflammation of the capsule is secondary to that of the iris. 
 Spots seen in the capsule, whether grey or brovi'n, are, we are 
 told, deposits of lymph, in which the prolonged vessels are 
 seen terminating. 
 
 The inflammation of the capsule and of the lens are de- 
 scribed as diseases marked by certain signs and appearances. 
 The latter is always chronic like that of the bones, cartilages, 
 and fibrous textures. When the disease is established, the 
 blood vessels of the lens and capsule become varicose. The 
 firm cataract is the termination of inflammation in induration 
 The milky exemplifies suppuration. The dry siliquous or 
 shrunk cataract is a dry gangrene. The hard cataract when 
 occurring without inflammation is a scirrhus, and the purulent 
 
 * I quote the words of the Analysis in the Quarter!}' Journal of Foreign 
 Medicine and Surgerj'. 
 
 G G
 
 450 NOTES. 
 
 may sometimes be the effect of ulceration of the lens. Other 
 cataracts are considered to be sarcomatous ! 
 
 The first part of these observations, namely, that referring 
 to the appearances exhibited in inflammation of the capsule, 
 from its consistency and analogy with the phenomena that are 
 open to observation, has been anticipated in the way of hypo- 
 thesis, and may be admitted with proper allowance for the 
 chances of optical delusion in the employment of a sextuple 
 magnifier. But unfortunately the enthusiastic devotion to 
 system which the author betrays in his pathological notions 
 (which are to my seeming pure nonsense), gives an air of mar- 
 vel to the whole story. 
 
 Professor Beer divides cataracts into true and spurious. 
 The true is Vidthin the capsule ; the spurious is placed be- 
 tween it and the iris. The principal kinds are. 
 
 True. 1. Lenticular. 2. Anterior capsular. 3. Posterior 
 capsular. 4. Morgagnian. 5. Capsulo-lenticular. 6. Cystic. 
 7. Siliquous. 8. Cataract with a cyst or sac containing pus. 
 9. Trabecular. 
 
 Spurious. 10. Lymphatic. 11. Purulent. 12. Sanguineous. 
 13. Pigmentous. 
 
 The distinction and dignity of a name given to each variety, 
 is the only novelty of this list. The cystic is the floating cata- 
 ract, the capsule opake and thickened, and the lens more or 
 less absorbed. The siliquous is the capsular cataract, the lens 
 being absorbed, as after wound or rupture of the capsule*. 
 The cyst containing pus is rare. The trabecular is probably 
 the radiated. As to the four last, they are results of iritic 
 inflammation, not cataracts ; nor are they in this country con- 
 founded with them. They ate seldom if ever met with but 
 after blows, wounds, and operations. 
 
 * Do the travelled pedants, who deal such heavy blows among their igno- 
 rant and besotted countrymen, suppose that -4ese every day forms have 
 escaped our notice ? In England, as in Germany, the same things are seen, 
 but their importance is differently estimated ; they are differently explained, 
 arranged, and reasoned upon. I am content it should be so.
 
 NOTES. 451 
 
 NOTE H. 
 
 The often mooted questions — first, in what cases topical blood- 
 letting commands an advantage, if in any, over phlebotomy, 
 as usually practised at the arm ; — second, whether draAving 
 blood from an artery is of greater efficacy than from a vein, 
 the quantity being the same — may be answered, I think, in a 
 few words. To the first I should reply — if the system is in- 
 flamed, i. e. if the pulse indicates that the action of the heart 
 is excited by the state of the organ, or if the activity or rapid 
 progress of the inflammation, however local, threatens the 
 safety of the organ, we ought not to trust to topical blood- 
 letting. In such cases it may be employed subserviently with 
 great advantage, but not principally. If, on the other hand, 
 no such sympathy is evinced, and the inflammation, though 
 acute, is in its nature weak and slow of progress, the local 
 blood-letting may commonly suffice. But is it in such cases 
 to be preferred? Generally I think it is, because the inflamed 
 vessels are relieved from the state of congestion and tension, 
 and are enabled to recover their contractile tone, at a smaller 
 expense to the system. To pale the inflamed conjunctiva by 
 opening a vein in the arm, supposing there is no disposition to 
 syncope, will require a loss of from twelve to sixteen ounces of 
 blood ; whereas this efi'ect will often be produced by a loss of 
 one third of that quantity drawn as quickly from the imme- 
 diate neighbourhood of the inflamed organ. Syncope from 
 dread of the lancet will produce tlie best eflfect of a topical 
 bleeding, and may stand in its stead. It will be no substitute 
 for general bleeding where that is indicated, for the same rea- 
 son that topical bleeding is no adequate substitute for general. 
 Thus, though a general bleeding will answer the main purpose 
 of a local one, it is least economical when neither the character 
 of the inflammation, nor the danger of its duration, calls for 
 it; and, therefore, in strumous and other weakly habits, in 
 atonic and sluggish inflammations, it is least eligible. 
 G G 2
 
 452 NOTES. 
 
 Nevertheless, when the inflammation and the part affected 
 are such as to require general blood-letting, and the patient 
 owes his safety to its employment, topical is continually had 
 recourse to with remarkable advantage, and the latter is more 
 eligible as an auxiliary in such cases, than the former as a sub- 
 stitute in those of an opposite description. The difference of 
 the inflammatory action according to the texture of the organ 
 affected, is comprehended in the above general statement. 
 
 Leeches are the least effectual mode of topical blood-letting. 
 In many instances, the blood derived by them is not sufllicient 
 to counterbalance the irritation caused by the wound, and they 
 act as irritants, augmenting the vascularity, swelling, and 
 pain. 
 
 To the second question my observation leads me to reply in 
 the negative. The effect upon the heart's action will be deter- 
 mined by the quantity lost, and by that alone — taking the dis- 
 tance from the heart and the size of the current — in any artery 
 which it is usual or would be discreet to bleed from. 
 
 NOTE I. 
 
 The gratitude of the public, the highest, if not the only re- 
 ward for public benefit to which an honorable mind aspires, is 
 unquestionably due to Dr. Vetch, for the successful treatment 
 of this formidable disease, especially in its first and most for- 
 midable stage. He reprobates the excision of the granulations 
 and the division of the conjunctiva. Although I have seen 
 cases of the absorption of large and even pendulous granula- 
 tions, and believe that such absorption almost invariably takes 
 place where the disease is left to run its course, abundant ex- 
 perience has convinced me that the employment of the scissars 
 is highly important to the favorable issue of the case, since the 
 preservation of the cornea depends chiefly upon the restoration 
 of the lining membrane of the lids, which this practice essen- 
 tially promotes. Yet so highly do I appreciate the importance 
 of caustic and astringent applications judiciously employed,.
 
 NOTES. 453 
 
 that if the joint use of these remedies were in any case pro- 
 scribed, I should prefer, as a single measure, the use of the lu- 
 nar caustic or the blue vitriol, to the employment of the knife. 
 Dr. Vetch objects to the use of these substances in solution 
 as too stimulant, and contends that when lightly applied in the 
 solid form they act most beneficially. There is much truth in 
 this observation. The fact is, that in this, as in all chronic 
 morbid changes, the treatment rests not upon one, but on a 
 variety, or perhaps a combination of measures ; not upon this 
 or that form or mode of application, but upon a form and mode 
 suited to the existing circumstances. A topical application 
 made with advantage to-day would probably be hurtful to- 
 morrow. To watch the caprices of the case, the moment of 
 excitement and of relaxation, to subdue, to soothe, or to sup- 
 port promptly, and thus to break the force of each successive 
 relapse, varying the means as the circumstances permit, are 
 points indispensable to conduct the case to a favorable termi- 
 nation, and are those which distinguish the man of science 
 from the empiric. But the local treatment is by no means the 
 only material part of the ' Therapeia' of these cases.
 
 454 NOTES. 
 
 NOTE K. 
 
 Where these circumstances are not present, the subjects of 
 this inflammation are;, in my experience, Avealdy and of a 
 scrofulous habit ; the tame, indolent, shifting character of the 
 disease, viz. the pink-colored zone at the verge of the coinea, 
 vivid one day, and scarcely perceptible the next, renders it 
 more diflicult to subdue than a fixed and vigorous action ; and 
 the practitioner is insensibly betrayed into irresolution by the 
 seeming inertness of the disease and the obvious delicacy of 
 the patient. But diseases, like other dangers, are formidable 
 in proportion as they are disguised, and it would often prevent 
 mischief, if a bolder practice were instituted in the outset 
 than circumstances appear to the inexperienced to warrant. 
 
 NOTE L. 
 
 This statement requires some qualification. What I mean 
 is this ; where the mercurial action being fairly established is 
 productive of no sensible improvement, its continued and 
 freer use is attended with no advantage, and is, therefore, 
 constitutionally injurious ; but I do not mean to say that the 
 full advantage will always be obtained by a short and gen- 
 tle course ; on the contrary, where in the commencement of 
 the mercurial action the improvement is only suflicient to 
 give encouragement to persevere, a course of three or even 
 four months is often necessary to accomplish the end in 
 view. 
 
 In amaurosis supervening on inflammation, especially re- 
 cent inflammation, the remedy promises most; but even 
 here, if the inflammation has induced perfect amaurosis, it 
 will often restore the iris to its colour and activity without 
 materially benefiting vision; for mercury is not a remedy
 
 NOTES. 455 
 
 for paralysis. If however from inflammation — wlietlier the 
 result of injury or spontaneous, whether from the operation 
 of a direct or a remote cause, the state of congestion or atony, 
 the state of serous or lymphatic, perhaps of partial san- 
 guineous effusion — the sensorial function be interrupted, our 
 first hope is topical blood-letting and counter irritation — the 
 second, the action of mercury. 
 
 At the distance of four years from a fall on the occiput, 
 followed by severe symptoms of cerebral injury, I have known 
 sight restored to the eye which had ever since been deprived 
 of it, by a full mercurial course. Again and again I have 
 seen the same effect produced by the same agent, where nei- 
 ther injury nor any other cause nor symptom of inflammation 
 had ever existed, and where only a slow moving pupil cor- 
 responded to the patient's complaint of dimness, to such an 
 extent as to render indistinguishable the features of a person 
 standing before him : and on the other hand I have never 
 known it to be of any eflicacy in cases, ushered in by severe 
 frontal pains, in which blindness was already complete, and 
 the pupil largely and permanently dilated, where the greenish 
 cast of the humors was strongly marked, and the visus luci- 
 dus was complained of. 
 
 NOTE M. 
 
 I CONFESS that I have seen no reason to alter the opinion here 
 expressed, in several trials of this plan of treatment with the 
 tube of M. Dupuytren, since the publication of this work. 
 Through a learned member of the university of Paris, a 
 patient of mine, and also of M. Dupuytren, I requested the 
 professor to favor me Avith a case that might serve as a report 
 in detail of the treatment which he had adopted. Upon this 
 gentleman the tube operation, though performed by the 
 Baron, was unsuccessful ; but as he had previously worn for 
 two or three years a nail-headed style with as little advantage.
 
 "^56 NOTES. 
 
 the case certainly did not afford a fair chance of success, and 
 the failure was attributed to this circumstance. M. Dupuy- 
 ren, with the liberal and courteous spirit of a true friend to 
 science, immediately transmitted to me the subjoined report 
 of an interesting case which had very recently occurred ; and 
 I have great satisfaction in presenting it to my readers. 
 
 " Madame Daive, agee de quarante deux ans, demeurant a 
 Sarre-Louis, vint a Paris dans le mois de Mai 1821, pour con- 
 suiter Mons. le Professeur Dupuytren pour une tumeur lacry- 
 male d'un cote, et une fistule de I'autre cote. 
 
 " II y a six ans que la malade s'apper9ut pour la premiere 
 fois, que I'ceil du cote gauche etoit larmoyant, qu'il se for- 
 moit souvent a son grand angle une petite tumeur qui se vi- 
 doit par la pression, et qui ne tardoit pas a se reproduire. 
 Cette dame avoit un ecoulement involontaire de larmes sur 
 la joue; I'ceil de ce cote etoit toujours chassieux, larmoyant, 
 la narine toujours seche. Cette petite tumeur augmenta bien- 
 tot de volume, la peau qui la recouvroit, s'enflamma, s'amin- 
 cit ; les paupieres se tumefierent. Ces accidens la firent re- 
 courir aux soins d'un chirurgien, qui ouvrit de suite cette 
 tumeur : du pus, des larmes, du mucus, et du sang s'ecou- 
 Icrent ; la malade fut soulagce, I'inflammation tomba ; mais a 
 la tumeur succeda une fistule qu'il falloit guerir, et voici les 
 moyens qui furent employes. 
 
 " On fit d'abord des injections. Quoique continuees pen- 
 dant un temps assez long, elles n'eurent aucun resultat heu- 
 reux. Ce premier moyen ayant echoue, on en essaya un 
 second ; c'est-a-dire, qu'on tenta de faire passer dans les 
 fosses nasales un ressort de montre. On fit des essais pendant 
 plusieurs jours, leur inutilite fit adopter le moyen suivant, 
 dans I'intention de desobstruer par cauterisation les voies 
 lacryraales. Un stilet rougi au feu fut introduit entre les 
 levres de la fistule, et les cauterisa : du gonflement survint ; 
 au bout de quelques jours il diminua; bientot les escarres 
 formees se detacherent ; des bourgeons charnus s'eleverent ; 
 mais le chirurgien s'appliqua chaque jour a introduire, pen- 
 dant quelqueis instans, un cilindre dc nitrate d'argent poudre. 
 Cette manicre d'agir cut pour resultat Taggrandibement de
 
 NOTES. 457 
 
 la fistule, I'adlierence de ses bords aux os ; les bords prirent 
 line organisation cutanee : enfin on introduisit pendant long- 
 temps une espece de broche en plomb — Tons ces moyens 
 loin- de guerir la maladie, I'avoient rendue presque incurable. 
 Desirant trouver uh remede a son infirmite^ IVIadame Daive se 
 presenta chez M. le Baron Dupuytren ; elle se trouvoit alors 
 dans I'etat suivant. 
 
 " Au grand angle de I'oeil gauche existoit une ouverture de 
 trois lignes de diametre ; les bords tapisses par la peau amin- 
 cie, avoient pris I'organisation cutanee dont s'emparent tou- 
 jours les ouvertures fistuleuses, qui donnent passage a des corps 
 etrangers. Par la s'ecouloient sans cesse des larmes qui ve- 
 noient irriter I'ceil, enflammer et excorier la peau de la joue. 
 
 " Au grand angle de I'autre ceil existoit depuis quatre ans 
 une petite tumeur, plus grosse pendant le temps humide^ plus 
 aussi le matin que le soir. Cette tumeur pouvoit etre facile- 
 ment videe par la pression; alors il s'ecouloit par les points la- 
 crymaux une matiere purulente, muqueuse, melee a Thumeur 
 des larmes ; la narine de I'un et I'autre cote etoit seche. 
 
 " La guerison de la tumeur lacrymale etoit certaine, celle 
 de la fistule pouvoit etre douteuse ; la malade en fut preve- 
 nue, et I'operation pratiquee le 4 Mai 1821, de la maniere 
 suivante. 
 
 " La malade etoit assise sur un chaise placee vis-a-vis 
 d'une fenetre, la tete appuyee sur la poitrine d'une aide : 
 Monsieur Dupuytren tend alors avec le medium et le doigt 
 indicateur de la main gauche, la peau des paupieres de 
 I'oeil droit, en la portant un peu en dehors, tandis qu'avec 
 la main droite armee d'un bistouri a lame etroite, il fait a la 
 peau qui recouvre la tumeur, une incision perpendiculaire, 
 qui la divise, ainsi que le sac lacrymal. On vit bien que 
 I'instrument n'avoit pas devie, par la profondeur a laquelle il 
 penetra sans difficulte, et a la sortie de mucosite purulente. 
 Changeant alors de main, JM. Dupuytren saisit avec la droite 
 le bistouri, et avec la gauche le mandrin, revetu de sa cauule 
 en or *. Le bistouri est un peu retire pour permettre a. 
 
 "* Voyez la description a la tin de Tobservation.
 
 458 NOTES. 
 
 rextremite du mandrin qui est gUsse sur sa lame^, d'etre intro- 
 iduite a mesure qu'on fait entrer le mandrin ; enfin lorsqu'on 
 est entre a la hauteur dxi canal nasal^ il ne reste plus qu'a 
 Tenfoncer. On est averti qu'il a penetre assez avantj par la 
 Resistance qu'on eprouve a I'enforcer davantage ; ce qui pro- 
 vient du contact de la caniile sur le rebord de la gouttiere 
 lacrymale. Voulant s'assurer que la communication existoit 
 entre le sac lacrymal et le fosse nasal^ Monsieur Dupuytren 
 ferma I'ouverture anterieure des fosses nasales, et ordonna a 
 la malade de faire des efforts comme pour se moucher, aussi- 
 tot on vit de I'air mele a du pus et a des mucosites sanguino- 
 lentes s'echapper par la petite ouverture j on y presenta la 
 flamme d'une bougie^ eUe fut eteinte. 
 
 " De I'autre cote I'ouverture fistuleuse permit I'introduc- 
 tion de la canule ; elle fut facile^ et chose etonnante^ mais qui 
 arrive toujours, c'est que la malade ne sentant nullement la 
 canule, avoit peine a croire qu'on I'eiit introduite. 
 
 " Restoit a savoir Tissue qu'auroient ces deux operations. 
 Au bout de vingt quatre heures la petit plaie du cote droit 
 fut cicatrisee, la tumeur n'existoit plus, le cours des larmes 
 etoit parfaitement retabli, et la narine de ce cote avoit repris 
 son humidite naturelle. 
 
 " Plusieurs jours apres Toperation, I'ouverture fistuleuse du 
 cote gauche parut un peu retrecie ; cependant la malade 
 eprouvoit de ce cote la meme incommodite. 
 
 *' Que pouvoit-on faire pour cicatriser cette ouverture ? De- 
 voit-on detruire les adherences de la peau^ enlever les bords de 
 la fistule ? Mais en agissant ainsi, on pouvoit craindre de ne 
 pas r^ussir, et d'aggraver au contraire I'etat de la malade ; 
 aussi ce parti ne fut-il pas adopt. 
 
 " Les succes brillans que Monsieur le Professeur Dupuy- 
 tren venoit d'obtenir dans la guerison de fistules recto-vesi- 
 cules, uretro-vaginales, par le cautere, lui suggererent I'idee 
 d'employer ce moyen. En effet quinze jours apres I'opera- 
 tion, I'ouverture fistuleuse n'ayant fait aucun progres vers la 
 cicatrisation. Monsieur Dupuytren la toucha avec un petit 
 pinceau de charpie trempee dans du nitrate de mercure, avec 
 exces d'acide nitrique ; par-dessus il mit encore dc la charpie
 
 NOTES. 459 
 
 hachee, egalement impregnee de ce caustique. Dxx gonfle- 
 ment, de la douleur surviiirent ; ils furent calmes par quelques 
 lavemens, des pediluves (bains de pieds) sinapiseS;, du petit 
 laitj &c. 
 
 " Au bout de quatre jours I'escarre tomba, et Monsieur 
 Dupuytren vit avec plaisir que la plaie s'etoit un peu retrecie. 
 Enhardi par ce premier succes, il fit une seconde, troisieme, 
 quatrieme^ et jusqu'a une septieme cauterisation; toutes 
 furent pratiquees a quatre ou cinq jours d'intervalle, chaque 
 fois on trouva I'ouverture retrecie. Enfin le 3 Julliet^ deux 
 mois depuis I'operation pratiquee, cette ouverture fistuleuse 
 a parois cutanees, organisee depuis plusieurs annees^ et que 
 plusieurs medecins avoient juge incurable, etoit parfaite- 
 ment cicatrisee, le cours des larmes retabli ; en un mot, il 
 etoit difficile de pouvoir assurer que cette malade avoit eu 
 une tumeur lacrymale d'un cote, et une fistule de I'autre, tant 
 elle etoit bien guerie. On ne pouvoit voir a I'ceil que la malade 
 avoit dans le nez deux canules en or, et leur presence se faisoit 
 si peu sentir, que la malade avoit peine a croire qu'on les 
 lui eut laissees. Enfin elle quitta Paris parfaitement guerie, 
 et heureuse d'avoir ete delivree d'une infirmite qu'on avoit 
 juge incurable." 
 
 Description de la cariulc d'or de Monsieur le Prqfesseur 
 Dupuytren. 
 
 " Cette canule doit etre anssi longue que le conduit nasal ; 
 par consequent elle est de 10 a 14 lignes, sur une, ou une et 
 demie de diametre, cependant sa partie superieure est un peu 
 plus large ; eUe offre une legere courbure pour s'accommoder a 
 celle du canal. Un rebord renfle, en forme de bourrelet saillant 
 en dehors, fait le contour de I'ouverture, qui doit aboutir au sac 
 lacrymal ; il est destine a s'opposer a la chute de la canule 
 dans le nez, chute qui permettroit a la maladie de se repro- 
 duire ; I'autre extremite de la canule est taillee en bee de flute, 
 afin qu'un de ces cotes moins long, ne depasse point le cote 
 interne du canal nasal qui finit avant I'externe. La canule
 
 460 NOTES. 
 
 est portee sur son mandrin forme de deux parties^ qui ae 
 reunissent a angle un peu obtus ; I'une d'elles, plus longue, 
 applatie, est celle que saisit la main de I'operateur ; I'autre 
 se cache dans la canule qu'un renflement subit I'empeche de 
 depasser. 
 
 " Par ordre de M. le Baron Dupuytren^ 
 
 " Maex." 
 
 niandr'm. 
 
 canule.
 
 NOTES, 4Gl 
 
 NOTE N. 
 
 Though their general complexion is little serious, very em- 
 barrassing and distressing cases of this description are some- 
 times met with. The conjunctival surface is highly irritable, 
 and a profuse gush of scalding tears overruns the cheek, at 
 the moment that the eye is opened and exposed to the light. 
 The skin of the lower lid and cheek is excoriated, and the 
 cuticle becomes rough and scaly from the quantity and quality 
 of the lacrymal discharge. The patient's only relief consists 
 in keeping the eyelids closed. The repeated passage of the 
 probe, if some slight obstruction should have existed, and the 
 flowing of water injected by the puncta in a stream from the 
 nostril, afford sufticient proof of the freedom of the canal, 
 but no relief to the epiphora. A preternatural sensibility 
 of the membrane may be inferred from the excessive pain 
 and dread of the operation. I have seen such a case in a de- 
 licate young female of many months' duration ; in which nei- 
 ther soothing nor astringent applications, neither antiphlo- 
 gistic nor alterative, tonic nor sedative medicine, produced 
 the smallest benefit. The congestion of the superficial ves- 
 sels is inconsiderable: no morbid appearance is seen on evert- 
 ing the upper lid; the orifices of the canaliculi lacrymales are 
 natural ; there is no fulness nor uneasiness felt on pressure in 
 the region of the lacrymal gland. What is this disease ? Is 
 it an affection of the lacrymal gland.'' and if so, does it result 
 from any undue excitement, or any morbid irritability, like a 
 ' tic sensitif ' of the lacrymal branch of the fifth pair.? Is it sym- 
 pathetic with the surface or the retina .'' Does it depend on 
 a deficiency of the mucus which dilutes and sheaths the tears, 
 or a chemical change in the quality of the lacrymal secretion, 
 or a spasmodic affection of the orbicularis palpebrarum? Of 
 these suggestions some may be negatived by the absence of
 
 '162 NOTES. 
 
 such a symptom during the palpable existence of such condi- 
 tions ; the infrequency of this case, and the frequency of the 
 cases proposed ; others are altogether hypothetical, and I will 
 not add to the ' obscurum per obscuriiis.' 
 
 THE END. 
 
 G. WoodfaU, Printer, Angel Court, Skinner Street, London.
 
 By the same Author, 
 AN INQUIRY 
 
 INTO THE 
 
 PROCESS OF NATURE 
 
 IN REPAIRfNG 
 
 INJURIES OF THE INTESTINES; 
 
 ILLUSTRATING THE 
 
 TREATMENT OF PENETRATING WOUNDS, 
 
 AKD 
 
 STRANGULATED HERNIA.
 
 f 
 
 ^. 

 
 Jt 
 
 H 
 
 m 
 
 ^vif^ ^ 
 
 'i?^ 
 
 ^^ 
 
 ,fVJ 
 
 
 l^) 
 
 *^^. 
 
 ...H^-