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' tfeiEi^'i A+/9$A 45006083 VfS# OF medicine national library of medicine national library of medicine natioi an ivnoiivn 3nidio3w jo Anvaan ivnoiivn jnidiojw jo Aavaan ivnoiivn inoio %^: te^jX^i teiXf^ J z vjp; BIT IVNOIIVN 3NI3IQ3W JO AIVlIll IVNOIIVN 3 N I 3 I 0 3 W JO AlVlflll IVNOIIVN 3NI3IQ A/ i OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIOK OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIOI NOIIVN 3NI3IQ3W JO UVHII IVNOIIVN 3NI3IQ3W JO A » V « a I 1 IVNOIIVN 3NI3I03W JO *E D I C I N E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LI 'NOIIVN 3NI3I03W JO A«V«ail IVNOIIVN 3NI3IQ3W JO A IIV II a I 1 IVNOIIVN 3NI3IQ3W JO VNOIIVN 3NI3I03W JO ABVBail IVNOIIVN 3NI3I03W JO ABVBail IVNOIIVN 3NI3I03W JO /v EDI CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LI r\ NOIIVN 3NI3I03W JO ABV II IT IVNOIIVN 3NI3IQ3W JO ABV *i II IVNOIIVN 3N I 3 IQ 3 W JO / r SYNOPSIS OF 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 TROVERS, F. R. S SURGEON TO ST. THOMAS'S HOSPITAL. WITH NOTES AND ADDITIONS BY EDWARD DELAFIELD, M. D. Surgeon to the Ntm-York Eye Infirmary, and Lecturer on Diseases of the Eye. FIRST AMERICAN FROM THE THIRD LONDON EDITION. NEW-YORK: PUBLISHED BY E. BLISS AND E. WHITE, AND H. C. CAREY AND I. LEA, PHILADELPHIA. IS25. Southern District of JVetv-York, ss. BE IT REMEMBERED, That on the twenty-seventh day of September, in the fiftieth year of the Independence of the United States of America, E. Bliss and E White, of the said District, have deposited in this office the title of a Book, the right whereof they claim as proprietors, in the word* following, to wit : " A Synopsis of 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 Hospital. With Notes an ITS APPENDAGE^. 3 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 freelv 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 BytU. spherical, the line forming the visual axis ex- 4 ANATOMICAL DESCRIPTION OP 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 different 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 The eyeball is composed of the following and mem* ° hrues. parts.--- 1. The vitreous humor, * united by their 2. The crystalline humor, $ common tunic. AND ITS APPENDAGES. £> 3. The aqueous humor. 4. The retina. 5. The choroid and its appendages, the annu- lus 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 termed4 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. D ANATOMICAL DESCRIPTION OP THE EYE EoT8 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 great tenuity and perfect transparency, is of 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 >lND ITS APPENDAGES. 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- tinae, 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 ^ystaiune 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 o-elatinous 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 decree resists this pressure. 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. The tunic of the vitreous 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 crystalline 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 shows 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. 9 the grooves corresponding to these septa, the posterior edges of the ciliary 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 Ra»ttu,et0f the crystal- margin of the crystalline, the proper tunic is luie' 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 conr siderably more dense and elastic than the proper tunic of the vitreous humor. Independent of the membranous enclosure 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 capsule enclosing 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- 2 ANATOMICAL DESCRIPTION OF THE E\E 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 in 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 convev red blood. A minute foramen 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 A!SD ITS APPEiNDAGES. 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 ex- erted to separate it entire. The retina is uni- formly expanded over the tunica hyaloidea, but has no demonstrable connexion with that membrane. The tunica choroides extends from the cir- 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, or ligamentum 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 latteT 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 jg^sels and nerves. The vessels terminatingmipon it 12 anatomical description of the eye its pigment are extremely numerous, and secrete a dark pigment or varnish, which stains the contiguous adhering surface of the sclerotic; it likewise 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 ma- ceration. 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. artrolwis r^^le c*nary nerves run in parallel lines, at equal distances, upon the chofoid; 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 branches, 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 ca&ryring. 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 irK ANATOMICAL DESCRIPTION OF THE EYE The processus ciliares. On the internal surface 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 insterstices 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 processes 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 arrange- ment. AND ITS APPENDAGES. 1") The processes having their edges thus inlaid in the tunica hyaloidea at the margin of the crystalline 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 the posterior chamber. The iris. This is the colored membrane Irie 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 i« ANATOMICAL DESCRIPTION OF THE EYE divided into a ciliary and pupillary portion. Its attachment is, as already observed, by in- denture with the extremities of the plicae cho- roidae, at the inner margin of the annulus ciliaris, from which it originates. The ciliary portion of the iris is the larger one, and is com- posed of a delicate fibrous and vascular tissue, in which grey serpentine lines or striae are seen proceeding like radii from the annulus ciliaris: from this the smaller pupillary portion 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. The ciliary 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. 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- brane occupying the pupil of the foetus, and 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 3 ANATOMICAL DESCRIPTION OF THE EYE this membrane laid back to back, to accommo- date it to the area of the posterior chamber. Si- milar uncertainty 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 phe- nomena of its action can be best explained upon the supposition that it is both muscular and elas- tic, and that these forces act alternately. 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. 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; 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- sile than the sclerotic, and perfectly transparent It is, onion-like, composed of concentric la mellae 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 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 ex- ternally 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 Avithout 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 effected 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 Membram ° . J of the a tunic proper to the humor, which is reflected ^e°rus from it upon the face of the iris, 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- tchhea™^rs ° 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. 22 ANATOMICAL DESCRIPTION OF THE EYE veins of the The ciliary veins and vasa vorticosa of the 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 abun- dantly 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, pro- trudes, compresses, and thus induces congestion 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 palpebrae; the rectus superior, inferior, internus, and externus; obliquus superior and inferior. The levator palpebrae has an acute origin from Elector of r r "the upper the periosteum above the foramen opticum; its eyelid 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 results that the partial division of the tarsal ligament, or even the removal of the cartilage, does not take away the power of elevating the lid as the paralysis of this muscle does; the elevation, how- ever, under these circumstances, is imperfectly . performed. The rectus superior lies beneath this muscle, Superior • arising from the border of the foramen opticum LSSe. and the partition between it and the foramen la- cerum. 24 ANATOMICAL DESCRIPTION OF THE EYE internal ud The rectus intemus and rectus inferior arise inferior. *; in common from a ligament which in part sur- rounds the optic foramen, and fills up the fora- men lacerum. External. The rectus externus 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 superior oblique muscle rising from the oblique. . ' ° 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 ligament 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 enclosed 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 oblique. 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 single actions of the recti are expressed Theirac J 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. Their 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- Arter»e» 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. 26 ANATOMICAL DESCRIPTION OF THE EYE The arteria centralis retinas which runs in the centre of the optic nerve, and the long ciliary arteries which pass upon either side of it, are its first brunches ; next the lacrymal artery. which contributes a ciliary brarirh, a branch to the rectus externus, and another which runs be- neath the globe to the obliquus inferior muscle and reaches the inferior palpebra. The lacry- mal branch then divides into two : one, a brancli 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 superior 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 the frontal, through the supra-orbitar foramen; one or two to the rectus intemus, the nasal branch which passes by the anterior aethmoid foramen into the nose, and the infra-trochlear branch. The ophthalmic artery at length emerges upon the inner canthus, furnishing the superciliary and pdprhml 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. ning in the same direction, appear beneath the conjunctiva on the sclerotic coat. Here they subdivide and ramily upon the conjunctiva ; the fasciculi inosculating so as to form a faint cir- culus arteriosus around the cornea, when filled with colored blood. Those of the rectus intcr- 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 ophthalmic vein ; and the an- terior and posterior (ethmoidal or nasal, the la- crymal, all the ciliary veins from the globe, the vena centralis retinae, the infra-orbital, 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 pathetici; 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 palpebral 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 interims, 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 side 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 off, ;. The supra-orbttar, which is subdivided the supra and infra trochlear ramuli, and AND ITS APPENDAGES. 29 ihe proper frontal nerve; which last, running in an external and internal branch upon the levator palpebra?, 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. 3d. 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 aethmoid 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 Lacl.yni,i 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- ANATOMICAL DESCRIPTION OF THE EYE nal the large extremity of the gland. Its posi- tion is oblique; the inferior and internal surface hollowed to suit the convexity of the globe; 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 ; 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. The supercilium, or eyebrow. The arch 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 gradually 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- cilii 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 ANATOMICAL DESCRIPTION OF THE EYE 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 a 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. The palpebra. 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 palpebrae is thin, and loosely connected to the.subjacent parts by a fine lax cellular texture, which abounds at the orbitar margins of the palpebrae. 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 APPENDAGE?. under the orbitar arch, which 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- traction of the sphincter fibres of the orbicularis palpebrarum, the tendon of this muscle starts for- ward, and the rugae are extensively radiated from the nasal angle over the skin of the cheek. On re- moving the skin and the subjacent cellular tissue of the palpebrae, the thinly spread fibres of the orbicularis muscle are seen. The tendon with which these fibres are connected is a little round cord, distinctly seen and felt beneath the tegu- ment, implanted in the nasal process of the max- illary bone, in the great transverse diameter of the orbit. The fibres which lie upon the palpe- brae are the interior fibres of the muscle, the fis- sure 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 maxil- lary bone, take an extensive sweep over the orbi- tar ridge upon the cheek, towards the temple, where they become thin and scattered. The 5 ANATOMICAL DESCRIPTION OF THE EYE superior from the round tendon and contiguous part of the frontal bone, take the direction of the superciliary arch; being at their commencement connected with the 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, which has been described as the ligament of the pal- pebrae 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. The tarsi are two elliptical cartilages which give figure and firmness to the palpebrae, 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- ing 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- Eyeu*«. 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- guv- nor border of the tarsus the mouths of a row of follicles, seated vertically on the concave sur- face of the tarsus, form a slightly eminent line. These follicles, when magnified by a glass, ap- 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. The puncta lacrymalia, sacculus, and duc- tus lycrymalis. The obliquity of the tarsal edges, which are opposed to each other, leaves a groove, or sulcus, between the meibomian borders and the surface of the globe, when the ciliary borders are in contact. This increases in breadth towards the nasal angles of the tarsi, where the puncta, or orifices of the lacrymal ex- cretories, are placed upon two small conicaremi- 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; 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 upper and anterior part of this sac, under the tendon 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. 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 off* by the nasal duct. The tunica conjunctiva. The integument of the eyelids is inflected at the edge of the tarsi, and lines 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 alimentary canal. AND ITS APPENDAGES. 39 The conjunctiva, having lined the interior surfaces of the tarsi, is connected to the liga- 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- perable 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 coming nally modified by its several relations with the ^aetaes'Jeby 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- ANATOMICAL DESCRIPTION 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 in 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 de- position 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 VAL.VULA SEMILUNARIS, AND CARUNCULA Semi-lunar fold SDd la.- lacrymalis. The conjunctiva is attached to ^™e!ca" 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 canthus. The ca- ANATOMICAL DESCRIPTION OF THE EiE 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 palpebrae are supplied. THE ARTERIES, VEINS, AND NERVES OF THE pupebr/b. A superior and inferior branch, 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 the superciliary artery, from the ophthalmic, 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 facial, infra-orbital and temporal artery, participate in the supply of the palpebrae. The veins, beginning by small radicles from the opposite margins of the tarsi, form an intri- cate plexus beneath* the skin of the palpebrae, 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, ETC. 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 fol- lowing 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 economy conveys. I shall suppose the reader acquainted with preliminary the prevailing opinions concerning the origin 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 corres- ponds to the point from which they emanate, and the base to the surface upon which they im- pinge. influence or The operation of the cornea upon the rays of oXraT %h* *s *° render them convergent towards the Rf 1,ght retina, by reason of the sphericity of its surface, and its greater density compared with the at- mospheric medium through which they pass. The rays which fall within an angle of 48°, or thereabouts, measured on the surface of the cor- nea pass through it, and are refracted in their passage. Those which are not included within this angle are reflected by the verge of the cornea and the sclerotic coat. The aqueous humor, being of inferior density to the cornea. AND ITS APPENDAGES. 4? diminishes 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 humor 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, which 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 memb rane. The result, then, it appears, of a series of re- fractions of the rays of light in passing through 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 this account it will be perceived that inversion ^ ol the image each pencil will consist of a double cone of rays, ™ j£ 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 in 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 image 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 necessary effect of the spherical figure of of aberra- 1 • • Ime1 uaimre- *ne cornea 1S *° occasion an unequal refraction rraction. 0f tne ravs wnich 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 arrive at it with a considerable AND ITS APPENDAGES. obliquity ; and secondly, by the mobility of the iris, which adapting the s;ze 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 omce iris. those rays which are denied admission through the pupil: they would be unequally refracted by those points of the lens through which, if un- interrupted, 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 distant object 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 steadfast 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 light 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- 7 PHYSIOLOGY OF THE EYE jects being conformable to the distance, the pu- pil, in viewing a distant object, is dilated so a? 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 to dis- tances is lost. I conclude, therefore, that the adaptation of the eye to light co-operates with its adaptation to distance. By the peculiar 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 occa- sion, and to throw the most oblique pencils of rays with sufficient accuracy upon the concave. face of the retina. AND ITS APPENDAGES. 51 .Notwithstanding that man, compared with and use of . . the pigment. 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- the lens lute of color, the decomposition of light by ir- regular refraction, being in ordinary vision pre- vented or corrected by the structure and cur- vature of the crystalline lens. Light, artificially separated, either by refraction, reflection, or in- flection, 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 w j vision. 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- PHYSIOLOGY OF THE EYE tificially induced, we have a clear perception of an object from which 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. The magnitude of the image formed upon the retina, 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 0f The duration of the impression made upon sion. 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 intently at a colored object, remaining even after the eyelids are closed. Distance. The eye possesses no absolute power of de- i£°°°f termining the actual distance, magnitude, and position of objects. Such knowledge is relative, and results from the experience derived from Magnitude of the image. AND ITS APPENDAGES. 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 have 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 images of objects are inverted upon the inversion of ° ° "the image. retina, yet we see them, as they are in nature, erect. If we look in a concave mirror, objects appear 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 convince himself, by preparing an eye, as before men- tioned, and placing beside and a little behind the flame of the candle a spoon, the hollow of which reflects it inverted, when he will observe, 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 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 eroneous impression before it is pre- sented to the sensorium. The celebrated 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 APPENDAGEc. JO The association of ideas, derived as they are intercourse . . J ofthe irom the external senses, operates imperceptibly ~; to an extent that we have no means of ascer- x^lmtlt" taining, because the original and absolute nega- 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 lavue 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 comme nous apprenons a parler eta lire. — Voltaire, Physique Newtonienne, Chap. 7. Our Shakespeare who' needed not the spectacles of books to read nature, but looked inwards and found her there,'1 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 names, as thu= To name the several colours we do wear. Sight may distinguish colours : But suddenly to nominate them all, It is impossible. ■< 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 measureable, but the simple ex- periment 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 oneeye *Elem. Phys. Vol. V. Sec. IV. 9. 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. Neither is double vision a common result of 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. Where double vi- sion occurs, it is seldom, if ever, a permanent symptom, although the squint becomes confirm- ed, 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 corres- pond 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- AojustmeDt der the subject, that the rays of light which issue ***»y* 60 PHYSIOLOGY OF THE EYE different from an object at some distance from the eye, and those 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 I shall content myself with a verv brief men- bypotheees. . " J tion ot the 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. 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 mus- cles, braci ng the anterior segment of the globe; the second assumes the muscularity of the iris, or the extension of its texture, by the sudden in- jection of its vessels, and vice versa, its abridg- ment by their contraction; the third, a power in the muscles of the globe either to shorten or elongate its axis; the fourth attributes muscula- rity 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- 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 m the various forms of amaurosis: it is suspended during the per- 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 favourable 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 results of my experience. I have already said that the iris, by regulating the quantity of light, assists 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 AIND ITS APPENDAGEb. 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 proof, I 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 b4 PHYSIOLOGY OF THE E1E to acquire a rigidity which scarcely admits of di- latation—its obedience, in all respects, to the laws which regulate the muscular system—its contractility 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, hyoscyamus, belladonna, &c. to which its proper nerves are in a peculiar man- ner irritable, The ciliary 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, thg 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 All animals which have a moveable iris, animals. , , , have the pupil circular, oblong or elliptical. AND ITS APPENDAGES. forms favourable t6 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- posed for a small space on its posterior aspect, we observe the plicae 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 plicae 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. 9 lift 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 die 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 pur 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 lio-ht and adaptation AND ITS APPENDAGES. 67 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 uveal Pro< " longatioos Haller as raised on the posterior face of the iris, °[yhperoiu" and advancing even to the margin of the pupil. 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, however 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- 68 PHYSIOLOGY OF THE EYE serve? 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 leris be protruded so as to bear down the natural resistance of the processes, the pupil becomes dilated by its pressure. ► acuity or It would require a more intimate acquaint- adaplatioD, \ * \™J" en ance than we possess with the economy of the various classes 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 APPENDAGE^. #9 mate, is of the softest consistence, and occupies the smallest portion of the volume 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 fujl 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- 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 go 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. 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. '* On the other hand, every one may satisfy udroiun- ' * ■ " " tary motion himself of a power which the will is capable of of the iris 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 ; and still more rare for the state of ac- commodation 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. 72 PHYSIOLOGY OF THE EYE Roget, in whom, I may be permitted to sav. 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 whieh 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, ,k 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 showing 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 asser- tion 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. 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- JO 74 PHYSIOLOGY OF THE EVE 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 culti- vating. " 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 expe- rienced. " 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. TRAVERS, ESQ." In addition to the nerves derived from the ciiiwy nerves lenticular ganglion, the iris receives two or more the naSi 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 supplies the levator palpebrae, which is purely a voluntary 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 bv an in- ganjlion. . *> J 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 derived from the lenticular ganglion, which I re- gard as a direct medium of communication be- tween these nerves and the retina. The phenomena of ocular spectra, or images 0cui« of luminous objects remaining upon the retina 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 re- tina, of which I shall speak hereafter. I have said that the duration of an impression is in proportion to its intensity. The experi- ment 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 succes- sively exhibited, in the order of their relation. 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 spectrum 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. 79 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; 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- Ef*p'2neation vous excitement; the first, simple over-excite- la- 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- 80 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 Tne levator palpebrae being purely a voluntary braimKs. muscle, the simple suspension of its action effects 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 be- longs to some morbid affections of vision, of which I shall have occasion to speak hereafter. A voluntary closure of the eyelids, as when the eye is from any cause irritable to light, is per- formed by the orbicularis palpebrarum, which in some casualties and morbid states contracts spasmodically, 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 therefore passive; in a voluntary shutting and opening of the eye it participates, although in- considerably, in both actions. Winking is an alternation of the actions of the levator and or- bicularis, 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 por- tion 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 separation by external force, knitting and de- pressing 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 11 •jo PHYSIOLOGY OE THE El E corrugator acts as a moderator to the levator: the orbicularis is the antagonist of the latter. Actionsor The actions of the straight muscles in various ^ue^bl. combinations, and in succession, explain the se- veral 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. guperciii- The prominence of the superciliary ridge, as muscles. 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- J i J meable to light, so as in ordinary circumstances to occa- 1,ght' sion waking, and distress to persons whose eyes are inflamed. The superior tarsus, when drawn up, slides under the arch of the orbit, but retains its apposition to the globe, owing to the laxity of its attachment with the integument of the pal- pebra. The origin of some fibres of the orbicularis Muscular o compression from the ligamentous expansion which supports mEih6eac!cr>" and protects the lacrymal 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. The conjunctiva has been supposed to secrete conjunctiva J „ anon-se- a lubricating fluid, which serves the purpose ot «e£°s sur- keeping the cornea clear, and facilitating the motions of the lids. This forms, according to 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 follicles aiie1 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. with what we see of the mucous membrane pro- perly so called, as of the urethra and intestinal canal, which continually show that the secretion can be set up by disease upon a whole surface, while in the healthy state this function is confined to its follicles and lacunae. 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 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- cree of elevation of the upper lid. By drawing 86 PHYSIOLOGY OF THE EYE, ETC. the lid upwards and towards the nose, it i* 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 plaee. PART II. PATHOLOGY THE MEMBRANES CHAPTER I. SECTION I. CONJUNCTIVA. The vessels of the conjunctiva of the globe are £\^f'«- derived from two sources:—1. The palpebral C0DJunctiva arteries and veins; 2. The ophthalmic muscular branches, and accompanying veins. The first, creeping upon the sclerotic conjunctiva in the sinus palpebrals, and at the angles of the pal- pebral, have a reticular distribution upon the loose portion of the conjunctiva. The second, after penetrating the tendons of the straight mus- cles. 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 ves- sels, and their distinctive character is preserved under very high degrees of inflammation. In a complete section of the 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 demons- trated 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 impractica- ble. 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. CONJUNCTIVA. 89 sclerotic __ cornea. under inflam- 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 the cnrot^ eve, little, if any, red blood is admitted into the Jnlj?H superficial vessels, yet under a very temporary ana™ excitement, colored blood has a ready admis- ™tion sion into the vessels of the sclerotic conjunctiva. Such, however, is the condensation of the con- necting texture upon the cornea, as to prevent 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 permeable to red blood to increased vascularity under excitement, is in proportion to the quantity of cellular texture entering into their composition, or connecting them with subjacent parts. Compare, in this view, the membrane of the fauces and the trachea * I believe further, that it is inadmissible, except a morbid change has previously taken possession of this texture. But of this hereafter. 12 CONJUNCTIVA, —pleura pulmonalis and costalis—periosteum and perichondrium—the lining membrane of veins and arteries. Since the easy admission 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 shows the rise and pro- gress of inflammation obscurely, its perfect trans- parency in health makes the results of it more conspicuous. The first effect of inflammation upon the cor- nea 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 perma- nent opacity; viz. effusion into the connecting texture, and thickening of the conjunctiva upon the cornea. This is the progress of simple oph- thalmia in the generic sense of the term. Con- trast the epidermis in the state of blush (conges- CONJUNCTIVA. 9] tiva to the tion) and of incipient vesication (effusion). The peritoneal coat of the liver, the arachnoid and synovial membranes doubtless exhibit, in the dis- tinct stages of congestion and effusion, the tran- sient and permanent opacity. The conjunctiva is to the cornea, what the ™*™u«_ periosteum is to the bone. It nourishes the su- £!" perficial lamellae; wherever it is completely de- tached, the exposed surface of the cornea ulce- rates, and its vessels repair the breach. To pur- sue the analogy, the interlamellar texture of the cornea 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 disor- ganize ; by the action of lime, gunpowder, strong acids, and other chemically destructive agents; or by the strangulation of the vessels of both tex- tures, as in the excessive chemosis, which de- stroys on the same principle as the paraphymo- sis, 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 in- flammation,* of which the ordinary signs are fa- miliar to every practitioner, originating in a heal- thy subject from an obvious occasional or acci- dental cause, as an extraneous particle, or a blow not injuring the texture, or a blast of cold air. An *See Plate I. fig- 1< 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. tionnornthea" The inflammation of the conjunctiva, termed modified by' * strumous,' where it has not proceeded to a scrofula. * 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 diffused 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 degree 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. the habitual depression of the head, and the obstinate maintenance of an awkward and un- natural posture of the body to screen the eyes from light. The disproportionate degree of inflammation 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 with the se- creting surfaces of the primae viae and the skin, for neither of these organs perform their heal- thy functions during its existence. The tongue. the index of the former, shows 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 re- moved, 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 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 snuflP- 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 always re- markably languid and protracted, as if the state of excessive irritability checked its progress, and prevented its completion. Aphthous or The conjunctiva of the sclerotic is disposed pustular in- r ofThTc'on- *° wrm aphtha? 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 CONJUNCTIVA. 93 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 lymph, 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 gene- rally 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 i,,ii^^ m, . . t»°n of the disease of the palpebrae. 1 he secretion is sup- ^,'^7^ plied by the meibomian follicles and the con- char£e junctiva bordering them, and likewise by the ca- runcula lacrymalis. A puriform discharge is furnished by the cryp- ta? of the tonsils, the lacunae of the urethra, and the mucous glands of the nares, fauces, rectum and vagina, in mild inflammation of these parts. But in the vehement acute form of inflammation. * See Plate I. fig. 6, 96 CONJUNCTIVA. the matter of suppuration is furnished by the tu- mid and villous surfaces of these membranes. pulatTveTn-" ^le sclerotic conjunctiva in acute suppura- ofThTcon- tive ophthalmia presents the following states: 1st, junctiva. . . Serous effusion (oedema) which is common to other inflammations, and especially those of a less vigorous kind. 2d, Effusion of lymph (che- mosis) peculiar to this form of inflammation, by which it acquires a solid augmentation of bulk. 3d, Villosity, or a subsequent prolongation 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 affected becomes preternatu- rally vascular, thickened, and scabrous, or forms fleshy eminences. That the vascular villi of the conjunctiva secrete pus, may be ascertained by the aid of a lens. The pus, when formed, col- lects in the interstices of the villous texture. We have no evidence, as I have before observed, that the conjunctiva is a secreting surface in the healthy state. aiiid acute A form of disease intermediate to these in suppurative _ ofthrcon-00 extent and seventy, a modification of the sup- purative ophthalmia, is the villosity 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- CONJUNCTIVA, mescent, giving it a more rounded figure, and moderately vascular. This is the mild acute suppurative ophthalmia, which seldom injures the cornea, but frequently leaves after it the same fungous or granulated state of the conjunc- tiva palpebralis whi,ch 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 palpebrae or the globe, is a difference in kind as well as in seat; 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- SuppUrativ9 live ophthalmia, whether in the mild or vehe- communi- r 7 cated by ment acute form, is sufficiently proved. For one CODtact 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 albus 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 confined fo that portion of the membrane. Where by n 98 CONJUNCTIVA. neglect or improper treatment, it extends to 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 armies, schools, and families. There is much reason to believe it epidemic as well as contagious, but the former is a point less easy of decision. • chemosis. The chemosis, 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 existence * In the forming stage of chemosis, it is frequently mis- taken for a mere cedematous effusion of serum. The apparent softness of the swelling at this early period may readily lead the practitioner into this error. 1 have not unfrequently known the conjunctiva of the eye-ball freely scarified, when in this condition, with the expectation of discharging the fluid supposed to distend it; and, as a necessary conse- quence, the inflammation thereby materially increased.— Editor. CONJUNCTIVA. of this morbid condition which is characteristic of the suppurative ophthalmia, that the con- junctiva 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- 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 the conjunctiva, concealed in the hollows of the palpebrae, 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- lible to irritation of inflamed parts by the dis- eased and confined secretion, as the warts in ex- ternal gonorrhoea. ,100 CONJUNCTIVA. simple fun- A firm fleshy fungus, which sometimes attains conjunctiva, considerable bulk, so as to project from between 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- toauscfDu0nma" There is a malignant fungus of the conjunc- £ctlvaon" tiva, for, like the mucous membrane of other parts, this is sometimes the seat of carcinoma; 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 palpebrae, and de-r 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. r»flm. The pannus is a chronic thickening and opa- city of the conjunctiva of the sclerotic, generally *S»e Plate II. fig. 1. CONJUNCTIVA. 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. The membranous pterygium is a true nebula of the sclerotic conjunctiva; the fleshy is an adipose or sarcomatous growth beneath the sclerotic conjunctiva. It extends from either canthus or sinus palpebralis, 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 well as its termination in simple nebula of the corneal conjunctiva, shows 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. conjunct.- Adipose, steatomatous, and even cartilaginous onthTscie- tumors form in the cellular tissue of the scle- rotic, rotic conjunctiva, and produce the same change when situated in the vicinity of the cornea as the disease last mentioned, viz. a marginal inter- stitial deposition. and cornea. Circumscribed tumors of a dense and firm texture are sometimes formed upon the surface of the cornea, and attain a considerable magni- tude ; but such cases are rare. I excised the anterior 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 measured CONJUNCTIVA. 103 a quarter of an inch in thickness from the exter- nal surface of the cornea.* The encanthis is a morbid enlargement of EncantMs 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 epiphora by a forcible diversion of the lacrymal puncta from each other, and from the surface of the o-lobe. 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- ™luM«9- 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 vaginae. The frena or frenula connecting the conjunc- f.«d» tiva palpebrarum and conjunctiva scleroticae, 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- Plate II. fig. 2. and fig. 4. 104 i ONJUNCTIVA* 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 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 relieve it, i. e. by the multiplication of frenula, that the patient became disturbed in his intellects, from an exaggerated sense of his misfortune. to adhering The co-adhesion or concretion of the tarsi by tarsi. # * organized adhesion of 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-adhesion of the nymphae or labia pudendi, and the closed anus in new-born infants. indisposi- The conjunctiva is not prone to ulcerate. tion of the x tco0Xerauvve whllst the substance of the cornea readily as- i^aamma- sumeg tnat action. 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 CONJUNCTIVA. lOf) 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 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- pathological ... . .. . . relations of thological character, bears in its respective rela- theconjunc- tions to the sclerotic and the cornea, an affinity to the two distinct classes of membranes: viz. the mucous upon the sclerotic, and the serous upon the cornea; hence the frequency of pustule and thetendency to suppurative inflammation of the sclerotic portion, and the indisposition to ulce- rate and proneness to adhesive inflammation of the corneal. 11 SECTION II. CORNEA. ulcers of The cornea is disposed to adhesive inflamma- the cornea, . - . . tion, ulceration, 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- .nd their lorless vessels. That the proper vessels of the modes of 1 1 /» heaimg. cornea are capable of secreting adhesive 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 • CORNK A. 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 ves- tige of it is discernible for a short time after the vessels 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 pro- cess, when the stimulus of a single injection is followed by the appearance of the red vessels, the effect of which is speedily manifested by a reddish 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 show that it is organized by the vessels of the lining membrane. The same <- ORNEA. 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 con- tinuity, 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 up- on the obstruction of the trunk. The appearance of colored vessels upon the colored * *■ vessels upon conjunctiva of the cornea is to be referred to the come. one 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. no 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.— 3d, 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 it.t 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 cor- nea from blood-vessels in other parts ; and the spontaneous 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. | See Plate I. fig. 5. CORNEA. 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 dis- appear. 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 deposited, is at the same time absorbed. This operation 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, 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 whieh 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 disorga- nized. 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 ; viz CORNEA. the extension and enlargement of collateral branches. Observe the vessels of the sclerotic conjunctiva in organic amaurosis; of the skin covering indurated tumors; and lastly, the com- municating branches after the ligature of the trunk in aneurism. Mr. Hunter thought that the vessels might be formed in a patch of lymph inde- pendent 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 co- agulum, 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 cel- lular, but there was no regular structure of ves- sels." Then, likening extravasation under inflam- mation, and the vascularization of the membranes of the chick to this appearance of a self-organi- zed coagulum, he adds, " I conceive that these parts have a power of forming vessels within 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. «5 114 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, ten- don, and other elementary textures. The depen- dence of one order of vessels upon another is shown 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 inter- The acute interstitial ulcer sometimes opens stitial ulcer * nea!he cor" externally, by absorption of the conjunctiva, as well as of that portion of the lamellae 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 conjunctiva will be found to be absorbed at the part opposite to the ulcer, and the exposed scabrous surface 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 which its CORNEA. 110 healing is perfected, as in the ulcer opening from the surface, before described. The terms onyx and unguis have been indis- onys and ... . unguis. criminately applied to extensive collections of 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 interlamellar 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- HyPoPion. 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 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 adhe- sive 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 stimu- lant is employed. The healing action is marked by a dusky white line at the verge of the open- ing. The contraction of the chamber and the disfiguration of the pupil are proportioned to the extent of the prolapsus. procidentia In the progress of an external ulcer to the in- comes. tenor 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 CORNEA. li- lts 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 circumscri- bed interstitial ulcer opens into the anterior cham- ber, serves to confirm this conjecture. I have never seen the appearance which I have heard others describe as demonstrating the adhesive inflammation of this tunic, viz. colored vessels arborescent upon a deposit of lymph coating the interior of the cornea. If the observation be ac- curate, the case is very rare. Chronic interstitial ulcers from pure ulcerative chronic k- . terstitial ut- absorption, succeed to acute inflammation, in ^D"gtbe 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: t°^S 1. Thickening of the conjunctiva and effusion IIB 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 ophthalmia. The corneal surface loses its smoothness and po- lish as well as its transparency, when the con- junctiva 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 which 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, similar 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 be- come 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 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 conspicuously their color is contrasted with this appearance, as yellow or brown, the less is the probability of re- ducing them. The peculiar hue and loss of tension, as well Gangrene 1 preceded by as lustre, of the dead cornea in acute suppurative f*£>™£- ophthalmia, has been aptly pictured by Mr. Saun- suppurative r ' r J tr J ophthalmia. ders, by the terms ' cindery, ragged, flocculent.' It is important, because I have satisfied myself that the first change of the cornea in this disease is purely nebulous, produced by the deposition of adhesive .natter; and if the inflammation be arrested even on the verge of gangrene, the cor- nea is susceptible of restoration by absorption. This fact I had lately an opportunity of establish- ing, in the case of a lady who was rendered blind by acute suppurative inflammation of the con- junctiva : so inevitable to all appearance was the destruction of the cornea, which had sloughed in a deep sulcus at its junction with the sclero- tic above, that the most experienced practi- tioner of my acquaintance in this branch of sur- gery pronounced the case hopeless and irreme- diable, and took his leave. The highest tonic regimen, bark, wine, and opium, followed close upon a very active and bold depletion, and the 120 CORNEA. anterior chamber was fortunately and unexpect- edly preserved. No sooner was a sign of the arrest of sloughing ulceration obtained, than I commenced a mercurial course; in three days the system was affected; the recovery of the figure and transparency of the cornea was rapid and complete beyond 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 en- sues. More frequently this disorganization is in- tegral and complete. The cornea, disorganized by acids, is rendered instantly opaque, shrivelled, and of a yellow color, almost resembling.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 in- terstitial deposition has been abundant and of long standing, and the lamellae are compacted, owing to the entire obliteration of the cellular texture; or in which a new portion of cornea is formed. cuticuiar I have seen several cases of the conversion of conjunctiva of^the cor- tne 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 conjunc- tiva, and am disposed to consider it depending on an obliteration of the ducts of the lacrymal gland. All stimulant substances, not escharotic, ap- Action of topical plied to remove opacities of the cornea, act in JJ^j™ the same manner as rubefacients upon the skin; 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 practi- cal illustration of Mr. Hunter's quaint but expres- sive phrase, " stimulus of necessity."' Opaque specks.even cicatrices, are obliterated ibw. 122 CORNEA. during during the period of growth, and, as is observed growth. . . . /> 1 i l l of cicatrices in other parts ot 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. staphyloma; The staphyloma is of two kinds, viz. from dila- its kinds. tation and from breach. In the first case the corneal lamellae 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 conse- quently affects the whole diameter of the cornea (spheroidal). In the second the staphyloma is circumscribed, the recent lymph, corresponding 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 lamellae 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 actu- ally 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 pullulations, 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 humor escapes, and the globe collapses and sinks in the socket. * I have seen in such cases a permanent staphyloma of the iris, 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. 124 CORNEA. 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- 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 0 process ir of the cornea exhibits beautifully the third kind ulcers of absorption, viz. the modelling, as decribed 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 trans- parent indentation occasions little, if any impedi- ment to vision. SECTION III. SCLEROTICA. vessels of Branches from the straight vessels of the the sclerotic. ° conjunctiva penetrate the sclerotic obliquely to- wards the 'margin of the cornea, and tne 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 demonstrate this anastomosis; for the commu- nicating vessels, like those which 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 sa- tisfaction of anatomists. SCLEROTICA. 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 affect- ing 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 from its situation and texture serves as a shield 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 mischie- vous. ord^ry When the sclerotic partakes of the inflam- u«rf3i mation of the conjunctiva, for it is only as inter- sclerotic, " secondary. me(jjate to tne 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 in- flammation is always present, during the morbid changes upon the cornea, viz. interlamellar de- posits of lymph and ulcerations. sclerotitis; I have occasionally 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 1. fig. 6. SCLEROTICA. 129 nebulous, and the surface roughened, from effu- sion beneath the conjunctiva. The inflammation of the sclerotic sometimes andrheumat . . . . • 1 'c °P',thal- accompanies, and is sometimes vicarious with mia- 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 go- norrhoea, 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 T- of the scle- yields in the spheroidal staphyloma, a disease rolic * See note A. 17 / 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 proportion 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 haematodes, and the extir- pation of the organ advised. I think it may not improperly be designated staphyloma sclerotica?. 1 have met with one or two instances of the actual protrusion of the choroid at the margin of the cornea, which had the appearance of result- ing from the separation of the sclerotic; like the staphyloma iridis from the fall of the cornea, de- scribed page 123. * See Plate 1. fig. 7. Staphyloma of the cho- roid. SECTION IV CHOROID AND IRIS. The appearance of the vascular zone at the choroid 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 consi- derable varieties in its form, its access and pro- gress, relatively to the superficial inflammation, and the kind and degree of pain and dimness 132 CHOROID AND IRIS. 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 inflammation, viz. the arrangement of the vessels, the pain, and the obscurify of vision. I have often seen cases of this description which I have felt disposed to de- nominate " Choroiditis." iritis. The indications above mentioned, are still fur- ther confirmed by the presence of an habitual aching pain affecting the globe of the eye, fore- head, and region of the orbit, and by certain ap- pearances of inflammation upon the iris, as hair- like red vessels and specks of extravasated blood in its substance. Adhesive inflammation takes place between the fibres of this muscle; the pu- pil loses its thin flowing edge, and becomes thick, stunted, and gibbous. Iritis of moderate acute- ness is often unaccompanied by any other ap- pearance of inflammation; there is no distinct deposit of lymph, and it is rather inferred from the fixedness or slight change of figure of the pu- pil, than demonstrated.* I believe the adhesive matter, in this case, is deposited on the posterior surface, formerly called uvea, for in the course of a few days, the opacity of the capsule of the crystalline, and the co-adhesion with it of the pupillary margin, becomes evident, provided the inflammation be unchecked. In this form of in- * See Plate I. fig. 2. CHOROID AND IRIS. 133 flammation the 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 affects the whole corresponding side of the head. In other instances, it is confined to the eyeball and its immediate vicinity, as the fore- head and temple, and bones of the cheek. The sensation is sometimes that of pulsatile pain, marking every injection of the ophthalmic ar- tery, 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 depo- sited upon the face of the membrane, in small tufts here and there, or large tubercular masses. The pupil, in this case, is usually much missha- pen, being rendered angular at those points of the circle at which the deposit has taken place, or is most abundant. Its aperture is sometimes partially covered, and sometimes 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 vi- sion is nearly, if not quite extinguished. The ap- pearance of a stratum of lymph, coating the face of the iris, with a turbid state of the aqueous humor, belongs to chronic inflammation, which tends to opacity of the capsule of the lens, and constriction of the pupil. CHOROID AND IRIS. A primary inflammation of the iris, as for ex- ample, from syphilis, or from mercury, is distin- guished from the secondary, or that by extension from the conjunctiva, by the more sparing vascu- larity of the conjunctiva, and consequently more distinct and conspicuous appearance of the vas- cular zone.* The attack is more sudden, the pain in the region of the orbit and head, com- mences with the inflammation, and is more se- vere ; the vision is more quickly and completely bedimmed. The effusion of lymph is en masse, and the disfiguration of the pupil greater. In the inflammation of the iris by continuity, the conjunctival vascularity is more conspicuous and diffused, 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 P>. CHOROID AND IRIS. 135 The terminations of iritis, if unsubdued, are, Termina- 1st, constricted or closed pupil, with opaque cap- sule ; 2d, co-adhesion of the iris and cornea, par- tial or entire, the former assuming the convexity of the latter; 3d, organic amaurosis, followed by disfiguration of the globe, and often by protru- sions of the choroid and sclerotic. Iritis, as I have formerly observed, is very fre- J^r™"*' quently in company with, or succeeding to sy- philis, 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 instan- ces. But I have since had additional opportuni- ties of confirming the facts.before advanced, that where mercury had been used in various ways before the iris was affected, and before the other symptoms appeared which were referred to its use;—where the primary affection was either al- together questionable, or at most a gonorrhoea, or a superficial sore, which healed by a simple to- pical application—the iritis has yielded to the steadily supported influence of mercury upon the system, in a manner the most satisfactory; and that no other remedy with which I am acquaint- ed, was competent to this effect.* * 1 think it right to state, that the salutary efl'ect of mercury 136 CHOROID AND IRIS. The iris undergoes a change of color as well as texture, by a continuance of inflammation. 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 iris 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 lea- ther-like toughness of the iris, and a varicose state of its vessels, are changes accompanying in iritis, unassociated with any specific action, was an obser- vation made at the 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. Saunders's work, then in the press. I am quite satisfied that the obser- vation was original, notwithstanding all the attempts of the German scholars to convince us, that at Vienna, and else- where, it was a matter " lippis et tonsoribus notum.^ I shall further add, that 1 am unacquainted with any fact in Medical Surgery which ranks with this in point of importance; whether we consider the urgency and frequency of the occa- sion, or the indispensable necessity, and almost unerring effi- cacy of the remedy. Morbid changes of the iris. t H0R0ID 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.* * There is a mild chronic form of iritis, so little resem- bling the acute disease, and so insidious in its progress, that the greatest attention is necessary in its diagnosis. The following case is a good specimen of this affection. An eminent upholsterer of this city applied to me, some time since, complaining that he was gradually losing the sight of one of his eyes ; and that the loss of vision had been slowly progressing for several months. The only other local symptom which attended the case, was a constant deep-seated pain in the back part of the head, on the affected side, together with a continual sense of coldness there ; and these sensations had existed since the patient first observed his vision beginning to fail. He had been labouring under dyspepsia for several years ; and as not the least trace of redness, or other ordinary evidence of inflammation, appear- ed in the eye at the time, or ever had done so, the case was at once suspected to be amaurosis, dependent upon disorder of the digestive functions. On a closer examination of the organ, however, the lower edge of the pupil was observed to be irregular, inverted, and adherent to the capsule of the lens, but not sufficiently so to strike the observer without very accurate attention. No other symptom of disease of the eye existed ; but this last became much more evident upon the application of extract of stramonium, and consequent dilatation of the pupil. This, however, taken in conjunction 18 CHOROID AND IRIS. with the loss of sight, and the pain in the occiput, was a de- cided proof that the disease was chronic iritis. Accordingly, the patient was cupped, and immediately commenced the use of mercury. The impediment to vision quickly disappeared, the pain subsided, and in a few weeks the patient was cured. Two months afterwards, the other eye was attacked in a similar manner, and cured by the same remedies. Other cases of the same character have occurred to me, but I have noticed that they all, like this, were connected with a disordered state of the digestive organs. I have remarked one fact as connected with syphilitic iritis, which I do not remember to have seen noticed else- where. The disease is very frequently accompanied with tinnitus aurium and deafness ; the organ of hearing appa- rently taking on the same congested condition as the eye. I have observed this symptom in protracted and badly treated cases alone, never in recent ones, nor in those which had not been preceded by syphilis.—Editor. SECTION V. RETINA. The retina is sometimes, though rarely, the ioomm* ° tionorthe seat of inflammation; but it is an error to sup- retin» 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 140 RETINA. light. The pupil, upon inspection, is gaping and motionless, as in confirmed amaurosis, and the humors are thick and muddy. The external signs of inflammation are in the commencement disproportionate, and quite insufficient to ac- count for the symptoms. Accompa- In some cases, however, the signs of choroid inHamma- inflammation are present with the attack of pain tion of the r r othertunics. and the ioss 0f sjght. The pupil is not thrown 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 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 afford time for the bene- ficial operation of a remedy. 1 have in more than one instance given a full trial to the lancet, and the immediate operation of mercury; 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 motion- less pupil, the discolored humors, and the super- ficial congestion, which remained, afforded little hope of its continuance. One lamentable instance occurred under my observation, of its destroying both eyes in a middle-aged lady within the short interval of a fortnight. She expressed, in the agony of her suffering, a conviction that she must either lose her sight or her senses. Amaurotic affections, as is well known, differ infinitely in degree, but they differ also in kind; and this affords a more scientific basis of classi- 142 RETINA. 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. 3. 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 cerebral irritation; suppressed or deranged, or excessive secretions, as of the liver, kidneys, uterus, RETLNA. 143 mammae, and testes ; various forms of injury and disease; and sudden translations of remote mor- bid 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. * To apply the term paralysis to a nervous tissue, is, to say the least of it, a misnomer. A muscle may be paralysed from pressure or injury of the nerve which supplies it, or the part of the brain or spinal marrow whence that nerve is derived ; but there is certainly nothing in the nerve itself suf- ficiently analogous to muscular structure or function to apply the term < paralysis' to both. We have indeed no evidence that a nervous tissue ever loses its function independently of some lesion either of itself or its origin, except where it is af- fected by sympathy with some other part. To attribute amau- rosis therefore, to idiopathic palsy is entirely gratuitous : and the result of practice directed to the removal of such a condition of the parts is never sufficiently encouraging to countenance the theory upon which it is predicated. Most. if not all the cases of amaurosis, which are attributed to idio- pathic palsy of the retina, are more probably dependent upon some antecedent congestion of the organ, or some other of the causes enumerated by our author.-Sduor. 144 RETINA. Even under the continued suspension of func- 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 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 RETINA. 145 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 disor- ders, than we could hope to obtain from any ana- lysis of the symptoms characterising the varie- ties of disordered function, in the present state of our knowledge. The history and concomitant appearances or History, »^ concurrent morbid states associated with amaurosis, usually d>se««- 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 10 RETINA. 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 maxillare, with exces- sive oedema of the integuments of the Jids and cheek, a large abscess under the masseter and muscles of the cheek, and an abscess at the ex- tremity of a molar tooth, while the crown of the tooth was sound. In all these cases it is to be understood that the eye was sound, and the or- bit 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 ob- stinately suppressed secretions, difficult dentition, the presence of worms in the intestinal canal, and the deleterious effects of noxious agents upon the organ or the system, are sufficiently obvious causes of the functional amaurosis. The professions, circumstances, and habits of patients throw much light on the origin and na- * A lesion of the frontal nerve is mentioned among the oc- casional causes of an amaurosis from Hippocrates downwards. A striking example is reported by Sabatier. Traits d'Anato- mie, Tom. 3, p. 228. RETINA. lure 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 ;f to acrid fumes and vapours ;§ and the customary employ- ment of optical glasses.|| Immoderate grief, ex- cessive indulgence in venery, protracted suck- ling, continued diarrhoea, repeated haemorrhages, profuse salivation; and, on the other hand, ob- stinate amenorrhcea, or constipation of bowels, with determination of blood to the head in a full habit, are ordinary predisposing or constitutional * 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 per- sons so employed at the Bank, at the issue of a new coinage of silver, were affected with symptoms of amaurosis. Color- manufacturers, burnishers, landscape-painters. J Smiths, stokers in iron furnaces and glass-houses, tavern cooks, &c. § A wholesale manufacturer 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 sulphu- ric acid, with the several ingredients, disengages a pungent and offensive vapor, by which the eyes are very painfully affected. II Watch-makers and engravers, philosophical instrument- makers, sea officers. J48 RETINA. causes of this disease, as I have had abundant opportunities of learning.* Amaurosis, of whichever class, is either per- fect or imperfect. The first is marked by total insensibility to light; the second, by defect of vi- sion, infinitely varied in kind and degree. 1 need scarcely remark, that not only the appearances and symptoms vary, but the essential character of the disease varies in its stages. Thus, an * 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 voluptu- ary rises with some degree of complacency as a ' conviva sa- tur' from the banquet of nature ; and contemplating the va- rious evils of the common lot in the circle of his friends, meets his calamity with somewhat of martyr fortitude. The most pitiable is the amaurosis of early life, from excess of sexual indulgence, and especially of solitary vice. The following are strong examples :—A country lad, of robust constitution, became the alternately favoured paramour of two females, his fellow-servants, under the same roof. He was the subject of gutta serena in less than a twelvemonth. Another, at an early period of puberty, suddenly fell into despondency, and shunned society. He never left his chamber but when the shade of night concealed him from observation, and then se- lected 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 mas- turbation. KET1NA. 149 affection, purely functional in its origin, by dura- tion becomes an organic disease. ORGANIC AMAUROSIS. When the eyeball is the seat of organic amau- sign, of or . , n /. i gsnic chsnj rosis, it commonly presents some, or all of the "theeye- following appearances: 1. A pupil fully or preternaturally dilated, con- tracting feebly, in the first case, on the sudden admission of light, and absolutely motionless in the second. This appearance is not peculiar but common to both classes, though by no means in- variable in either. 2. A congestion of the superficial vessels, es- pecially of the long fasciculi of conjunctival veins. 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 obser- vable 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 1.00 RETINA. cataract; and I have known it called a black ca- taract, and the operation of extracting the trans- parent lens performed. It appears deep-seated, diffused, and of uniform density; and in examin- ing 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 resembling that of incipient cataract, that it becomes next to im- possible to decide the actual state of the lens. I have seen the latter, upon an experimental ex- traction in such a case, semi-transparent, and of a bright yellowish tint throughout, and the sight of the patient has been considerably improved. The vision is in general defective in a much greater degree than the visible opacity explains; and this, combined with the depth of the opacity, a dilated and sluggish pupil, and some other symptoms of amaurosis, makes for the opinion that it belongs to the latter class. But where other signs of impaired retina are wanting, and the states of dimness and opacity correspond, the operation would be warrantable, although the site of the opacity should be disputable, if it were the express desire of a patient properly in pos- session of the circumstances. 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 of the visual axis: sometimes it has a disc of RETINA. (51 such breadth and splendor, as to look like the tapetum of sheep, or the colored choroid offish; but more commonly it occupies a circumscribed annular space, and is seen only in a strong light, and in particular directions of it. Although this appearance is commonly associated with impair- ed vision, I have now and then seen it in persons who made little, if any complaint of their sight. This appearance has been referred to a circum- scribed 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 conjec- tured to be the macula lutea of Soemmering.* It is probably with more propriety to be attributed to a deficient secretion of the choroid pigment, a preternatural adhesion betwixt the choroid and retina, and a discoloration or resplendent ap- pearance of the retina from that cause. I have been led to this opinion from observing it com- bined with that form of amaurosis in which the vision is confused to dimness in the broad light of day, and is tolerably clear and agreeable after * 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. 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 re- tina would certainly pass undetected. 152 RETINA. sunset; 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; for it is by no means a constant appearance in that disease, nor is it incompati- ble with useful vision. opacity or I have more than once seen a condensed and the retina. 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 texture of the retina. What adds to the probability is, ' that the crystalline in this case afterwards, as if progressively, becomes opaque; a common se- quel of amaurosis induced by inflammation. Amaurosis In the amaurosis from inflammation of the from deep- fummatL. choroid or retina, where the diseased action has entirely subsided, the veins of the conjunctiva RETINA. 153 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. I some time ago dissected the eyes of a man FtQm3Lh- ill • i • mi sorption of who had cataracts with amaurosis. I he cata- the vitreous humor ana racts had been formed ten years prior to his ct^7iinl death; one of them fell down 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 the 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 20 154 RETINA. 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 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- 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 RETINA. 155 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 optic ganglion and nerve at its origin thence, of the same side. I have seen several cases of amaurosis from Amauro-« from con. concussion, as by a blow on the temple, or the cu,sion eye. Of these some were attended with signs of disorganization—some were superficially in- flamed—and others presented no external ap- pearance of injury. One was the case of a cap- tain of artillery, who was struck by what is called the wind of a ball, on the right side of the head. He received no wound, but lost, instantly and irrecoverably, the 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 156 RETINA. 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 affected. One remarkable case 1 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 the sight of his right (or perfect) eye,which has now the faded appearance 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. congenital I have observed several forms of congenital organic . > • 1 • 1 j 1 amaurosis, organic amaurosis : one, in which the organ is 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 ; 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 RETINA. 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; goggles; glasses covered with black gauze, and every other contrivance to absorb light; 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- * Professor Beer states, that dark colored eyes are more inclined to become amaurotic than those of lighter color. This observation is not at variance with my own, since the above remark refers only to white-haired persons, the cha- racteristic of whose amaurosis is photophobia, or intolerance of light, and in whom the disposition depends on a defective pigment. 158 RETINA. 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 asso- ciated 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- 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, ge- neral debility, &c. RETINA. 159 2nd. 1'he 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; as for example, the visus nebulosus, muscae voli- tantes, &c. I proceed to treat of them in succession. 1. Symptomatic. Like nervous deafness, amaurosis sometimes follows typhus and scarlet fever and the various forms of acute constitutional disease. This I have several times met with as a result of infan- tile 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 i»een incurably deaf many years, when, during the existence-of a Amaurosis from con- stitutional disease and general de- bility. 160 RETINA. 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 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. Itconsisted in occasional drastic purging, 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 nerve. By adopting it, he had more than once re- covered a perfect state of hearing, which remained while he had resolution 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 still further extending this digression by adding a much more re- markable proof of the influence of vascular action upon the brain and its more immediate functions, and leave the reader r"'tn his own conclusions. $ JW£ ^oman, who was employed as a domestic servant 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, shows itself especially in this organ, afford fami- 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 recognised 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 circum- stances respecting his family, and others which had happened to herself in her earlier days. But alas ! it was only the gleam of reason. As the fever abated, clouds again enve- loped 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 after- wards took a full dose of emetic tartar. After vomiting, he became immediately sensible. "21 162 RETINA. Amaurosis liar instances of the amaurosis from constitu- from pletho- ricwnges- t;onaidebility. Amaurosis depending on vascular congestion is marked by some or all of the following symp- toms, 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- sation of which is a cause of much distress to him. A person thus affected accurately descri- bed to me the zona minor iridis, as distinctly pre- sented to his view. From deter- A loss of balance in the sanguiferous system, mioation of # # J tad?t0 the occasioning an undue determination of blood to the head, often exists, distinct from general ple- thora, and is aggravated by loss of blood. The following case is an example : * Persons labouring under dyspepsia are often troubled with this symptom on first closing the eye to sleep ; and in the progress of amaurosis from nervous exhaustion, it is sometimes accompanied with the sensation of a crackling or snapping noise. RETINA. 16/S 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 0? 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 muscae in excess, for a year and a half past; he had now fire sparks flashing before 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 * The subjects of chronic iritis, and in whom the pupil \s 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. 161 RETINA. Amaurosis from inaoi tion. 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. The amaurosis, from depletion, is sometimes mistaken for its opposite, viz. that from pletho- ric congestion; this is owing to the coincidence of a dilated and immoveable pupil, muscae, 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; 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 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 RETINA. 165 m*arked 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 "£$*£. * imperfections of vision. An unhealthy secretion juncliTa'" of the meibomian follicles and caruncula lacry- malis, a very inconsiderable obstruction in the excretories of the tears, or a preternatural ex- citability 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 c6njunctiva from any cause, frequently com- plain, not that their sight is indistinct, but weak; by which nevertheless they mean, that they cannot maintain distinct vision for any consider- able time together. The retina appears to be sympathetically affected in these cases. They are often accompanied with muscae, and remarkably benefited by blisters, as well as by applications, which improve the condition of the conjunctiva and evelids.* * See note C. 166 RETINA. FUNCTIONAL AMAUROSIS. 2. Metastatic. Am.urosi, Amaurosis by metastasis is not unfrequent. I sufromthe 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 2:ood 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, the pupil of which was dilated and motionless. On the morning of the third day, the upper eyelid of the right eye was para- 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- RETINA. 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 150, 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. A man, the subject of hernia humoralis, lost an 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.* 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- * I once saw an attack of hemiplegia originate under simi- lar circumstances, viz. a sudden reduction of enormously en- larged testes by leeches and cold lotions ; and since the first edition of this work was published, I have known a case of fatal apoplexy succeed to a gangrenous inflammation of the scrotum, from extravasation of the fluid injected for the cure of hydrocele, within three days from the operation. RETINA. 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. A gentleman, after an attack of gouty inflam- mation in the foot which suddenly 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. To this class belongs 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.* * See note 1). RETINA 169 FUNCTIONAL AMAUROSIS. 3. Proper. A short case or two will best explain what I would call a temporary palsy of the retina from over excitement. The following account is that of a young gen- tleman who was ardently engaged in the study of the profession when thus interrupted: " Having habituated myself for the preceding twelve months to intense study, reading and wri- ting to a very late hour, which had been only in- terrupted for a few days by a slight inflammation of my right eye, L 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, unac- companied 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 examination, 1 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, ex- tending from the centre of the forehead round the eye to the root of the nose. This drew well, and I continued it open for ten days, closing the Amaurosis from over- excitement. RETINA. 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 experience^ a gradual recovery of vision. In the course of six weeks, I was enabled to resume my studies, and could perceive no defect of vi- sion. I had gradually reduced the dose of calo- mel, and now discontinued it, drinking the de- coction 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 superfi- cial irritable ophthalmia, accompanied with much dimness and confusion of vision. This continued after the inflammation had subsided under the ordinary treatment. He became seriously alarm- ed to find, upon attempting to renew his occu- pations, that he was unable to discriminate 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. 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- RETINA. 171 tion. I have repeatedly seen it of sudden acces- sion with no other external sign than an inactive pupil. 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 it 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 ap- plied to the temples. He then rubbed in a drachm of the strong mercurial ointment for sev- eral nights in succession; this produced a copi- ous 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 delighted to find that he could tell the hour by his watch. He continued improving so rapidly that, at the expi- ration of ten days, he could read an ordinary print with perfect facility. The pupil had reco- vered its natural magnitude and activity. In one instance this form of the disease fol- 172 RETINA. 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 affected, and pro- bable in some cases that the discovery of the amaurosis, and not the disease itself, is of recent occurrence. This point, however, can gene- rally be ascertained. symptoms or I now proceed to mention the leading symp- amaurosis. r ^ 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 my de- Pain. scription. Pain affecting the forehead and tem- ples is a precursory symptom of amaurosis, diminishing in proportion as the dimness in- creases ; 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 and 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 RETINA. 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 viae, 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- 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 h6ur, 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 in the appearance of the organ to explain its na- ture and origin. What has been described as an intermittent ophthalmia, is I think improperly so termed—the pain, not the inflammation, is inter- mitting. The pain of tooth-ache and ear-ache, according to the state of the vascular system, is subject to intermissions more or less complete, 174 RETINA. but the periodic pain to which I refer, is indepen- dent of any visible sign of inflammation. I be- lieve 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 paroxysm* I have known one instance of a similar affection, without any defect of vision. raraiysis. Paralysis of the levator palpebrae is a sign oi cerebral pressure, and always accompanied with 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. 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 much di- minished 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. * 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, 175 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 or 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 palpebrae 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 cervical ver- tebrae after an interval of some months, without any other symptom of palsy. It is remarkable 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 mer- cury. The use of strong lead washes will pro- duce a ptosis. I lately saw a temporary paraly- sis of the muscles on one side of the face, from frequently touching an ulcer of the fauces with the oxymel aeruginis. In proportion as vision fails, the eye affected loss of as •i -i • fii i • -ii ciation au with amaurosis loses its fellowship with the direction. sound eye, and this loss of correspondence be- comes a conspicuous character of the disease. RETINA. 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. Strabismus is either congenital, or from the 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 vision oblique: or from violence RETINA. 177 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, I 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 den- tition, worms, &c.; or of pressure at the origin, or in the course of the nerve proper to the af- fected muscle.t * Mr. Cheselden relates the case of a gentleman 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 (atnendment of the distortion. "f A remarkable case of strabismus, with double vision, oc- curred in a patient who consulted me, about twelve months since. J. G. was attacked, six years ago, with a remittent fever of extremely tedious and obstinate character, leaving him in a state of debility from which lie very slowly recovered. During his convalescence, the right eye began to be affected with strabismus and double vision, which increased, until it was impossible for him to look with both eyes without pro- i ducing pain in the head and confusion of thought. It dis- tressed the patient exceedingly, and kept him in a nervous, irritable condition, which impaired his health, and rendered life a burden to him. Four years after the accession of the disease, he applied at the New-York Eye Infirmary, with a request that the affected eye might be destroyed, in order to RETINA. 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 put an end to his distress. It was then ascertained, that he saw perfectly well with either eye singly, when the other was covered, but the double vision was complete when both were used. As his request could not properly be complied with, he would not consent to any other plan of treatment, and suc- cessively applied to different surgeons in the city, who uniformly refused to perform the operation for which he was'so anxious. Eventually, however, he found an empiric who undertook to sink the eye. He made an incision through the sclerotica, posterior to the cornea, at its lower edge, and thrusting in a probe, succeeded in removing the lens, but did not reduce materially the size of the organ. Severe in- flammation followed the operation, which soon also attacked the internal textures of the other eye. After three weeks had elapsed, I was called and found him in a most deplorable situation ; the one eye ruined, the other excessively infla- med, the iris adherent, and the pupil filled with lymph; the patient suffering continually intolerable pain. The most ac- tive treatment was pursued to subdue the inflammation, but only with partial success. After six weeks of acute suffering, the inflammation began slowly to subside, and the sight grulmlly to return in the left eye. The patient then went into the country with the hope of advantage from change of air. But here again, his constitutional irritability getting the better of his judgment, he suddenly set off for another of our principal cities. There, before the inflammation was completely reduced, several operations were performed to clear the pupil and remove the lens. The result was, destruction to the patient's sight, and an eye gra- dually falling into a state of atrophy. RETINA. on the same horizontal plane with the eyes, it is not perceived. It is a relaxation of one of the inferior straight muscles. Although incidental instruction may be gained from the bad practice pursued in this case, the point intended to be illustrated is, the duration of the double vision, as accompa- nying the strabismus. No change took place in this respect during five years. In general, it is well known that double vision gradually subsides, and the squinting eye be- comes accommodated to the new direction of its axis. The degree of distress which the patient suffered was also suffi- ciently remarkable, when it could induce him to desire the destruction of one of his eyes. Covering the affected eye gave him but partial relief, as the slightest ray of light com- ing to it brought on the confusion and pain under which he continually suffered. Another case of double vision has since occurred to me, not unworthy of record. A EgMi received a violent kick upon the cheek, just below the righ\ eye, from a maniac, whom he was endeavouring to secure. The immediate consequence was double vision, but in a vertical instead of a horizontal direction. Every object at which the patient looked appeared double, but the image of one above the other. On examina- tion, a firm swelling, caused by extravasated blood, was felt below the eye, deep in the orbit, and it was evident that the organ was somewhat pushed up out of its natural direction. On placing a finger beneath the other eye and pressing into the orbit, the double vision was immediately corrected, by the axis of the sound eye being made to correspond with that of the injured one ; while the symptom returned as soon as the finger was removed. The extravasated blood was gradually absorbed, and the patient after a few weeks regained correct vision.—Editor. 180 RETINA. Hemiopsia The retina is often partially affected in orea- or partial r •* ° Kreti»i. "ic amaurosis. Thus some persons describe a 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 :$6th year, and who lost eight pounds of blood in the three days preceding his death, had consulted me for depraved sight of one eye, six months before that event. The pupil was permanently dilated. He had double vision whilst looking RETINA. 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 oppor- tunity 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 bedim- med, 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 not an uncommon symptom of organic amauro- 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 affected. If one object be seen in its proper place, the situation of a contiguous object is er- roneous, 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. 182 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 organic af- fection. I have been led to this conclusion from observing the morbid appearances, and the in- efficacy of remedies, where such signs of the disease were established. But I have known in- stances of their removal. Muse*, Muscae are either fixed, when they are usually fixed and ... , 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 RETINA. shapes of the floating,* 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. 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 intellect, 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. tion, probably a deposit or extravasation be- tween the choroid and retina, compressing to a certain space the papillae 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 muscae 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 objects remaining upon the retina, are usually preceded by the fixed musca?, 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. 186 RETINA. plaint. This is not always the case: I have known them to be symptoms of functional de- rangement, and to disappear as the vision re- covered. In this affection, a halo of light en- circles the opaque spot during the exercise of vision ; and if a bright luminous object be con- templated, a colored 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 species are the various morbid refractions of luminous 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 represen- ted, 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 a needle in a capsular cataract, so that the moon appeared a? if cut in pieces. RETINA. 187 musce and case of an intelligent young gentleman, very ac- curately drawn up by himself, for the purpose of showing the gradations of this disease in its pro- gress, as well as its origin. " About a year and a half ago the first symp- c«e of toms appeared, which gave me any uneasiness spectra 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 188 RETINA. 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 darkness, 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. 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 I 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. u 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 AmbiyoP . . /» s'a: nebu- of functional amaurosis is a thin mist, fog, ^f0°rinist smoke, or gauze, or, as I have heard some pa- 190 RETINA. tients represent it, an indefinable something, ab 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. 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- sis is a loss of the faculty of distinct vision at 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 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 ip 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 supersedes 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 reti- na is direct. The correction of a defective ad- justment 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 cor- rective, which is frequent in the cases referred to, demonstrates the functional debility of the retina. 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 phenomena 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. I have observed that the point of clear vision shifts accordingly; in others it contracts slowly and imperfectly ; in others again it is permanent- ly contracted or dilated, and this, independent of any other defect of sight than an abridgment of the original range of distinct vision, at one or other extremity.* I have met with different reports, as to the Influenceo time of day in which persons affected with im- "mlSta. 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 retir- ing to rest, than they have seen at any period of the day. These differences are, in most cases, referri- according to hie to the varieties in susceptibility of the retina, the retf,1»' * See note F. 2.r> 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 qua- lity or quantity of the pigment, which renders a screen or colored glasses, or a dark day or twi- light, in their several degrees, favorable or even essential to vision. This partakes of the nature of an organic disease. I have known 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 consulted. The RETINA, 195 cases of day and night blindness present the op- posite extremes of variation in susceptibility of the retina, and these must be regarded as cases of proper functional amaurosis. The remarka- ble 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 motions Actionom.e * iris an index of the pupil, is, generally speaking, the surest in- ofthlrettlt dication of the health of the retina. The con- traction is slow, or it is incomplete, or both, upon the sudden admission of light 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 some- times discover to an attentive observer, which of the two eyes is affected. When the perception of light fails altogether, the pupil is generally fully dilated, and absolutely motionless. It is in other cases not perfectly a circle. The activity of the iris requires the free and Phmomc- J nnn of activ* uncompressed state of the retina, iris, and ci- irl:i»fw 196 RETINA. rect nmau- liary nerves. In the various forms of amauro- sis. J 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 conclu- ding 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 instru- ment, not the organ of perception. The iris, in such a case, acts by a sympathy independent of the brain. Thus in a case of circumscribed tumor com- RETINA. 197 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; 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 shows, 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 Obsopv. sur VCEil, p. 426. 198 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 lo- cality is definable.* Blindness A man was trepanned for a fracture with de- with dilated *■ ?rac1urerd0,n pression of the right frontal and parietal bones. After the operation he became sensible, but it was discovered that he was totally blind, being unable to perceive a lighted candle held close before 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; and these two fractures were connected by a transverse fracture, extend- ing 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, 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 gene- rally, but with exceptions; sometimes contract- ed, but still immoveable; which Dr. Cooke, in his late Treatise on that subject, considers a fa- tal prognostic. In injuries of the head, with symptoms of depression, the pupils are generally dilated and motionless, but sometimes inconsi- derably enlarged, and slightly moveable; in other instances contracted; and very frequently one is permanently dilated, and the other contracted. These varieties depend on the situation in which pressure is applied, and the extent which it oc- cupies, and in some degree on the nature of the compressing cause, whether bone driven in or fluid effused; in hydrocephalus the result is uni- form. But it is not the loss of the sight which occasions the dilatation of the pupil, in injuries where these circumstances coincide, but com- pression 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 sudden effect of the loss of sight, and it seldom happens that the vi- sion is lost in those casualties in which the pupil is permanently dilated. RETINA. Among the morbid changes of the retina, ossi fication 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 dis- eased appearance has seldom extended beyond the ganglion opticum. The eyeball has frequent- ly been free from disease. The blindness has probably 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- in ilton. # . ° 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 his own words for the sake of accuracy. * Vide Morgagni, Lett. 52, Art. 30. RETINA. 201 '• Decennium, opinor, plus minus est, ex quo debilitari atque hebesccre visum sensi, eodem- que tempore lienem, visceraque omnia gravari, flatibusque vexari; et mane quidem, si quid pro more legere ccepissem, oculi statim penitus do- lere, lectionemque refugere, post mediocrem deinde corporis exercitationem recreari: quam aspexissem lucernam, Iris quaedam visa est redi- mere: haud ita multo post sinistra in parte oculi sinistri (is enim oculus aliquot annis prius al- tera nubilavit) caligo oborta, quae 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; frontem totam atque tempora inveterati quidem vapores videntur insedisse ; qui somnolenta qua- dam gravitate oculos, a cibo praesertim usque ad vesperam, plerumque urgent atque deprimunt; ut mihi haud raro veniat in mentem Salmydessii vatis Phinei in Argonauticis: ____________xapog Si jaiv a/xipfxaXu^Ev Horcpugeog, yaTav 5s of simple i. e. an inflammation not sympathetic with in- °Phthalni,a 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 the commencement, it is scarcely less manageable. 3-1 266 SIMPLE INFLAMMATION. Fobrneirri- 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. Bioodiet- 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 desi- rable 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 convenience 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 make the system * 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. 267 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 very decided superiority over leeches ; both are well adapted to relieve local congestion. But these modes of depletion are obviously too indirect, 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 chro- nic it is highly beneficial, as in the thickened and over-vascular state of the palpebral conjunctiva ; and a considerable discharge of blood ^.'j be thus obtained if it be briskly performed with a sharp lancet, the lower lid kept everted, and con- tinually fomented with hot water, t On the subject of local applications in acute Topicaup- J . plications, ophthalmia, there is considerable variety of pro- * See note H. t Little good is derived from scarifications of the conjunc- tiva in the mode in which that operation is very commonly performed. If the scarification be not made exactly in the proper situation, so little blood is obtained as to be of no ad- vantage to the patient. On everting the lower eyelid, we may observe about a line within the margin of the lid, a narrow strip of the membrane, exactly parallel to the tarsal border. 268 SIMPLE INFLAMMATION. fessional opinion, but little in the evidence of patients. Dr. Johnson, whose opinion in these more vascular than the rest ; the vascularity still more con- spicuous if inflammation be present. A single stroke of a sharp scalpel drawn along this line will furnish a large quan- tity of blood, if the lid be kept everted as long as the bleed- ing continues. If the scarification be made even a single line nearer the globe of the eye, little or no blood is obtained. The situation meant to be designated is thHt in which the conjunctiva is firmly adherent to the tarsus ; as opposed to the loose portion of it passing from this part to the eyeball. In this country, scarifications of the conjunctiva are so con- stantly practised in acute inflammation of th.it membrane, that I cannot avoid bearing my testimony against it. In the early part of my practice, I extensively used it, and must frankly acknowledge, often did much harm by it. The au- thority of Mr. Saunders, however, sanctioned by the re- mark on the subject by our author, ought to be decisive. "Scarifications," observes Mr. Saunders, "as far as I have seen them employed in the active state of the inflammation, are certainly injurious ; they have manifestly aggravated the symptoms ; and 1 conceive it will appear highly improbable that the infliction of mechanical injury on a part already ac- tively inflamed, can be advantageous—a similar practice does not obtain in surgery on other parts of the body.—When the activity of the inflammation is gone, the vessels of the con- junctiva that have been engaged in the process remain pre- ternaturally enlarged. At such time, the division of a great number of them might cause the whole series to contract, and thus accelerate the diminution of the vascularity, and the ad- hesive inflammation might only produce a degree of reaction, which would then be immaterial. But the condition of the part is widely different during the progressive state of inflam- mation. At this stage, the wounds of the lancet are only ad- SIMPLE INFLAMMATION. 269 matters there can be no presumption in critici- sing, hadt a saying, " that there is little virtue in a lotion." In the main, and speaking of them comparatively, if it refers, as 1 conclude, to me- dicated lotions, I am much of his opinion; but warm and cold baths, whether employed for a warm ma * _ J cold. part or the whole, have very unequivocal and sensible effects. These effects are likewise very ditional stimuli co-operating with the disease, and consequent- ly exasperating the state of the eye." Of the same character, as a remedy, as scarifications, we may consider the application of leeches to the palpebrnl con- junctiva ; a practice attributed in England to Mr. Crampton, but long ago recommended in France, by Demours. Mr. Crampton insists upon the utility of the remedy in every stage and species of inflammation which attacks the eye. During the first stages of acute conjunctival inflamm-ttion, 1 have seen it do much mischief, and therefore would think it safer to limit its application to cases of chronic ophthalmia, or at least to those in which the severity of the symptoms had first been reduced by other means. With this caution, leeches thus applied constitute a safe and excellent remedy against oph- thalmic inflammation. The mode of applying the leech is sufficiently simple. Having selected one rather less than the medium size, the surgeon everts the lower eyelid with the fore finger of his left hand, and places the animal in such a manner as to fix itself upon the conjunctiva lining the lid, being careful to pre- vent its attaching itself either to the eyeball or the tarsal edge. Where the leech fixes itself to the eyeball, it some- times produces severe inflammation, although no permanent injury is the consequence : on the edge of the lid, it gives great pain, and occasionally several day* elapse before the irritation produced by it subsides.—Editor. 270 SIMPLE INFLAMMATION. 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 1 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 this question is of less importance, but the indication is the same with very few exceptions. To conclude these remarks on what may be regarded as too trifling SIMPLE INFLAMMATION. 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 of medicated lotions irritate, and none more than that which is esteemed of all the most sedative, 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 substitute warm water for the aqueous solution of opium, and infusions of poppy and hemlock. The same observation applies especially to painful herpe- tic cutaneous affections, and acutely irritable ulcers. Upon these a solution of opium often acts as a stimulant and augments pain, while the lunar caust'c solution as often assuages it. I do not deny that there are occasional exceptions 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 stru- mous ophthalmia, viz. irritability to light. Although during the state of morbidly eleva- ted sensibility accompanying the outset of acute inflammation, warm applications are most sooth- ing, and therefore most eligible; the continuance 272 SIMPLE INFLAMMATION. of them beyond their necessity is a loss of time, if not injurious.* When the extreme vascular * To avoid doing our patient injury is certainly of as much importance a» to do him good. I shall therefore take occa- sion, whenever necessary, to warn the student of tin -licine and young practitioner against the use of lemedies, which I know to be common in our country, where they are evi- dently prejudicial. Of these one of the worst, in inflammation of the conjunctiva, either simple or purulent, is warm poultices applied to the eyes. I have repeatedly seen young infants brought to the New York Eye Infirmary, with the corneae of both eyes sloughed, and the organs entirely ruined, after having been kept under poultices even as long as six weeks without in- termission : and the practitioner, perhaps, has not, during that whole period, once examined the patient's eyes. I have now under my care a gentleman, whose eyes were kept constantly under poultices more than a month, where the cor- neae are both, completely opaque and vascular, and the lids loaded with granulations. I need not say that he is totally blind, and many months will elapse before he recovers his sight. Such cases are by no means uncommon, and their result is a sufficient proof of the impropriety of the practice. There is also another common practice which is equally prejudicial ; the unnecessary confinement of patients suffer- ing under ophthalmic inflammation, in dark chambers. A high degree of morbid sensibility to light is thus induced, which does not belong to the disease. Inflammation of the conjunctiva, when not modified by struma, is attended with very little intolerance, and hardly even requires the use of a shade ; confinement in the dark is never necessary. No better guide can be found than the patient's own feelings; and he should be kept in just that quantity of light which is pleasant and agreeable to him. By an opposite practice, patients are often thus confined even months, until they cannot bear the slightest ray of light in their apartments ; and long after the inflammation has subsided, the eyes are still useless from their want of power to bear its admission. SIMPLE INFLAMMATION. 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 oint- ment may be advantageously substituted. The cedematous elevation of the conjunctiva is 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 pre- cordial oppression, which manifest disorder of When the inflammation is more deeply seated, and the su- perficial vessels of the sclerotic becoming enlarged, shoot over the margin of the cornea, and involve that membrane in the disease; then indeed, intolerance of light becomes a marked and distressing symptom ; and it is necessary so far to diminish the light of the patient's chamber, as to make him comfortable. But even in this case, absolute darkness is pre- judicial. A patient deprived of all light in his room, suffers acute and distressing pain at the opening of a door, or any other unavoidable admission of light; whereas if the room be only partially obscured, he suffers little inconvenience from any temporary admission of light. Observations so minute as these, may perhaps appear tri- vial ; but they are of so much consequence to the comfort el our patients, that they cannot be deemed useless.—Editor 3-r) 274 SIMPLE INFLAMMATION. the stomach and liver in cutaneous erysipelas; and the solution of emetic tartar given at short intervals, operates very beneficially in reducing it. Atonic oph- There are inflammations which assume a chro- thalmia. nic character in their commencement, evidently depending on a state of atony, of very partial extent, void of pain, and scarcely possessing any sign of inflammation, except the congestion of vessels, or if any, so feebly marked as to encou- rage 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 importance, 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 morning's urine with admirable effect in these cases. It is the character of the morbid action, not the ap- plication, that explains this sudden recovery. The re-excited or increased momentum of the arterial. 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. SIMPLE 1NILAMMAT1UN. 275 In certain habits, or states of the system—whe- irritable ophthalmia 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 de- gree of advantage; and if the plan is persevered in, it soon becomes injurious; the irritability 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 tendency to check the natural secretions, has an admirable effect, viz. with calomel, antimony, or ipecacuanha. In the treatment of simple acute ophthalmia, infiam™ tioD threat the object to be kept in view is the soundness «™|athe 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. -76 SIMPLE INFLAMMATION. pie™ndam-m" It is seldom that the simple inflammation be- comes chronic. 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 termination of it. Here scarification and the diluted mercu- rial ointments are employed with obvious advan- tage; but with some persons all greasy applica- tions inflame so much as to aggravate the com- plaint, and in such instances moderately stimu- lant washes, of which a portion is to be admitted within the lids, may be substituted. SECTION II. INFLAMMATION MODIFIED BY STRUMA. The aphthous inflammation, the inflammation of the follicles, and that characterized 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 278 INFLAMMATION especially, 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 tendency to such diseases is demonstrated before they ex- ist, 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 neglecting to follow up the cure to its completion, and properly 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 affected 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- MODIFIED BY STRUMA. 279 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 remov- ed. 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 280 INFLAMMATION 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 ap- pearances upon the cornea are notwithstanding stationary, or slowly progressive, issues and se- tons are of great avail. The principle of treatment indicated in such cases is, to lessen the irritability without mate- rially depressing the power of the system. The selection of medicine and applications, the regu- lation of diet, the degree of relief proper for the organ from its natural stimulus, when painful, must of course be determined by the circum- stances 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 ex- hibited in combination with opium, slightly to affect the system. The efficacy of the mercu- MODIFIED BY STRUMA. rial preparation mainly depends on its combina- tion with opium ; it irritates too much if admi- nistered alone in quantity sufficient for the pur- pose. 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 exces- sive. Calomel and opium, or hydr. c. creta and Dovar's powder at night; emetic tartar to nausea ; gentle alvine evacuants ; diaphoretic drinks; large open blister on the nape of the neck; leeches; tepid bath ; 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 conjunc- tiva, and.vessels raised upon and over-shooting the cor- neal margin. Calomel and antimony, or opium, or any other more appropriate exhibition of mercury, to pty- alism; occasional purgatives; 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. 36 282 INFLAMMATION 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 ; 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 writh irritability to light; treatment as in strumous inflammation without breach. Ung. zinci. et sub-acet. plum- bi. 5. With inflammation of the follicles and puriform discharge. Active measures at first, but not long conti- nued. Blisters, when becoming chronic, if with thickened lids, scarifications; zinc, alum, or cop- per wash, dilute; ung. hydr. nitr.; hydr. nitr. oxid.; sub-acet. cupri; tonics and sedatives. If obstinate, issue or seton. MODIFIED BY STRUMA. 283 6. Convalescent 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 sequela?, 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. INFLAMMATION OF THE CONJUNCTIVA. 28/> 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. In the mild form of the complaint the cornea is not endangered, unless the disease be neglec- ted 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 solu- tion 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 Mild. 286 ACUTE SUPPURATIVE an ivory pipe, introduced at the temporal angle of the lids, without forcibly separating them. Simple purging and abstinence are generally sufficient to allay 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 the 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. vehement. The vehement acute suppurative inflamma- 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 indescri- bable. The pain is mitigated, if not removed; the pulse softened, and the patient sinks into a INFLAMMATION OF THE CONJUNCTIVA. 287 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 those 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 288 ACUTE SUPPURATIVE shows a lack-lustre and ragged ness 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 ap- pearance, the portion so marked out will infalli- bly 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. INFLAMMATION OF THE CONJUNCTIVA. 289 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 employ- ed, the system stands in great need of the power thus lost for its recovery; to restore parts par- tially injured, and to supply the place of those which are destroyed. We see this fact exempli- fied 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 detrac- tion of blood (and it applies as forcibly to the abuse of mercury) which proceeds without pro- portioning the quantity to the absolute necessity of the case, and, secondly, without balancing the effect upon the system at large against the im- portance 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 repeated smaller bleedings, I must protest against the necessity of such a practice. 37 290 ACUTE SUPPURATIVE and say with Faistaff, " the better part of valor is discretion." 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 pseu- do-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 * 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 inflamed organ is augmented by the retention of its se- cretion, 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. INFLAMMATION OF THE CONJUNCTIVA. 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- 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 or- ganic amaurosis, in which however the sight is perfect. Here the plan of irritative applications had been unremittingly pursued by several prac- titioners in succession. The anomaly consists in the existence of such appearances unallied with the states of which, by their habitual association, we consider them characteristic. An apprehen- sion suggests 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 confirmed existence of the one may predispose to the production of the other. > SECTION IV. SECONDAPcY DISEASES OF THE CONJUNCTIVA. orauuiar The granular state of the tarsal conjunctiva conjunctiva. is a very common result of the mild suppurative 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 granules shaved off from the surface and orbitar edges of the tarsus, with a keen-edged lancet, or, if pe- duncular and prominent, they will be more con* veniently snipped off with the flat scissars. In doing this, care should be taken to avoid injur- ing the continuous membrane. withvascu- When in addition to the state above described, lar cornea. ' vessels are ramifying over the cornea, opacity of 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 line's distance from the margin of the cornea. SECONDARY DISEASES OF THE CONJUNCTIVA. 293 For this purpose, the globe should be thrown forward and fixed in a state of tension by de- pressing the edges of the palpebrae with the fin- 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.* t Another consequence of the disease above Fungous 1 conjunctiva, described, are folds and flap-like elongations of •^Scm-' the conjunctiva filling the palpebral sinuses, and fcc!'paa' occasioning 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. t See note at the end of the Chapter. SECONDARY DISEASES 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 lid 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 differently 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. OF THE CONJUNCTIVA. 295 or ring-ended forceps are often convenient dn these occasions. The fleshy pterygium is sometimes a chronic ptery?iu* -. . and eocan- and even a stationary condition of disease pro- this 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 296 SECONDARY DISEASES 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 corres- ponding to the cornua of this fold. The treat- ment consists in simple excision. FreDa. The membranous bands connecting the lid to the globe should be divided, with the precaution to avoid wounding the palpebral conjunctiva. No bandage should be employed, and during the day the patient should not be suffered to keep the eyelids closed. In my experience, escharo- tics only exasperate the evil. Tumors. Tumors upon the globe, unconnected with 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 OF THE CONJUNCTIVA. 297 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 eversion of the lower lid, by a strip of plaster carried from its margin in an oblique direction across the cheek, and frequent- ly renewed.* *" Granular conjunctiva of the eyelids, with vascular and opaque cornea, is an extremely common disease in every part of the state of New York ; but more particularly in our northwestern counties : and not a few of the inhabitants of those counties are permanently and irremediably blind, from the long continuance of this most unpleasant consequence of purulent ophthalmia. Such patients are constantly present- ing themselves at the New York Eye Infirmary ; and in a large portion of the cases, the result may be fairly attributed to improper treatment of the acute stage of the inflammation. The disease generally proves extremely difficult of cure, and is constantly liable to severe relapses during the whole pro- gress of the treatment. From the very concise directions for its treatment given by Mr. Travers, the student might be misled, and imagine that it might always be readily and quickly cured. The operations of removing the granulations by the knife or scissars, and dividing the vessels which run upon the cornea, are by no means sufficient in themselves to eradicate the disease ; the latter is generally unnecessary as well as inefficient. Cutting off the granulations removes them indeed for the time, but does not remove that condition of the conjunctival membrane which gives rise to them ; and if we confine our treatment to this remedy, we will generally be disappointed. When such cases present themselves, they are always ac- 38 298 SECONDARY DISEASES companied with more or less of inflammation. Our first object must be the removal of this inflammation, and before this is effected, all operations are improper. For this purpose, the usual means in common use are sufficient, cupping or leeches, keeping the bowels open by proper medicines, re- gulating the diet, and removing all sources of irritation. Counter-irritation is, however, our most efficient agent in fulfilling this indication, and should be kept up during the whole course of the treatment. Blisters behind the ears, kept open by ung. sabin. or ung. canthar. may be employed ; or still more conveniently, the tartar emetic ointment may be applied to the same situation, or to the nape of the neck In the recent state of the disease, a due perseverance in these means will often be sufficient to subdue it; and in all cases they must be continued as long as inflammation is present. If they do not succeed, it becomes necessary to use means for the direct removal of the granulated surface, and the res- toration of the conjunctiva to a healthy condition. For this purpose, in mild cases, we may succeed merely by the use of astringent applications to the granular surface ; and of these, one of the mildest and most efficacious is the liq. plumb. acet. undiluted, dropped into the eye once or twice a day, or smeared over the diseased surface with a camel's hair pencil. Other astringents are useful with the same view, such as solutions of alum and of nitrate of silver ; but neither of them is so efficacious as the liq. plumbi. The ung. hydr. nitrat., diluted with three or four parts of lard, may at the same time be applied to the edges of the lids every day, to prevent their agglutination, and act as a beneficial stimulant to the parts. Counter-irritation should still be kept up either by means of ung. tartr. antim., setons, or issues. If the case be more severe, or these means fail, still more active measures must be resorted to. If the granular bodies be large and hard, they should be removed by the knife, as directed by our author, and the operation should be repeated, if they grow again, until they are removed as far as possible. OF THE CONJUNCTIVA. As the whole of the disease, however, can hardly be eradi- cated in this manner, escharotic substances are employed to complete their removal ; and of these the sulph. cupri arg. nitrat., and the mineral acids are the best; the first prefer- able to the other two. In applying them, the lids must be everted, and if the sulph. cupri be used, it should be lightly rubbed over the granulated surface; if the arg. nitrat., the projecting points may be slightly touched with it. The part should then be freely washed off with water to prevent the application of the caustic to the eyeball. When the acids are employed, they should be diluted with three parts of water, and applied with a camel's^nair pencil. Sometimes the use of any of these means excites active inflammation in the eye ; and then all irritating applications must be avoided, and antiphlogistic and soothing treatment employed. The use of the knife or scissars to remove the granulations is very rarely necessary, and I believe, falling much into disuse in Europe. The sulph. cupri is a better remedy, and generally adequate to the object in view, if perseveringly employed. It may be applied every other day with per- fect safety. Having succeeded in removing the diseased state of the pal- pebral conjunctiva, the vascularity and opacity of the cornea generally subside, without the use of any direct remedies for their cure. They are excited and kept up by the irritation of the granular lids, and disappear with their cause. They are removed more rapidly, however, by still persisting in the use of the ung. tartr. antim. The circular incisions around the cornea recommended by Mr. Travers will some- times quicken the process, but should never be used while any inflammation is present, nor until the palpebral lining is restored to a healthy condition. When employed under these circumstances, they sometimes excite severe inflam- mation. This last remedy, the division of the enlarged vessels which overshoot the cornea, is so frequently employed in this coun- 300 SECONDARY DISEASES, ETC. try, that it is necessary to make some further remarks with regard to it. Another modification of the same remedy, as recommended by Mr. Ware, the excision of a portion of the enlarged vessels is also much in use among us, and when im- properly made use of, is still worse than the first: indeed, if either be necessary, a simple division of the vessels is ade- quate to every purpose which the remedy is capable of effect- ing, and is liable to do much less mischief. Mr. Ware's me- thod, therefore, is never necessary ; and the other very rarely. Our object should rather be to remove the inflam- mation which enlarges the vessels, than to diminish their di- ameters by any operation on themselves. An opposite prac- tice is very often productive of serious injury to the organ, by increasing the inflammation and aggravating all the symp- toms. The common error is, to divide the vessels while in- flammation still subsists : very often it is done in its very commencement. In severe acute inflammation of the cornea, in ulcers of that membrane with red vessels running to them, and even in common pustular inflammation of the conjunc- tiva, this operation is very commonly performed, and in every such case, if it does any thing, it does harm. No ar- guments are necessary to prove the impropriety of the prac- tice in such cases ; it is repugnant to the very first principles of surgery, and its employment cannot be justified on the slightest ground. Were I not a daily witness of the mischief arising from the improper use of this remedy, I could not have supposed that what is so evidently wrong, should so often be done. But with this evidence constantly before me, I feel it absolutely necessary to caution the student of this branch of surgery against an operation he will often be ad- vised to perform.—Editor. TREATMENT OF THE 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 texture 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 lamella? 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 302 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 pro- cesses to the conjunctiva and sclerotica, makes 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 ^ ls only necessary to observe, that the prac- 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 ^he superficial ulcer is commonly attended u"c"oa 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. Opi- um 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 nitratum, DISEASES OF THE CORNEA. 303 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 indoientand r do deep siough- may be touched once, or oftener, with the caustic ine ulcer- 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 inter- stitial ulcer. distinctly from the adhesive inflammation; it is a sign only of the inflammation which constitutes the disease. In proportion as this is reduced, 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 ne- 304 DISEASES OF THE CORNEA. tion, vicarious with destruction, and commences on the arrest of inflammation. Abscess. A large collection of matter in the cornea, whether the puriform onyx, or central abscess, requires, at the same time, a supporting constitu- tional treatment, mild cathartics, and the appli- cation 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 to- wards the pupil, and the ulceration of the cornea is extending, I think its discharge by section near its margin advisable. If not too long de- layed, 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 circumstance depends on DISEASES OF THE CORNEA. 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 chronic m- .. , , . ... ,. terstitial ul stimulant and astringent injections; blisters in cer 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 effective in- jections are the lunar caustic and the oxymuriate 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, calomel, loaf- 39 306 DISEASES OF THE CORNEA. sugar, are by some coarse practitioners blown into the eye for this purpose. The principle of their operation is the same. In the use of appli- cations to remove opacities, the points of impor- tance to be determined are the time and the fre- quency of their use. They are mischievous when inflammation is excited or increased by them ; their effects as excitants should be tempo- rary. 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 inflammation which has given rise to opacity, its effect upon the latter is more marked than that of any local remedy.* * The extent to which opacities of the cornea are remov- able in very young patients is truly surprising, and should always prevent an unfavourable prognosis in such cases. The purulent ophthalmia of new-born infants often leaves the cor- nea universally and densely opaque ; and an inexperienced observer seeing the organ in this state, would pronounce its usefulness irremediably destroyed: while in these very cases, the lapse of a few months, and with no other remedy than a weak solution of nitrate of silver, will exhibit the cor- nea entirely restored to its transparency and the vision per- fect. In the treatment of opacities of the cornea generally, it must never be forgotten, that until all inflammation be rf mov- ed, stimulant applications can only do harm. Nor are such applications always necessary. The means which are calcu- lated to subdue the inflammation, and of these mercury is one of the principal, will, in many cases, remove the opacity, if perseveringly employed; while the incautious and precipi- tate use of a stimulant collyrium will, as often, re-induce in- DISEASES OF THE CORNEA. Under the head of strumous nebula with ves- sels overshooting the cornea, I have advised pty- alism, upon the strength of several decided proofs of its efficacy; but no form of recent opacity is so intractable; 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 as- certained by close inspection; and the uncon- trollable nature of sclerotic inflammation, of which I shall speak presently, is well known to those who have seen much of it. The deposition is interstitial. The oxymuriate or the hydr. cum creta, in small but frequent doses, will sometimes succeed better in this case than the other forms of mercury; and the combination of blue pill or calomel with antimony, better than that with opium. In constitutions which discover an insuscepti- bility to be affected by the mercurial pill, or in which its exhibition in sufficient doses is attend- flammation, and extend the opacity. Such collyria are in- deed extremely useful in their proper place, but even more injurious if employed too soon. Slight scarifications of the corneal conjunctiva covering opacities, assist materially in removing them, if made use of after the complete subsidence of inflammation.—Editor. DISEASES OF THE CORNEA. ed with griping pain and diarrhoea, friction should be employed; and indeed in all cases in which the saving of time and strength is peculiarly an object, this is the more certain and efficacious proceeding. I know that the prejudice often ex- isting against the use of the remedy in any shape, is most strongly opposed to this, its best form. But among persons otherwise 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 confidence in himself—by a steady perseverance in his design: having, there- fore, upon mature deliberation decided, that the mercurial action should be set up, nothing but the clearest demonstration of the patient's ina- bility to support it should interfere with the full and fair execution of the plan. A character no- toriously abused by indiscriminate excess, is in much danger of being further injured by half measures. This, 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 ac- count by the practitioner. The progress of dis- ease during its exhibition is no argument against its continued 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 DISEASES OF THE CORNEA. signs of absorption were manifest, its operation upon the disease was for a time unobserved, or was null, and was yet ultimately all that could be wished. I venture upon these remarks from hav- ing myself felt " afraid to go forward lest I should go wrong," in some very obstinate cases of stru- mous 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 introduction, for a time to be limited, would not deter me from prosecuting it in a case wherein I 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, de- termine 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 in- flammation 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 310 DISEASES OF THE CORNEA. that it stands upon the same ground as scarifica- tion, and no other. staphyloma. The staphyloma, if purely corneal, and of such size as to occasion deformity, and expose the or- gan to further injury, or if producing habitual ir- ritation 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 sec- tion is at the base of the cornea, although the iris should be included in it, for the vitreous hu- mor is in a considerable degree sunk by absorp- tion in the staphyloma, and the aqueous as much superabundant. A flat double-edged knife is the most convenient instrument for a circumcision 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 conical, the DISEASES OF THE CORNEA. section is corneal, and its edges should be touch- ed with the argentum nitratum to prevent a cor- neal fistula. But when, as in many cases, the protrusion is not such as to prevent the easy mo- tion of the lids, or occasion inconvenience, 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. 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 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 impro- bable. 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/ * A young man from Rhode-Island applied at the New- York Eye Infirmary about eighteen months since, with both rorneae conical and a cataract in one eye. His near-sighted- 312 DISEASES OF THE CORNEA. ness was so extreme, that he could read with great difficulty. The cataract was removed from the one eye, and with much advantage to his vision. He could see without any glass much more distinctly with the eye operated upon, than with the other assisted by a concave glass of any degree. This case tends somewhat to prove the propriety of the plan recommended by some surgeons of removing the lens in cases of conical cornea, in order to compensate for the in- creased refracting power of the cornea. I have had no op- portunity, however, of ascertaining the degree of perma- nency of the improved vision in this case, as the patient im- mediately returned home, and I have learned nothing from him since.—Editor. 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 is 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 * The pain attendent upon these forms of inflammation, which generally attacks in paroxysms at regular hours, may 40 314 SCLEROTITIS, CHOROIDITIS, AND IRITIS. influenced by mercury as the iritis, and its ob- stinacy and disposition to relapse render the case 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 frequerit 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 be materially alleviated by rubbing upon the eyebrow and forehead, a short time before the expected paroxysm, an ointment composed of strong mercurial ointment and powder- ed opium, in the proportion of six grains of the former to two of the latter.—Editor. * See note K. SCLEROTITIS, CHOROIDITIS, AND IRITIS. 315 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 Dovar's powder, hemlock, and hyoscyamus, and the extract of sarsaparilla, either dissolved in the decoction or taken freely in the solid form. I have seen an obstinate chro- nic inflammation yield before these latter reme- dies, 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 extended from the conjunctiva, yields to a copious vene- section, and two or three brisk doses of calomel and rhubarb, followed up by the infusion of sen- na; bu,t, generally speaking, the system must SCLEROTITIS. CHOROIDITIS, AND IRITIS. 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 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 seldom 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, SCLEROTITIS, CHOROIDITIS, AND IRITIS. 317 1 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- 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: sometimes the eye-ball suppurates, and the little remaining vision is Completely extinguished. In cases where age, or the existence of other dis- eases, or the already excessive 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 em- ployment. 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. organic The diseases of the other coats and humors of f^minaam- the eye which are present in a considerable num- 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 capsule 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. AMAUROSIS. 319 But there are cases in which a change in the From» change of structure of the retina is to be inferred, of a de- *ex,ur„e jfn- 7 dependent scription less conspicuous indeed, but not less maSSST" fatal to 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. When the eyeball has the appearance of Functional # ' amaurosis. 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. I 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 affects practice and character. An amaurosis 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 \MAUR0SIS. 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 I 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, worms, &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 AMAUROSIS. functional disease, that should in most cases in- fluence our prognosis, yet the latter circumstan- ces, it is equally clear, afford more or less encou- ragement, in proportion as the pre-existing states of diseases ordinarily admit of relief or other- wise. Thus, for the sake of illustration, I may observe, that the amaurosis from gastric diseases, from plethora, from irritation, are all of them re- lievable, and, if treated at an early period, reme- diable. 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, ex- cepting 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 un- illumined 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. n 322 AMAUROSIS. 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 he- meralopia,t and many other cases not assuming * 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 which 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. t See an excellent paper on this disease as it affects seamen in tropical climates, by Mr. R. W. Bampfield, Surgeon of the Royal Navy, in the 5th Vol. of the Medico-Chirurgical Trans- actions. AMAUROSIS. this precise character, are essentially depending 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 correc- tion of this sheet 1 have been consulted for an amaurosis immediately succeeding to exposure, during several hours, to cold and incessant rain; and which I have the pleasure to say is advancing towards recovery. I have exemplified the treat- ment of these cases in the pathology ;# if active measures are taken without delay, they generally warrant a favourable prognosis, 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 is more to be apprehended in the result, that is, is less tractable than either the sudden or the rapidly advancing disease, supposing all to be alike free from the unequivocal sign* of organic change. 4,1 Page 169 et seq. 324 AMAUROSIS. 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 muscae, 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 AMAUROSIS. 326 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. The treatment of amaurosis is almost exclu- External • 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 326 AMAUROSIS. eyelids exists in conjunction with 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 setons, in certain cases which it is unnecessary to Blisters. specify, and of blisters in almost all. These, if 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 165. AMAUROSIS. 327 big as a crown piece, will sink the powers of a delicate female for days, and this effect will be especially 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 blister would be injurious. How is it that a blis- ter 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. I have heard and read of the effects of elec- Electricity tricity and galvanism in amaurosis. Some nar- rators of their occasional efficacy are undoubt- 328 AMAUROSIS. 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- 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 dis- crimination 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- AMAUROSIS. 329 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, assafcetida, 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; and secondly, on the employment of such restora- tives as the system requires and can bear. The blue pill, with colocynth, rhubarb, or aloes, and the combination of soda with rhubarb and ca- lumba or gentian, are best adapted to the former purpose. 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 regula- tion of the digestive functions. I know of no article of the class of stimulants that has any di- rect claim to notice, or any approach to a specific 12 330 AMAUROSIS. virtue, such as has been ascribed to the arnica montana, aconite, &c* Mercury. When the amaurosis is recent and sudden, and either the signs of an obscure inflammation are present, or only the amplitude 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; when mercury is beneficial, its efficacy is per- ceived as soon as the mouth is sore.f I have seen it tried, and have myself tried it in many cases of perfect amaurosis, without the smallest advantage; 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; " 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 euphrasy and rue " The visual nerve." t See note L. AMAUROSIS. 331 Superadded to the entire repose of the organ, Dietetic. 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 perti- naciously 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 EYEBALL. suppuration The treatment of those injuries to which the of the ball. . . ^ organ is subject from external violence, is com- 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 bao-. Extirpation The extirpation of the eye, when that opera- tion is determined upon, is most conveniently performed with a straight double-edged knife, 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 palpebrae 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 following 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 extensive 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 evi- dent. 334 DISEASES AFFECTING THE EYEBALL. 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. oianduiar The propriety of this measure, from its seve- enlarge- , . "bweie^ nty an" *ne uncertainty of its preserving life, should be always matter of very deliberate con- ( sulfation. 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 vicinity of the orbit, or of tubercles of a suspicious character in other parts of the body. Such affections, supposed to be of the same morbid character, have disappeared in more than one case of malig- nant fungus, after the removal of the diseased part. DISEASES AFFECTING THE EYEBALL. 331 A gentleman, whose case, a fungoid tumor involving the knee-joint, was considered despe- rate, and was absolutely abandoned as hopeless by the ablest surgeons in this town, on account of many tubercular swellings on other parts of his body, in addition to extreme weakness and emaciation, put himself under the care of an older practitioner, who considered the objections theo- retical ; the limb was amputated by this gentle- man, 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 dis- ease of a character totally dissimilar. It is right however to state, that the period of survival has been short in these cases. An extensive abdo- minal abscess proved destructive to a man whose leg had been amputated three months before for a genuine fungus haematodes; another died sud- denly of apoplexy, several months after the re- moval of a fungoid testicle of great size. In both 336 DISEASES AFFECTING THE EYEBALL. 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. V "' TREATMENT DISEASES OF THE EYE, CHAPTER III. SECTION I. ON THE OPERATIONS FOR THE CATARACT. Before speaking of the operations, I shall of- fer a few preliminary considerations. The extent and importance of the subjects of this and the following chapter, the deep profes- sional interest which 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 43 338 operations for the cataract. 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. Cataract in It has been a custom with oculists where a 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 destroying inflammation, in others of a partial absorption of the vitreous humor. with amaU. The cataractous eye is not unfrequently amau- operations for the cataract. 339 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 syirptcms. In this case the cataract of the latter should be removed without delay. In cases of congenital or infantile cataract, w»han- which become the subject of operation at an "r 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. It would be incorrect to say that the opera- Degree or ^ l vision. 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 340 OPERATIONS FOR THE CATARACT. 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 OPERATIONS FOR THE CATARACT. 341 beyond the period at which useful vision ceases, nor do I think any reason can be given for delay, tantamount to the risk of injury from incidental inflammation, or impotence from a continued sus- pension of the function of the organ. There are several circumstances in the struc- Local err 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 proportional diameter of the cornea to the globe, and its ac- tual diameter; the healthy state and proportion 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 contracted pupil, are circumstances decidedly unfavorable to any and all operations. The operations have been so repeatedly and cues,* * To these might be added circumstances of temperament, viz. a calm and steady, or an irritable and very moveable eye. 342 OPERATIONS FOR THE CATARACT. minutely described, that I shall not fatigue my reader with a prolix detail of them. They are three in number : couching or depression, ex- traction, and absorption. The first and most ancient is now seldom performed in this country. The cases to which it is alone applicable are those cataracts of firm 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 * The needle employed by the Editor is somewhat dif- ferent from Scarpa's. Instead of a triangular point like his, it has a lancet point, cutting on both edges, flat on one side, convex on the other, and curved at the point like that of the Italian surgeon. A needle of this form enters the sclerotic more readily, makes an incised instead of a punctured wound, and may be more easily made perfectly sharp by the cutler. See Plate 5, Fig. 1. OPERATIONS FOR THE CATARACT. 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 left entire, it would become a secondary capsular cataract, and require a subsequent operation. The operation 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 the smallest injury, and to con- clude that it is least liable to be followed bv se- vere inflammation. But the subtilties of theorv have little weight in the scale against experience, and no one who has seen much of these operations considers the puncture of the tunics to form a ma- terial objection, if it is executed with a proper instrument, and agreeably to the directions which are furnished by a knowledge of the or- gan. I have so often seen the eye perfect in its aspect and function, after several such penetra- tions of the larger tunics, and the inflammation immediately resulting from each operation so slight and transitory, ns to be convinced that the 344 OPERATIONS FOR THE CATARACT. 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 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 OPERATIONS FOR THE CATARACT. 345 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 unathorized in their experience. For example, 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 ? Vet all these are marshalled in formidable array as objections, for the obvious purpose of de- monstrating the superior advantages of couching through the cornea. If the operation just described is attempted Absorption. upon a flocculent cataract, the lens, instead of descending solidly, breaks into pieces, which undergo a gradual 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- 41 3.1(5 OPERATIONS FOR THE CATARACT. lure 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 to in a case of 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 * I pass over the description of an operation which* con- si~ts in 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 cau- tion be necessary against a measure so desperate and ill- advised. It levels with the proposal to extract through the sclerotica. OPERATIONS FOR THE CATARACT. 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 tliin 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- tion with safety, if this operation were otherwise as eligible, 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. The primary cataract adhering to the iris is for the most part capsular; but whether it be so 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. 348 OPERATIONS FOR THE CATARACT. rather than the detachment of the membrane entire. In this, 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 oftener in the twenty-four hours, and this var- 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 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 per- formance. OPERATIONS FOR THE CATARACT. 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 show 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; and the essay 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 important 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 ventured for himself to deny it; but I may be allowed to ask, is not this exception to the general issue of the operation, a condition of every human work? What operation, I should be glad to learn, is not impugnable by such an argument ? Thirdly, it is followed by a higher degree of in- flammation, and one of a less manageable kind. This again, as the former and all the objections in detail, admit of this general answer. They 350 OPERATIONS FOR THE CATARACT. apply to the performance, not to the principle 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 ex- tent as to allow of the perfectly easy escape of the lens ; if the sclerotic conjunctiva, sclerotica, and especially the iris be untouched, and the capsule freely lacerated, without laesion of the vitreous capsule, then the operation is perfect. But although all these points should be imper- fectly, 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 repeatedly seen reversed, and yet the patient has recovered excellent vision. So that the failure of the ope- ration is by no means a necessary consequence of the casualties that may attend it, even al- though they should be such as to excite a con- siderable 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 OPERATIONS FOR THE CATARACT. 351 common candor to clear it of all imputation from an imperfect result. 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, and the difficult and forcible removal of either as certainly augurs unfavorably. The enlargement of the section, if too short, is difficult, and alwavs dangerous to the iris in the collapsed state of the cornea; it is attended, moreover, with imminent 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 nar- row section, is almost always followed by the falling of that membrane into the wound, a pro- tracted healing of the wound, and a loss of figure of the cornea. The free escape of the vitreous humor, owing Escape or . vitreous hu- to an imperfect section, undue pressure, occ. mor occasions the sinking of the lens in the globe. Such a circumstance may embarrass an operator, and induce him to leave the cataract, in the 352 OPERATIONS FOR THE CATARACT. 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 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 already 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. section Ifc is a Point of considerable importance that Sio- the section should be purely corneal. I mean 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 OPERATIONS FOR THE CATARACT. 35 union.* Two ill consequences arise from this: first, 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. Soft and semi-transparent and unadhering Extraction . of the soft capsular cataracts may all be conveniently ex- Mtaract * 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. 354 OPERATIONS FOR THE CATARACT. 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 touch of the needle passed through the cornea after the healing of the section. instru- The construction of instruments employed in ments. . . operations is a point which every man must de- cide for himself. The knife of the eminent Pro- fessor Beer of Vienna is that which I am in the habit of using, thinking it on the whole better adapted than either Richter's or Wenzel's, to make a safe and expeditious section.* preparative The more or less inflammation which follows and after treatment. ^e 0perati0n is of course depending in great 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 fulness 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 * See Plate V, fig. 4. OPERATIONS FOR THE CATARACT. patient rest for a few minutes with his eve 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- 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 bandage passed round the night-cap and fastened to it is a suffi- cient covering for the eyes. Compresses on the eyelids are generally better omitted ; the band- age may in most cases be laid aside on the se- cond or third day, and a deep black shade sub- stituted for it. During the night, however, the bandage should be applied for the first week to prevent the accident of rubbing 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 * It is the custom of M. Roux, of Paris, a dexterous and successful operator, to apply a blister to the nape of the neck after the operation. 356 OPERATIONS FOR THE CATARACT. 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 considera- ble, the patient is afterwards subject to repeated irritable ophthalmia, and a troublesome exulce- ration of the cicatrix sometimes occurs. I have in 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. unfavorable The inflammation of the iris, the interstitial theojen- ulceration and opacity of the cornea, the sepa- 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 lassion of the iris. Al- though the process of healing is painfully re- OPERATIONS FOR THE CATARACT. 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 ve- hement, and proceed to amaurosis, or it may ter- minate favorably in constricted pupil. This state is seldom uncombined with a secondary cataract, 1. e. a portion of continuous capsule, which hav- ing become opaque, knits up the pupil by adhe- sion to its margin. The dimness of the cornea, if any, is slight and 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 vi- sion of objects. In fact, the cornea precisely re- sembles that of the dead subject. Mercury is of uncertain efficacy in this case, which fortunately 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 OPERATIONS FOR THE CATARACT. with, or witnessed in the practice of others. When the operation is perfect, its pre-eminence is too conspicuous to require illustration. It ex- acts 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, the 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 oppo- site border of the membrane, so as to anticipate the escape of the humor, and preserve the iris in situ; the deliberate completion of the section, all pressure being removed, either by the pro- gress 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 expedient, 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 frequent and OPERATIONS FOR THE CATARACT. numerous to admit of being always anticipated, and the only security against them is the con- stant habit of practising the operation, and the confidence thence acquired, tempered with a due sense of responsibility. Habit will make any man ambi-dexter; and the rest for the elbow, so much insisted upon, having been once laid aside, would prove a hindrance rather than a help to the operator. After thoroughly understanding the minutiae of the operation, habit will also render it unnecessary for him to rehearse the several steps and stages of the performance 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 11 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 couch- ing or extraction. The first supposes a healthy state of the irih and anterior chamber, the second a transparent cornea. OF THE OPERATIONS FOR ARTIFICIAL PUPIL. 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 extent 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 OF THE OPERATIONS 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, although interesting as 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 me- rits, general and comparative, of each manoeuvre to the test. FOR ARTIFICIAL PUPIL. 36 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 particu- lar state described. Simple states : 1. A central opacity eclipsing the pupil. A section is to be made, with the cornea knife, in the trans- parent 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 recedes, 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 ad- hesion with the capsule, or if adhesions exist be- tween the iris and cornea, no protrusion will take place. In making the section, it is very impor- tant that the direction of the knife should be per- pendicular 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 to draw out with OF THE OPERATIONS forceps and excise the pupillary margin, more completely answers the intention. There is another operation which I have per- formed successfully in this 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 scle- rotic coat and ciliary margin of the iris into the anterior chamber, with its cutting edge opposed to the face of the iris; that membrane is then to be completely divided on the temporal side, in- cluding the border of the pupil, by repeated gentle nickings. The iris being sound, and con- sequently elastic, the section immediately as- sumes the figure of an equilateral triangle. The superiority of the operations before-mentioned consists in their less liability to be followed by cataract. If cataract ensues, as is pretty uni- formly the case in the simple division,'it must be broken up for absorption in a subsequent opera- tion 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 ob- served, that in the majority of instances the cap- sule and lens have undergone the change here presumed; but this is a matter not always pos- *>See Plate IV. fig. 9. FOR ARTIFICIAL PI PIL. •^lble to be ascertained, and one which affords no ground for varying the plan of operation. It is therefore best to provide for it. The section should be made precisely as in extraction. The centre of the iris should then be raised under the flap of the cornea with the forceps, and as large a piece of the membrane as can be embraced by the convex scissars, should be clipped off Through such an opening there will be no impe- diment to the passage of the lens. I have re- peatedly performed this operation'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 tri- angular flap thus formed, with a stroke of the scissars; a method perfectly efficacious in the state of closed pupil, whether the cataract re- mains 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 Wenzel's directions do not ex- tend, 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 Pro- fessor Maunoir, of Geneva, relating three suc- cessful operations for artificial pupil performed 366 OF THE OPERATIONS with his scissars in the manner recommended by him. In two of these cases the pupil was con- stricted 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 opera- tion compounded of Wenzel's and Maunoir's, is the most appropriate to the case of constricted or closed pupil with opaque lens.* Complicated states: 1. Closed pupil, combined with a partially opaque cornea. To this state either of the operations last described may be applicable; this must how- ever depend upon the extent of the opacity. A section of the opaque part of the cornea is unad- visable, 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, 1 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 the section * See Explanation of Plate IV. FOR ARTIFICIAL PUPIL. ot that membrane would obscure the small por- tion 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 con- stricted 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 pu- pillary margin on the nasal side, so as to include a sufficient portion of the iris. If after the re- moval of the lens, the incised portion should not be completely detached, the flap may be easily snipped off with the iris scissars. It may be use- ful to remark, that pressure should, as much as possible, be avoided during the extraction of the lens. Other modes of procedure 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 * See Explanation of Plate IV. 368 OF THE OPERATIONS side, and couching or breaking up the cataract before withdrawing the needle, which 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 per- formance of the operation for artificial pupil, and the treatment of the lens by the absorbing pro- cess, after the lapse of an interval, is for obvious reasons objectionable, when it is possible to do otherwise. 3. 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 alto- gether unadvisable. It is only at that part of the 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 FOR ARTIFICIAL PUPIL. 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 resort- ed to. 4. Permanent prolapse of the iris through a breach of the cornea, involving more or less of the pupillary 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 favorable 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. Phis was a very important step in advance, and 17 370 OF THE OPERATIONS 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 be 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 pre- ferable, on account of preserving the transparen- cy 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, nom 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-vascularity— FOR ARTIFICIAL PUPIL. 37 I 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; the organ upon which we are operating is an unsound one, and having been recently and perhaps re- peatedly 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 therefore decidedly disapprove of coupling with the formation of an artificial pupil, the displacement and breaking up of the lens to undergo the tedious process of absorption, whenever it is possible to extract or even to couch it. The organ has already suffer- ed too much, and the operator should either not interfere with the transparent lens, or should re- move that which is already opaque -f and as the latter may almost always be presumed, while it remains in situ behind a closed pupil, that ope- ration is preferable, which provides for its re- moval. 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 372 OF THE OPERATIONS 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, duration, and character of the inflammation. If the dis- ease is confined to the cornea, the case affords the best encouragement. In the prolapsus iridis from ulceration of the cornea, the iris is only passively concerned, and here it seldom happens that the retina has suffered. If the closure of the pupil has supervened upon wound or injury, as the operation of couching or extraction, it is in general more favorable than when it results from idiopathic inflammation of the choroid 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 sclerotica under the impression of the finger, the perma- nent congestion of the sclerotic and choroideal vessels, the great convexity and discoloration of the iris, and the yellowness of the opaque lens. FOR ARTIFICIAL PUPIL. if any part of it is visible, the partial detach- ment of the pigmentum nigrum, &c. An exten- sive adhesion of the iris to the cornea denotes the greatest degree of organic derangement, and constitutes the most unfavorable state for opera- tion. In a great proportion of cases in which the operation might, in a manual view, be executed with perfect success, no advantage would result from it; as in cataract, complicated with amau- rosis, 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 at- tempted ; without some healthy perception of light, I should think it offered a very small chance of usefulness.* In the most favorable circum- stances, the patient should be led to entertain a moderate degree of expectation ; and as persons in a state of blindness are invariably over-solici- tous to submit to any experiment for the reco- very of vision, the surgeon, for his credit's sake, * 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 disorga- nization of the retina. I OF THE OPERATIONS 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 un- decided, let him so state the circumstances as to make himself responsible only for the mecha- nical process. Let it, for example, be expressly understood that without 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 remaining 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 mor- bid actions which ensues from the thoroughly diseased condition of the cornea and iris, where the instant result had inspired a hope of better fortune.* * Previously to the performance of any operation for ar- tificial pupil, we should always ascertain whether any im- provement to vision may not be gained by the use of bellai donna or stramonium. The 3ilatation of the constricted pu- pil to the size of a small pin's head, or even less, will often give the patient a degree of vision, which will render any operation unnecessary. This precaution should in no case be neglected ; for we will frequently in this manner restore good sight, when we least expect it. A very remarkable in- stance of this fact occurred in the following case. FOR ARTIFICIAL I'LPlL. T. Steinberg was received March 12th, 1824, at the New \ork Eye Infirmary, by my colleague, Dr. J. Kearny Rodger9 ; blind, in consequence of closure of the pupils from inflammation of the iris. The constriction of the pupils appeared to be so complete, and the original inflammation so severe, that the patient was assured that he could ex- pect no relief, except from an operation for artificial pupil, and that even in that case, success was extremely doubt- ful. The sight remaining to the patient was totally insuf- ficient for any useful purpose. He could not discover the form of any object, and, indeed, could do little more than distinguish light from darkness. Before performing an ; operation, Dr. Rodgers took the precaution to order the application of extract of stramonium. At the next visit, the patient had gained a degree of vision which made it evident < that no operation would be necessary. He was therefore directed to continue the stramonium. Under this appli- cation, the sight regularly improved, until at length the patient could read without difficulty type of very moderate size. The most surprising circumstance attending this case is, that notwithstanding a slight enlargement of the < pupils could be observed after the application of the stra- monium, yet they were still so excessively small, that it was altogether unaccountable how the patient could see so accu- rately. The improvement in vision was permanent after the discontinuance of the stramonium ; and this man now gains a comfortable subsistence by his occupation of comb- making, which he performs to the perfect satisfaction of his employer. The appearance of the pupils is shown in Plate 4, Figures 5 and 6. This case is taken from a Paper on Artificial Pupil by the Editor, in the New York Medical and Physical Journal, No. 14. He has also annexed the plate from the same paper, with delineations of the results of some operations for artificial pupil, and given an account of the cases in the ex- planation of the plate.—Editor. TREATMENT OF THE 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 commu- nicate information upon a department of patho- logy, 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 with the point of a lancet, and poulticed, or bathed with a slightly astringent wash, according to circum- stances. When phlegmonous, indurated, and slow to suppurate, occasional friction will often pro- mote absorption of these little swellings, as we may conjecture was known of old, from the re- puted specific 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 the 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 18 378 DISEASES OF THE APPENDAGES. washes assist this object. The chronic indurated 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 sin- gle stimulant application. Some exceptions however occur. The lead and zinc ointment, or one combined with opium, will often agree with those slight, but very irritable lippitudos some- times met with ;* but there are persons to whose sensations 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 acet. to two drachms of the ung. zinci, I have found to answer completely in such cases. DISEASES OF THE APPENDAGES. :m» much distended by inspissated mucus, as to occasion 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 stimu- lant 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 likewise 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 impor- tance 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 conjunctiva 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 stand- ard of strength. As to the manner, patients should be instructed in the intention; and for the strength and quantity, in the desired effect of DISEASES OF THE APPENDAGES. the remedy. The degree of irritation 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 con- junctiva, by advancing gradually 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 injus- 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 operation would be without exception ; and indeed the great- est 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, whose 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 having enriched herself by a successful traffic, 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 which her soul was encumbered. « Soyez tranquille, mon amie,'" said the professor, " de tous les Medecins vous Stes le plus innoqent: vos remedes n'ont fait du rnal a personne !" DISEASES OF THE APPENDAGES. 381 The correction of the diseased states and se- Tinea ex- cretions of the ciliary 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 pa- tient than the surgeon in the cure of these com- plaints, and that the incurable states, those which admit only of palliation, are invariably the conse- quence of neglect, and might therefore have been prevented. When cilia are inverted from a diseased growth, Trichiasis. they must be kept plucked until by the improved DISEASES OF THE APPENDAGE.^. condition of the hair-gland, under the means used, the disease is removed. If a case occurs in which the vitiated site or incurvation of one or more cilia does not admit of correction, the corresponding follicle should be obliterated by repeatedly touching it with a fine caustic pencil. When the incurvation is depending on a disease of the tarsus, the case must be treated as entro- peon. The 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 a 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 * A more recent method of treatment adapted to entro- peon, and in some respects superior to the one recommended by our author, consists in the application of concentrated sul- phuric acid to the skin of the affected eyelid, in such a man- ner as to produce the necessary degree of eversion, by the contraction thus effected in the skin. For this purpose, a small quantity of the acid is rubbed upon the skin of the eyelid, either with the blunt end of a probe, or a piece of smooth wood, opposite to the inverted DISEASES OF THE APPENDAGES. 3H3 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 cir- cumscribed inversion produced by cicatrix from bum or wound, I have found an operation similar to that of Dr. Crampton, an effective remedy; sometimes the complete division of the con- junctiva and tarsal cartilage, including the inverted portion, and parallel to its border, with the aid of sticking-plaster, has proved suffi- cient. 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 cilia, and including a space, extending a little beyond the dis- ease on each side ; and from a quarter to half an inch wide, according to the degree of inversion. After remaining a few seconds, the acid must be wiped off, to prevent its spreading over parts which we do not wish to injure. The application is then to be repeated a second and third time, or even oftener, until the contraction thus induced in the skin shall have everted the lid sufficiently to prevent the cilia any longer rubbing upon the eyeball. A detailed ac- count of this mode of treatment, and of this disease generally, may be found in Guthrie's Operative Surgery of the Eye, re- '•ently published.—Editor. 384 DISEASES OF THE APPENDAGES. 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 af- fords; to say nothing of the permanent deformity which it occasions. Eotropeon. The ordinary ectropeon is cured by the ex- 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. 252, 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 palliations of the deformity. I have, howrever, succeeded in greatly lessening the deformity in some such cases. Palpebral Concerning; tumors of the eyelids I have little tumors. ° J to add to what will be found in the pathology. Often the encysted tumor is seated superficially * Simply rubbing the everted and redundant conjunctiva with sulphate of copper, on alternate days, is sufficient to cure cases of very considerable ectropeon. This mode of treatment, however, requires perseverance.—Editor. DISEASES OF THE APPENDAGES, 385 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 li- gamentary membrane which covers it,) and the appearance of a white circumscribed indentation is seen upon everting the tarsus, that the excision is to be made from the interior by division of the cartilage; in which case it is always executed with perfect facility. If the cyst be not extirpated, but merely incised and its contents expressed, the tumor speedily re-appears.* If its adhesion to the tarsus be such as to prevent the entire re- moval of it, the remnant of the cyst should be touched with the caustic pencil. For the permanently drooping lid, if an opera- Lag0Phth»i- 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 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 and coherinJ£ describe an operation for dividing the cohering tarsi. When complicated with adhesion to the globe, the case is incurable. * My experience does not, in this instance, correspond with that of Mr. Travers, as I have repeatedly succeeded in permanently removing these little tumors by merely punc- turing them from the inside of the eyelid, and evacuating their contents.—Editor. 49 SECTION II. OBSTRUCTION OF THE LACRYMAL PASSAGES. stricture or The treatment of the disease improperly the lacrymal . Su^r*1 termed «fistula lacrymalis," 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 works of Sharpe, Pott, Desault, and other eminent writers. t In proof of this remark, I may observe that nearly all the schemes hitherto suggested have been executed within my knowledge, by different surgeons, viz. the small probe and injecting 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 seton, a coil of catgut, such as is used for fiddle-strings. Among the surgeons of London, Mr. Ware's style is chiefly in use, although the practice is evidently losing credit. DISEASES OF THE APPENDAGES. 387 potties is. Mr, Pott was in error when he concluded in his criticism of Anel's practice, that the strict- ure of the lacrymal ducts was very rare, because the mucus of the sac was habitually, or upon pressure, discharged at their orifices; the strict- ure of the ducts is, on the contrary, frequent; 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 symp- tom exists. The absorption of the meibomian mucus by mucous dis- change. the puncta lacrymalia, and its regurgitation on !™!5Srhr pressure, as described and considered by Scarpa 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 thev have derived ii 388 DISEASES OF THE APPENDAGES. from the eye. Further, there is every reason to believe 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 lid of the affected 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. origioof The effect of a severe cold in the head to stricture. 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 the other parts to which it is distri- DISEASES OF THE APPENDAGES. buted; I mean a state of vascular congestion and intumescence. This continued, would lead to a permanent thickening of this membrane, and from that cause a diminution of the calibre of the ca- nal. An adhesive process, whether primary or consecutive to the states of suppuration and ul- ceration, finally closes the duct, so as to render it absolutely impervious. The actual oblitera- tion of the canal by the degeneration of the mem- brane into a texture resembling cartilage, is a secondary morbid change, and only the result of long continued obstruction. I have had occasion before to observe that Abscess iD- ... dependent of 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 consi- derable degree of obstruction endures for years without a tendency to excite inflammation of the sac; and on the other hand, the inflammation 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 inflammation of the sac often admits of resolution by the use of leeches, &c. without further inconvenience to the patient; and the whole treatment required for the abscess in many cases, is simply the discharge of the DISEASES OF THE APPENDAGES. matter, or, in other words, the treatment appli- cable 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; but unless the previous existence of symptoms demonstrates the presence of a stricture, an abscess of the lacrymal sac is by no means a sufficient proof of it, to warrant the employment of any further measures. The existence of an abscess is of itself 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 and its 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 injurious treat- ment 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 applying a soft poultice in a bag to the inner angle of the orbit. Supposing, therefore, the case of abscess so far advanced, instead of introducing a style into the ductus nasalis, after opening such abscess, 1 recommend simply the examination of the duct DISEASES OF THE APPENDAGES. with a fine probe; if the probe pass without re- sistance into the nose, the case requires no fur- ther operative treatment, the integument reco- vers its healthy condition under an emollient application, 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.* * Abscess of the lacrymal sac, terminating in fistulous open- ings through the integuments, is a disease of no uncommon occurrence in children, and for the most part, in such cases, is a scrofulous affection. It is unattended with stricture, and simply a strumous inflammation of the membrane lining the sac, furnishing a muco-purulent discharge. Accordingly in these young subjects, all operations for the purpose of di- lating the nasal duct are unnecessary ; fortunately so, for they would be extremely difficult at this e;irly age. The principal object of the surgeon is to correct the state of the constitution which gives rise to the disease, by means which it is unnecessary here to point out. Little local treatment is necessary. An open blister behind the ear is as useful here as counter-irritation generally is in scrofulous diseases : and a weak astringent wash to the part, together with the appli- cation of some stimulant ointment, if the sac have burst, such as the ung. hydr. nitrico oxyd. constitute all the topical re- medies which are required.—Editor. 392 JM0 394 DISEASES OF THE APPENDAGES. puncta and with a swollen and atonic state of the canals atony of the . r , .~ sac and sac ; there is no contraction ot the onnce 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 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 The stricture which is occasioned by the ex- tlcmofcon: tension of conjunctival inflammation to the la- junctival in- ^ crymal excretories, should be treated only as a sign 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 tiammation. DISEASES OF THE APPENDAGES. 395 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 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- threatening suppuration. tention of the sac and the discharge of mucus excessive—the conjunctiva towards the inner angle has a preternatural vascularity, the outline of the sac assumes a circumscribed phlegmonous hardness, and ablush begins to appear upon the skin covering it—when the eminences of the puncta lacrymalia are shrunk and absorbed iiv 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. 396 DISEASES OF THE APPENDAGES. 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; we have now a disease requiring a distinct treat- ment, and to prevent a complicated fistula—such as results from the yielding of the sac, the diffu- sion of its contents into the cellular substance, and sinuses spreading in various directions be- neath the integument,—the free incision of the sac should be made without delay, and the treat- ment of the original disease postponed. When the integrity of the parts is restored, it will be necessary in 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 how7 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 stvlc DISEASES OF THE APPENDAGES. 397 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 ; 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 double the latter period, in which the disease did not exist in undiminished force, under the modi- fications which I have just described, that is, as an established lacrymal fistula. Patients are re- luctant to part with the style, because, as is na- tural, they ascribe the degree of relief they have obtained from the opening of the sac, and the di- version of the excretion, to what appears to them to be an essential part of the process. I have recommended the introduction of a Dilatation . , . 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 DISEASES OF THE APPENDAGES. 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, 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 oblite- rated 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 increasing facility with which it passed was not a compen- sation for the pain it inflicted, and the ulceration DISEASES OF THE APPENDAGES. 399 of the wound by the repeated interruption of the cicatrizing process. The practice which I have long employed, The author ,,.. 0 r J practice, and 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 ob- vious 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- 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 1 should oc- cupy the time of the reader in showing that the 100 DISEASES OF THE APPENDAGES. 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 treatment of the urethra, as well as of the ductus nasalis, and it is only in case of abscess, in which the distended and inflamed integument threatens to give way by ulceration, that in either case it be- comes necessary to deviate from it. Lacrymal A set of silver probes, of about five inches long, varying in size, flattened at one end, and slightly bulbous at the point, are the instruments 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 en- tered 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 Dl.SEAtsES OF THE APPENDAGES?. 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 liberty, while a half circular motion is performed by the instru- ment ; the surgeon neither suffering the point to recede, nor, on the other hand, allowing it to be- come entangled in the membrane. The probe now rests in a perpendicular di- rection upon the eyebrow towards its inner angle, and in this direction it is to be gently de- pressed until it strikes upon the floor of the nos- tril, where its presence is readily ascertained by a common probe, passed beneath the inferior tur- binated 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 considerable 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 inter- vals of one or two days. 402 DISEASES OF THE APPENDAGES. 1 have seldom met with a stricture so firm as not to yield to the full-sized probe. I am fully aware of the objection that immediately presents itself, viz. that a passage so obtained is not per- manent ; by several repetitions of the operation it is often rendered so; but if the resistance is not altogether removed, after a trial of the expe- riment for some days in succession, I introduce a i.acrymai style having a small flat head, a little 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 ul- cerates the orifice; but I have never seen it in- jure 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 lacrymal duct. The injection of tepid water should be made on the interve- ning days with Anel's syringe. The plan requires perseverance, as may be said of all plans by which so difficult an object is sought to be effect- ed. In many cases the resistance, in the first in- stance opposed, is inconsiderable, yet it is suffi- cient to maintain the disease. The probe passes daily with increasing facility, and after a very few repetitions, with as much ease as through the 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. DISEASES OF THE APPENDAGE*. 403 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 func- tion of the parts, in treating the morbid altera- tions of structure which have interrupted and deranged them. For this mitigated, but not re- covered state, time alone, with attention to pre- vent distention by occasional gentle pressure of the sac if accompanied with mucous discharge, is often sufficient; but the injection of a solution of alum, or even of cold spring water, and the use of astringent washes, will assist. Sniffing a stimulant vapour, as of vinegar, or diluted 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 al- ways painful, and often tedious, I can only reph, that there is too much truth in the objection. I shall be happy to be instructed in one equally effective, and free from these objections. I am DISEASKS OF THE APPENDAGE-, far from assuming that all the other measures em- ployed might not be crowned with success in favorable cases; this, like other complaints, some- times recovers, not so much in consequence, as in despite of treatment. Of all the other modes, the seton of Mejan 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 the most objectionable. I have seen cases of its employment, in which it very speedily became plugged with mucus, the sac habitually loaded, the nostril dry, and the stillicidium permanent. But how a metallic tube can be expected 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 restor- ed, and as it were in consent with it, I confess myself at a loss to conceive. I have more than once heard patients sorely regret that they had submitted to its introduction, having received no degree of permanent 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 symp- toms 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 DISEASES OF THE APPENDAGE.". 4O.0 Knglish 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; 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; and no consi- 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 EPi,»hor;. m- . , -it i*ii dependent of epiphora not depending upon mechanical ob- obstruction struction of the lacrymal excretories.f The zinc and the lunar caustic solutions, the thebaic tinc- ture, the mercurial ointments introduced be- tween the lids, will remove such forms of the complaint, if the patient is so far inconvenienced * See nolo V. t See note V 406 DISEASES OF THE APPENDAGES. 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 stricture, 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, thickened, 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 oint- ment. A small fistulous aperture, where the dis- ease 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 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. I am not practically acquainted with the effect of pressure upon the relaxed or hernial lacrvmal DISEASES OF THE APPENDAGES. 407 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. For the opportunity of seeing and treating an grow * interesting case of dropsy of the sac, (the dis- ease described at page 260,) 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 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 globu- lar tumor, I have repeatedly seen and removed by persevering in the use of the probe and sy- ringe. In this case the lacrymal and nasal ducts are equallv obstructed. It may be proper!) 408 DISEASES OF THE APPENDAGES. termed 4 mucocele,' and should not be permitted to continue. [Third Edition.]—On the general treatment of this disease I have only to observe, that addi- tional experience has fully confirmed the efficacy of the practice which I have here recommended. I have frequently anticipated the impending sup- puration of the sac by the early and gentle intro- duction of the probe, by which the disease has been arrested; and it is only when the skin par- takes of the inflammation as a consequence of distention, that I have recourse to an external opening. After the relief of the sac, a poultice reduces the inflammation; and in a few days the use of the probe may be resumed. In recent ob- structions, the disease yields to a very limited course of treatment. In the chronic, perseve- rance is required, and the early alternate employ- ment of the syringe greatly promotes the object in view. The lacrymal style I have discontinued, finding the benefit resulting from its use dispro- portionate to the inconvenience. 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 per saltum, and always slowly and with very mode- rate force; much counter resistance rends the sac, and extravasates the fluid : and although DISEASES OF THE APPENDAGE-. 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 ablu- tion of the sac, and I believe makes a compro- mise on better terms with the disease than by wearing the permanent tube or style. APPENDIX. Or. 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 visit 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 derived 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 ta- lent 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 an- nounce, 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 present employed. OBSERVATIONS ON SOME POINTS OF THE ANATOMY OF THE EYE. Sclerotica, before reaching the cornea, increases in thick- ness, and divides into two layers ; the outer advances be- yond 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 termination, is an annular groove in the whole cir- cumference, which receives a tendinous ring (annulus tendi- nosus*) ; this ring is situated without the choroid, and firmly adherent to the sclerotic 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 shown in eyes of aged persons ; this membrane can be separated from the innermost layer of the cornea, and differs from it in its greater tenacity and transparency. The latter quality it pre- serves in spirit; the greater firmness and more express cha- racter 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, some- times protrudes and forms the disease called by Professor Beer, « Keratokele.' * Doellingeri descriptio oculi humani. Wurceburgi. APPENDIX. 1 I 3 Int. Having subjected the iris to maceration, as I knew that by such a process the choroid coat might easily be divid- ed 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 dis- section. If there is such a continuation over the iris, this membrane must be divided into two layers ; in ascertaining this I succeeded, and shall now endeavour to give a descrip- tion 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 evidently distinguish the turn which is formed by the anterior layer of the iris conti- nued into the uvea ; betwixt these two membranes I saw dis- tinctly the nerves and vessels distributed in a tortuous man- ner. 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 difference of this pigmentum in its co- lor, I am inclined to think, that the different color of the iris particularly depends upon it, which then only can 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 consider the ori- gin 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 latter ; these processes are, like the ciliary processes, more distinctly seen in dark eyes, and differ from them only in their smallness. Choroidea is easily divided into two layers, after maceration of several days. 1. The outer layer, or choroidea, stride sic 414 APPENDIX. dicta, is the 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 pig- ment ; just behind the ciliary ligament it is perforated by the ciliary nerves and vessels of the iris. 2. The inner layer, or ruyschiana, 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 (corpus ciliare), which begins with a dentated margin, and secretes 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 ad- hesion in the human eye. Professor Beer calls the anterior part of this body, pars plicata, to the formation of which the ciliary processes contribute. The ruyschiana, after having formed this body, continues forward—having to its inner sur- face 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 continuity is not disturbed, after having separated the ciliary processes with their origins ; and the appearance of both membranes is completely the same, each exhibiting the nature of a thin serous membrane. APPENDIX. ■115 Having now described the choroid coat and the iris, and the connexioti 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 anterior lamina of the iris form one membrane turning to- wards the cornea for the space of about one line ; which ap- pearance 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 show clearly its continuation. Yet it is evident that this membrane divides before the ten- dinous ring into two, the outer and posterior forming the venous layer; the inner and anterior, forming the iris, con- tinues, uvea and ruyschiana. That it is a division of this mem- brane in these two different directions, I conclude from the finer structure of each of these two membranes than of that before the tendinous ring. The expressed character of a se- rous 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; patho- logical 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 eminent pathologists. As to the nature of the iris, choroidea, and ruyschiana, 1 am inclined to think that they are of a serous kind, from the appearance which they exhibit in their natural state, and the more sc, from the morbid alterations to which they are 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 ad- hesions of the iris to the cornea. The tubercles in the syphi- litic iritis, which Beer calls condylomata, and appear at the ciliary 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 coagluable lymph. 41(5 APPENDIX. In a higher degree of iritis, though more rarely, there may be formed an abscess, which occupies, as Beer observes, the middle of the iris ; in these respects, as to the liability of ad- hesive inflammation, and rare occurrence of suppuration, in the substance 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 performed 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 difference of function in the iris and ruyschiana, though they are the continuation of a serous membrane, I explain from the addi- tion of other parts, as in the iris, of the ciliary nerves and vessels, to which 1 think the motion of the iris is to be at- tributed ; and in the uvea and ruyschiana, from the other cili- ary arteries, which secrete the pigmentum nigrum. Ligamentum 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 si- tuated 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 APPENDIX, 417 smaller processes, and two commonly arise together. The origins 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 ruyschiana 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 con- nected with the choroid coat, but 1 could not find such a con- nexion. That they are formed by the ruyschiana, I can also not admit, because, 1. they maybe separated and raised from the corpus ciliare without injuring the continuity of the ruyschiana ; 2d. they are different in their structure, endow- ed with greater firmness and elasticity ; 3d. they do not se- crete pigmentum nigrum in the human eye. I consider these processes as consisting in themselves of a different structure 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 ligament. These processes are co- vered with a cellular tissue, which 1 have seen fully injected ; this cellular tissue seems to be the secreting apparatus of the aqueous humor in the posterior 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 ciliaris originates at the dentated margin of the ciliary body ; here it forms the ora serrala, which is considered the end of the retina. Professor Doellinger describes a thinner continuation under the zonula ciliaris as far as the canal of Petit. I repeated these dissections, and found that there ex- ists a substance exhibiting itself as cellular texture, destitute of medullary substance ; whether this is mere cellular tex- ture, or a continuation of the inner layer of the retina, is un- certain. As to the membrane described by Jacob in a lafe r>:t APPENDIX. number of the Philosophical Transactions, 1 have seen it in hrutes ; it appears evidently of a serous nature. Zonula Ciliaris. An accurate description of this part has been given by Professor Doellinger (tiber das Strahlen-blatt- 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 attenuated continuation ofthe retina ; the anterior part ofthe zonula is free. The canalis Petiti is formed by the zonula Zinnii and hyaloid membrane ; the hyaloid membrane is con- nected with the posterior capsule ofthe lens more backward, and the zonula Zinnii more forward with the anterior capsule, so as to leave a triangular space. The zonula consists of fasci- cles, which appear more evident when the canal is filled with air (Zinn) ; these fascicles are connected with the serrate prominences of the retina. Since Winslow's time, this zo- nula 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 divided into two layers, as Zinn had already observed. 2. The zonula has a quite different structure ; the hyaloid mem- brane has nothing fibrous. 3. The hyaloid membrane is at the posterior convexity of the lens not thinner than in the other regions of the vitreous humor. 4. Between the corona ciliaris and hyaloid membrane is situated the continuation of the retina under the zonula. 1 have to mention last, the dis- tribution of vessels in the zonula, which also proves that it is not a continuation of the hyaloid membrane ; the anterior part ofthe zonula obtains its vessels with the anterior capsule APPENDIX. ofthe lens ; the posterior part ofthe zonula from the arteria centralis after its division upon the posterior capsule of the crystalline lens, and forming here an anastomosis with the other vessels ; and finally the zonula has been injected with the capsule, but the hyaloid membrane has not shown the least trace of injection. Lens crystallina, is included in a proper capsule ; the an- terior is firmer than the posterior, which depends on the con- nexion 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 viireus, 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 resem- bles aqueous humor. \ K /. ^*^?; . ''/msoh. jfcng.pnnt.C?a>l. tyl'dtr. A EXPLANATION OF THE PLATES. PLATE 1. Fig. 1. Simple acute inflammation ofthe con- junctiva. See page 91. Fig. 2. {Inserted by the Editor.) Inflammation of the iris, strongly contrasted in character with that ofthe conjunctiva. In the former, the white line around the cornea, the arrangement of the inflamed vessels in straight lines, running in radii from the cornea, the intensity of the inflammation near the cornea, and its gradual diminution as you recede from it, together with the evidently deeper seat of the enlarged vessels, are easily distinguished from conjunctival inflammation, in which the redness is most intense upon the eye- lids, and diminishes as you approach the cornea: the vessels are superficial; evidently in the con- junctiva and not moving with the motions of the eyeball, and not arranged in right lines like those ofthe sclerotica, which are enlarged in iritis. Fig. 3. A plan to show the cicatrization of an ulcer of the cornea, whether pustular or intersti- tial, and communicating with the surface by a EXPLANATION fasciculus of vessels carrying red blood. See page 109. Fi, •! :• ■. • .■ 1 p;; >m.^ ,f ...••.» '» - . -; ''•'.• ! •'• Zt »•' » t'lerkf■:■ f^:'. *.\ \ secii,-. < i ?' ■'■ '. enlrr»l -' \ peculiar ;. .i^s.iiis ^rovite. > • :.*!•.' ■ •HV;l ;il ' ' j- :.':ft. See {•....'>; 102. ■>■' •■»,nls the aj/j.« .\ • -•■ •*" >L < -» nted to me i : • ' ,, . ."-.jmcrsetshiir. ;*ini / • w:is that i! »■ '-ji.guj. h:«4 eh«i. iml !: -, ro"^'> : , liif ec: if. ■' )]:>'_] nV" i '•' .4- f TLATE.l ''ty ■ /. --^v>. 2. :^--V- //. Z». www ,/W. ■m./.J/inwrak jv EXPLANATION OP PLATE II, 425 facility, and the patient quickly recovered, the remaining portion of the globe collapsing in the orbit. The surface had the deep blue tint, ami the currant or berry-like appearance denoted, likening it to what is termed by the Germans, c Staphyloma racemosum,' but it proved to be to- tally different in its nature from that disease. 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 clos- ed, and the capsule of the lens, which is shrunk and opaque, 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 fungus, has lost its lamellated structure, and hence ap- pears 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, se- parated by whitish lines intersecting the mass perpendicularly. The lobes differ in structure and in color, as if originating in cells and distinct from each other. In one part adjoining the sur- f>4 426 EXPLANATION OF PLATE II. face a whitish spot is conspicuous, of a cartilagi- nous 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 cover- ing membrane is formed ofthe 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 con- necting membrane indicated by the white lines intersecting it. Fig. 5. Abscess of the eyeball terminating in ulceration and death of the cornea and disorga- nization of the globe. See page 228. Fig. 6. Scirrhus of the lacrymal gland. See page 244. The deformity was removed by ex- tirpation ofthe gland. "1 /'/,/.?. lll&i /Vy../ r'-^^t*^.. Dmtm fvJi J'/ipmsf/i. Enr'1 tv Js.uhMaMt* Ml tig. 2. is ;. !"";.e-.«» ■■'•• tion4- -1 ha -. . |M"):»r.|b{ illflil <> v LTOWth \ substance ans^ or. . i, 4.:j.»n of tlK- •sarcoma nKV.ul'rre, -"viii -ivper ',; ! * bark part <*'.' the ♦■yebali ■ imirio; nhich has undo;- -; ■ ■■■; i , i* coiupn -ed v•;.; downward. 'T'Jm* schv- n r*t "V^^Wftl^s ( 427 ) PLATE III Fig. 1. and 3. represent in different positions the eye of a child affected with the malignant fungus, prior to the opacity of the cornea; in which are observable the change of figure ofthe globe and annihilation of the anterior chamber. by the bulging ofthe opaque 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 medullare,' 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 perfectly 428 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; 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 nigrum 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 capsule, formed by the surrounding cellular texture. A similar tumor is formed by the optic nerve at its en- trance. 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 ill. 129 Fig. 6. is a section of the fungous mass. The optic nerve filled with the morbid deposi- tion has its neurilema 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 entrance of the optic nerve, a mass is formed on the interior of the sclerotica, resembling that on its outside, ex- cept 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 subjoin them. The interstitial deposit is seen in the whole anterior circumference of the sclerotica, but the layers of this membrane are less widely sepa- rated 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 opposite surfaces have no direct com- 430 EXPLANATION munication. By the mass formed on its inside, the choroid coat is distinctly seen to be pro- truded forwards. At the anterior part, the scle- rotica is firmly connected with the thickened choroid coat. The entire centre of the cornea has perished by an ulcerative process, but a frag- ment of corneal lamella remains to denote its place, and behind it is a portion of membrane adhering, and resembling 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 hu- mors or retina. This anterior mass is distinguish- ed from the posterior growth of the sclerotica, from which it is separated by the choroid, by its softer texture and darker color. Hence it appears that the morbid substance within the ball con- sists of two different formations; first, of the sclerotica degenerated on its exterior and inte- rior surfaces, and likewise in its substance; se- condly, of the choroid degenerated on its inte- rior 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 212, where Fig. 4. is referred to by a misprint. The cells of the vitreous humor are filled OF PLATE III. 431 with an opaque lardaceous substance, by which the lens was slightly protruded, and the iris ren- dered convex. The eyeball was but little in- creased in size or altered in figure. The sclero- tica was in some parts thinner than usual, and had a bluish hue from the preternaturally firm adhe- sion ofthe choroid coat. The retina was for the most part absorbed, the other tunics perfect, 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. ( 432 ) PLATE IV. (BY THE EDITOR.) Fig. 1. and 2. are delineations of the eye before and after the operation for artificial pupil in the following case. In the month of November, 1821, Mr. R. Wortendyke, aged sixty-three years, a farmer from Sussex county, New Jersey, applied to me, blind of both eyes. When he was three years of age, he received a wound in the right eye from a fork, which penetrated the cornea near its lower mar- gin, pierced the iris, and wounded the crystalline lens. The consequence was, opacity and subsequent absorption of the lens, and adhesion of the iris to the lower edge ofthe cornea. In this situation I first saw the eye, sixty years after the ac- cident happened. The pupil was extremely small, and drawn down to the edge of the cornea ; but adhering only at this point, and free at its upper edge. The lens had dis- appeared and the capsule remained behind the pupil, much thickened and opaque. The patient could see light with this eye, but was totally unable to distinguish objects. The left eye became blind from an injury of much later date. At the age of fifty-nine, four years previously to my seeing him, Mr. Wortendyke received a severe blow upon this eye, from an ear of wheat. In consequence violent in- flammation, sloughing of the cornea, protrusion of the iris, and total destruction of vision took place. The eye recover- ed from all the acute symptoms, but the greater part ofthe cornea remained densely opaque, and the iris partially ad- herent to it. PLATE Fig.lO. Kg. I 1. *.'•■..'■'£!. Fftf.5 '■'■ .■-•-»'-"'■ h Pig. ? »•**<%" *Ki- Fig. 2 >3*!». '%?' ??*"$ Kg. 6 Hff-« J. /AZ? ,K# afc? EXPLANATION OF PLATE IV. The patient applied to me with the expectation of having some operation performed upon this eye, as he had long since given up all hope of receiving any benefit to the other. The right eye, however was evidently in the best situation for successful operation, and the only unfavorable circumstance about it was, the great length of time which it had remained blind. I determined, however, to make an at- tempt upon this eye, although it was not without difficulty that the patient could be induced to consent to it ; so im- possible did he consider it, that any operation upon it should succeed. The operations which it required were sufficiently simple. It was first necessary to remove the opaque capsule. This was effected without difficulty by means of Saunders' needle. When the eye had recovered from this operation, the patient had some degree of vision, but the pupil was so small and distant from the centre ofthe cornea, that the sight was extremely imperfect. It was necessary, therefore, to perform some operation for artificial pupil. For this pur- pose an iris knife was introduced, about two lines behind the cornea, and after puncturing the coats of the eye, its point was pushed through the iris into the anterior chamber, about two lines from its ciliary margin : the point of the in- strument was then directed towards the small pupil already described, and all that part of the iris was divided, which lay between this pupil and the point at which the instrument was introduced. The iris immediately retracted, and left a large oval pupil, with its transverse axis running obliquely across the eye. The patient recovered, with very little superven- ing inflammation, and the pupil remained full as large as the natural one. By degrees he gained so much sight, that he was enabled to- distinguish the countenances of his friends, and attend to his usual avocations on his farm. When I last saw him, he had still further improved ; but although his sight was sufficiently good for all ordinary purposes, he was 55 434 EXPLANATION unable to read. The success of the operation, however, was fully as great as could have been expected, under the cir- cumstances. Fig. 1. shows the eye before the operation for artificial pupil, but after the removal of the opaque capsule. The original pupil is seen drawn down and adhering to an old ci- catrix, and so -mall as to be useless. Fig. 2. is the same eye after the operation. Fig. 3. A central artificial pupil made in the eye of J. Thomson. This patient was admitted into the New York Eye Infir- mary, May 25th, 1824. He had been the subject of severe iritic inflammation, which had closed both pupils. In the right eye the blindness was complete, the only remaining aperture in the iris being filled with a mass of lymph. In the left, a small portion of the pupil remained free, and gave the patient sufficient sight to enable him to find his way with- out a guide, about places to which he was accustomed. The situation ofthe right eye was most unfavorable to the success of an operation, but as the other was of some use, it was deemed most prudent not to risk any operation upon it, until after an experiment upon the worst eye. The right eye, therefore, was selected for operation, which was performed in the mode originally practised by Cheselden, but now revived and improved by Sir W. Adams. The iris knife was introduced through the sclerotic and iris, as in the preceding case, and a section made across about two-thirds of the diameter ofthe iris, leaving a large clear pupil in its cen- tre of an elliptical form. But although the operation succeeded perfectly, as regard- ed the formation of a good pupil, it was of no advantage to the OF PLATE IV. patient. The eye proved entirely amaurotic, and remained perfectly blind. The case, however, was a striking illustra- tion ofthe excellency of this mode of operating. The pupil was made with great facility, and remained afterwards per- manent, without the least disposition to contraction. The drawing, made from recollection, will give abetter idea ofthe appearance of the eye after operation, than any description I can give. Fig. 4. The result of a somewhat similar operation upon the eye of a patient, whose case follows : Peter Simpson, aged forty-two years, in the month of July, 1822, received a slight blow from a hook attached to a pul- ley, upon the right eye, which caused immediate blindness. He had lost the left eye several years before. In conse- quence ofthe last accident, he became a patient of the New York Hospital, whence he was discharged, after the expira- tion of two months, having recovered sufficient vision only to distinguish light from darkness. During this period he had suffered severely from the violent inflammation which fol- lowed the accident. In September, 1823, he was admitted a patient into the New York Eye Infirmary, with his eye in the following con- dition. In consequence, apparently, of a rupture of the cornea, from the blow he had received, the iris had prolapsed, was drawn over to the inner side ofthe eye, and adhered to that edge ofthe cornea, totally obliterating the natural pupil; but leaving an open space through the iris, at the inner edge ofthe cornea, which would have been sufficient for good vi- sion, if that membrane had been transparent. Unfortunately, however, the injury had so far rendered this part opaque, as nearly to make the pupil useless, and it was still further im- paired by the presence of an opaque lens behind it. In consequence, the patient's vision was totally insufficient to 436 EXPLANATION enable him to gain a livelihood, although he could, without much, difficulty find his way in the streets. From this inabi- lity to work, he had for the previous year been a tenant at the Aims-House. From this description it will be evident that the fibres ofthe iris were on the stretch, drawn towards the inner canthus, and also upwards and downwards, by their adhesion to corresponding points of the cornea. The case was, therefore, evidently favorable for the operation of sim- ply dividing the fibres of the membrane ; and as the cornea was transparent in its centre, the most advantageous situation was afforded for a new pupil. Accordingly, the operation was performed upon that prin- ciple. The iris knife was introduced through the sclerotic, at the usual situation for the introduction of the couching needle, the back ofthe knife being held towards the operator. When its point had arrived about two lines from the external edge ofthe iris, it was pushed forward through the membrane, and then carried on in the anterior chamber, as far as possi- ble, towards the inner canthus of the eye. The iris was next divided by a back stroke of the instrument, in the mo- tion of withdrawing it; the fibres immediately retracted, and left a large pupil of a triangular form, opposite to the centre of the cornea. It was now discovered, through the new pupil, that the lens had been partially dislocated by the accident, and thrown to- wards the inner canthus of the eye, remaining attached op- posite to the junction of the cornea and sclerotic ; but its external edge projecting so far behind the new pupil, as to render it useless. It was, however, deemed most prudent to defer the operation for its removal to another time. Little inflammation followed the operation ; and in a fort- night, the patient was able to bear the full light with no other streen than a common shade.- OF PLATE IV. 437 In the month of November following, another operation was performed, for the removal ofthe opaque lens. A punc- ture was made through the cornea, near its inner inferior margin, and a section made, corresponding to about one- fourth its circumference. The lens, already softened in tex- ture, and somewhat reduced in size by its exposure to the aqueous humor, immediately glided through the opening, and left the new pupil perfectly clear and bright. This slight operation was immediately recovered from without any untoward accident. After the expiration of a few weeks, the patient returned to his occupation as a sawyer, and has ever since gained his own subsistence by his daily labour. He can now see so well without glasses as to pick a pin from the floor. Having never learned to read, the accuracy of his sight cannot be tested in that particular ; but he can distin- guish the difference of small letters, and trace them accu- rately. Fig. 5. The appearance of the pupil in the best eye of Steinberg, alluded to in the note, page 374, after it had been dilated to its fullest extent by extract of stramonium. The very minute dark line, between the upper edge of the pupil, and a deposite of white lymph lying within it, appears to be the only situation in which light can pass to the retina. Fig. 6. The same eye, before the application ofthe stra- monium. Fig. 7. J. M'Gilvra's eye before the operation : a dense cicatrix across the centre ofthe cornea, and the only remains of the pupil shown by a few dark lines in its original situ- ation. Fig. 8. The same eye, with an artificial pupil made in the lower half of the iris. EXPLANATION This patient was received into the Infirmary, October 27th, 1824. His right eye was completely blind from organic amaurosis, and had been in that situation about*six years. The left had been deprived of vision by an accident which had happened sixteen years before. The eye had been wound- ed by a thorn, which had torn the cornea entirely across, in its transverse diameter, wounding at the same time the iris and capsule ofthe lens. In consequence, when these wounds healed the pupil was closed, and the cornea, iris, and cap- sule united in one firm cicatrix. The upper and lower por- tions of the cornea were perfectly transparent, and the iris apparently sound. These appearances are more fully shown by the annexed drawing. The patient was deprived of all useful vision, and could only perceive the motion of objects before him, or their interposition between him and the light, Three operations had been performed upon the left eye, by an eminent surgeon in the northern part of this state, the exact nature of which I could not learn ; but they had the effect, as was afterwards proved, of destroying the lens, and thus rendering the subsequent operation less compli- cated.* In this case, it was evident, that a very favorable situation was offered for a new pupil, in the lower half of the iris. The fibres of this membrane, being adherent at opposite points, viz. at its ciliary margin below, and to the firm cicatrix above, it might fairly be calculated, that upon a simple inci- sion, they would retract sufficiently to leave a good and permanent pupil. Accordingly, on the 1st November, the * It is perhaps a matter of doubt, whether the removal of the lens was the effect of absorption, excited by these operation?, or by the original injury ; either being competent to this effect. OF PLATE IV. 439 operation was performed, in a manner similar to that de- scribed in the last case. The iris knife was introduced through the sclerotic, somewhat below the transverse dia- meter of the eye, its point pushed through the iris about a line from its ciliary junction, and after carrying it forward to a corresponding point on the opposite side, the membrane was divided by a gentle back stroke of the instrument, as it was withdrawn. The fibres of the iris immediately re- tracted, and left a large pupil, such as is shown by the drawing. The patient soon recovered from the operation, but al- though his sight was somewhat improved, it was still insuffi- cient to answer any useful purpose. On very close exami- nation, after the organ could bear exposure to a full light, I perceived some minute portions of the capsule of the lens, which obstructed the passage of the light through the new pupil. On the 20th November, these were removed by a second operation, so simple as not to require description. Still, the degree of vision gained was not very material, for several days after the eye could bear full exposure to light; and I had almost despaired of eventual success in the case. About two weeks after the last operation, however, the sight suddenly began to improve, and gained so rapidly in the course of the following fortnight, that with proper glasses the patient could read with facility the title page of a book. The long disuse ofthe organ in this case, seemed at first to have rendered it incapable of performing its functions, after the obstacles to vision had been removed; but, by degrees, it regained its powers. The patient was discharged from the Infirmary early in December. In March following, four mouths after the last operation, I received from him the following letter. 440 EXPLANATION Princetown, March 4th, 1825. Dear Friend, With much pleasure I inform you that my eyesight has gained so, that I can see to read small print ; as small as that of a pocket bible. My health is good, and I hope you enjoy the same blessing. I return you my humble thanks for your kind attention to me. Yours with respect, John M'Gilvra. Dr. Delafield. The success experienced in this case, was certainly more than I expected. It was not the first instance, in which I learned not to despair of eventual success, when sight was not immediately recovered, after operations on the eye. A more striking one occurred in the case of a young lady, upon whom I operated for cataract about eighteen months since. The cataract, which proved to be soft, was removed by lacerating the capsule, loosening the texture ofthe lens, and placing a portion of it in the anterior chamber. In two months after the operation, the whole ofthe lens and capsule were absorbed, and the pupil perfectly clear and bright; but the eye was useless, and the patient could distinguish the form of no object with it. It continued in this situation, with very little change, more than eight months ; after which, it began rapidly to improve, and when I last heard from the patient, the sight was so perfect, that she could read and sew without glasses. I do not recolleet any author who notices this important fact; although it can hardly have escaped the observation of those who have had extensive opportunities of operating on the eye. Fig. 9. The iris knife used in the foregoing operations, resembling a very small scalpel, cutting only on one edge, OP PLATE IV. 44| and extremely sharp at its point. It is the instrument al- luded to by Mr. Travers, page 364. Fig. 10. a. Reisinger's double hooked forceps, noticed page 367. b. A side view of a single limb ofthe instrument. Reisinger's operation consists in separating the iris from the ciliary body, and strangulating it afterwards between the edges of the cornea ; to effect which, he uses a very fine double hook, which by a slight pressure of the finger and thumb, is made to resemble a single one. An incision is first made in the cornea near its outer edge, one and a half, or at most two lines in length, and if possible, three lines (one quarter of an inch) distant from that part of the iris which is to be separated. kC After the incision in the cornea is completed, the eye should be allowed to close for a moment to aff'ord it rest, and prepare it for the subsequent proceedings, unless it has been previously fixed by an instrument. " The operator should hold the hooked forceps nearly in the same manner as the cataract knife, the points of the hooks downwards, the thumb resting on the flat side of the shank which is facing the operator, and the first and second finger on the flat side ofthe opposite shank, so that the point ofthe second middle finger may reach the end of it. The handle must rest against the radial side of the first joint ofthe first finger ; the little finger serving to steady the hand. '< The instrument is now drawn along the edge of the cor- nea, pressing gently and steadily with the convexity of the united hooks against the small incision, in order that the edsres of the wound may be gently opened, and the closed 56 EXPLANATION forceps insinuated into the anterior chamber ; then glide the instrument with the convexity of the hooks against the inner surface ofthe cornea, as far as the spot where the iris is to be separated ; taking care, however, to bring the hooks as near as possible to the ciliary edge ofthe iris. The forceps are now to be turned, so that the point ofthe hooks may be directed towards the iris ; then let the instrument be opened, so that the two hooks may be at least.one line, and not more than two lines asunder ; press the convexity of the hooks against "the ciliary ligament, sink the points into the iris, and close the forceps, at the same time gently drawing them to- wards you; by these motions, which must be almost simul- taneous, the iris is steadily seized and easily separated. The closed forceps are now to be further drawn out of the eye, the convex edge of the hooks being carefully turned towards the inner surface of the cornea to avoid pricking it. In this manner a considerable part of the iris will be separated, and a triangular pupil formed, ofthe size of at least one quarter of the iris, and which will reach the middle ofthe eye. " The handle ofthe forceps is now to be depressed, and as the convexity of the hooks glides out at the upper angle of the incision, withdraw the forceps, together with that part of the iris which has been laid hold of, so as to produce a prettv considerable procidentia iridis. The eye should now be im- mediately closed to assist the strangulation of the prolapsed iris by the pressure ofthe eyelid. " If the prolap?ed portion ofthe iris should recede, it will generally happen from the incision having been made too large. In this case, it may probably be advisable to cut off the part of the iris which has been separated, and which must again be drawn out ; and so combine Coredialysis with Coretomia, to insure an artificial pupil of a proper size.*" * Reisinger, in his description of this operation, part of which I have quoted, gives many more minute directions concerning it. I have ex- tracted sufficient to show the nature of the operation, and to do more would unreasonably lengthen this article. OF PLATE IV. 443 Maunoir's operation with the scissars is noticed by our au- thor without any particular description of it. I have intro- duced it as described by Scarpa. The scissars are made so small and delicate, as to be easily introduced through an incision in the cornea, with their blades forming a large angle with the handles.* The upper blade, or that which is intended to pass through the anterior cham- ber between the cornea and iris, terminates in a small button. The lower one, with which the iris is to be pierced, has a very sharp lancet point. " An incision is made in the cornea at its lower or lateral segment, as may be most convenient, of half the extent of that which is usually made for the extraction of the crystalline lens. Through this small opening in the cornea, the scissars are to be introduced closed, with the flat part in a line paral- lel to the transverse diameter of the iris ; and as soon as the point of the instrument has advanced near to the great mar- gin of the iris, that is to say, nearly opposite the small inci- sion made in the cornea, it is gently opened and inclined in such a manner that the inferior pointed blade may perforate the iris, and run along the posterior surface of that mem- brane, until the small button of the upper blade reach the part where the cornea and sclerotica unite. The iris is then to be divided in its transverse diameter, by a single stroke passing as nearly as possible through its centre. This inci- sion being executed, another is to be expeditiously made, so far diverging from the'first, that the two incisions may form in the centre of the iris a triangular flap of the figure ofthe letter V, the apex being precisely in the centre ef the iris, and the base near its greater margin.—On opening the eye operated on,.five or six days after, the apex of the triangular shred is found to have retracted towards its base, leaving in the middle of the iris an artificial pupil of the form of a pa- rallelogram." " See Plate V. Fig. £. 444 EXPLANATION By means of the scissars, also, an operation may be effected, according to Scarpa, without injury to the transparent lens or its capsule, in the case of a " contraction ofthe natural pupil occasioned by the iris and pupil being stretched towards some point in the cornea. This happens, in general, in consequence of prolapsus of the iris through ulcers of the cornea." In this case, the lens and capsule often preserve their transpa- rency, and the cornea is only opaque immediately around the adhering point. For this operation, it is necessary to have the scissars of Maunoir, made with the point of each blade terminating in a button. Then the operation having been commenced as in the first instance, " one ofthe blades, by means of the small button, is introduced within the contracted natural pupil, and conducted behind the posterior surface of the iris, until the other blade, defended in the same manner, has reached the confines ofthe cornea and sclerotica. The iris is then to be divided in the form of the letter V, without at all injuring either the capsule or the lens, both of which have preserved their transparency." How far this operation is practicable without injury to the lens or capsule, I cannot say, as I have never performed it; but I confess, I somewhat doubt the possibility of carrying an instrument between the iris and capsule, without lacerating the latter membrane. If practicable, the operation is cerj tainly very beautiful. If a hard lens be supposed to be present, Maunoir operates with his scissars in a manner similar to the first case, but di- vides, with one stroke of the instrument, the iris, capsule, and lens, which is afterwards extracted through the incision in the cornea, either by means of a forceps or scoop, or sim- ply by slight pressure on the eyeball. *«/. /. '<-t Fig. 3. Saunders" •.•(.' ;», kvi :die alar'* useful in ongf aititl • ■•".- freer* fts>'- .- i Mi- -i extra*, ung '*<■ -.">'>■ K/;>. 6. ^t u* o!. - ^:«>t?. described in the <„ i n of Plato. •! ( 445 ) PLATE V. (BY THE EDITOR.) Fig. 1. Front and side views of the couching needle em- ployed by the editor. The only material difference between this instrument and Scarpa's needle is, that it has a lancet point, instead of a triangular one, and therefore makes an in- cised, instead of a punctured wound, and being somewhat wider, it less readily passes through the lens in the act of depression. Fig. 3. Scarpa's couching needle. This instrument i* generally used in this country of a much larger size than re- commended by Scarpa. I have seen it at least four times the proper size, and of course, unnecessary violence com- mitted by it upon the eye. The delineation in the plate shows the precise size recommended by the inventor. Fig. 3. Saunders' needle, for the anterior operation, more particularly useful in congenital cataract in infants. Fig. 4. Beer's cornea knife for extracting the cataract. Fig. 5. Maunoir's iris scissars, described in the explana- tion of Plate 4. NOTES. 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 Sclerotica?," 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 ' affinity and vascular connexion 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 affected, and is thence pro- perly denominated ; as in the instances of sclerotitis to which this note refers. Intolerance of light is considered by some respectable au- thors to be diagnostic of self rot.c inflammation. This is not my opinion, having in numberless instances wilue-s d 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 sclero- tic inflammation is often present in such instances. The sympathy of the sclerotica and the ligamentous cap- sul■■••* vi'h th urethra in gonorrhea, h as unquestionable as thai which has been more generally observed, because more NOTES. frequently occurring, between the latter and the synovial membrane. I have seen cases so nearly resembling that de- scribed 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 suppurative inflammation ofthe conjunctiva with acute gonorrhea, which, notwithstanding the apparent contradiction of some experi- ments, I am convinced originates from contact, as is indeed proved by the history of the ophthalmia of infants, and by the fatal effects 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, inde- pendent ofthe alliances of structure and organization, which disposes parts different in properties to be affected recipro- cally by the same form of diseased action (joints of the hand and foot, stomach and retina, in gout; muscular fibre and li- gamentous capsules in rheumatism ; skin, mucous membrane, and iris, in syphilis). To the numerous, extensive, and com- plicated sympathies of the latter class belong many cases of metastasis, in which the secondary often differ from the pri- mary forms of diseased action. Inflammation in one organ occasions in another congestion, and vice versa; and the ces- sation of an habitual secretion in qne, whether natural or morbid, gives occasion to inflammation in another. Preterna- tural irritability, swelling, pain, spasm, are thus excited by this reciprocal sympathy, in remote organs ; or a metastasis, a change of place, strictly speaking, occurs ; the morbid ac- tion abruptly quitting one part before it appears in the other. *See "A Practical Treatise on the Diseases ofthe Eye," by John Vetch, M-.D. F.R.S.E. London, 1821. .NOT E.n. But not only does the reflected action often differ in its nature from the original, but this, in many instances, continues in undiminished activity, so that the metastasis is only an inci- dental 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 tex- tures, as in the case of hernia humoralis and gonorrhea, whe- ther simply propagated or metastatic; and of rheumatic or scrofulous inflammation passing from joint to joint. But if the above mentioned parts are, as I believe, subject to be consen- sually affected during gonorrheal inflammation,* I should ex- plain it by reference to the second and more diffused sym- pathy which connects all organs and textures through the medium of the common sensory, with various degrees of affi- nity, 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 ef 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 lymph 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 * I speak here of true sclerotic inflammation independent of any mjx* ture of puriform conjunctival ophthalmia. 57 NOTES. would 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 author, which he names the arthritic, an inflammation either primary or se- condary in a gouty habit to a common ophthalmia. It is at- tended with excruciating pain. Its diagnostic signs are the appearance of a narrow white ring at the verge ofthe cornea, and a varicose disposition of the vessels of the conjunctiva. In spare and irritable individuals the pupil becomes contract- ed as in the idiopathic iritis, the blood-vessels of the iris are varicose, and the disease terminates in a diminution of volume of the eyeball. In persons of full habit and relaxed fibre, the pupil, on the contrary, becomes remarkably contracted, but not uniformly, being transversely oval. No lymph is effused, but a greenish yellow appearance of the humors is observed, and the lens bulges forward, of a sea-green color. This pain, which is periodical, and announced by a burning viensation around the organ, and a profuse flow of tears, is of the most severe description. The vessels ofthe choroid as- sume the same varicose state as those of the conjunctiva, and the transparent sclerotica presents a dark ring in the situation ofthe corpus ciliare. Total blindness accompanies this state, aHd atrophy of the globe ensues. In this country we have not been accustomed to distinguish gouty inflammations in this organ. If an inflammation, charac- terised as above, is peculiar to the arthritic diathesis, the dis- tinction is borne out; if not, the division is frivolous. I am unable to decide upon the value of the diagnostic sign first mentioned ; not that it has altogether escaped my observa- tion, as being in some instances of deep-seated inflammation 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 inflammation, whatever be the texture affected. The same may be said of the ultimate state of atrophy of the entire organ from inter- stitial absorption. But to speak my opinion candidly, the two NOTES. 451 states which are here described as varieties of iritis, accord- ing 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 disorganized iris, the varicose vessels ofthe choroid and conjunctiva, the atte- nuation ofthe sclerotica and bulging ofthe ciliary ring, all in- dicate not an existing inflammation, but a disease gone by; they are slow after-changes which ensue upon acute destruc- tive inflammation of the choroid and retina; and the agoniz- ing attacks of pain which I have often witnessed in this pre- cise condition, are the result of an universal congestion ofthe 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 ofthe 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 inva- riable and specific distinctions ; and to look at them as types uf corresponding constitutional states, is almost ludicrous. NOTE C. This head and that of amblyopsia, page 189, include a very considerable proportion of the cases of functional amaurosis. The amblyopsia may be regarded as the advanced 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 ofthe complaint. We must therefore consider it in such cases as a primary nervous NOTES. 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 vi- sion ; in short, the sum and substance of the complaint is the sensation of an effort to see, and the want of power to conti- nue it. The removal ofthe exciting cause, the first and most important step in the treatment of all diseases, although so negative 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 advan- tageously 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 musca?, 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 cor- ner of a chimney-piece,* 1 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 symptom of a tender, or highly irritable retina. It seems to me to resem- ble those disagreeable but natural sensations, viz. the teeth on edge, or the cutis anserina, when amounting, as in some individuals, to a morbid exces?, and excited by impressions of which they alone are susceptible. NOTES. appearance ofthe 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 cor- responding 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 regulation ofthe bowels, attention to diet and exercise, with as much indulgence ofthe 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. Eh own observation is, that his sight is evidently 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. Reading a few pages of a book is infinitely more distressing than the glare of a theatre or a ball-room ; and the sense of debility is greater during the morning than at any other time. But even though the bowels are perfectly regular, and the digestion strong, the same feel- in^ prevails ; and on the other hand, when these functions NOTE*. have been very irregular, it has 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 ofthe 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. He 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 an- gular and drawn toward the outer canthus, he considers the prognosis encouraging. He mentions as rare and unfavour- able forms of the metastatic amaurosis, those arising from suppressed secretion 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 difference between the two eyes. About the time that his sight grew dim, he complained of uneasiness and oppression in the head. He NOTE*. 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, were considered to threaten apoplexy, he was freely and re- peatedly blooded, and in other respects treated accordingly. He became totally blind and soon afterwards dark. His eyes were perfect in appearance. They had the unmeaning roll characteristic of the disease in its last stage. Pupils a good deal dilated and motionless. A full course of mercury and electricity were 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 ofthe head, the ventricles ofthe 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 cylindrical, and of a straw color instead of a silvery whiteness. In slit- ting, 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 respects 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 nervi motores referred to in the paragraph to which this note belongs. * Another morbid horror, somewhat resembling this, I have heard de- scribed* viz. the approximation of the walls ofthe apartment, so as to give the patient the impression of being in a closet just large enough to con- tain his person. I need scarcely observe that all such delusions have their origin in the sensor'mm. VOTES. 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, which 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 consulted. The bowels, he informed me, were so obstinately costive as to be with difficulty acted upon by powerful cathartics. Be- ing still unrelieved after brisk and effective purgative me- dicine, she concluded it to be rheumatism, and wrapped her head in flannel. In crossing the road on the 8th of Novem- ber following, she felt a sudden smart shock between the or- bitar processes, like a pea striking her forehead. From this moment the pain in the head ceased ; but she found the vi- sion imperfect—that is, she saw objects in unnatural posi- tions, and although she could see distinctly with either eye, she could not with both, and therefore tied up one, the 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 counte- nance. 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 cup- ped to twenty ounces from the nape ofthe 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 esta- blished. Previous to this event, it was noticed that her vision had NOTKS. 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 steadfastly 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 labored evidently under great debility, both muscular and nervous. The re- covery of the eyes was very gradual; no sensible accelera- tion of the rate of progress was observed during the mer- curial 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- thetic 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 58 (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 gentleman 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 medi- cal 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 stricture in some part of the intestinal canal: a very imperfect and disturbed state ofthe 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 ofthe 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 utmost, as in hydrocephalus ; he had no sense of light, no percep- tion of its interruption. I directed his head to be immedi- ately shaved, and twelve ounces of blood to be taken by cup- ping 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 NOTI>. be taken, composed of five grains of calomel and half a gram 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 com- pression ; effusion was instantly threatened ; a stimulus at this moment appeared hazardous. We expected to see him expire in each fit. The pill, followed by the stimulant glys- ter, was remedial, and for the time saved him. P. S. Since the above was written, this gentleman is de- ceased. On inspection, a firm, very irregular, fungoid tumor, ofthe 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 ofthe mu- cous membrane, partially inverting and concealing the termi- nation ofthe ileon and the caecum, of which only the appen- dix 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 interruplus-the person in reading sees only single words or letters. NOTE?, Visus dimidiatus—S. hemiopsia. Visus muscorum—S. myodesopsia. Visus reticulatus—a higher degree ofthe former. Visus lucidus—Photopsia. Marmaryge. {Hipp.) Sparks and flashes of lightning perceived by the patient. Photophobia—light 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 primitive 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 develope- ment ofthe 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, with but one cavity for the mouth and nostrils. The iris is imperforate, and so are all the apertures of the perfect body. The eyelids are fas- tened together over the naked eye, and the cavity of the urn- NOTES. bilical cord being one with the abdomen, exomphalos is the natural and original state. Walther considers cataract to be always the result of inflam- mation ofthe capsule, acute or chronic. By a powerful mag- nifier he has discovered a wreath of vessels about a quarter of a line distant from the pupillary edge ofthe iris,.forming a concentric 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 net-work of more delicate vessels is described to have been seen deeper seated in the lens itself, ".the l.irger trunks of which are not always derived from the circumference of that body, but evi- dently come from its posterior surface directly forwards, and then divide into branches."* Tiiis is an appearance entirely morbid, the same authority deciding that there is no organized connexion 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 ofthe capsule, into which it again deposits its waste, being.merely furnished with absorbent 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 ofthe iris. Spots seen in the capsule, whether gray or brown, are, we are told, deposits of lymph, in which the pro- longed 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 ofthe 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 ofthe Analysis in the Quarterly Journal of Foreigu Medicine and Surgery. 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 marvel to the whole story. Professor Beer divides cataracts into true and spurious. The true is within 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. Cys- tic. 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 vari- ety, is the only novelty of this list. The cystic is the floating cataract, the capsule opaque 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 cap- sule.* 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 confounded with them. They are seldom if ever met with but after blows, wounds, and operations. * Do the travelled pedants, who deal such heavy blows among their ignorant and besotted countrymen, suppose that these every day forms have escaped our notice ? In England, as in Germany, the same things are seen, but their importance is differently estimated ; they arc differently ex- plained, arranged, and reasoned upon. I am content it should be so. NOTES. 463 NOTE H. The often mooted questions—first, in what cases topical blood-letting commands an advantage, if in any, over phlebo- tomy, as usually practised at the arm ;—second, whether drawing 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 inflamed, i. e. if the pulse indicates that the action ofthe heart is excited by the state ofthe organ, or if the ac- tivity or rapid progress of the inflammation, however local, threatens the safety of the organ, we ought not to trust to to- pical blood-letting. In such cases it may be employed sub- serviently with great advantage, but not principally. If, on the other hand, no such sympathy is evinced, and the inflam- mation, though acute, is in its nature weak and slow of pro- gress, the local blood-letting may commonly suffice. But is it in such cases to be preferred ? Generally I think it is, be- cause the inflamed vessels are relieved from the state of con- gestion and tension, and are enabled to recover their contrac- tile 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 effect will often be produced by a loss of one third of that quantity drawn as quickly from the immediate neighbourhood ofthe inflamed organ. Syncope from dread of the lancet will produce the best effect of a topical bleeding, and may stand in its stead. It will be no substitute for general bleeding where that is in- dicated, for the same reason that topical bleeding is no ade- quate substitute for general. Thus, though a general bleed- ing 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 in- flammations, it is least eligible. 464 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 substitute in those of an opposite description. The difference ofthe inflammatory action according to the texture ofthe or- gan affected, is comprehended in the above general statement. Leeches are the least effectual mode of topical blood-let- ting. In many instances, the blood derived by them is not sufficient 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 de- termined by the quantity lost, and by that alone—taking the distance 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 reward for public benefit to which an honorable mind aspires, is unquestionably due to Dr. Vetch, for the successful treat- ment of this formidable disease, especially in its first and most formidable stage. He reprobates the excision of the granu- lations and the division of the conjunctiva. Although I have seen cases of the absorption of large and even pendulous granulations, and believe that such absorption almost invaria- bly takes place where the disease is left to run its course, abundant experience has convinced me that the employment of the scissars is highly important to the favorable issue of the case, since the preservation ofthe cornea depends chiefly upon the restoration of the lining membrane of the lids, which this practice essentially promotes. Yet so highly do I NOTES. appreciate the importance of caustic and astringent applica- tions judiciously employed, that if the joint use of these reme- dies were in any case proscribed, I should prefer, as a single measure, the use of the lunar 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 ap- plication made with advantage to-day would probably be hurt- ful to-morrow. To watch the caprices of the case, the mo- ment of excitement and of relaxation, to subdue, to soothe, or to support 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 fa- vorable termination, 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. 59 466 \OTF>. NOTE K. Where these circumstances are not present, the subjects of this inflammation are, in my experience, weakly and of a scrofulous habit; the tame, indolent, shifting character ofthe disease, viz. the pink-colored zone at the verge ofthe cornea, vivid one day, and scarcely perceptible the next, renders it more difficult 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 gentle course ; on the contrary, where in the commencement of the mercurial action the improvement is only sufficient 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 color and activity without materially benefiting vision ; for mercury is not a remedy for NOTES. paralysis. If however from inflammation—whether the re- sult 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 sanguine- ous effusion—the sensorial function be interrupted, our first hope is topical blood-letting and counter irritation—the se- cond, 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 neither injury nor any other cause nor symptom of inflammation had ever existed, and where only a slow moving pupil corresponded 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 efficacy in cases, ushered in by severe frontal pains, in which blindness was already com- plete, and the pupil largely and permanently dilated, where the greenish cast of the humors was strongly marked, and the visus lucidus was complained of. NOTE M. 1 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 re- quested the professor to favor me with 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 NOTES. advantage, the case certainly did not afford a fair chance of success, and the failure was attributed to this circumstance. M. Dupuytren, 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 occur- red ; 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 la- crymale d'un c6te, et une fistule de l'autre cote. " II y a six ans que la malade s'appercut pour la premiere fois, que l'ceil du cote gauche 6toit 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 ; l'ceil de ce cote fetoit 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- lerent; la malade fut soulagee, l'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 inutility fit adopter le moyen suivant, dans l'intention de desobstruer par cauterisation les voies lacrymales. 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 de'tacherent; des bourgeons charnus s'eleve*rent; mais le chirurgien s'appliqua chaque jour a introduire, pen- dant quelques instans, un cilindre de nitrate d'argent poudre. notes. Cette maniere d'agir eut pour resultat 1'aggrandisement de la fistule, Padherence de ses bords aux os ; les bords prirent une organisation cutanee : enfin on introduisit pendant long- temps une espece de broche en plomb—Tous ces moyens loin de guerir la maladie, l'avoient rendue presque incurable. Desirant trouver un remede a son infirmite, Madame Daive se pr^senta chez M. le Baron Dupuytren ; elle se trouvoit alors dans Tetat suivant. " Au grand angle de l'ceil gauche existoit une ouverture de trois lignes de diametre ; les bords tapisses par la peau amin- cie, avoient pris l'organisalion 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 venoient irriter l'ceil, enflammer et excorier la peau de la joue. " Au grand angle de l'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 Stre facile- ment vidde par la pression ; alors il s'ecouloit par les points lacrymaux une matiere purulente, muqueuse, mGlee a l'hu- meur des larmes ; la narine de l'un et l'autre cote* etoit s£che. " La guenson de la tumeur lacrymale eHoit certaine, celle de la fistule pouvoit Stre 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 sut 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 l'ceil droit, en la portant un peu en dehors, tandis qu'avec la main droite armee d'un bistouri a lame elroite, il fait a la peau qui recouvre la tumeur, une incision perpendiculaire, qui la divise, ainsi que le sac lacrymal. On vit bien que l'instrument n'avoit pas devie, par la profondeur a laquelle il penetra sans difficulty, et a la sortie de mucosite purulente. Changeant alors de main, M. Dupuytren saisit avec la droite le bistouri, et avec le gauche le mandrin, revetu de sa canulc en or.* Le bistouri est un peu retire pour permettre a ' Voyez la description a la fin de Tobservation. 470 NOTES. I'extremite du mandrin qui est glisse sur sa lame, d'etre intro- duce a mesure qu'on fait entrer le mandrin ; enfin lorsqu'on est entre a la hauteur du canal nasal, il ne reste plus qu'a. l'enfoncer. On est averti qu'il a penetre assez avant, par la resistance qu'on eprouve a l'enforcer davantage ; ce qui pro- vient du contact de la canule 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 1'ouverture anterieure des fosses nasales, et ordonna a la malade de faire des efforts comme pour se moucher, aussi- tot on vit de Pair mele a du pus et a des mucosites sanguino- lentes s'echapper par la petite ouverture ; on y pre"senta la flamme d'une bougie, elle fut eteinte. " De l'autre cote Touverture fistuleuse permit 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 l'eut 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 l'operation, 1'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 ? Devoit-on detruire les adherences de la peau, enlever les bords de la fistule ? Mais en agissant ainsi, on pouvoit craindre de ne pas reussir, et d'aggraver au contraire l'etat de la malade ; aussi ce parti ne fut-il pas adopte. " Les succes brillans que Monsieur le Professeur Dupuy- tren venoit d'obtenir dans la guenson de fistules recto-vesi- cules, uretro-vaginales, par le cautere, lui suggererent l'idee d'employer ce moyen. En effet quinze jours apres l'opera- tion, 1'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 de la charpie NOTES. hachee, egalement impregnee de ce caustique. Du gonfle- ment, de la douleur survinrent ; ils furent calmes par quel- ques lavemens, des pediluves (bains de pieds) sinapises, du petit lait, &c. " Au bout de quatre jours l'escarre tomba, et Monsieur Dupuytren vit avec plaisir que la plaie s'etoit unpeu 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 1'ouverture reHrecie. Enfin le 3 Juillet, deux mois depuis l'ope'ration pratiquee, cette ouverture fistuleuse a, parois cutanees, organisee depuis plusieurs annees, et que plusieurs medecins avoient juge incurable, e'toit 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 l'autre, tant elle etoit bien guerie. On ne pouvoit voir a l'ceil que la malade avoit dans le nez deux canules en or, et leur pre- sence se faisoit si peu sentir, que la malade avoit peine a croire qu'on les lui eut laissees. Enfin elle quitta Paris par- faitement guerie, et heureuse d'avoir ete delivree d'une infir- mite qu'on avoit juge incurable." Description de la canule d'or de Monsieur le Professeur Dupuytren. " Cette canule doit etre aussi 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 ; elle offre une legere courbure pour s'accommo- der a celle du canal. Un rebord renfle', en forme de bour- relet saillant en dehors, fait le contour de 1'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 reproduire ; l'autre extremite* de la canule est taillee en bee de flute, afin qu'un de ces cotes moins long, ne *;