WITH COMrTIMENTS OF TME AUTHOR. 
What Course should be pursued with an 
Eye lost through an Accident? 
in' 
JULIAN J. CHISOLM, M. D., 
Professor of Eye and Ear Surgery in the University of Maryland, and Surgeon in Charge of 
the Baltimore Eye and Ear Institute, 
Reprint from the Virginia Medical Monthly, August, 1875. 
BALTIMORE; 
KELLY, PIET & CO., Printers, 
1.74 Baltimore Street, 
1875. MAT COURSE SHOULD BE PURSDED WITHAK EYE LOST THROUGH AN ACCIDENT? 
BY 
JULIAN J. CHISOLM, M. D., 
Professor of Eye and Ear Surgery in the University of Maryland; 
Surgeon in Charge of the Baltimore Eye and Ear Institute. 
(Reprint from Virginia Medical Monthly.) 
Having had occasion in the last two weeks to remove ten eyes 
lost through accident, all of which were giving trouble, both in 
the lost eye and in the good one—some of them after a few 
weeks, others after many years loss—l have thought that the 
views elicited by ophthalmic study would be conducive of good 
to the profession at large. So seldom is an injured and lost 
eye carried through life without sooner or later giving trouble, 
that one of the most important axioms established by modern 
ophthalmic surgery is to regard every such lost eye as a thorn, 
which will at some time cause irritation, both in the eye lost, 
and, through sympathy, in the good eye, and will eventually 
destroy the good eye also, through repeated attacks of inflam- 
mation. These inflammatory processes prove rebellious to every 
kind of medication, and will surely recur and run their de- 
structive race, unless the only controlling means be used, viz: 
the extirpation of the lost and injured eye from which the 
danger to the good eye comes. (ORIGINAL COMMUNICATIONS—CHISOLM. 
This axiom, “ that every lost eye from injury should he taken 
out,” has no qualification, and is absolute. By this I mean to 
say, that no surgeon will ever do wrong who removes an eye 
lost through injury, whether at the time of operation the eye 
gives trouble or not. Whenever it is taken out a lurking, dan- 
gerous enemy is surely gotten rid of. 
A lost eye from accident is usually a deformed one, marred 
in its fair proportions by shrinkage, or made conspicuous by the 
whiteness of its opaque lens, or exhibits a scarred surface and 
discolored iris, indicating the character of the injury which had 
destroyed the sight. Such unsightly eyes, from which the per- 
ception of light has forever departed, often flush up under the 
slightest exposure, and remain both a deformity and an ever- 
threatening source of trouble. 
The period at which inflammation makes its appearance in a 
lost eye is by no means fixed. The accident is always the imme- 
diate cause of a certain degree of inflammation, with more or 
less impairment of vision ; often there is complete destruction 
of sight from the very reception of the injury. After some 
weeks the pain and redness may altogether pass away, leaving 
the eye with defective or with lost vision, and with more or less 
disfigurement, but otherwise giving no discomfort. This quies- 
cent stage may be of very variable duration. In the course of 
time—possibly in a few weeks after the accident, or it may be a 
few months, or, in rare cases, after many years—the lost eye 
becomes sensitive and the sympathetic trouble in the good eye 
begins. Recently I have had occasion to remove a lost eye 
which had become painful and was threatening the good one 
after thirty years’ of latency. 
When this pain comes on, the patient imagines that he has 
caught a cold in the lost eye. A few days later the good eye 
is complained of as being weak; strong light annoys, and read- 
ing for even a few minutes causes fatigue. The so-called cold 
in the eye may pass away, releasing the good eye from sympa- 
thetic irritation. The lost eye, however, remains sensitive to 
the touch, with a lingering blush of congestion. This redness, 
from the tardiness of its withdrawal, seems disposed to make a 
more or less protracted stay. REMOVAL OF EYE FOR ACCIDENTS, &C, 
3 
After an interval of very variable length another cold is 
caught in the lost eye, followed by the same peculiar syrupa-* 
thetic irritation in the good one, but with more pain and red- 
ness than on the previous occasion; also with some dimness of 
vision. Relief may be again experienced, and all inflammatory 
troubles subside both from the lost eye and from the good one. 
The sight in the good eye is, however, not so sharp as formerly, 
and a careful inspection will reveal an irregularly contracted 
pupil. This shows that the sympathetic inflammation has 
invaded the tissues of the iris, and the glutinous inflammatory 
deposits have stuck the iris to the capsule of the lens. Sooner 
or later another attack comes on. This time the good eye 
sympathizes to a greater degree, the pain and inflammation 
extending beyond the iris to the choroidal structure—a serious 
complication for vision. When the inflammation now subsides, 
as it had so often done before, it leaves the former good eye a 
nearly useless organ. This eye that ought still to be good 
retains only a perception of light, but is bereft of all useful 
vision. The end of the trouble is not even yet reached, for 
with loss of sight there is no immunity from suffering. On 
the contrary, attacks of inflammation, in greater or less severity, 
continue to harass the patient, until he begs to have both eyes 
taken out, the only means of relief from suffering. One 
of the most grateful patients that I have ever had was one to 
whom I gave immunity from frightful torture by taking out 
both eyes. His relief was prompt and permanent, and he has 
never ceased to express the greatest gratitude. 
If, in cases of loss of an eye by accident, the inflammatory 
attacks would restrict themselves to the lost organ, the useless 
and painful eye might be soothed by treatment, and, barring 
the temporary distress, would not require to be operated upon. 
It is on account of the intimate sympathetic connections 
between the two eyes that the inflammatory irritation in the one 
is so surely transmitted to the other, to its injury,or its com- 
plete destruction, depending upon the readiness with which the 
trouble is detected and the promptness with which the remedy 
is applied, the only safe one that we have, viz : the removal of 4 
ORIGINAL COMMUNICATIONS—CHISOLM. 
the injured eyeball. Any other treatment is temporizing, and 
will prove itself ineffectual in establishing any permanent 
good. 
The peculiar kind of irritation which excites these metastatic 
destructive processes seems to reside in the ciliary nerves. In 
all cases when the lost eye is removed, and cut into, the chief 
inflammatory changes are found centred in the ciliary region. 
In acute and recent cases extensive lymph deposits cover the 
ciliary processes, and both aqueous and vitreous chambers may 
contain more or less pus. In the very old cases, where the eye 
is shrunken, bony plates are found in and without the choroid. 
These hard structures, by pressure upon the ciliary nerves as 
they pass forwards from the back of the eyeball, may be among 
the immediate cause of sympathetic irritation. 
All wounds of the eyeball are not equally dangerous in 
causing sympathetic inflammation. Wounds strictly within 
the limits of the cornea may let out all of the aqueous humor j 
and if the lips of the wound gape, may even permit a portion 
of the iris to protrude through the cut, forming a large iritio 
hernia. Should this protrusion remain, nature will in time 
remove it or convert the protruding iritic substance into cica- 
tricial tissue. The inner portions of the iris stick firmly to 
the inner face of the cornea, shutting up the pupil and shutting 
out vision. Patients suffering from such an accident are not 
likely to have sympathetic inflammations, although the eye has 
temporarily lost its usefulness. The operation for artificial 
pupil will restore sight and enable the individual to regain a 
useful organ. When the entire protruding portion of the iris 
is trimmed off with scissors, at the time of the accident, and 
an atropia solution is dropped into the injured eye, a good, 
although an irregular pupil, is preserved. Strictly corneal 
wounds are, therefore, not the most dangerous wounds to the 
eye; otherwise our many cases of cataract extraction, where 
the opaque lens is removed through an extensive cut in the 
cornea, would necessarily be followed by sympathetic troubles 
in the eye not operated upon, which is not the case. 
The very dangerous eye-wounds are lacerations through the 5 
REMOVAL OF EYE FOR ACCIDENTS, &C. 
ciliary region. The extent of such a wound divides the cornea 
and the sclerotic tissues, extending across the junction of these 
and injuring the deeper parts which lie in this locality. From 
such a wound an eye seldom escapes permanent injury and 
future trouble. When a wound is received through this pecu- 
liarly sensitive portion of the eye—especially if the sight be 
seriously impaired from the moment of the accident—the 
tediousness of the inflammation which follows, the great suf- 
fering, and the nearly certainty of sympathetic trouble in the 
course of time, warrants the prompt removal of the injured 
eye as the proper course of treatment. 
It is always best to remove the lost eye before the good one has 
become in. any way affected. Should an active sympathetic 
irritation be excited before this precaution has been taken, 
there is no surety that the good eye will not be more or less 
permanently injured by the inflammatory process. Sometimes 
the attack in the good eye does not yield at the moment 
the injured eye is removed, and in some rare cases the destruc- 
tive process, once commenced, will go on in the good eye, 
notwithstanding the extirpation of the lost one. 
I have often seen patients with dangerous wounds of the eye 
experience such protracted suffering as to incapacitate them from 
all work for many months after the accident. In such cases, if 
the eyeball be extirpated, relief comes so promptly and decidedly 
that the patient is ready to resume his regular employment in a 
few days. To the laboring man, a correct diagnosis and a 
speedily executed operation, based upon the fore-knowledge of 
what is to be expected should an antiphlogistic course be alone 
pursued, will save the mechanic many weeks of suffering, and 
possibly protect his family from want. Should a foreign body 
inflict the injury and remain imbedded in the eyeball, the 
necessity for immediate removal of the eye becomes even more 
imperative, as the presence of the foreign body (usually a piece 
of metal) makes the future suffering more certain. 
When an injured and lost eye has been removed, the operation 
gives 'perfect protection to the good eye, which has not yet experi- 
enced any serious imflammatory attacks. Until the injured and 6 
ORIGINAL COMMUNICATIONS—CHISOLM. 
lost eye has been enucleated there is no positive safety for the 
remaining one. 
To the uninitiated the extirpation of an eye seems but one 
step removed from the sacrifice of life. The operation is looked 
upon not only with horror, but is considered a most fearful one. 
To those familiar with the facility with which an eyeball can 
be removed, the little blood lost (not a teaspoonful), the absence 
of danger, and the immediate relief which it brings, the opera- 
tion is justly considered the most successful, as well as one of 
the most brilliant, in surgery. 
The present method of extirpating an eye consists in first 
cutting the conjunctiva all around the very edge of the cornea. 
Through this circular incision a blunt hook is introduced, upon 
which the tendons of the recti muscles are hooked up. Each 
of these muscles are cut through at their line of attachment to 
the sclerotic coat. As some of these muscles are much more 
developed than others, it is more convenient to divide them in 
the following order: first, the internal rectus; then the upper; 
then the external; and lastly, the lower one. It is well to 
leave a small ledge of tendon from the internal rectus attached 
to the sclerotic, for convenience of holding and rotating the 
eye, so as to facilitate the more ready exposure of the optic 
nerve. When all of these muscles have been carefully divided, 
the remnant'of the internal rectus tendon is seized with a for- 
ceps, and the eyeball rotated forcibly outward, which brings 
the optic nerve entrance into the sclerotic, near the surface, at 
the inner corner of the eye. A curved scissors is introduced 
into the conjunctival incision from this inner canthus, and push- 
ing it backwards it glides behind the eyeball, catching the optic 
nerve between the blades. The nerve is severed, and the scis- 
sors, used as a lever, lifts the eyeball out from between the lids, 
all the structures having been divided which had kept it firmly 
held in the socket. Now clip the tendons of the two oblique 
muscles at their points of attachment to the back of the eyeball, 
and the eye comes away in the sclerotic coat alone. In the 
socket remain for future use all of the muscles tied together by 
stout connective tissue, and also the entire conjunctiva. The REMOVAL OF EYE FOR ACCIDENTS, &C. 
7 
elasticity of the conjunctiva effaces nearly the entire wound in a 
few hours, leaving only a very small central exposed raw sur- 
face of about one-fourth of the size of a finger nail to heal by 
cicatrization. As this wound is too small to enable us to see 
the divided vessels for ligation or torsion, a sponge thrust into 
the socket between the lids and firmly bandaged in position for 
the space of an hour will prevent any oozing of blood. When 
the surface has lost its soreness, an artificial eye can be easily 
adjusted, which the retained muscles will move in similar 
directions to the good eye by acting upon the cicatrix in the 
conjunctiva. By this means the natural expression of the face 
is perfectly restored. 
By extirpating a deformed, lost and painful eye, not only is 
perfect protection against future trouble secured, hut good looks 
are also regained, and one escapes many annoying expressions 
of sympathy. 
The operation for the removal of an eye should always be 
performed under the full influence of an anaesthetic, so that the 
patient experiences no pain whatever. I have used chloroform 
since its discovery (now twenty-five years). I administer it cer- 
tainly once every week, and often several times a day. During 
these twenty-five years’ experience as a surgeon I have never 
had an accident from its use. As to the dangers of removing 
an eye lost from accident; I would state that I extirpate, on an 
average, about one for every week of the year, and I have never 
had any trouble from the operation. As to the speedy relief 
which follows; within twelve hours, the nauseating effects of 
the anmsthetic having altogether passed off, the patient, freed 
from pain, is ready to leave his room and take outdoor exercise, 
often starting upon a long journey the day after the operation. 
The following, one of the ten cases referred to as having been 
extirpated in the last fortnight, will give a good insight into 
the progress of a case of enucleation of an eye: 
F. G., aged 62, came to the Baltimore Eye and Ear Institute 
from his country home, two hundred miles distant. He had lost 
his eye three years since. For the past six weeks he has been 
suffering intense pain in the lost eye, which has kept him from 8 
ORIGINAL COMMUNICATIONS—CHISOLM. 
working, and which has recently made the good eye weak and 
dim. I found the lost eye in a state of acute inflammation, with 
the cornea in a sloughy state, and the anterior chamber apparently 
full of pus. He was anxious for immediate relief, and walked the 
room restlessly on account of his severe suffering. Chloroform 
was administered, prefaced, as I invariably do, with a drink of 
whiskey. The patient quietly went to sleep after inhaling 
chloroform for only a few minutes. The eye was enucleated 
in accordance with the method already described, and the 
patient put to bed. Four hours after the operation, I found 
the patient free of all pain, and feeling so well that he desired 
to accompany a friend who had some business in a distant 
portion of the city. He had experienced no nausea from the 
anaesthetic. Eight hours after the operation, he was enjoying 
such perfect relief that he took cars to return to his distant 
home. 
The rule laid down for the treatment of eyes lost by acci- 
dent is equally applicable to eyes lost by acute diseases—espe- 
cially from extensive corneal ulcerations, followed by projecting 
staphylomas; also from the disastrous results of internal 
inflammations attacking the choroid and iritic tissues. In 
fact, the rule is a good one, even when generalized, so as to 
cover every lost eye that has been marred in its appearance by 
the destroying cause, whatever that cause be. In every such 
case the safest course to pursue is to remove the lost eye.