NEUROTOMY: 
A SUBSTITUTE FOR ENUCLEATION. 
A NEW OPERATION 
IN 
OPHTHALMIC SURGERY, 
BY 
O'TJLT.A UST CT. GHIISOXjIsd:, JVL. ID,, 
Professor of Eye and Ear Diseases in the University of Maryland, and Surgeon- 
in-Charge of the Presbyterian Eye and Ear Charity Hospital, 
of Baltimore, Md. 
REPRINT FROM VA. MED. MONTHLY, NOVEMBK 
RICHMOND : 
J. \V. FERGUSSON & SON, Printers, 
i 879- NEUROTOMY; 
A SUBSTITUTE FOR ENUCLEATION. 
A NEW OPERATION 
IN 
OPHTHALMIC SURGERY, 
BY 
JTJLIAIT CT. CHISOLM, IMI. ID,, 
Professor of Eye and Ear Diseases in the University of Maryland, and Surgeon- 
in-Charge of the Presbyterian Eye and Ear Charity Hospital, 
of Baltimore, Md. 
REPRINT FROM VA. MED. MONTHLY, NOVEMBER, 1879. 
RICiISTOSij,: 
J. W. FERGUSSON & SON, Printers, 
1879. NEUROTOMY INSTEAD OF ENUCLEATION 
A New Operation in Ophthalmic Surgery. 
The case which is now before yon for operation is that of 
a woman fifty years of age, who has been suite ring severely 
with her right eye for the past four months. Twenty-seven 
years since, she injured this eye so seriously as to lose all use 
of it. When the inflammatory attack induced by the accident 
had passed, all pain disappeared from the eye, and in the 
course of time it ceased to give her any anxiety. In this pain- 
less condition, twenty-seven years have elapsed; when four 
months since, from no known cause, it became very painful. 
The lost eye has kept her in such constant trouble from that 
time, that she desires to get rid of it, so as to be freed from 
pain. Upon examining the eye you see her shrink from the 
slightest touch. The conjunctiva is injected and the iris dis- 
colored, wdth a little blood in the anterior chamber; hut the 
cornea is clear, and the eye full. She has no perception of 
light in this eye. Recently, the left eye has become fretful 
upon use, and strong light annoys, which points to irritation 
through sympathy—a warning that should never be over- 
looked, as blindness in the good eye will be the consequence. 
The lost eye looks too good to enucleate, which should be 
the proper course to pursue, and yet is too painful and use- 
less to be retained. 
It is just for this class of cases that the new operation of 
cutting all the nerves entering the eye at the back of the eye- 
ball has been suggested, so that the lost visual organ may be 
retained in the head for appearances, while it is deprived of all 
power of doing harm to the other. 
A law laid down in eye surgery, which should have fewer 
exceptions than are found, is, that an eye lost from accident, 
and which continues to he painful, is a dangerous organ. On 
account of the nervous sympathies which tie the two eyes 
together, such a lost and painful eye cannot be retained, ex- 
cept at the risk of injuring, sooner or later, the good one. 
When sympathetic inflammation is once set up in the hereto- 
fore good eye, no course of medication, nor of surgical proce- 4 
NEUROTOMY INSTEAD OF ENUCLEATION. 
dure can stop it in its onward progress to the painful destruc- 
tion of the visual organ. Blindness for the remainder of life 
must be the portion of the unfortunate individual, and we 
recognize no greater bodily affliction. 
The general practitioner does not lay sufficient stress upon 
the dangers incident to carrying a lost eye; hence, the number 
of blind persons who might, at least, have retained one good 
eye, if this law in eye pathology had been better known. 
These observers come across men who have lost one eye in 
the pursuit of their occupation, still busily engaged in the 
daily task of making a support for their families, and continu- 
ing in the same, month after month, until a life-time slips by. 
No special annoyance seems to have been caused by the lost 
eye, the presence of which the}7 have often forgotten. If 
such an experience had no exception, there would be no 
ground for anxiety for the remaining eye, when an individual 
has, by accident, lost one of them. 
Even the dread of over-work could do it no harm. The 
widely accepted belief that one eye does double duty 
when used alone, is altogether without foundation. An eye 
does its whole work whenever used, and can do no more un- 
der any other condition. The two eyes, when used conjointly, 
give us a greater range for lateral vision, and enable us to 
appreciate distance, solidity and perspective. What is still 
more important, the two eyes give us a double chance for see- 
ing, in case of accident to one. But when it comes to sharp 
sight,' one perfect eye can do, and does do, all that two are 
able to accomplish—no more, no less. There is, therefore, no 
strain when one eye has been removed, even should the one- 
eyed person read, write or sew all day long. 
When an eye has been lost, especially from a penetrating 
wound which has cut into the eye-ball, then danger threatens. 
The lost eye resembles a keg of dynamite—safe enough if 
nothing disturbs it, but fraught with terrible consequences 
from slight provocation. 
Sometimes it happens in the experience of a physician that 
one of his patients gets a cut or thrust in the eye from a piece 
of broken glass or stick, or receives a puncture from an ar- 
ticle of every-day use, as a pair of scissors or a fork. Inflam- A NEW OPERATION IN OPHTHALMIC SURGERY. 
matioii is excited by the injury. After weeks of suffering, 
the eye quiets down, and although no useful sight comes back 
in the injured eye, it gives no special annoyance. Weeks, 
months, years may elapse without trouble or interference with 
daily labor. Suddenly, from no known cause, the useless 
organ becomes painfully inflamed—the eye becoming red 
and sensitive to pressure. The physician, when consulted, 
satisfies all parties with the familiar expression of a “cold has 
fallen in the eye,” and prescribes the usual astringent reme- 
dies. Often the case exhibits a rebellious disposition, but 
the obstinate attack yields to treatment, and the pain, water- 
ing and redness subside. An interval of repose, more or less 
long, is now enjoyed; then a second inflammatory attack en- 
sues, with its accompanying pain in and around the lost eye. 
On account of this, it is irksome for the patient to read or do 
any near work; for the good eye is weak from sympathy, and 
strong light annoys. Seclusion in a dark room, with the con- 
tinued use of remedies, again restores quiet, and enables work 
to be resumed after a few weeks of confinement. 
Another interval of irregular duration, and then another 
attack occurs, and now the good eye may also become in- 
flamed, painful and watering. Sight is somewhat blurred 
in it, and pressure upon the heretofore sound organ sends a 
sharp twinge of pain through it. A “.very severe cold,” says 
the family physician, and prescriptions for catarrhal ophthal- 
mia are again given. An improvement from the injected 
and painful condition is long and anxiously looked for; 
and, when it finally comes, sight continues very defec- 
tive in the good eye. A careful examination of the re- 
cently involved eye would show a discolored iris and a small 
pupil, which has lost its peculiar and appropriate blackness. 
If a solution of atropia be applied to this eye, the pupil either 
does not yield or it dilates with a very irregular outline, show- 
ing that adhesions of the pupillary opening to the contiguous 
lens prevent expansion. The anterior chamber will also be 
found shallow, and the iris appears to bulge forward as if 
pressed from behind. From this appearance, the surgeon 
recognizes a condition called sympathetic iritis. It has been 
induced by the irritated nerves within the opposite and lost eye 6 
NEUROTOMY INSTEAD OF ENUCLEATION, 
Such an inflammation, when once excited, is prone to extend 
to the entire uveal tract, involving the ciliary region, and 
also the choroid membrane. It means, always, destructive work. 
These cases occur so seldom in the experience of any one 
general practitioner, that he does not trace the trouble in the 
second eye as a logical consequence of injury to the first. 
He often discourses upon the frightful affliction of his 
patient, who, from a simple cold in the eye should lose the 
valuable organ, made doubly precious, since the loss by ac- 
cident of the other. That “troubles never come alone,” he 
also quotes, not seeing how he has himself innocently played 
a conspicious part in the tragedy. 
The specialist in eye surgery, who collects these individual 
cases from many physicians, and supplements them by the 
many who seek aid primarily at his hands, has often to no- 
tice the intimate relations which exist between the accident 
to the one, and the subsequent irritation of the other. He 
has also become aware of the fruitlessness of all medication, 
when applied to the saving of the good eye. When the iris 
and ciliary region is sympathetically involved in acute in- 
flammation, blindness is sure to follow, regardless of the 
most active interposition of the surgeon. 
Persons have been brought to me, with head enveloped in 
many cloths for the total exclusion of every ray of light, so 
irritable had the good eye become from a recent accident to 
the other. So impossible was it to admit light enough for 
examining the eye, that an anaesthetic was needed to permit 
an investigation as to the extent of the injury. Under its 
quieting influence, the injured eye was found completely torn 
across, and so full of blood as to be utterly destroyed, and 
from which not even light can be detected, I removed the 
injured organ, and in twenty-four hours—what a transforma- 
tion ! A child, struck in the eye with a sharp piece of metal, 
who, for days, has had his head buried in pillows, crying out 
in agony, should the door of the darkened room be left ajar— 
is seen at the open window the day after the enucleation, with 
every trace of the distressing sympathetic irritation gone from 
the good eye. The extirpation of the destroyed eye has been the 
active means of cure, and is the only one. A NEW OPERATION IN OPHTHALMIC SURGERY. 
7 
Although the sympathetic attack has no fixed time for 
coming, this is no reason why it will not put in an appear- 
ance when least expected. I have seen an intense irritation 
excited by an eye that had only been injured a few days; and 
again I have seen thirty-five years elapse before a shrunken 
ball would take on inflammation and excite serious trouble 
in the good eye. For this very long interval, the patient has 
carried a useless, deformed organ, and the sequel has proved 
it a dangerous one. 
Ophthalmic surgeons who have studied most carefully this 
subject, agree that, although a person may carry through a 
long life a lost eye which some penetrating wound has de- 
stroyed, he is at any time liable to have attacks of destruc- 
tive inflammation in the good eye, induced by nervous sym- 
pathies which nature establishes between these twin organs; 
and that safety alone resides in breaking up these sympathies 
by the removal of the lost eye. By this operation, the good 
one remaining is made permanently safe, as if no accident 
had occurred. 
We therefore lay down the rule, and recommend as the 
only safe course, the enucleation of lost eyes, knowing that, 
in this particular instance, the ounce of prevention is worth 
more than all other so-called curative remedies. 
While every one shrinks in horror-from the contemplation 
of blindness, and is ready to accept any alternative to escape 
from so frightful a doom, the extirpation of an eye is not to 
them a pleasant contemplation—notwithstanding the assur- 
ance that it is a safe operation, and, under some anaesthetic, 
altogether free from pain, and one calling for only a few 
hours’ confinement. Unfortunately, there are too many who 
cannot be made to believe that so serious an injury to one 
eye can cause extension of danger beyond its own side of the 
face. Such persons resist, until too late, the good advice 
given to have the lost eye enucleated. This is more espe- 
cially the case when the lost and painful eye retains, to all 
appearances, its good looks. A marred and white stump is 
given up much more readily. 
It does not always need an extensive disfiguring wound to 
destroy eye-sight, and make the lost organ a dangerous one. 8 
NEUROTOMY INSTEAD OF ENUCLEATION. 
A wound of small extent, provided it perforates the eye-ball 
at the ciliary region, where the colored and white parts join, 
will destroy sight amidst much suffering, and yet not leave 
any very perceptible deformity to the casual observer. In 
such cases, the owner of the good-looking eye battles against 
mutilation, and is backed up in his false position by hosts of 
relatives and friends, as if they could or would share his 
blindness when trouble comes. Were it not that the oph- 
thalmic surgeon foresees the great risk for the other eye, he 
would do, what the general practitioner so constantly does, 
and side with the friends. By yielding to the wishes of the 
patient, he would, however, expose him to great danger. The 
injured man has no objection that you do what you think 
proper to relieve him of pain and danger, provided you do 
not remove the eye-ball. It is to meet these very cases that 
the new operation has been suggested. 
It was in a case of this nature that I first put into practice 
the conciliatory course of protecting my patient, and at the 
same time save him a good-looking but useless eye-ball, 
which he did not wish to give up, although it had caused 
him so many sleepless nights of intense suffering. The 
course pursued was to cut all the nerves entering into the 
injured eye from the ophthalmic ganglion, and thereby end 
abruptly all sympathetic connection between the offending 
organ and the rest of the body. This leaves the living eye 
in place, acting, as far as movements go, with the other, 
keeping up its relations with the lids and lachrymal appa- 
ratus, but deprived of all internal nervous connection likely 
to cause future annoyance. 
Those who dissect eyes in their natural position, find that 
most of the nerves which enter the eye-ball perforate the 
sclerotic coat in the immediate neighborhood of the optic 
nerve entrance. A very small area at the very back of the 
eye-ball will cover this entering region. The nerves which 
perforate this space are, first, the optic nerve for special sen- 
sation, and then the many offshoots from the ophthalmic gan- 
glion, carrying with them motor, sensative and sympathetic 
influences. When these numerous threads have entered the 
ball, they meander forward between the choroid and sclerotic A NEW OPERATION IN OPHTHALMIC SURGERY. 
9 
coverings to reach the ciliary region and iris, to which they 
are so very freely distributed. If destructive inflamma- 
tion arises within the eye, these are the peripheral nerves 
within the eye-ball which cause the agony and excite out- 
side sympathies. It is from this small posterior area that 
the eye-ball receives its chief nerve supply. Arteries and 
veins have entrance and exit through the same region, but 
not so exclusively as the nerves. Many vessels perforate the 
sclerotic in the front of the eye-ball, and, passing inwards, 
give, also, nourishment to the eye contents. The muscles 
which move the eye-ball hug the walls of the socket, in their 
course to the apex of the orbit, where they seek a bony sup- 
port. In their backward course, they enclose quite a large 
conical space, filled with fatty tissue, in which these nerves 
and vessels entering the back of the eye are imbedded. 
It is easy to sever all of these nerves and vessels without in- 
jury to the muscles which move the eye-ball. In this way, 
nerve-connections can be effectually and permanently cut 
off from the interior of the offending organ. The blood-ves- 
sels which feed from the front are quite numerous enough to 
keep the eye well nourished—the uninjured muscles preserv- 
ing to the ball all the natural motions, and the surface nerves 
still giving it all the protection needful from the presence of 
foreign bodies on the conjunctiva. By this neurotomy of the 
ciliary nerves, the patient is to gain protection, escape from 
pain, and yet receive no mutilation. Although recognizing 
the uselessness of an organ in which there can be no sight, 
he still values the retained eye beyond all price. 
The first case upon whom I operated was a bright lad, 14 
years of age, who was brought to me by his family physician 
to have an injured eye removed. The sclerotic had been cut 
open in a clean wound, running from before backwards, and, 
with a free escape of vitreous humor, the eye-shell had col- 
lapsed. Haemorrhage within the chamber refilled it, and the 
lips of the scleral wound having come in contact, healed up 
most kindly. Two weeks had passed, and the physician was 
congratulating himself upon the unusual good result ob- 
tained, when the eye became painful, with some injection. 
Atropia solutions were tried in vain to ease the suffering. 
The patient then came under my care. I found a clear cor- 10 
NEUROTOMY INSTEAD OF ENUCLEATION. 
nea, with a pupil distended to the full capacity of the corneal 
border. No fundus reflex could be obtained by ophthalmo- 
scopic examination, and the patient could not detect light 
with the injured eye. For two weeks he had been crying, 
night and day, from constant pain, and had sought the seclu- 
sion of a dark chamber to escape some of the suffering. A 
scar on the temporal side of the eye-ball indicated the loca- 
tion of the sclerotic wound. It stopped short of the ciliary 
border of the cornea, and lost itself in its backward course 
under the fold of conjunctiva. As the eye was good-looking, 
and the child had a long life before him, with much annoy- 
ance and expense from the prospective wearing of an artifi- 
cial eye, I determined to test for him the efficacy of a neu- 
rotomy. 
Chloroform having been administered, a vertical incision 
was made over the tendon of the internal rectus muscle, one 
line from the margin of the cornea, and the exposed tendon 
was carefully dissected from its sclerotic attachment. This 
made.quite an opening at the inner can thus, through which 
the back of the eye-ball could be reached. A little shelf of 
tendon left on the sclerotic was now seized, and by its means 
the eye-ball was rotated forcibly outwards. This rotation 
brought the optic nerve area nearer to the nose, and the pos- 
terior portion of the eye within easy reach of a heavily 
curved scissors, introduced into this opening made between 
the eye-ball and the internal rectus muscle. Between the 
open blades of the scissors, the nerves and vessels were 
caught, and all were divided by one single stroke. The scis- 
sors were then drawn partially out, the blades opened, pushed 
forward, and again closed, so as to divide any structures which 
might at first have escaped. Precautions were taken not to 
allow the blades to reach across the conical cavity and dis- 
turb the, bellies of the eye muscles on the opposite side of the 
socket. The scissors were now withdrawn from the opening; 
a gush of blood escaped—an evidence that the retinal and 
ciliary vessels had also been severed, along with the optic 
and ciliary nerves. A suture, with a needle at each end, 
was thrust through the inner rectus muscle—the needles 
being made to perforate deeply from within the recently- 
made orifice, and coming out near the caruncula. Then, by 
passing the needles anteriorly through the wound and under 
the conjunctiva, the point of one was made to protrude over 
the site of the superior rectus and the other through the mu- 
cous membrane over the inferior rectus. Upon tying the 
noose, the muscle was drawn forward into its natural posi- A NEW OPERATION IN OPHTHALMIC SURGERY. 
11 
tion; and its raw edge came in contact with the scleral sur- 
face, from which it had been dissected. When the muscle 
had been secured in its place, the eye-ball bulged consider- 
ably forward, on account of a quantity of blood accumulating 
behind it, and now exhibited a very decided prominence, but 
the sutures, so deeply placed, held it firmly in position, and 
prevented any appearance of squint. A compress bandage 
was applied over the eye, and cold water dressings were 
ordered. 
A good deal of nausea and vomiting ensued from the chlo- 
roform. This increased the bulging of the eye from post- 
ocular bleeding, but did no damage. After some hours, 
when all the anaesthesia had passed off, the patient found 
himself free of pain. He slept well the first night after the 
operation, and had an uninterrupted convalescence. The pres- 
ence of the suture excited much injection of the conjunctiva, 
with some muco-purulent discharge; and the extravasated 
blood, after some days, found its way into the lids, giving 
them a much bruised appearance. In three weeks this had 
all disappeared. The replacement of the muscle had been so 
satisfactory, that the movements of the eye-ball were perfectly 
natural, and, to all appearances, no operation had been per- 
formed upon the eye. From the moment of operation, all 
pain ceased in the eye. Five months have now elapsed since 
the operation, and the patient has not had the slightest dis- 
comfort. Upon examination, an external squint of one de- 
gree is present—-just enough to show that the eyes are not 
perfectly parallel. An ophthalmoscopic examination now 
shows the chambers perfectly clear. The pupil is still di- 
lated. The lens was luxated the blow. Its suspensory 
ligament was torn from the outer side of the eye, which al- 
lows the outer edge of the lens to divide the pupillary area. 
It retains its transparency. In the fundus, near the optic 
nerve entrance, is the evidence of a large rent in the choroid, 
the edges of which have become pigmented. The optic disc 
is grayish—the vessels upon its surface having shrunk to the 
finest pink lines. Ho other change could be observed in the 
interior, except some palor in color of the choroid. The 
tension of the eye was normal. The cornea retained its sensi- 
tiveness, and the general nourishment of the eye-ball seemed 
perfect. 
The second case was that of a woman, aged 25, who had 
lost an eye from choroido-iritis. The pupil was closed, and 
the cornea hazy; all light had disappeared from the organ, 
and the slightest touch indicated active cyelitis, and caused 
sharp pain. For four weeks her suffering had been intense, 12 
NEUROTOMY INSTEAD OE ENUCLEATION. 
so that she was quite willing to give up the eye, to escape 
further torture. A similar operation was performed upon 
her with like results. The severity of the pain at once ceased, 
and only the soreness of the traumatic conjuctivitis remained 
the day after the neurotomy. 
The third case was similar to the second. A man, 35 years 
of age, had lost his right eye from iritic inflammation, which 
had extended backwards to the ciliary region and choroid. 
He had lost sight for over a year, and for the last three months 
his life had been one of torment, from the continued pain in the 
lost eye. The good eye had become very weak, and was the 
seat of sympathetic irritation. Neurotomy of the optic and 
ciliary nerves was determined upon in his case, and performed 
in the manner already described. He also secured prompt 
relief, and has had no return of pain from the time of opera- 
tion. The blood extravasation in his lids was excessive, but 
in good time was absorbed. 
The fourth case was one of great interest. A gentleman, 
aged 25, occupied in the construction of iron bridges, was 
struck in the right eye by the end of a broken bolt, driven 
from a steam punch. The piece of iron resembled, in size 
and appearance, a Minie ball. Why it did not crush up 
the eye and break into the skull, cannot be explained. I saw 
him a few hours after the accident. The face had been tied 
up with cloths, which were saturated with blood. I found 
the upper lid slightly cut, but not enough to explain the free 
flow of blood from beneath its under surface. I had great 
difficulty in checking this haemorrhage, and finally had to use 
compresses and careful bandaging, without being able, at the 
time, to discover the wound from which the blood so freely 
flowed. 
By the next day I was able to examine the eye. I found 
the anterior surface normal. A cut was seen in the upper 
part of the sclerotic, three lines distant from the corneal 
border, from which the free haemorrhage had taken place. 
There was only perception of light in the eye. There 
was a little blood in the anterior chamber, and the vitre- 
ous was so turbid that no fundus definition or reflex could 
be obtained by ophthalmoscopic examination. By the use 
of atropia drops and cold water dressings, all redness passed 
away, and- in one week the patient returned to his super- 
vising work; sight was not regained. For one month, the 
eye gave him no trouble, when, from no exposure that he was 
.aware of, the eye became injected and painful. He applied 
,at once for treatment. I used the artificial leech, gave opium A NEW OPERATION IN OPHTHALMIC SURGERY. 
freely, and applied atropia and iced cloths. These failed to 
give him more than temporary relief. During the day he 
would feel tolerably comfortable, but would pass nights of 
agony. After three weeks of suffering, he came to the con- 
clusion that the pain was more than he could endure, and that 
he must get relief, even if the eye-ball had to be taken out. 
Sympathetic irritation had, by this time, made its appearance 
in the good eye, which prevented any use of it, or even ex- 
posure to light. In this case, the cornea was clear, and the 
iris of good color. The pupil was black, the lens not having 
been injured. The ciliary region was of a deep pink injec- 
tion, and could not bear the slightest touching. 
Under chloroform, I practised tenotomy upon him, making 
the usual opening at the inner canthus by separating the 
inner rectus muscle from its line of adhesion to the eye-ball. 
In this case, haemorrhage was free upon making section of the 
posterior tissues, and the after exophthalmic condition was 
very decided. The day after the operation, I found him 
singing joyously. He had had such a splendid sleep, and 
was nowr absolutely free from all pain. For five days, he was 
kept in doors, and, before the end of the week, he was ac- 
tively at work supervising the construction of a long iron 
bridge. The sutures were removed on the sixth day, and he 
has had an uninterrupted convalescence. The eye to-day 
looks as well as it did two weeks after the accident, when he 
thought it quite recovered, barring the absence of sight. It 
possesses all the motions of the other eye, without exhibiting 
the slightest trace of squint. He is delighted with the superb 
results, and so am I. 
The fifth case was that of a police officer who, in arresting 
a disorderly person, was stabbed with a knife. The blade 
perforated the upper lid of the left eye, and, entering the ball, 
passed through the ciliary region and transfixed the lens. 
When he came under my observation, seven months after the 
accident, I found the left eye lost to even the perception of 
light. The eye was cataractous, with cornea and iris still 
good, and the eye-ball very desirable to be retained. He 
was extremely anxious for the good eye, and came to me from 
a distance to have the lost eye removed. The case seemed 
in every way a proper one for neurotomy. Under chloroform, 
the ciliary and optic nerves were divided, and the internal 
rectus muscle replaced as usual. The results were as here- 
tofore reported. Ho trouble ensued from the neurotomy, 
and a good looking eye, in its natural position, has been re- 
tained. 14 
NEUROTOMY INSTEAD OF ENUCLEATION. 
The sixth case was one of unusual interest. The patient, 
a man 40 years of age, had lost the right eye six years since 
from corneal ulceration. A perforation in this membrane 
was stopped hy a hernia of the iris, and, in time, a leucoma 
was left, in which the iris was incorporated, covering two- 
thirds of the cornea. One month before I operated, he was 
brought to me suffering from very foggy sight in the good 
eye, which he said was becoming, day by day, more smoky. 
He had suffered no pain in either eye, nor was there any in- 
jection. A careful ophthalmoscopic examination gave no sign 
of disease to explain the daily increasing amblyopia. Finding 
no tangible pathological lesion in his trouble, I advised strych- 
nia, and placed him under the influence of this powerful drug. 
He continued the medication for two weeks, with no benefit, 
the sight undergoing a daily reduction, until he could only 
count fingers at four inches. As the ophthalmoscope indi- 
cated no cause for the deterioration in sight, nor were there 
any evidences of cerebral disturbance, I turned to the lost 
eye for a solution of the trouble, explaining it by some obscure 
sympathy. The lost eye was very markedly strabismic, and 
he was quite willing to give it up, if any benefit could he de- 
rived from its enucleation, for the good eye. I practised upon 
the lost eye neurotomy, but instead of bringing the muscle 
back to its old position, I left it free to permit the eye to 
straighten itself from the 5° of squint. Haemorrhage was exces- 
sive, and great bulging of the eye-ball took place. The results 
of the neurotomy in this case fully sustained the belief that, in 
some way,the good cyehad been seriously oppressed by thelost 
one, for reaction at once ensued after the operation, and with- 
in a week the very cloudy eye had regained much of its vis- 
ual power. . Fingers could be counted at fifteen feet and Ho. 
16 of Jaeger’s test types could be made out, with the eye 
strengthening every day. There is every reason to expect in 
this case a complete restoration of the lost visual function by 
the removal of nerve influence from the lost eye. 
How, gentlemen, you see before you the seventh case apply- 
ing for neurotomy. My experiences in substituting neurot- 
omy for enucleation have been so extremely flattering, that I 
am anxious for you to spread the good tidings, and to offer 
this great boon to such suitable cases of eye accident as may 
come under your care. 
Some of you are aware that nerve-section is not always a 
permanent remedy. The temporary relief can always be se- 15 
A NEW OPERATION IN OPHTHALMIC SURGERY. 
cured, as shown in section of the supra- or infra-orbital nerve, 
in cases of severe tic douloureux. In many of these cases, 
the pain comes back, and, in time, regains all of its intensity. 
The ends of the nerves, when simply separated by the knife, 
can, in time, re-unite and permit the nervous excitement to 
be conducted across the place of union, as if no severance of 
the nerve fibres had ever been effected. The position of the 
posterior eye nerves seems to be peculiarly fortunate to pre- 
vent this return. In the first place, these nerves are many. In 
the second place, they lie imbedded in loose, fatty tissue. In 
the third place, the cutting of the vessels along with the nerves, 
ensures an amount of blood extravasation and clot, which 
forces the socket tissues backwards, while it forces the eye- 
ball forwards. This blood effusion must separate the ends 
of the nerves for at least an inch apart, and at the same time 
so change the direction of the free cut ends as to mash some 
against the eye-balls, while the posterior free ends are pushed 
back out of line in the fatty tissues of the socket, where they 
become firmly fixed prior to the absorption of the blood clot 
behind the eye-ball. There is, therefore, every reason to ex- 
pect, by this process, not only immediate relief from suffer- 
ing, but permanent protection from all sympathetic irrita- 
tion. 
I can here offer this new operation, already well tested, as a 
substitute for enucleation in a certain class of cases, of great 
interest to all of us. It is not designed for all cases of osteyes; 
for many are so marred in appearance, that their removal and 
after-use of an artificial eye is still the best course to pursue. 
It is when the lost eye retains its good looks that the neurot- 
omy is especially applicable, and can be made use of early 
after the accident, as a preventive remedy of great value. 
Great care is necessary in readjusting the divided muscle, 
and also in limiting the socket section exclusively to the 
nerves and their “ vascular companions.” Experience will 
soon guide you aright in this matter. 
As our seventh case is now under chloroform, and on the op- 
erating table, I will show you how the various steps of the 
operation are carried out. 
(It is now four weeks since this seventh operation has been 16 
NEUROTOMY INSTEAD OF ENUCLEATION, ETC. 
performed. The results in this case confirm all that has 
been said in favor of the new operation. The patient was 
promptly relieved of the pain which had been her constant 
companion for four months. The eye moves well; has no 
squint deviation, and has already lost nearly all the injection 
consequent upon the division of the conjuctiva and the read- 
justment of the rectus muscle.)