*ww
**> >
m
m
»» >
-*-»-*>
r**?>er

 *  »  '•'
?e>  >>  >
  i. , ■•> >  e>*>  **»  *> »r>
-- ->■)} »  e> O »5>

  j ; >!>>  )^>  > ^ DQ

  > *'; > >^  J> ->y»
.  ^ * >   >*•  >  ->  <f*^

|*.«:->  ,   ■>%>.»>  >> »   -
  -, ■-,  - v :>; *>>">  >   » >
  S -  >:  ->;>,>  >>*>*>
  ' 'I, j  >> >>*» > *•'** *
     ►iu*)  )>>^*0 >»>



      V**fife>7>» ^  >3>^


          r&J2fe> >  ^>_-
         >■*>-***■  >  >A':'.
         v  •>>:
>5S  }>>>>
m>-q
>x)v)
3> > > P,'^ * ^> > "^	e> *0 j > >	■> ■*> v-2			> > > > ■> o . ~>		
			ID >> 1			^r >e - *> >T*JL. *-» )*- "^">^ ^	
					*> •• >> > **		
3P-*P	> > "> > > -» **^	^> e>					
		*SflBB^^§*i»^			> >	VjT » -»J3l^^3	
J^l >"						K-> .7 ' ?.	^<^a
**^-^ -*					~> > 3 *>		s
J"pl> J '^mj» ■**							3Q^
							
^						'SP' ^	
»• ;■* T3




 »j»o e?
rVvf>  T^


.'via TTSv-.'. 
'/> QroeejDeQO^e:€e;eejt'eej€£XCOroejt:d;b.u C." >*<
   Surgeon  General's  Office



rie,, -5 ■ VrTS 4rv ^/A> 'tTv s>\"

!&*
   <-/ec&<m,..........






-6aQcejQcocv"OGaac'
M4SB»
OQOOGrOiQei^
*4 
 
 
^     ENUCLEATION  OF THE  EYEBALL.
 \           One of the selected papers read before the Mass. Medical Society, June2d, 1868.
Communicated to the Boston Medical and Surgical Journal.
kmt Imtermarg &mm of impair^ $isim
       Communicated to the Boston Medical and Surgical Journai.
                      1/

      By  B.  JOY JEFFRIES,  A.M., M.D.

FELLOW OP THE MASS. MED. SOCIETY.  OPHTHALMIC SURGEON MASS. CHARITABLE EYE AND
    EAR INFIRMARY.  MEMBER OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY.
       LECTURER ON DISEASES OF THE SKIN, BERKSHIRE MED. COLLEGE.
^LIEEAirr V
                 BOSTON:

DAVID CLAPP & SON, PRINTERS, 334 WASHINGTON STREET,

                   1868. 
eT4-7&n
 181,9
  c.)
  From conversation with some of my fellow members of
the American Ophthalmological Society at our  recent meet-
ing at Newport, R. I., I am induced to circulate these papers
among my professional brethren in the New England States.
                     Respectfully,
                                B. JOY JEFFRIES,
                           15 Chestnut Street, Boston, Mass. 
ENUCLEATION OF THE EYEBALL.
   I have found among my patients a perhaps natural horror
in reference to removal of the eyeball, no matter how  use-
less this organ may have become as respects sight, and even
when it has been  the seat of severe or lasting pain; and I
have also found my medical  brethren, when bringing  their
patients to the specialist, shrinking from advising them to
submit to the removal of a sightless globe.  There seems to
be a sort of vague sensation  among  the laity, and I have
found it also among physicians, that enucleation of the  eye-
ball is a formidable and dangerous operation,  only to be re-
sorted to in malignant disease, and  as a dernier resort.   The
laity  also  do  not distinguish between  the  comparatively
trifling operation  of  enucleation of the globe,  and the, at
present, rarely necessary and more formidable  one of evacua-
tion of the contents of the  orbit.  I propose, therefore, to
fully explain the anatomy of the operation, prove its simpli-
city and show its  application, and thus, I trust, place before
the members  of the Society  some of the advances of my
specialty, which may not have  been brought to their imme-
diate notice.
  The foundation of surgery rests, of  course,  on pure anato-
my, and the instance before us is one of the  many where
anatomical points have been  forgotten and  only  recalled
when the requirements of surgery have brought them again
into notice.  The capsule of  the eyeball, which now bears
the name of Tenon, was known to  the students of anatomy 
282
ENUCLEATION OP THE EYEBALL.
hundreds of years ago.  Galen knew it but imperfectly, for
he says (De usu part., cap. 2), " Sexta quiedam tunica ex-
trinsecus prope accedit, in duram tunicam insert a."   Reald.
Columbus, in his " De re Anatomica '; (Tenet. 1559, lib. 10),
calls  it  tunica innominata.   The  first  correct anatomical
description, however, of this, to us  ophthalmologists so im-
portant membrane, was given by Tenon,1 before the French
Institute in 1804, and the capsule is now known by his name.
Hyrtl7 calls it tunica  vaginalis bulbi.   Richet,6 aponeurosis
orbiti  ocularis.   Budge8 and Arnold make some further sub-
divisions of this fascia, not  affecting, however, our  present
operation.  A most  careful subdivision  and description is
given  by Hcnle.10  I would refer also  to Linhart,32 Helie13
and to Richet,14 and  of course to the various recent compen-
diums on ophthalmology, particularly Pilz.Dl  Mr. Dairymple,2
of London, described it in  1834 as the cellular capsule of
the eye.   Malgaigne has the credit of first pointing out its
surgical  importance; he considered it an aponeurosis, and
called it albugiuca.    In 1840 Mr.  Lucas,9 of London, and
in 1841  O'Ferrall,4  in  Dublin, and Bonnet,3 of Lyons, re-
described this membrane, each independently of the other,
and therefore naturally individually considered themselves the
discoverer.  This was one  of those circumstances  still  too
often  occurring, where anatomical  and physiological truths
are claimed as novelties, without a previous thorough search
through medical literature, which  would  often prevent  the
critic  from the disagreeable necessity of showing that there
is in reality nothing  new under the sun.
  I will  here give, in order, a brief account from  each of
these  last three authorities  mentioned, because their  investi-
gations were made in special reference to the pathology and
treatment of affections of the  eye, and lead directly to  the
substitution of enucleation  of the globe  for extirpation of
the contents of the orbit. 
ENUCLEATION OF THE EYEBALL.
283
   Mr. Lucas called Tenon's capsule the submuscular fascia,
and thus explains its demonstration:—" The eye  and its
appendages, with half an inch of the optic nerve, should be
removed from the orbit and placed upon a plate,  the  cornea
being  downwards.  The masses  of fat,  together with the
loose cellular tissue and  bloodvessels,  should be carefully
dissected away, and the  muscles be turned forward towards
their insertions, not dissected as if with a view of exposing
their appearance, but merely expanded  on the surface of the
plate.   If the  neurilemma  of the  optic  nerve be now ex-
amined, it will be found covered with  a fine fascia, which
can be easily raised with the forceps, and with little difficulty
can be traced  off the neurilemma to  the sclerotic coat at
the point where the nerve enters.   It will now be found  to
cover the posterior aspect of the sclerotica, and to advance
as far as the insertions  of all the  muscles of the eye;  at
these points it turns upon itself, lines the ocular  surfaces  of
the  muscles, and  passes backwards along them to where
they surround the optic nerve.   This fascia possesses a high
degree of elasticity, and forms rather a membranous  sheath
for  the  sclerotica than an expansion  for  the  muscles; it
takes the form of the  eyeball, and acts the part  of a mem-
branous cup for the  organ to move  in, separating it from the
bellies of the recti muscles, and covering the ciliary nerves
as they pass onwards to pierce the sclerotica.  In the dead
eye, more or less fluid will be found to exist between this
cup-like membrane and  the eyeball, which always  enables
the anatomist to separate one  from the other with the great-
est facility."
   Dr. O'Ferrall has the  merit of a pathological  application
of the capsule.  Mr. Haynes  Walton11  gives a print of his
own dissection, and a condensed  account from   O'Ferrall,
who says, " It is a distinct tunic of a yellowish white color
and fibrous consistence, continuous in front with the posterior 
 284          ENUCLEATION OP THE EYEBALL.

 margin of the  tarsal cartilages,  and  extending backwards
 to the bottom or apex  of the orbit,  whore  its consistence
 becomes  less  marked;  the sharp end  of  a  probe  or  a
 director will be sufficient to separate it from the eyeball, by
 breaking  the  fine cellular tissue which  connects  them.
 Within, where  the eye glides over it,  the  surface is smooth,
 the external or orbital part loose and cellular.   The muscu-
 lar portions of the recti muscles  lie outside of this tunic,
 which  isolates  and protects the  eye in the  most  perfect
 manner possible.   Half an inch  posterior  to  its  anterior
 margin are six well defined  openings,  through which the
 tendons of the  muscles pass to their insertions in the sclero-
 tic coat, and over which they play  as  through a pulley."
  Bonnet, in his treatise on "Section of tendon and  mus-
 cles," says, " When. I meet with a  case favorable to the ap-
plication I would thus proceed to enucleate the globe.  Dis-
tending the lids with suitable instruments which I employ,  I
would  cut the internal rectus with  the same  precautions as
for the operation for strabismus.   Then sliding the  scissors
along the  wound I have made, between the  sclerotic on one
side and  the subconjunctival  fascia  and muscles on the
other, I would cut in turn all the  recti muscles  near  their
ocular insertion.   We need then only divide  the obliqui as
near as possible to  the globe,  and afterwards  the  optic
nerve.   The globe will then be removed  without  my inter-
fering  with any vessel or nerve, and without  penetrating the
orbital fat."  By not touching vessel or nerve, of course he
means as in the old operation for extirpation of the contents
 of the orbit.
  Stober,8 of Strasbourg, first performed this  operation in
 1841.
  Here I  think it worth while to go back to Tenon's  descrip-
tion, which, as it has  been so often  misquoted, I translate
from his own words:— 
ENUCLEATION OF THE EYEBALL.           285
   " A little behind the tendon of each of the  recti muscles
 around the eye, there is  formed  a tendinous fascia, which
 proceeds from the fleshy fibres of each of the recti muscles and
 the  membranous sheath surrounding and penetrating them.
 These tendinous fascia* separate from the tendinous muscles
 which they arise from; they are*-a continuation of the fleshy
 fibres of  the  muscles, and spring  from  the  membranous
 sheath enveloping  each  of the muscles.   The largest  and
 thickest belongs to the abductor muscle.  It springs from the
 external side of the muscle, and is attached to the external
 angle of the orbit near the lower edge of the lachrymal gland.
 It acts as  a counter  brace  on the muscle, and prevents it
 while contracting from pressing on the eye.   The  fascia  of
 the  adductor (rectus internus) is shorter and not so thick as
 that of the abductor  (rectus  externus).   It  commences at
 the  point of termination of the fleshy fibres, and is implant-
 ed on the inner angle of the orbit at the  edge of the nasal
 canal.  It acts  also  as a counter brace.  The tendinous
 fascia of the elevator  of the  eye (rectus  superior)  forms  an
 aponeurotic band extending from one  side of the orbit to
 the  other, to the depth  of the upper  lid.   The tendinous
 fascia of the depressor (rectus inferior) is lost in the lower
 lid."  Tenon called it, '•' the new tunic of the eye."
   For the surgical purposes of our operation we may regard
 it as a membranous sac on which the globe rolls, and which
 is pierced by the tendons of the muscles, the cutting of which
 tendons in front of the capsule  at their  insertion into  the
 globe will leave this membranous sac as a basis or support for
 an artificial eye,  and  the muscles being still attached to this
 capsule will therefore move it and the glass eye lying on it
in nearly as great degree as when an  artificial  eye lies
against a stump  of the  globe left  by  disease  or surgical
interference.
  This so simple  operation, recommended by  Bonnet, is in 
286
ENUCLEATION OF  THE EYEBALL.
such contrast to the former one, really to be dreaded, of ex-
tirpating the whole contents  of the orbit, mus'-les, nerves,
fasciae, gland, &c, that it is a  wonder that ophthalmic sur-
geons  did not  sooner practise it, but  not more wonderful
than that  even  to this  day, perhaps, unfortunate patients
are undergoing  extirpation  of their  orbital  contents, much
as certain bivalves are their contents, and with not very dis-
similar instruments.
   1 would dwell upon this, because one  of the  purposes of
this paper, as I have said, is to prove to you how simple and
little to be dreaded this present operation is, and that it has
no  relation with  extirpation  of  the orbital contents,  an
operation only  applicable to  certain tumors in the  orbit.
The method of  operating  for enucleation  of  the  globe,
taught me by Prof. Arlt, in Vienna, is the following:—
   Dilating the lids with  a speculum and holding in one hand
a pair of toothed forceps and in the  other a  small pair of
curved scissors,  the tendinous insertion  of the  rectus inter-
nus muscle on the globe  is seized and cut through.  Retain-
ing the grasp with the forceps  the conjunctiva is cut around
the cornea, and the tendons of the other three recti divided at
their insertion.   The scissors are  now passed in behind and
the optic nerve severed close to the globe, which  will then
start forward, and we have only to cut the tendons  of the
two obHqui muscles to free the eye from the orbit and leave
intact the capsule of Tenon with the muscles attached to it.3*
This operation I have done, and  it is comparatively easy,
when inflammation has not bound down the  conjunctiva or
fastened the globe to the capsule,  but under anaesthetics, at
least, I would advise the following:—Raise with  forceps a
piece  of conjunctiva near  the corneal edge,  pass in the
curved scissors  and separate the  conjunctiva  all  round the
cornea.   With strabismus hook lift up and cut all  four recti
tendons as carefully as in operating for squint.   Steady the 
ENUCLEATION OF THE EYEBALL.          287
globe with fingers and thumb, and pass a large pair of curved
scissors behind it and divide the optic nerve, which  releases
the globe from the orbit, and then  we can sever the obliqui
attachments.   There will be but little bleeding.   A piece of
ice in the orbit is all that is required, and filling the latter
with sponge or charpie  and applying pressure is not only
absolutely useless, but apt  to be painful.  A glass eye may
be inserted, often within a  week, and always  should be as
soon as possible to avoid shrinking of the soft parts, which
it certainly does.
   Perhaps some one  will  here say to  me, there must be
something wrong about all this, for I certainly  was  taught
and learned, that removal of the eye was a severe and dan-
gerous operation.   Moreover, I remember the first proceed-
ing was to enlarge the palpebral aperture in  order to have
room to work in.  My reply is, I desire only to remove the
useless and now offending  organ,  namely, the eyeball,  and
would as soon think of  slitting  up the lids, as a dentist
would of enlarging a man's mouth to extract a molar tooth.
   Yet the following is  from the American Edition of  Erich-
sen's Surgery, 1866.   "Extirpation of the eyeball is also
occasionally  called for, when in consequence of  injury
or disease one eye has become disorganized and the vision
of  the  other  is sympathetically  affected, and can only
be  preserved by the  removal of the globe that is already
useless.  The operation may be performed in the following
way:—The surgeon standing in front of the patient,  makes
an incision through the outer commissure of the lids as far as
the edge of the orbit.   The eyelids are then  well everted
and held apart with a wire  speculum.   The  surgeon next
passes a double hook into the globe and  draws  it well for-
ward ; then with a curved,  broad pair of scissors he divides
the conjunctiva at its  upper part, and then proceeds  to cut
            2 
288
ENUCLEATION OF THE EYEBALL.
across the several muscles of the orbit, and lastly the  optic
nerve."
   The operation of enucleation has  been found so  simple,
so effective when needed, and  so  perfectly adapted to its
ends, that we may well wonder at  its having been neglected
so many years after Bonnet proposed and St(vber performed
it.   What was called sinking the eye, namely, cutting out a
piece and letting the contents of the globe escape, was for-
merly the operation practised where now enucleation  is in
place.  Pathology and experience soon taught  that in the
operation of sinking the eye,  exactly  that portion of the
globe was left which was most often the source of trouble,
namely, some part of the ciliary region.   Hence soon  came
from one and another the improved method of removing the
anterior part of the globe up to the edge of the  retina or
or a serrata, leaving  the rest to form a stump.  Dr. E.  Wil-
liams, of Cincinnati, especially, proposed at  the Ophthalmic
Congress, at Paris, 1862,14 to remove a portion of the an-
terior part of the eye instead of enucleation, for the purpose
of having a better stump for the eye to move  on.  He cut
through the ciliary body, the only part  of his operation I
would object to, as  we must remove all of the ciliary region
to avoid sympathetic trouble of the other eye, as time has
since proved.    This  operation, when  done  with stitches
passed behind  the portion to be  removed, now has  Mr.
Critchett's name attached to it, as  he introduced  it for sta-
phylomata.16  Four or five curved needles are passed through
the globe just behind the part to be cut off,  and the  wound
brought together, an operation which might  be in place in
certain  cases, rather  than  enucleation, and we must  then
decide between the two.   The  disadvantages  are  the  long
time consumed in recovery,  the probable subsequent pain,
great swelling during suppuration,  and the possibility that
even tlien enucleation of the stump  must  be  practised, as I 
ENUCLEATION OF THE EYEBALL.
289
have been obliged to do where  I have found  traumatic  or
artificial sinking has occurred.  On the other hand, we may
get good union of the sclerotic and no great pain or swell-
ing.  But the stump remains a doubtful source of irritation.
   Prof. Knapp,36 of Heidelburg, has quite recently proposed
a modification of this operation  which may prove  of very
great service.  He passes the needles through the conjunc-
tiva alone, above and below, and by drawing it together
closes the sclerotic wound, thus avoiding any chance of sym-
pathetic irritation of the other  eye,  which the  continued
presence  of stitches in the sclerotic may produce.
   I will at once answer the  question  which may arise, by
saying the false eye will  move nearly if not  quite  as  well
and sometimes even better, bedded on Tenon's capsule, than
if resting on a stump which it may  possibly irritate.   I  may
say, I have seen the muscles move the capsule sufficiently to
deceive at first glance, even an oculist, as to whether the eye
was false or not.  But the point is just here, and it must be
kept steadily in mind.  The capsule will move the artificial
eye well enough, and the stump, if composed of any part of
the cornea or ciliary region, is never safe  from the danger
of producing sympathetic irritation.
   In the adult, when the  features, the bones and soft parts
have reached their fullest development, an objection to  enu-
cleation does not apply to the same extent as in the  young.
The objection is this, and I  would dwell  upon  it because
little if anything will be found in regard to it in the ophthal-
mic literature which you  will meet.   After enucleation  of
the globe by  the method proposed by Bonnet, the orbital fat
seems to become absorbed, allowing the muscles and Tenon's
capsule to sink in more than natural, and more than when a
stump or portion of the globe remains.  When done in youth
before the bones are perfectly formed, or perhaps  even after-
wards, the  osseous  tissue about the orbit seems  also to 
290
ENUCLEATION OF THE EYEBALL.
shrink, giving a different outline and feature to this compared
with the other side of the face.   The expression is peculiar,
making the patient on that side look as if thinner or not in
good health, to which the bright cheek and lips give the denial.
This I have seen  so marked, that it  always arises to my
mind in deciding whether to enucleate the globe or abscise
the anterior portion of it, and I have  in  the  young chosen
the latter simply on these cosmetic grounds, otherwise enu-
cleation is greatly to be preferred, removing as it does all
source of irritation which has called for the operation.
   That the laity may  better  understand  the necessity, sim-
plicity and  effectiveness of   enucleation,  by being taught
through you to no longer dread  it as  something terrible, to
be avoided till the last, is, as  I have said, the purpose of this
paper.   It  remains, therefore,  to show  when  and why we
ophthalmologists employ it.
   Enucleation may be needed simply to get rid of an en-
larged or staphylomatous globe  which the lid will not cover,
or which we desire to  remove to give place to  a false  eye;
or, as a prophylactic operation, to subdue or prevent sympa-
thetic inflammation in  the other eye.   Years  ago  (1802)
Beer, and afterwards especially  Himly in  1843,  noticed and
laid stress upon the fact, that continued irritation or chronic
inflammation of one eye caused  its  fellow  to  sympathize.
Graefe,18 Arlt,19 Badcr,20  Muller,21 and Augustine Prichard22
of Bristol, have since then given us their  special studies  of
sympathetic irido-choroiditis, so that at present it is as re-
cognized as  dreaded by the  ophthalmologist.   Trouble  in
the sound eye  does not commence, as you might suppose, in
the retina or nerve or choroid, but in the uveal  tract, and
gradually extends  back from there towards the posterior
part of the globe.   A  patient with an injured  or inflamed
eye will have,  in the other sound one, intolerance of light,
sensation  of fulness, even perhaps perceptible to  the touch, 
ENUCLEATION OF THE EYEBALL.
291
 inability  to use  the eye, fatigue of accommodation and con-
 traction of the range of accommodation, long before he may
 apply to the surgeon, who at once recognizes this  insidious
 sympathetic irritation from the other eye.  I do not propose
 here, however, to discuss sympathetic inflammation, except
 so far  as  regards the removal  of  the injured or inflamed
 eye, to control or avoid it.
   It is rather curious that the idea of destroying an injured
 or inflamed eye to prevent its acting on  the  other, comes
 from veterinary  surgery.  This in the horse was at first
 done by pushing a nail into the  globe or putting  lime be-
 tween the  lids; afterwards by Wardrop, in a less cruel man-
 ner, by opening the globe.   Credit is due the English for first
 having proposed destruction of one  eye to save the  other
 from sympathetic trouble, and formerly the same method was
 used  as in the horse  by Barton,23  Crompton and others.
 Grasfe destroyed the eye by passing a thread through  the
 sclerotic and cornea, or through the ciliary body.   Walton
 and Taylor, as Dr. E. Williams, of Cincinnati, above quoted,
 preferred to cut away more  of the  cornea, to remove if
 necessary   an  old cataract, results of exudations, foreign
 bodies, etc.  Now it is  curious to see, that notwithstanding
 the knowledge which  then  existed  of Tenon's capsule, its
 being repeatedly brought into notice, and  even enucleation
 within this membrane having been  distinctly  proposed and
 to a small  extent practised, yet ophthalmic surgeons did not
 commence  the employment of this method of  removing an
 injured or  inflamed eye to save its fellow, till Mr. Critchett25
 in 1851, probably from  seeing how successful enucleation
 was when practised for tumors, staphvlomata,  &c, and  how
 well the false eye  set and moved in the cup of the  capsule,
proposed and  carried  out  this operation in  preference to
others for sympathetic irritation, and, as Prof. Gracfe said in
 1857, its practicability and success were at once established. 
292
ENUCLEATION OF THE EYEBALL.
 Again, in 1860, he says, practitioners ought to understand
 enucleation better than they do, for they seem to have a sort
 of dread of it, as if  dangerous to  the other  eye, and  as
 though it was a severe and bloody operation.   The success
 attending Mr. Critchett's operation of course  led  other En-
 glish ophthalmic surgeons to  follow  him,  and enucleation
 soon became so frequent in London practice as to astonish
 the French and German schools, and naturally excite their
 opposition, which was  perhaps  fortunate, as the whole sub-
ject  of enucleation for sympathetic  trouble  has  in conse-
 quence been now thoroughly discussed, and the results care-
 fully weighed and considered, so that we already have some
 definite laws to guide our decision.
  The more this operation has  been  used by surgeons at the
 great centres of ophthalmic practice  and clinical study and
 teaching, the more strongly do  they speak of its value, sim-
 plicity and necessity.   A  few  quotations from the highest
 authorities in the English, French and German ophthalmic
 schools will here be directly in place, and probably have their
 due  weight.
  Dr. Bader,26  of London, says, " The  facility with which
enucleation is performed, its great freedom from  risk, and
the adaptability of an  artificial eye, ought to  make  us  con-
sider a disorganized eye, which is the seat of pain  or annoy-
ance, as a foreign body whose  removal the  sooner it  is ac-
complished the better.   If not  painful at the time it is a de-
formity, and is liable at any time of ill health  to become the
seat  of inflammation, and affect sympathetically the opposite
organ.  It is not only unwise, but incorrect to bring before
the patient's imagination the idea of  • taking  the  eye  out,'
and  omitting the scientific advantage of excising; medical
men  must soon learn to value the operation."
  Mr. Jonathan Hutchinson27  says, in regard to enucleation
of the eyeball even during the  acute stage of traumatic pan- 
ENUCLEATION OF  THE EYEBALL.
293
ophthalmitis, " Whenever I am satisfied that an injured globe
is utterly lost, I always advise its  excision without loss of
time.  By adopting this course the patient's suffering, often
extreme, is at once put an end to, and I think, also, the risk
of sympathetic inflammation of the other eye is avoided.   I
have excised globes in  all stages of  inflammation, and have
never seen the slightest  ill consequence, whilst the patients
have invariably been most grateful for the complete relief
afforded."
   Mr. Critchett, at the Ophthalmic Congress at Heidelburg,
in 1863, says:—1st. That injuries which cause sympathetic
ophthalmia are those which occur in the ciliary region.   2d.
The effects of such inflammations differ in important points
from those dependent on the other forms of iritis.  3d.  Lo-
cal or constitutional remedies have as little beneficial effect
on the eye as surgical  interference.   4th. Operation must
be suspended till all inflammation is gone by,  and even then
a doubtful prognosis must be given.   5th. In view, therefore,
of the uncontrollable inflammation and the danger of total
blindness, it may be perhaps safer, when injuries have affect-
ed the ciliary region and threaten long irritation, to enucleate
the injured eye before signs of trouble  appear in the other."
   From  the Franco-German school  Wecker28 says, " It is
vain to attempt  to substitute iridectomy or  section  of the
optic nerve for enucleation.   There is no longer any  doubt
of the necessity of removing an eye which is lost, as soon as
it becomes dangerous to the  other.  The only  question aris-
ing is in reference to the case itself and the  time  when  re-
course must be had to enucleation.  We are forced to enu-
cleate: 1st. Whenever one eye remaining sound, the other is
the seat of intolerable pain which, not yielding to remedies,
makes  us  fear for the sound one.  2d.  In every case where
a lost eye has given rise to sympathetic irido-choroiditis in
the other, no matter how slight, for this is our only  means 
294          ENUCLEATION  OF THE  EYEBALL.
of controlling it.  3d. In every case where the eye, till now
sound, has become in any  degree amblyopic, its  range of
accommodation  rapidly  diminished, intolerant  of light, or
incapable of prolonged  use; these symptoms  often being
the precursors of irido-choroiditis.  Enucleation will be all
the more  urgent when careful  examination cannot  find for
these troubles, either in the eye itself  or in the general con-
dition, other cause than this sympathetic influence in question.
Under all circumstances  when in doubt, it is better to ope-
rate too early than  too  late, for we may  find enucleation
useless after  sympathetic  irido-choroiditis is  fully  estab-
lished."
  From the various  ophthalmic clinics of Germany  we also
have concurrent testimony.   Graefe's18 and Arlt's19 results
and observations I have  already quoted.   Pagenstecher, at
Wiesbaden, found enucleation necessary from the following
causes:—
  1st. Traumatic irido-choroiditis occasioned by
       (a) Lesion of the iris, resulting from its being nipped
              between the edges of the wound.
       (b) Lesion of the choroid.
       (c) Suppurative  choroiditis, or suppuration in  the
              vitreous.
       (d) Presence of a foreign body in the eye.
       (e) Lesion of the capsule of the lens.
       (f) Choroiditis  after reclination, or  depression of
              the lens.
  2d.  Incipient exudative irido-choroiditis and haemorrhage
         from the choroid.
  3d.  Processes leading to staphyloma (choroiditis serosa).
  4th. Extensive separation of the retina.
  5th. Tumor developing from the choroid or sclerotic.
  6th. Formation of bone within the choroid.
  Let me  here add one more testimony from Dr. Mooren's30 
ENUCLEATION OF THE  EYEBALL.           295
clinical experience for eleven years with 32,000  patients  in
Diisseldorf.   He says, " The causes of sympathetic disease,
according to my observation, may  be divided into three
distinct groups.   1st. Direct injuries of the ciliary  region.
2d.  Mechanical irritation of the ciliary  body, whether by
the action of a foreign body (wearing  an artificial eye),  or
by the lens turned into a foreign body  by displacement, re-
clination, luxation, staphyloma, etc.   3d. Every inflammation
of any  part of  the  uveal tract,  when  by cyclitis it has
reached its culminating point."  And finally, as do all other
authorities, Dr. Mooren gives, "pain upon pressure in the
ciliary region as  the  never-failing symptom which pointed
to and proved danger from sympathetic disease.  When this
is present, the only  possibility  of saving the  second is by
enucleation of the first affected eye."
   To the above I would add the testimony of my own ex-
perience in ten years  of ophthalmic practice in this commu-
nity.  In the medical literature of this  country you will find
reports of successful  cases  of this operation,  coming  from
the scientific ophthalmologists of our larger cities, who strive
to avail  themselves of the  sound sense of the English, the
elan of the  French, or the patient industry  and  scientific
attainments of the German surgeons in this specialty.
   I trust, therefore, my efforts have succeeded  in proving  to
you that enucleation of the eyeball from within the capsule
of Tenon, is un anatomical  possibility,  a surgical  necessity
and a powerful prophylactic remedy.

  Note.  This paper having been intended for a large State Medical Society,
will explain to my brother ophthalmic surgeons why no comparison is made
with simple iridectomy, section of the optic nerve, or of the ciliary nerves.
2 
   The accompanying wood cuts are from  photographs of a
diagram  and dissection  exhibited  to  the Society when the
paper was read.

  Fig. 1.   The lids are slit up vertically, and the four flaps  turned
back.  The conjunctiva dissected off and strings passed under  the
tendinous  insertion into the sclerotic of the external, internal and infe-
rior recti muscles, just as they would be lifted on the hook to be cut in
operating  for squint.  A needle is passed under the tendon of the supe-
rior rectus, which is seen to pass to the capsule of Tenon, showing itself
between the upper half of the globe and  the upper lid, from both of
which it is freed.  In a single wood cut it  is of course difficult to give
a more definite view of a minute dissection.

  Fig. 2.   Represents in diagram a vertical section through  the orbit
and eyeball.  The  heavy dotted  line shows the fibrous lining of the
orbit, which at the anterior upper and lower edge passes  off to the lids,
and also backwards  to the globe which it surrounds to the  optic nerve,
thus  forming Tenon's capsule.  A layer behind runs over the  nerve  to
form its sheath, and in front a prolongation extends forward to  the
conjunctiva.  The superior and inferior recti muscles are represented,
and where their tendons pierce Tenon's capsule to become attached to
the globe.  It will thus be seen that cutting the tendons  of the muscles
at their insertions, and the optic nerve, releases the globe and leaves
Tenon's capsule like a cup for an artificial eye to rest on and be moved
by the muscles. 
Fig. 1.
Fig. 2.
 
 
BIBLIOGKAPHIC    REFERENCES.
  Tenon.  Memoires et Observations sur 1'Anatomic, la Pathologie
    et la Ohirurgie, et principalement sur l'Organe de l'CEil. p. 193.
    Paris, 1816.                                                     1
  Dalrymple.   Anatomy of the Human Eye.  London, 1834.             2
  Bonnet.  Read at Paris Academy  of  Sciences, Feb.  1,  1841.
    Gazette Med. de Paris,  Feb. 13,  1841.   Dublin Med.  Press,
    March 3, 1841, p. 133.  Annales d'Oculistique, t. v. p. 27, and
    t. vii. 1842, pp. 141, 237.                                         3
  O'Ferrall.   Dub. Med. Press, March 10, 1841, p. 158.  Dub. Jour.
    Med. Sci. Vol. 19, p. 336.                                         4
  Stbber.  Annales d'Oculistique.  Tome vii. p. 31.                     5
  Richet.  Traite pratique d'Anatomie Medico-chirurgicale.   Paris,
    1857.                                                          6
  Hyrtl.  Handbuch der topagraphischen Anatomic   Wien,  1853.      7
  Budge.  Ztschr. fur rat. Med. 3 R. vii. p. 273.                       8
  Lucas.  Practical Treatise on the Cure of Strabismus.   London,
    1840.  American Journal Medical Sciences, Oct.  1841.              9
  Henle.  Handbuch der Anatomie des Meschen.  Vol. 2, Prt. 3.       10
  Walton. Treatise on Operative Ophthalmic Surgery.   London,
   1853.                                                          11
 Bonnet.  Traite des Sections Tendineuses et Musculaires.  1841.      12
 Helie.   Theses de Paris.  1841.                                   13
 Richet.  Anat. Chirurg.  Paris.  1860.  2d edit. p. 324.             14
 E. Williams.  Congres Internationale d'Ophthahnologie.  Paris,
   1862, p. 139.                                                   15
 Critchett.  Royal London Ophthalmic Hosp.  Reports.  Vol. 5.
   Part 1.  1863.                                                 16
 Pagenstecher.  Klinische Beobachtungen aus der Augen heilanstalt
   zu Wiesbaden.  1862. p. 42 et sequitur.                         17
 Grcefe.  Archiv f.  Ophth. B. 3. Abth. 2.  B. 12. Abth. 2.  B. 6.
   Abth. 1.                                                       18
Arlt.  Zeitschrift der  Gesellschaft  der Aertze zu  Wien.   1859.
   Nr. 10.                                                        19
 Bader.   Pragcr Med. Vierteljahrsschrift.  57.   Band.                20
Mutter.  Archiv. f. o. B. 4. Abth. 1.                               21
Prichard.  " Association Journal."  Oct. 6, 1854.                   22
Barton <Sf Crompton.   Loudon Medical Gazette, 1837.                23 
300
BIBLIOGRAPHIC  REFERENCES,
Walton <5f Taylor.  Annales d'Oculistique.  t. 31, p. 256.           21
Critchett.  Allgemeine Wiener Zeitung.   Feb. 14, 1860.  Lancet,
  1851, p. 368.                                                  25
Bader.  Royal Lond. Opth. Hosp. Reports.  No. 1, 1857.            26
/. Hutchinson.  Roy. Lond. Opth. Hosp. Reports.   Vol. 5, Part 4.    27
Wecker.  Traite theorique et pratique des Maladies des Yeux.        28
Blodig.  Zeitschirft der Gesellschaft der Aertzte zu Wien.  1860.      29
Mooren.  Opthalmiatrische Beobachtungen.  Berlin.  1867.         30
Pih.   Compendium der Operativen Augenheilkunde. Prag. 1860,
  p. 3.                                                  •       31
Linhart.  Wiirzburger Verhandlungen.  Bd. 9.  Heft. 2 et 3, 1859.    32
Lenoir. These sur la Strabisme.                                   33
Demarquay.   Traite des Tumeurs de l'Orbite.  Paris, 1860.           34
Liebreich.  Eine Modification der Schiel Operation.  Archiv f.  Opth.
  12. 2.                                                         35
Knapp.  Staphylomabtragun°j und Vereinigung der Wunde  durch
  Bindehautnahte.  Archiv. fur Opth. 11. 1.                        36
Hart.  London Lancet, Jan. 1863.                                 37
Carter.  Br. Med. Jour., Nov. 1864.                               38
Wecker.  Gazette des Hospitaux,  93.  1864.                        39
Hulke.  British Med. Journal, Jan., 1866.                          40
Lawson.  London Lancet, Jan., 1863.                              41
Lawson.  London Lancet, Aug.,  1864.                              42
Wolf.  Gazette deB Hospitaux, 100.  1864.                         43
Calderini.  Jahrbb.  135.   p. 356.                                44 
SECTION OF THE CILIARY NERVES AND OPTIC
                        NERVE.
   Dr. Rondeau, in a pamphlet published in 1866,* on sym-
 pathetic ophthalmia, says, in concluding:—"In studying the
 pathology of the secondary lesions which occur in an eye
 subsequent to  injury of  its fellow, in considering the in-
 tractable nature of the affection, its insidious and intermittent
 march, we notice  the striking analogy between   neuralgias
 and so-called  sympathetic ophthalmia.  No affection is so re-
 bellious to medical treatment, and when in facial neuralgia
 all our therapeutic remedies are  exhausted, we often have
 recourse with success to section of the nerve, and  if this does
 not suffice, to excision of a piece of the nervous trunk.  Not
 yet having clinical facts to rely  on, I can but  express the
 opinion that the same treatment is applicable to sympathetic
 ophthalmia.   It is often  difficult to make the patient  compre-
 hend, in an affection so  slight in appearance, the danger of
 his situation and the necessity of removing the eye.  He hesi-
 tates,  and, waiting till the eye becomes enfeebled to the last
 degree, re-appears to confirm the surgeon's prognosis.  When,
 finally, he  decides upon an operation, the changes in the
 globe have often so far  advanced as to insure but a limited
 advantage  from enucleation of the injured eye, if he is not
 already condemned to  incurable  blindness. The first indi-
 cation in this  disease is to act as promptly as possible, in
order to prevent the changes of secretion and structure con-
secutive upon  reflex troubles of the circulation."
  * Des Affections Oculaires Reflexes, et de l'Ophthalmie Sympathique. Paris.
1866. 
o
SECTION OP
  " Break the nervous  chain  necessary to  the  accomplish-
ment of the  changes which constitute  reflex action; divide
the sensitive nerve, or destroy the ganglionic centre, or di-
vide the recurrent nerves (electrometer), any one of these
lesions, the breaking of the chain  at a  single point, is suffi-
cient,  and all  re-action,  all  sympathy between  the  organs
ceases."*
  Dr. Rondeau then goes on to say :—"  Nothing is easier than
this  operation, which I  have several times  practised in the
amphitheatre.  It consists in making a small opening through
the conjunctiva at the upper and inner part, and  introducing
a slightly curved tenotomy knife, to be kept close to the globe.
We divide, at the same cut, the ciliary nerves, the optic nerve
and the central artery.   The advantages and disadvantages
of this  operation  are these :  It  is very  simple, and  as the
patient has much less  dread of it than  enucleation  of the
globe, he is less reluctant to submit to it earlier.   It serves
the same purpose  as enucleation in breaking the continuity
of nervous tissue.  Section of the optic nerve, it is true,
destroys vision in the eye ; but as in the majority of cases
vision, if not  lost,  is greatly reduced, it  is better  at once to
sacrifice the eye becoming useless, and  which may endanger
the other.
  " In  animals, this section  of the nerve does  not  cause
haemorrhage  to be dreaded;  we  only cut vessels of small
calibre, the ciliary arteries and the central artery of the retina,
the haemorrhage ceases quickly, so that the blood  does not
exercise any  injurious pressure on the nerves we have cut.
  "If this.section  does  not  avert the progress of the reflex
trouble in the sound eye, we must at once enucleate the af-
fected one.   Experience  will decide  on the value of this op-
eration."
  In  the Memoirs of the  Vienna Academy, 1864,  Dr. B.
Rosow gives  two  ophthalmoscopic pictures of the  eye of a
rabbit,  before  and after section  of the optic nerve.   From

  * Lecons surle diagnosie et le traitement des principales formes de paralysie
des membves inferieurs.  Par Brown-Sequard. 
CILIARY NERVES AND OPTIC NERVE.
3
 his experiments  carried out  in  the  Physiological Institute
 of the Vienna University, he draws the following deductions :
 1st. " Section of the optic nerve  (in rabbits) when  unaccom-
 panied with accidents  (disturbance of the retinal circulation,
 severe inflammatory reaction), does  not cause, as formerly
 supposed, such rapid fatty degeneration  of the fibrous layer
 of the retina.  In one case, he found the largest part of the
 fibres perfect after one hundred and forty-two  days.   This
 is more than time enough for fatty degeneration to take place
 in other nerves separated from the central system. In another
 case, after one hundred and seventy-eight days, well-preserved
 nerve-fibres were found, althpugh few in number.  2d. The
 causes which destroy the fibrous layer of the retina have no
 injurious  effect on the other retinal elements ; from which we
 may conclude that the vitality of these  elements is entirely
 independent of that of the fibrous layer."
  We mention these results of Dr. Rosow because they may
 throw some light on the question of the usefulness of section
 of the optic nerve in man.   The  Journal has lately noticed
 this as a new operation spoken  of by Prof. Graefe as a re-
 medy for subjective  luminous  sensations,  and as he  has
 changed his views as regards  its applicability in sympathetic
 ophthalmia, we quote  the following from the report of the
 Ophthalmic Congress  at Paris last year :—" I have at times
 recommended the substitution of this operation for enuclea-
 tion to counteract sympathetic  ophthalmia, but experience
 and more mature judgment of the subject have soon  shown
 its  inapplicability.   It is  undoubtedly  through the ciliary
 nerves  that  sympathetic ophthalmia is communicated, and
 section of the optic cannot therefore serve to cure it.
  But there is another order  of symptoms besides pain, and
which in  the class of special sensations is  also dependent
upon the optic nerve.  I mean the subjective luminous sen-
sations remaining after the loss of the eye, and accompanying
certain forms of blindness; for instance, in detachment of the
retina after irido-choroiditis,  and when there  is calcareous
deposit within the globe, we often have subjective sensations
             4 
4
SECTION OF
very distressing to the patient.   They have spectral corusca-
tions  (photopsia)  tormenting them day  and night,  and we
even find these, followed by cerebral  hallucinations,  due to
irritation  of the brain  from  communication  with the optic
nerve.
  Section of the optic nerve seems indicated under other cir-
cumstances  also than these photopsic phenomena observed
with the blind.   I mean where there are intraocular tumors.
It is well  known that the trunk of the optic  nerve is partic-
ularly liable to  propagate degeneration (sarcomatous or car-
cinomatous) to the parts outside the eye.  Microscopic ex-
amination of the cut surface of the  nerve after enucleation
often  shows us that it is already here affected, although
the interior  of the globe may be but partially filled with the
tumor.  In  such a case the insufficiency of the  extirpation
will be apparent, and we shall soon have a return  or  the de-
velopment of the tumor from the orbital part of the diseased
nerve.  If we are prompt enough in  ascertaining that the
cut surface of the nerve is diseased, the free end of the nerve
must  be cut off immediately after enucleation.  This, how-
ever,  is very difficult to do, and we cannot reach the remain-
ing portion of the  nerve in the orbit without extending our
dissection in a  dangerous manner.   It is, therefore, more
prudent, in cases of  intra-ocular glioma,  sarcoma  and carci-
noma, to first divide  the optic nerve beneath the conjunctiva,
and this as far back  as possible, then proceed  to  enucleate.
We shall thus have some third of an inch of the nerve with
the globe, which we shall be glad of having effected if the
cut surface proves healthy, whilst nearer the globe the nerve
is found diseased.
  Method of Operating.—We penetrate the orbit, or rather
the cellulo-fatty tissue, by puncturing the cul-de-sac of the
conjunctiva at its outer side, whilst the globe is drawn forci-
bly forward. The instrument used is a very strong tenotomy
knife, moderately curved, which must follow  the  external
wall of the orbit till the point is far enough advanced to cover
the optic nerve.  The latter being stretched by the position 
CILIARY NERVES  AND OPTIC NERVE.
5
given to the globe, is  readily presented to the concave cut-
ting edge  of the knife, and divided according to the rules
for subcutaneous section.  The distance of the section from
the globe  may be  greater or less, as we choose.  It is more
readily made about one fourth of an inch behind the sclerotic,
but can be carried within a few lines of the optic foramen.
   I performed this  operation with success  in  a case  where
blindness had lasted fourteen years.   I observed, at the time,
the difference between the character of the  retinal hallucina-
tions, as we notice  them,  and the cerebral hallucinations pro-
perly so called.  In the first, simple  figures  are seen, geome-
tric, so to speak;  in the  latter appear all the products  of
the imagination and the memory."
   It seems pretty  definitely settled that sympathetic irrita-
tion is conveyed by the ciliary nerves and not by the optic ;
section of  the latter,  therefore, would be confined to such
cases  as Graefe speaks of.  The knife sent me by Liier,  of
Paris,  for  this purpose, has a shaft about  two inches long,
and  the blade, but  slightly  curved,  five sixths  of an inch
long.  Its  use, of course, necessitates perfect familiarity with
the anatomy of the orbit and the relations  of the soft to the
hard parts.
   Prof. Graefe, having convinced himself of the action of the
ciliary nerves in conveying sympathetic irritation, proposed,
in 1866, in the Archiv fur Ophthalmologic, the section of these
nerves locally, where pain was produced by pressure on the
sclerotic over them.  The operation was, however, practised
for the first time in  May, 1866,  by Dr. Ed. Meyer, who
translated  into French Graefe's  "Clinical Ophthalmology."
In the September  number of  the Annales d' Oculistique, Dr.
Meyer reports  three cases operated on, the  method of doing
which latter I translate from this piece.  " Having determined
on the  place,  painful to  the touch, where section of the
ciliary nerves  is to be performed, we  lift up and cut a fold
of the  conjunctiva  near the  edge  of the cornea,  just  as  in
the operation for strabismus.  Then,  with blunt-pointed scis-
sors, we separate, to the extent determined  n  in the plan  of 
6      SECTION OF CILIARY NERVES AND OPTIC NERVE.

our operation, the cellular tissue uniting the conjunctiva and
sclerotic.  The eye is now fixed by a strabismus hook passed
under the nearest rectus muscle ;  we thereby also determine
the place of insertion of the tendon of this muscle.   Holding
the hook in the left hand, we puncture  with Graefe's narrow
knife  the sclerotic in the ciliary region, obliquely to its sur-
face, avoiding the crystalline lens.  The counter-puncture is
made so that when the cut is finished we shall have a linear
wound parallel to the border of the cornea, in  which the
vitreous immediately presents.   We then  carefully remove
the hook,  and turn back the conjunctiva towards the cornea.
Suture of the conjunctiva has not seemed to us of any real
advantage; there is,  however, no difficulty  in applying it.
The edges of the sclerotic wound remain several days unu-
nited, and  in one case we were obliged to cut off the vitreous
on the third day, and  apply the compressive bandage more
than a week.  There is very moderate reaction after the ope-
ration, and only rest needed, unless pain or sleeplessness call
for subcutaneous injection of morphine on the temple, and
the compressive bandage.  Of three eyes operated on in this
manner, one, which had already commenced to atrophy before
the operation,  continued to do so completely afterwards ; the
other two  retained their normal shape."
  Time must prove whether this section of some of the ciliary
nerves,  namely,  those  shown to be implicated by pain upon
pressure over  them,  will not supersede  enucleation of the
globe otherwise indicated to prevent insidious sympathetic
ophthalmia.   Being forced  to wear an  artificial eye entails
considerable expense  upon the patient, and I have too often
seen constant trouble  from the best made  and most perfect
fitting one. I therefore look with much interest for the results
of the operation as now practised at home and abroad. When,
however, this is  unsuccessful in preventing or subduing sym-
pathetic ophthalmia, we have  still left the certain remedy of
enucleation of the globe, as I have  fully shown in a late paper
before the Massachusetts Medical  Society. 
SOME  UNNECESSARY  CAUSES  OF IMPAIRED
                       VISION.
   It is already several years since Professor Donders unhesi-
 tatingly declared that a near-sighted eye was a diseased one.
 His studies  of refraction  and accommodation are now,  so
 to  speak, the classical  literature of this specialty.  It is the
 duty of all ophthalmic  surgeons to render them of service  to
■the communities in which they  live, by continually bringing
 before their professional brethren the necessity and value  of
 a thorough scientific investigation of the refractive condition
 of every eye not perfectly normal.   For it is in this way alone
 the laity can be brought to recognize the need  of applying to
 the professional specialist,  to  have errors of refraction  or
 accommodation corrected by the means modern science has
 placed within  our reach.   This seems so self evident  that it
 might at first  sight be regarded as needlessly  said ; but how
 many people here in New England, either of their own accord
 or perhaps directed by their family physician, purchase spec-
 tacles at the village  clockmaker's, the village  toy-shop, or of
 the travelling pedlar and the peripatetic quack  oculist!   Nat-
 urally it will be a long time before our community learns that
 it is  not a necessary part of every watchmaker or repairer's
 business to keep on hand and sell spectacles, which, accord-
 ing to his degree of honesty or "brass," he advertises  as
 " helps to read," or  "restorers of sight,"  &c.  The amount
 of injury done  by this  special form  of quackery is not  gen-
 erally known,  but abundantly proved by  the daily records
 of the eye infirmaries of our larger cities.  Oculist and opti-
 cian are  regarded as synonymous terms by nearly all classes
 of the community, and ophthalmic surgeons fail in their duty 
8
SOME  UNNECESSARY
if they do not teach their medical brethren and through them
the community that an ophthalmic surgeon alone can  make
a proper and correct examination of the human eye, and decide
what glass, and whether any, should be worn by the patient,
and the optician's business is confined entirely  to preparing
and  setting in a proper frame  the glass  directed  by the
former;  exactly as an apothecary  compounds  and puts up
the medicine prescribed by the  physician.  An honest and
intelligent  optician would no  more  think  of substituting
another for the glass written for by the surgeon, than the
druggist  would  of  altering the  physician's  prescription.
Now we  do not  suppose that any amount of teaching or ex-
planation will ever prevent a certain class  of the community
from applying to those who sell spectacles and allowing them
to choose for them, any more than we suppose that apothe-
caries and druggists will cease to be applied to for " some-
thing good for summer complaint," " a cold,"  "children's
fits "  or " liver complaint," or cease to sell the applicant the
last quack compound.  But that apothecaries should prescribe
quack medicines wo do not admit, any more than that watch-
makers and jewellers, as a class,  know anything about phy-
siological optics or are competent to select proper spectacles
for those applying to them.   Moreover, we would unreserved-
ly say from others' as well as our own personal experience,
that the community would save money by first applying to the
ophthalmic surgeon, and where  that cannot  be done, to the
charitable eye infirmaries now established in our larger cities.
  If the  condition  of  things is  such, as will  be seen from
what follows, in  the land of Graefe, Arlt and Jager, what  is
it likely to be in our country, where German scientific culture,
its adherents and promulgators, are so commonly ignored, if
not positively disbelieved,  by the family doctor ?  So far as
relates to the amount of light, the public schools of this city
in particular, and of New  England in general, are perhaps
free from the evils to be spoken of.  This is not,  however, the
case with the private schools which  have increased in num-
ber so rapidly within the last few years.   School committees 
CAUSES OF IMPAIRED  VISION.              9
look after the former ; but no one but convenience, and now
and  then an intelligent parent,  after the latter.   The public
schools in this very city  are, however, not free from defects
that should be remedied, as we shall see further on.
  The results of the investigation of the ophthalmic diseases
of school children have appeared from James Ware, in Chelsea,
England,  in  1812 ; the  authorities  of Grand Duchy Baden,
1840;  Sczokalski,  1848,  Paris; Jager, 1861, Vienna;  and
Rtite, 1865, Leipzig.  Beger, in Saxony, has also studied the
development and increase of myopia,  and Farhner, in the
Wien.  Jahrbucher Kinderkrankheiten, 1863, vi. 3.   But scien-
tific  research in this direction has lately been followed out
so thoroughly and with such important results,  as to merit
the attention of every one connected with the education of
the young, as well  as the special interest of the ophthalmic
surgeon.   Vide  also  Guillame,  Nuenburg,  Hygiene, v. ii.,
Geneve, 1860, and Coccius, Der Mechanismus der Accommoda-
tion des menschlichen Auges, Leipzig, 1868,  p. 67.
  Dr.  Cohn,  of Breslau, has  recently carefully examined the
refractive  condition of the  eyes of 10,060 children in the
lower, middle and upper schools of  Breslau and other places
in Silesia.   Besides  this, he has examined 410 of the 964
students at the  Breslau University in the winter of 1866-67,
and from his publications of the first at Leipzig, 1867, the
second in the Berliner Klinische  Wochenschrift, 1867, No. 50,
we  gather the following results.   We should  premise by
saying that  Dr.  Cohn  was  induced to  undertake the task
from finding, whilst at work  on  the statistics of some fifteen
thousand patients  of Prof.  Fbrster's clinic, that out of the
750 near-sighted people who presented themselves within four
years,  400 had applied on account of severe trouble depend-
ent on myopia.   Desirous of finding whether the refractive
and other troubles of the  eye were not induced by inadequate
and improper light, badly arranged and badly planned school-
desks,  &c,  he  first  examined  the  schools in Breslau, and,
to avoid  errors, afterwards those of other places in Silesia,
not content  till his lists contained over 10,000 records.   His 
10
POME  UNNECESSARY
example is fortunately now being followed by competent ob-
servers in various parts of Germany.
  Dr. Cohn chose five village schools in Langenbielau, with
1486 scholars, and 28 city schools in Breslau, with 8574 scho-
lars ;  of these latter, 20  were elementary,  2 intermediate,  '2
girls' high, 2 where languages and science were taught (Reals-
chule), and 2 gymnasiums.  Among the ten thousand children,
he found 1730 with defective vision,  making  17*1 percent.,
the average number increasing with the degree of demand upon
the eyes at school.   In the  city schools tliere were four times as
many children with defective vision as in the country.  With
regard to sex, boys 18-8 and girls 14-3 per cent.  The re-
lation of defective vision to abnormal refraction is shown by
the following table :—
             Normal eyes,       8330 =  83.
             Abnormal refraction, 1334 =   13.
             Other affections,       296 =   4.

                               10,060 = 100.
Thus showing three times as many cases of  abnormal refrac-
tion as other ophthalmic troubles in youth.
  Of these abnormal refractions,
      1004 were near-sighted.
         10 myopes (parents also).
         5^ myopes (after previous disease of eye).
         81 hypermetropic.
       158 hypermetropic, with convergent  squint.
         23 astigmatic.
  Hence we have myopia 12 times more frequent than hyper-
metropia, and 6 to  7  times  more  frequent than  hyperme-
tropia with convergent squint.
  The following are deductions from his data in reference
to near-sightedness.
  1st. No  school  was without myopic  scholars.  2d.  The
number varied greatly in the different schools.   3d. In the
village schools very few (L4 per cent.).   4th. In city schools
eight times as many (1L4 per cent.).  5th.  In the city ele- 
CAUSES OF  IMPAIRED VISION.
11
mentary schools 4 to 5 times as many as in village  (6'7 per
cent.).   6th. Girls'  high  school more than the elementary
(7'7  per cent.). 7th. In the city schools there is a steady
increase  of  the number of myopes  from the lower to the
upper (elementary 6'7 per cent., middle 10*3 per cent., Real.
19*7 per cent., gymnasiums 26'2 per cent.).  8th. In the mid-
dle one  tenth and more, in the Real, one fifth, and  in the
gymnasiums more  than one fourth  of the children are near-
sighted.   9th. The number of myopes varies in the number
of different  village schools, never  more  than  2*4 per cent.
(varying  from 0"8 to 3 2  per  cent.).  10th.  In the several
middle schools  the  number of myopes varies scarcely 3 per
cent., in the Real,  scarcely 2 per  cent.,  in the gymnasiums
not 4 per cent.   11th. In the girls' high school, however, the
difference in number of myopes varies  7 per  cent.   12th.
This difference varies most in the elementary schools, from
1'8 to 15*1 per cent.
  Let us follow now these young persons as they grow older.
  As we said above, Dr. Cohn examined 410 of the  964 stu-
dents at  the Breslau University, without selection, however.
Among these 410  not one third had normal eyes, and nearly
two thirds were short-sighted.   His data showed myopia to
be the most frequent affection of the eye among students,
and that it  increased with the age, and number of terms of
student life.  The following table gives the average degree
of myopia at the different schools, showing how steadily it
increases.   (The denominator of the fraction represents the
focus of  the  concave glass  required to correct the near-
sightedness.)
In 5 village schools,	M.	2l4-4-
" 22 elementary "	M.	1 22"' 7"
" 2 middle "	M.	1 2T-9-
" 2 real	M.	tV 6 •
" 2 gymnasiums,	M.	tW
" 2 prima	M.	l TT-
Among the students,	M.	1
  The relation of myopia to staphyloma posticum, or bulging
of the  posterior pole of the eyeball, is shown by the follow-
             5 
12
SOME UNNECESSARY
ing,  and confirms Prof.  Donders's views above expressed
Of the 1004 myopic  children, 200 had  staphyloma poxlicum,'
the number increasing with the age.  The greater the degree
of myopia  the  more frequent is staphyloma, as this table
shows :—
M.	i i	3
M.	i _ i •2 3 16	17
M.	tV - tV	48
M.	1 1 TT S	#65
M.	l f	71
M.	1 "J	100
Yet exceptional cases occur, such as M. ^\ with staphyloma,
and, on the other hand, M. | without it.   M. £ was always
accompanied with staphyloma.
  With regard  to hereditability, 24 boys  and 4  girls = 28,
had father or mother near-sighted—the mother 11,  the father
17 times.  The mother's myopia seems to affect the daughters,
the father's the  sons.  From this it would seem that myopia
is by no means so hereditary as it has been thought.
  These data led  Dr.  Cohn to endeavor  to  ascertain what
there  was in the schools which originated or increased near-
sightedness.  He had taken the bodily measurement of these
10,060 children, and measured in comparison the school desks
and seats, from which he found that all school furniture was
badly constructed, so as to readily induce or increase myopia.
From the furniture not being adapted to the body of the chil-
dren, they are obliged to bend the head over forward, thereby
hindering the return of the blood from the eye, and keep the
print so near (3 to 4 inches) as  to  too greatly task  the power
of accommodation.  Both of these, as we know, induce near-
sightedness.  Inadequate light  and misplaced windows  Dr.
Cohn found greatly affecting the amount of myopia amongst
the pupils of  the  school,  as also  inadequate and  badly ar-
ranged artificial light where used.
  Let us see now  how it is with the spectacles of these near-  *
sighted youths  of both sexes, even in  the land from which
almost all our knowledge of refraction and accommodation of
the human eye comes.  Dr. Cohn found only 107 wearing 
CAUSES  OF IMPAIRED VISION.
13
glasses.   Of these only 8 had been ordered by a physician,
the other 99 bought by the children upon their own selection.
Some had changed the glasses prescribed for them by a phy-
sician for stronger ones.   Of the 107 only 26 neutralized the
myopia, 41  were weaker, 40 stronger than the myopia.   But
11  out  of the number had concave glasses that were not in-
jurious.  Well might Dr. Cohn say,  "If  I accomplished
nothing else by my whole labor than, that hereafter no scholar
wore a, glass except  by the  ophthalmic  surgeon's advice, I
should feel amply rewarded."
  Now  let  us see how it  is  with hypermetropia  or  over-
sightedness, comparatively  recently recognized  as a fertile
source of impaired vision.  Only the manifest, namely that
which could be ascertained without the use of atropine, was
determined.  Of the 10,060  children,  152 boys and  87 girls
-=239 were  over-sighted.  Very differently from  myopia, no
increase of hypermetropia was found with increase of age or
number of school terms.   It varied between ^ and £.  Only
9 children wore convex glasses, generally strong ones, by
physicians'  directions.   One hundred and fifty-eight of the
239  hypermetropic children  squinted inwards.   Among the
students examined Dr. Cohn found only 15 hypermetropic,
varying in degree from FV to ^.
  Dr.-Cohn  also found convergent squint in 64 children who
were not hypermetropic, in 19 of whom  it was complicated
with other troubles which may have produced it.  But in 45
cases it was unassociated with any anatomical or refractive
anomaly, and  35 of these children squinted periodically, the
other 10  permanently.   These facts especially  excited Dr.
Cohn's attention, and he sought the cause.   The amount of
t*quinting struck him at once upon entering the rooms of cer-
tain classes.  In one of the elementary and one of the girls'
high schools there were quite  a number of hypermetropic
scholars who squinted in consequence, and Dr. Cohn thought
whether or  no  others who squinted periodically did not  do so
from imitation.   This, as it seemed  very  doubtful and is dis-
believed by  many competent observers, he was not disposed
to admit, till observation showed it to be true.  In examining 
14
SOME UNNECESSARY
one of the girls' schools he could find no explanation of the
large  number of scholars who  squinted without  cause, that
is, who were not hypermetropic, &c.   One of the teachers,
however, he found, squinted periodically, although her eyes
were normal.   She attributed the cause of it to a game much
in vogue in the school,  which she herself  had  but  lately
ceased playing.  Many of the children  every  day in the
recesses amused themselves by holding the fore-finger at a
distance and then  bringing it up close to the  nose to within
two inches, keeping the eyes fixed upon it.  Then they re-
moved the finger and strove to see  which one could longest
keep  the  eyes turned in.   Upon further examination  he
found that those who squinted without cause had in this
manner actually acquired the habit.
  In a hundred cases of strabismus convergens, Dr. Cohn
found 71  hypermetropic, 8 with other affections,  and but  21
without other trouble.  Granting these latter to have perhaps
acquired it from imitation, we have out of 100 cases of squint,
71 dependent  upon  hypermetropia, thus   confirming Prof.
Donders's expressed views.  It is with the medium degrees of
hypermetropia that squint becomes associated.
  How is it now with another cause of impaired vision which
properly constructed glasses can correct, namely astigmatism
or unequal curves  of the different meridians  of the cornea ?
Dr. Cohn found 23  astigmatic children,  and  only one wearing
a cylindrical glass  to correct the trouble, ordered of course
by an ophthalmic surgeon.
  Now then comes the question, whether any of these causes
of impaired vision can be prevented or removed.   If so, cer-
tainly it is our duty to teach the community what they ought
to do, and how.  First, then,  in regard to  near-sightedness.
Prof. Donders said,  "the cure of myopia belongs to the piis
desideriis.  The greater our knowledge  of the causes of this
anomaly, the less seems even any  future hope of  our curing
it."   For Dr. Cohn says,  we cannot shorten the too long axis
of the eye, or reduce the bulging of the posterior pole of the
globe.  But we can do a great deal to  prevent near-sighted-
ness developing in those prone to it, and check it where pro- 
CAUSES  OF IMPAIRED  VISION.
15
gressive ; by adequate  illumination,  natural  and artificial,
not forcing the scholars, proper type  and impression, and,
most  of all, by seats and desks appropriately constructed.
We  sent from America with  considerable pride our school
furniture and appurtenances to the World's Fair.  These were
carefully examined and  measured  by Dr. Cohn, and like all
the others, found so arranged as to produce these evils we are
speaking of, as he  has  shown in  the Berliner  Klinischen
Wochenschrift, No. 41, 1867, under title, "The school-houses
at the Paris Exposition from a hygienic point of view."
  With reference to the necessity of wearing proper glasses to
correct  near-sightedness the community  seem  totally igno-
rant ;  and as little appreciate that the ophthalmic surgeon
alone can choose these properly.  We regret here to add that
our experience proves that a large number of practising phy-
sicians share the ignorance and prejudice of the laity.
   Dr. Cohn  found 9 only of the 239 hypermetropic or over-
sighted children wearing  glasses.   Yet as he says, the sooner
(even at six years of age if necessary)  we give the hyper-
metropic a  proper convex glass, the less will his  power of
accommodation be strained and injured.  And here we can-
not resist quoting the following, for it is perfectly applicable
to our community :
   "The hypermetropic child who has found his seeing diffi-
cult,  or almost impossible,  and  notwithstanding repeated
injunctions laid his head again upon his book,  puts on  unwit-
tingly his  grandfather's  or grandmother's  spectacles, and
suddenly can now see clearly and  without effort the finest
print  at the  usual  distance, asks therefore to be allowed to
wear  them.  But  the parents' fear of  spectacles for young
children prevents his having these so very important  assist-
ants for his  work, no physician is questioned, and the child is
forced to compensate for  the  refractive error of his eye by
calling upon his whole power of accommodation."
  Probably  90 per cent, of the cases of convergent squint are
due to  hypermetropia.   But we know, as Dr.  Cohn  says,
" An eye which squints a long time gradually loses its power
of seeing, because  it does not  exercise vision with the other, 
16
SOME  UNNECESSARY
just as the left  hand  is generally weaker than the right
because  it is less  used.   This  is a long-known fact that
should induce every teacher to prevent the scholar's squinting.
Among 135 cases of permanent squint, the power of  vision
in the turned eye was reduced  in varying degrees.   We call
V.  (Vision) equal 1, when a type,  which a normal  eye  can
read at 20 feet, can be deciphered at this distance.  If it can
only be read at 10 feet  then V=§§=|,  &c.   Correcting  any
near or over-sightedness with proper glasses, and then letting
the eye armed with them read the type  where it can, and we
shall,  if this  distance  is less  than normal and  there is no
disease of the  several  parts  of the eye, have proof  that the
retina  is less sensitive to impression, which  is exactly the case
with squinting eyes.'1''
   "So  surely  as squinting is  caused by hypermetropia, so •
surely  is it alone cured in the first stage, periodic squint, by
wearing convex glasses, which neutralize  the over-sighted-
ness.   If, however, the  squint has become permanent, the in-
ternal straight muscle of the eye that caused the convergence
becomes shortened, and soon the antagonistic muscle which
turns the eye in the opposite direction  is weakened and no
longer able to perform its function.  Hence an eye which has
long turned in,  finally cannot be turned out again.
   " With permanent squint the correcting glasses no longer
avail.  Only an operation can help the patient, namely, cut-
ting the shortened muscle of   the squinting eye,  when it
becomes attached further back  on the  globe and  acts  then
as if it had been lengthened.  This operation  is so perfectly
safe, simple and rapid of performance, that  the earlier done
the better, not only to remove the deformity of the squint but
to improve the power of sight.  For as soon as  the eye which
has squinted resumes its motion with the other, it wholly or in
part recovers its  power of vision.  Of  the  114 permanently
squinting eyes not one had been operated  on.  And not one of
the 44  periodically  squinting wore a  convex  glass.    These
eyes will therefore, if nothing is done to prevent the squint-
ing, assuredly lose a considerable power of vision."
   Still further,  Dr. Cohn found  23 astigmatic children, only 
CAUSES  OF IMPAIRED VISION.
17
one of whom was wearing cylindrical glasses, and he  says,
" The astigmatic  patient who after long searching at the
optician's does not find any glass to suit him, is rejoiced to
suddenly see everything clear and plainly  through a cylindri-
cal glass."   A  distinguished ophthalmologist, Dr.  Emile
Javal, of Paris, who has specially studied impaired vision
from astigmatism, and is himself the subject of it, said in the
Annales d1 Oculistique, 1865, "Cylindrical glasses have com-
pletely  changed  my existence;  before uijing them  I was
obliged to forego all work at night, but now I read, so to
speak, indefinitely by the light  of a single  candle."  Now
astigmatism does not increase with age and is almost always
congenital; proper glasses, which can only be selected by a
scientific ophthalmic surgeon, correct the difficulty and greatly
improve vision.  It is true, such  selection requires long and
patient  examination, but the  improvement of sight  amply
repays the time given by both physician and patient.
  Finally, does all here said in reference  to  school children
and students  apply to our community ?  We believe from
personal experience that it does,  and that such extended re-
searches as Dr. Cohn has made, if here  undertaken, would
prove it beyond doubt.  A  higher standard of education is
being steadily demanded and striven for,  and can be gained
only by taxing the eyes more  severely.  It would certainly
seem  therefore the duty of parents,  as well as all interested
and occupied with the education of youth,  our Boards  of
Education and School Committees, to assure themselves that
they are doing all in their power to avert what even the com-
munity  generally  recognize as  a growing evil, namely, the
graduation of a large number of highly educated young men
and young women with  permanently impaired vision from
unnecessary causes. 
 
 

C%  (  cc
*"   *-1 '
     t».«"



f4 «<*<
<*■<■ ^